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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 61, 12th October 1999
2 (9.45 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Mr Maclean.
5 MR MACLEAN: Good morning, sir. This morning we are
6 going to hear from Professor Gianni Angelini, Professor
7 of Cardiac Surgery at the University of Bristol.
8 Professor Angelini is here and raring to go, but before
9 he does, I think there may be an application from
10 Mr Lissack, QC.
11 THE CHAIRMAN: Yes, please.
12 APPLICATION BY MR LISSACK
13 MR LISSACK: I shall not keep Professor Angelini waiting
14 long. Good morning, sir. May I, before I make my
15 application, on behalf of those of us who were here
16 yesterday on behalf of the BCHAG, apologise to the
17 Inquiry for our constant toing and froing of notes to
18 counsel if it was in any way distracting. Sometimes it
19 can be. The impact of the less trailed parts of the
20 evidence yesterday was perhaps a surprise to all of us,
21 and perhaps something Miss Grey was good enough to
22 pursue in so far as time permitted.
23 That said, may I please come to our application?
24 It is our application, for reasons I shall take perhaps
25 two minutes to explain, that four witnesses should be
0001
1 required to reattend before this Inquiry to give further
2 evidence to it. The issue is this: on 23rd September of
3 this year, you, sir, heard evidence from Professor
4 Berry. Present during his evidence, as you may recall,
5 was Mr Barrington of the UBHT. He had previously given
6 evidence on Issue J which Professor Berry was giving
7 evidence on, as had Mr Ross before him and Mr John Gray.
8 Each, from our perception, which matters of course
9 considerably less than yours, left the Inquiry with the
10 impression of having, firstly, a deep regret for the
11 hurt that had been caused by the long established custom
12 of keeping the organs of dead babies without the
13 knowledge or consent of their parents; secondly, that in
14 February 1999, the Trust had made a clean breast of the
15 matter with both the families and perhaps for these
16 purposes more importantly, with you, the Inquiry;
17 thirdly, they made plain what was retained, leaving my
18 clients with the understanding that that which was
19 retained, be it their child's heart or brain or other
20 organ, was retained whole and in one place.
21 Each would have the Inquiry accept that he was
22 candid in what was said. You will recall that
23 immediately before he gave his evidence, I said it would
24 be interesting to see if Professor Berry was as candid
25 as to events at Bristol as Professor Anderson had been
0002
1 as to the national and international picture before him.
2 Indeed, sir, in this chamber in the moments
3 immediately after you rose on the day Professor Berry
4 gave evidence, he approached me and asked me whether his
5 evidence had been "candid enough" for me. It is
6 a strange comment. If it was humour, it may be
7 ill-placed; if it was not, I do not know quite why he
8 said it.
9 What happened next, which gives rise to this
10 application, casts a different light on events to date.
11 After that day's hearing, and still at this
12 building, Mr Barrington intimated to one of my
13 clients -- who will obviously remain anonymous, but her
14 identity I think is known to you privately through the
15 usual channels -- that more of her child's organs were
16 retained than she had originally been led to believe.
17 It is said in the letter, which again you may have
18 seen because it was copied to the Inquiry, that that was
19 an error which was not brought to the Inquiry's
20 attention partly because the wrong questions were asked
21 and partly because of the inability to identify
22 individuals, the evidence given not being patient
23 specific. I will return to that reasoning in moment.
24 That revelation as to the retained organs was
25 followed by my learning that in the case of at least two
0003
1 of my clients, the UBHT had confirmed to them that from
2 the organs that were retained had been taken tissue, so
3 in one case the heart was not in one piece but in 41
4 pieces and in another, not in one piece but 53 pieces.
5 These additional samples are tissue. They are
6 retained on slides. The answer is that they cannot be
7 returned because they form part of the medical records,
8 but the revelation, which has inevitably passed quickly
9 amongst the group that I act for, has had a shocking
10 impact and is entirely at odds, in our respectful
11 submission, with the general tenor and thrust of the
12 evidence given by the Trust to date.
13 That Professor Berry never said anything about
14 this is apparently caused by, as I say, two factors: his
15 evidence was not said to be patient-specific; and
16 patient confidentiality may be breached, he feared, by
17 stating the facts as he knew them to be.
18 It may be said on behalf of the Trust that we are
19 wrong to raise this matter before you today and that in
20 doing so, we do a disservice to the parents. That may
21 be said to you. We will see. If it is, may I put what
22 I say in context by reading you please four lines from
23 an e-mail typical of the response:
24 "How much further does this go? How much more do
25 we have to take? How many more times can they do this?
0004
1 Our children died at their hands and then they tear them
2 apart bit by bit. The little we have left of them is
3 not all there was; there is almost nothing left.
4 I thought I was bereft enough. This is a total
5 desecration of lives so pure and innocent it has to
6 stop. I want them to know what it is like to be in this
7 much pain. I want them to know how much this hurts."
8 That is from a member of my group. That is
9 typical of the responses that we, the lawyers acting for
10 them, have received as the clamour to raise this matter
11 before you has grown.
12 The reasoning, we submit, of Professor Berry and
13 those acting on behalf of and advising the Trust, for
14 not volunteering this to the Inquiry, never mind us, to
15 you, is threadbare at best. There are some serious
16 questions raised here in our submission which require
17 answers. Why was this information not volunteered to
18 the Inquiry? Can the Trust confirm now that they have
19 actually returned everything that they are willing to
20 offer to return, and what they still retain is
21 everything that they retain? If the work of
22 identification was as rigorous as they say, and I am
23 sure it was an arduous task, how have these admissions
24 occurred and how are we who advise the families to tell
25 them that they can rely upon the assertion that there
0005
1 are no more?
2 In how many cases has tissue been removed from
3 organs so when organs are returned they have not been
4 returned complete?
5 As to the division of organs and the retention of
6 parts on slides, what was and what is the current
7 practice?
8 I fully understand, having discussed the matter
9 with Mr Langstaff at length on more than one occasion,
10 first of all it is the Inquiry's prerogative to call for
11 a written explanation if you feel one is required at
12 all. That we fully understand and that is inevitably
13 the first stage, if there is to be even that stage
14 reached. Secondly, I fully understand that it is highly
15 unlikely that the Inquiry will want to respond today and
16 that there are other more important things to get on
17 with immediately pressing with constraints of time.
18 I understand that entirely. But I tell you this as
19 a footnote. On Sunday, at the annual general meeting of
20 the Bristol Heart Children's Action Group there was
21 bewilderment that, as my clients see it, the Trust
22 continues to behave in this high-handed fashion. This
23 is something which we respectfully submit must be dealt
24 with openly and in public in your Inquiry, with the
25 appropriate searching questions by the Inquiry and on
0006
1 its behalf, on this issue which is of national
2 significance.
3 We call for four people to be recalled:
4 Messrs Ross, Gray, Barrington and Berry, for fear, if we
5 only have one or two, of you being subjected once again
6 to another round of elegant buck-passing.
7 That is our application.
8 THE CHAIRMAN: Thank you, Mr Lissack. I should hear
9 Mr Chambers.
10 MR CHAMBERS: Sir, I am obliged.
11 THE CHAIRMAN: Please do come forward.
12 REPLY BY MR CHAMBERS
13 MR CHAMBERS: Sir, may I first say that the true extent and
14 nature of this morning's application was not really made
15 clear to me until this morning. Until this morning
16 I had really seen a letter only from Mr Fudge addressed
17 to Mr Ross, together with a reply from Miss Austin,
18 which I believe you have seen.
19 I wish to take the matters quite briefly, but
20 first of all firmly, to refute the allegations that
21 there has been "buck-passing" or fudging of the issues
22 or that Professor Berry was in any way untruthful with
23 you. Indeed, it may be best if we were to start with
24 the actual facts that appear to have led to this
25 application, which themselves, with respect, were not
0007
1 accurately put to you by my learned friend.
2 It was during the luncheon interval of the
3 evidence being given here by Professor Berry that
4 Mr Barrington was approached by the person concerned,
5 whose name I think you know and therefore I do not need
6 to go further.
7 What he told her was not that it was her child,
8 but that another child in her group, they had discovered
9 on rechecking that there was additional material
10 available and that this was in fact dealt with the very
11 next day.
12 Professor Berry, as you will recall, sir, came
13 here expressly in order to give evidence as to the
14 general issues. That was the way in which his evidence
15 was introduced before you by Mr Langstaff. In his
16 witness statement -- I deal with that rather than with
17 the actual evidence that he gave -- he dealt in
18 paragraphs 24 to 26 with what was kept, which, as he
19 indicated, sometimes included other tissues as well as
20 the heart, and in paragraph 28, he explained the
21 difficulties that he had.
22 In paragraphs 75 to 81 he dealt with the requests
23 that were received for information regarding the hearts,
24 and indeed, at paragraph 81 he expressly referred to "an
25 error" that had arisen in respect, in that particular
0008
1 case, of whether a heart had been preserved or not.
2 All of that was put candidly before the Inquiry.
3 As I say, his evidence was dealing with the
4 general rather than with the particular cases.
5 What has happened is that on being asked to
6 recheck -- I think there had been 30 cases where further
7 information was being sought by the parents -- on these
8 additional occasions they have discovered, on rechecking
9 by Professor Berry, that some additional material,
10 tissue, had in fact been retained. On each of those
11 occasions, the information was immediately reported and
12 explained to the parents concerned.
13 I am bound to comment that if those parties
14 referred to, the four of them, were indeed to be guilty
15 of buck-passing or of some form of failure to be candid,
16 it is remarkable that it was Mr Barrington's initiative
17 that in fact has brought all this about, because he was
18 the man who raised the subject with the person at the
19 lunchtime of the hearing of Professor Berry.
20 We would suggest, and we understand -- no doubt
21 sir, you will confirm -- that all the correspondence
22 with the individual cases is disclosed to the Inquiry so
23 therefore the correspondence that we have had with the
24 parents concerned has been put with you, although it is
25 not in the public domain for obvious reasons with regard
0009
1 to the protection of confidentiality.
2 We are very concerned by this morning's
3 application, not least by the way in which, in our view,
4 it may lead parents to unnecessary distress, in
5 misunderstanding precisely what has happened.
6 The task that faced Professor Berry is very fully
7 set out in his statement and of course you heard
8 evidence from him. Inevitably, when checking and
9 rechecking, from time to time errors are disclosed. In
10 our view, it is unlikely, but we cannot say it is
11 impossible, that there will be a discovery that further
12 tissues have been retained. We think it unlikely, but
13 as I say, we cannot say that it is impossible.
14 But none of this can or should be seen in our view
15 in the context of any change of policy or any attempt to
16 hide either from you or from the parents concerned any
17 of the issues that have arisen as a result of retention
18 of tissue.
19 In our submission, there is nothing new that has
20 been presented before you today that requires you to
21 recall these four witnesses, one of whom in fact,
22 Mr Gray never gave evidence in person before you.
23 I am reminded that one further point I should make
24 is with regards to the slides, the position being that
25 in the standard letter, and I have one before me dated
0010
1 back into March, it was made quite clear that if the
2 hospital were to return all the tissue in its possession
3 to the parents of the child, that would be with the
4 exception of tiny samples and microscopic slides which,
5 I am reading from the text of the letter, a standard
6 letter, "we require to keep as part of each child's
7 medical record."
8 That was contained in any letter, it being
9 a standard form of letter sent to any parent, and again,
10 you have copies of all that correspondence.
11 Again, I do stress that Professor Berry was
12 expressly here to deal with general issues and not to
13 discuss individual cases for very obvious reasons
14 relating to confidentiality.
15 I should finally say that it is of course -- I do
16 not wish my tone to be misread -- a matter of great
17 regret which has been promptly expressed, it was the
18 reason why Mr Barrington mentioned the matter to the
19 person at the luncheon interval when Professor Berry was
20 giving his evidence. It is of course a matter of great
21 regret that these instances, one having already been
22 raised by Professor Berry in his evidence, these two
23 further instances have arisen, but nonetheless, in our
24 submission, there is nothing new that has been raised by
25 my friend in his application before you today, and it
0011
1 should be rejected.
2 Of course you know the identity of the person
3 concerned, but she was not unconnected with the group
4 that my learned friend represents. I am instructed that
5 the reason why he raised it was specifically because he
6 did want the group representatives to know that there
7 was a further instance of tissue retention that had been
8 discovered, to forewarn the parents that correspondence
9 would be following, as indeed it did the very next day,
10 from Professor Berry.
11 Sir, unless there are any other matters, those are
12 my points.
13 THE CHAIRMAN: Mr Chambers, thank you. Mr Maclean, can you
14 help me on this?
15 MR MACLEAN: Sir, yes. The Inquiry below stairs has
16 certainly seen the correspondence which has passed
17 between the solicitors for the Action Group and the
18 solicitors for the Trust. I know, sir, that very
19 recently you yourself have seen this correspondence.
20 I am not sure what the position is with the rest of the
21 Panel, but, sir, it would seem that this is a matter
22 which would require the Panel to look at the evidence
23 that was given, to look at the correspondence and to
24 take, I would imagine, a little time in considering
25 having to take this matter forward. No doubt the Panel,
0012
1 once they have deliberated, will report back as soon as
2 they can, in public, to the Inquiry, presumably at the
3 start of one of our sitting days either this week or at
4 the beginning of next week.
5 RESPONSE BY THE CHAIRMAN
6 THE CHAIRMAN: Thank you, Mr Maclean. That is very
7 helpful. Thank you, Mr Lissack. Thank you,
8 Mr Chambers.
9 The Panel is, of course, aware of how deep
10 emotions do run on this issue. I think Mr Maclean must
11 be right and Mr Lissack makes the point also, that
12 whatever is to be said and done, it ought to be done in
13 public because that is how we conduct our business. We
14 will resolve this matter in public by whatever we decide
15 to do.
16 We have heard the points made by Mr Lissack and by
17 Mr Chambers, helpfully on both sides. I have the
18 correspondence, my colleagues on the Panel will peruse
19 the letters at the first break.
20 What I propose to do is to reflect -- I speak for
21 the Panel -- on the application and let you know as soon
22 as possible how we think this matter can best be
23 resolved, bearing in mind that the resolution has to be
24 in the best interests of the Inquiry first and foremost,
25 because that is what we are charged to conduct.
0013
1 So, having consulted with my colleagues, we will
2 come back and give an answer as soon as we are able to
3 do so.
4 Mr Maclean?
5 MR MACLEAN: Sir, we come then to this morning's witness,
6 Professor Gianni Angelini. Professor Angelini, come and
7 take the witness chair, please.
8 PROFESSOR GIANNI DAVIDE ANGELINI (sworn):
9 Examined by MR MACLEAN:
10 Q. Could you give us your full name, please?
11 A. My name is Gianni Angelini.
12 Q. You are the Professor of Cardiac Surgery at the
13 University of Bristol?
14 A. That is correct, a British Heart Foundation Professor of
15 Cardiac Surgery.
16 Q. Can I ask you to have a look at the screen in front of
17 you, and could I have WIT 73/1?
18 Is that the first page of the formal witness
19 statement that you have made to this Inquiry?
20 A. Yes, it is.
21 Q. If we go, please, to page 19, whose signature is that?
22 A. Yes, it is my signature.
23 Q. That is the last page of the statement, is it?
24 A. Yes, it is indeed.
25 Q. Have you read that through recently?
0014
1 A. Yes, I have.
2 Q. Are the contents of that statement true?
3 A. Yes, they are.
4 Q. You understand, Professor Angelini, you are not going to
5 go through the statement paragraph by paragraph. The
6 Panel have read it and that will be taken as part of
7 your evidence to the Inquiry.
8 A. Yes, I do.
9 Q. You have also submitted, I think, an appendix to your
10 statement. That is WIT 73/20, which is your
11 professional CV, which runs, I think, to some 35 pages?
12 A. That is correct.
13 Q. We are not going to go through that either, paragraph by
14 paragraph.
15 There have been some comments on your statement,
16 some of which I think you have had a chance to read at
17 more leisure than others. Can we have page 55, please?
18 At the bottom of the page there is a comment there
19 from Mr McKinley. If we go over the page, please,
20 page 56, have you had a chance to see that?
21 A. No, I have not.
22 Q. Well, we will have a chance to see that in the course of
23 the day, Professor.
24 Page 57.
25 THE CHAIRMAN: What Mr Maclean means there is that for
0015
1 example, at the first break, at your leisure, you will
2 be able to read it and take account of it. We would not
3 for a moment contemplate asking you about things until
4 you have had a chance properly to read it.
5 MR MACLEAN: I think you have had a chance at a rather more
6 leisurely pace to see this document, have you?
7 A. Yes, this is the one I was given last night.
8 Q. Yes, comments from Mr Dhasmana?
9 A. Yes.
10 Q. And page 87, from Professor Vann Jones?
11 A. Which I was just shown earlier on for literally
12 a minute, but I have not read it.
13 Q. And I think finally -- this one I have not yet read
14 properly either; it came in this morning, again no
15 criticism to be attached to Mr Wisheart, but
16 Mr Wisheart's comments at page 88. That is the first
17 page of his comments which run to some 23 pages.
18 A. I have not seen this yet.
19 Q. Let us leave those comments and let us leave your
20 statement and go back to the beginning of your
21 involvement with Bristol. You were interviewed for the
22 Chair of Cardiac Surgery at the University?
23 A. That is correct.
24 Q. And the interview panel included, did it not,
25 Mr Wisheart and Dr Roylance?
0016
1 A. Yes, it did.
2 Q. And the University recommended your appointment and
3 offered you a Chair there in January 1992?
4 A. That is correct.
5 Q. And there was then the question of whether or not the
6 British Heart Foundation was going to fund this Chair?
7 A. That is true.
8 Q. What was Mr Wisheart's attitude towards your prospective
9 appointment at that stage? Was he keen or not keen to
10 you being appointed?
11 A. No, he was very supportive on my appointment. I had
12 several conversations with him prior to the interview
13 and I believe he was very supportive, as the rest of the
14 University was, to my application to the British Heart
15 Foundation for a personal chair. As you know I have
16 made the acceptance of my chair for the University of
17 Bristol subject to the British Heart Foundation awarding
18 me a personal chair, and I believe everybody in the
19 University and the Trust was supportive of my
20 application.
21 Q. So you would not have come to Bristol without the offer
22 of a personal chair from the British Heart Foundation?
23 A. No, I would not.
24 Q. Can we have a look at JDW 2/220, please. Could I ask
25 you just to speak up a little, please?
0017
1 A. I have a bit of a sore throat, I am afraid. I will do
2 my best.
3 Q. This is a letter from Professor Stirrat, the Dean of the
4 Faculty of Medicine, to the Vice Chancellor of the
5 University on 3rd March 1992.
6 A. I have never seen this letter.
7 Q. Can I ask you to have a look at the last paragraph:
8 "In discussions about contingency plans,
9 JW [Mr Wisheart] and JF [Professor Farndon] felt it
10 important that we be allowed to put together a package
11 which would allow Professor Angelini to come to Bristol
12 without the BHF support on offer."
13 You see the reference being made to an approach to
14 the special trustees of the Trust?
15 A. Yes.
16 Q. That letter would appear to indicate Professor Farndon
17 and Mr Wisheart were keen for you to come to Bristol?
18 A. They were indeed very supportive.
19 Q. We do not need, I think, to go into the details of it,
20 but in due course, after a delay of some months, you
21 were offered the personal chair by the British Heart
22 Foundation?
23 A. That is correct, the end of May 1992.
24 Q. May 1992?
25 A. Yes.
0018
1 Q. You were an adult cardiac surgeon, not a paediatric
2 specialist?
3 A. That is absolutely correct.
4 Q. Did you know that before you took up this post, attempts
5 had been made to recruit a Professor of Paediatric
6 Cardiac Surgery?
7 A. Yes. I was fully aware. I do not know the details, but
8 I was fully aware that several individuals had been
9 contacted.
10 Q. Did you know that one of those was Mr Martin Elliott?
11 A. Yes.
12 Q. Did you speak to Mr Elliott before you were appointed to
13 your chair?
14 A. Yes. I spoke to him at least on a couple of occasions.
15 The one I best remember was at the Hammersmith Hospital
16 some time in December 1991, during a meeting of the
17 Cardiac Research Club, and at that meeting, he expressed
18 to me his view that he was not interested in going for
19 the chair in Bristol.
20 Q. Can we have a look at JDW 3/102?
21 This is a letter from Mr Elliott to Mr Wisheart.
22 It is dated 3rd January 1992. Have you ever seen that
23 letter before?
24 A. It is possible that I saw it at the GMC Inquiry, but
25 I cannot remember.
0019
1 Q. If we go over the page, please --
2 A. Yes, I have seen this letter to the Inquiry.
3 Q. Your surname is incomplete?
4 A. It does not spell my name very well, nor the place,
5 "Piza".
6 Q. "I spoke to Gianni Angelini on the phone last night from
7 Piza [sic] so he knows the situation. I do not quite
8 know how to finish this letter ..."
9 Do you recall the conversation with Mr Elliott at
10 the beginning of January 1995?
11 A. No. I was never in Pisa, incidentally.
12 Q. You were at least 100 miles from Pisa?
13 A. Yes.
14 Q. I do not think we need to get into Italian geography.
15 If we go back to page 102:
16 "Mr Elliott gives three reasons why he was not in
17 a position to accept a chair. Two of them are personal
18 to himself, (1) and (2), but (3) is concerned with the
19 security of the volume of paediatric work", and makes
20 reference to the separation of cardiology from cardiac
21 surgery, what has become known as the "split site".
22 Did you have any discussion with Mr Elliott about
23 the relative merits or demerits of the split site?
24 A. Not really. The only conversation I had with Mr Elliott
25 was whether he was interested to go for the job or not.
0020
1 I never got into any details with him because to
2 a certain extent it was none of my business. At the
3 same time, I had conversation with other people who had
4 been approached, like, for example, Mr John Pepper from
5 the Brompton Hospital, so in a way, to cut a long story
6 short, I was not prepared to go to Bristol for an
7 interview if I had to compete with several other
8 people. My attitude was, if they are interested in me
9 as an individual, as a Professor, I am here and they
10 have to express an interest. If they are not, I will
11 stay where I am.
12 So there was no detailed discussion with
13 Mr Elliott on the reason why he had decided not to go to
14 Bristol. I do not think it would have been even proper
15 for me to ask, really.
16 Q. You had some experience of working in a cardiac surgery
17 centre which had a split site?
18 A. Yes, indeed. In 1988 to 1989, prior to my appointment
19 to a senior lecturer position in Sheffield, I had worked
20 for about a year in the Thoraxcenter in Rotterdam and
21 most of the time I specifically worked with Professor
22 Quaegebeur who was at the time regarded as one really of
23 the best paediatric surgeons certainly in Europe and
24 perhaps in the whole world, particularly with regard to
25 switch operations. It was indeed a split site. The
0021
1 children were some 10 miles away in the paediatric
2 hospital. The day of the surgery they were brought with
3 an ambulance to the main unit, which was predominantly
4 an adult unit. They would have their operation; they
5 would stay one day, perhaps two days, in our intensive
6 care, which was shared with adult patients, and they
7 would then be transferred to the paediatric unit as soon
8 as this was feasible.
9 Q. So the set-up was similar to Bristol but the distance
10 between the two hospitals was greater in Rotterdam than
11 in Bristol?
12 A. Yes. It was several miles, almost across town.
13 Q. Was that seen as being a problem in Rotterdam?
14 A. It was not a problem at all. Of course he had
15 a logistic problem, because if he needed an opinion from
16 a cardiologist, he had to travel across town. In an
17 ideal world, children should be operated in a paediatric
18 hospital, but this did not affect the quality of the
19 results, which incidentally were absolutely outstanding.
20 Q. So when you applied for the job at Bristol, you knew
21 there was a split site for paediatrics?
22 A. Yes, I was aware of that.
23 Q. You were going to be an adult surgeon?
24 A. That is correct.
25 Q. So what was your attitude to the split site at Bristol?
0022
1 A. I was not very concerned, for two reasons. The first
2 one because I had worked in a split site condition with
3 very good results. The second because I was not really
4 the paediatric surgeon. My main objective when
5 I arrived, beside the academic side, was to establish
6 myself as a competent and reliable adult cardiac
7 surgeon, so, really, it was never really a big issue for
8 me, the split site, because I was not coming to Bristol
9 as a paediatric surgeon.
10 Q. You took up your post in October 1992, at Bristol?
11 A. That is correct.
12 Q. And you were an employee of the University?
13 A. Slightly more complicated than that, actually. Paid by
14 the British Heart Foundation, by the University, yes.
15 Q. What was the split in your responsibilities between
16 academic and clinical work?
17 A. My main aim was to establish an academic unit, which did
18 not exist prior to my arrival, and also, if you like,
19 between myself and my senior lecturer, who was appointed
20 a few months after, we were supposed to provide more or
21 less one full-time NHS consultant commitment.
22 Q. Between you?
23 A. Between the two of us. As a matter of fact, it turned
24 out to be more than that, but this was the minimum
25 requirement.
0023
1 Q. Can we have a look at your CV at the time you applied to
2 Bristol, JDW 2/194.
3 Just before we look at this, your appointment
4 would have entitled you to attend the Hospital Medical
5 Committee?
6 A. Yes, indeed, I think every consultant has that right.
7 Q. How regular an attender were you at that committee?
8 A. Once in seven years I have been at Bristol.
9 Q. Why did you go to the meeting you went to?
10 A. I was introduced to the hospital, as you say to the
11 "consultants fraternity", therefore, I felt that it was
12 rather impolite if I did not turn up.
13 Q. So having been introduced at the beginning, you never
14 went back?
15 A. Yes.
16 Q. Why not?
17 A. I am not very much of a meeting person, really.
18 I suppose I had a lot of other things to sort out and to
19 get involved with. This was really not at the top of my
20 priority list.
21 Q. Did you always know who the chairman of that committee
22 was?
23 A. I think so, yes.
24 Q. You would have known that it was --
25 A. I used to get the minutes of every meeting, as I still
0024
1 do, as every consultant in the hospital does.
2 Q. Do you read them when you get them?
3 A. Not in detail, I have to be honest. As I would read
4 probably the Sunday paper, really.
5 Q. Let us look at the CV. If we go to page 196, skipping
6 over your athletic achievements in your youth, if I may,
7 and scanning down this page, if we pick it up in 1983,
8 just above that you worked at the University Hospital of
9 Wales in general surgery between 1981 and 1982?
10 A. Yes.
11 Q. Then you went to Newport in casualty?
12 A. Yes.
13 Q. And then, more materially, Registrar in Cardiothoracic
14 Surgery in Cardiff from 1983 to 1986, and then promoted
15 to Senior Registrar March 1986 to May 1988?
16 A. That is correct. I did most of my cardiothoracic
17 training in the University of Wales.
18 Q. If we scan down a little more, you have just under
19 a year in Rotterdam that you refer to?
20 A. Yes, that is right.
21 Q. Then back to Cardiff?
22 A. That is correct.
23 Q. As an intermediate research fellow, again supported by
24 the British Heart Foundation?
25 A. That is correct.
0025
1 Q. During your time in Cardiff, you published various
2 papers and articles that you set out in the CV.
3 A number of those were in collaboration with Professor
4 Henderson, were they not?
5 A. That is correct. He was indeed my mentor.
6 Q. Professor Henderson encouraged you to pursue your work
7 in coronary artery bypass grafts, did he not?
8 A. That is correct.
9 Q. And if we go to page 214, he was one of your referees?
10 A. That is correct.
11 Q. Along with Mr Butchart, who was a surgeon based in
12 Cardiff?
13 A. Yes, that is correct.
14 Q. Do you remember while you were in Cardiff in about 1986
15 and 1987, there being discussions about the development
16 of a paediatric service in Cardiff?
17 A. Yes, indeed.
18 Q. What can you tell us about those?
19 A. They wanted to have a unit for various reasons. The
20 first one was that for a big institution, the capital
21 city of Wales, to send patients across the bridge into
22 England was regarded as not very satisfactory, which to
23 a certain extent I do agree was not regarded as very
24 satisfactory. They looked at various possibilities.
25 Indeed, I was somehow sent to Rotterdam to gain some
0026
1 experience in paediatric surgery. It was after my
2 return that it was agreed to establish a unit, but
3 I then almost immediately left to go to Sheffield and
4 a friend of mine, an Italian who at the time I did not
5 know was working in Harefield to lead the paediatric
6 surgical unit very, very successfully.
7 Q. So he has been there until very recently?
8 A. I think he left about a year ago when he was offered
9 a very prestigious position back in Italy, in Rome.
10 Q. Did you have any knowledge about the discussions that
11 took place as to whether or not under 1 year old heart
12 patients should continue to be sent to Bristol at the
13 time when Cardiff was contemplating establishing its own
14 paediatric unit?
15 A. Being a senior registrar, I never really had any
16 involvement in depth of what the politics was or what
17 the views were, but I certainly remember that generally
18 there was the view then that the quality of the neonate
19 paediatric surgery in Bristol was not really up to
20 scratch and there was a reluctance to send these
21 patients to Bristol. In fact from what I remember, they
22 were not sent to Bristol, the majority of the cases,
23 perhaps with the exception of children from around the
24 Gwent area.
25 Q. From whom did you get the impression that neonatal
0027
1 surgery in Bristol was not up to scratch?
2 A. As I said, in a very informal conversation with Andrew
3 Henderson and the cardiologist who was in charge of or
4 had an interest in paediatrics, who is now dead,
5 Dr Leslie Davies. He was really the one running most of
6 the paediatric referrals at the time, and I think he
7 used to send most of his patients either to London or
8 Liverpool or places like that, so people had said,
9 really in a very informal conversation, that "we would
10 rather send them to London than Bristol because we are
11 not very happy with the service provided in Bristol",
12 but this was perhaps more a, I do not know, gut
13 feeling. Certainly I did not have or I was not provided
14 with any evidence, and why should I? I was only
15 a senior registrar, really.
16 Q. So when you went to Rotterdam to get some paediatric
17 experience, was it contemplated by Cardiff that you
18 might return and undertake paediatric surgery there?
19 A. There was that possibility, but I almost immediately
20 made it clear that I was not interested to be
21 a paediatric surgeon. I sort of changed my mind, for
22 two reasons. First is because my children were born,
23 I had two children in the space of literally 18 months,
24 and this somehow put me off the idea of doing paediatric
25 surgery. The second reason was that I wanted to be an
0028
1 academic cardiac surgeon, and since, if you like, in the
2 early stage of my career I wanted to become a British
3 Heart Foundation Professor of Cardiac Surgery, and
4 I knew then this was almost incompatible with wanting to
5 be a paediatric surgeon, and indeed --
6 Q. Why?
7 A. Because my main research interest had been in adult
8 surgery, and I think, if you want to be a very
9 successful paediatric surgeon, you have to be really
10 very, very dedicated.
11 In my view, it would be almost impossible to run
12 a very busy academic unit and at the same time have
13 a busy successful paediatric surgical practice. If you
14 operate on an adult, you do the operation and then you
15 may say to your Registrar, "All right, look after my
16 patient, I have to go to a meeting" or "I have to
17 supervise some research project". In paediatrics you
18 need to be a lot more involved with all aspects of the
19 work.
20 Q. So how would you characterise your impression of the
21 quality of the work at Bristol at the time you applied
22 for the chair?
23 A. At the time I applied for the chair, I had had
24 a conversation with various people, including the last
25 referee of mine, Professor Smith, who had told me of
0029
1 what they knew about the situation in Bristol. I must
2 say, most of the time, rather than me going to ask these
3 people, these people were telling me. I can understand
4 the case of Professor Smith because he wanted me to stay
5 in Sheffield, they had offered me a chair, so somehow,
6 if you like, he was trying to put me off coming down to
7 Bristol. He told me then he was aware of the fact that
8 there were problems with paediatric cardiac surgery in
9 Bristol, but he did not elaborate all that much. He was
10 like, on passing by, "Look, why do you not stay in
11 Sheffield? You are going to Bristol; you will be faced
12 with problems and then perhaps they will take you away
13 from your main aim, which will be to set up an academic
14 unit".
15 Q. Did you press for any further details?
16 A. Not really. Also, because I had the impression that he
17 was not prepared to give me any further details because
18 he had been part of a committee which had been looking
19 at the performance of paediatric surgery nationwide, and
20 I think he must have been there at the time Professor
21 Smith was the Secretary of the Cardiothoracic Society
22 and was also an adviser to the Department of Health, so
23 obviously he had a pretty in-depth inside knowledge, but
24 I guess his information was, if you like, confidential,
25 and I did not feel that I ought to press him to know
0030
1 about things, then, it was unfair for me to ask and for
2 him to give me an answer, really.
3 Q. So he would have known, because he happened to be the
4 Secretary, which return was which for the register,
5 would he?
6 A. Not only because of that. I understand --
7 Q. He would know that, would he not?
8 A. Possibly not, because a lot of the returns were
9 anonymous, but I suspect, yes, he would have seen from
10 which centre they were coming. But what I was referring
11 to before, I believe there was a panel under which the
12 auspices of the Royal College of Surgeons was set to
13 specifically evaluate the state, if you like, or the
14 condition of paediatric cardiac surgery in the nation as
15 a whole, and I think Professor Smith was the Secretary
16 of that panel, or at least one of the panel members
17 anyway.
18 Q. When you came to Bristol, what was your impression of
19 whether any steps had been taken or were about to be
20 taken in order to move paediatric surgery to the
21 Children's Hospital?
22 A. I do not think any step had been taken. My
23 understanding was that one of the reasons, as you have
24 just shown me in that letter, I have heard from various
25 conversations of people like cardiologists and others,
0031
1 that one of the reasons why Mr Elliott was not keen to
2 come to Bristol was the split site. This was quite
3 common knowledge. So if they had not appointed
4 a Professor of Cardiology because they were not prepared
5 to amalgamate the two sides, I could not see how, in the
6 short term, that should have happened now they had
7 a Professor of Adult Cardiac Surgery.
8 Q. You said a Professor of Cardiology?
9 A. I meant "Cardiac Surgery", I beg your pardon.
10 Q. Can I show you UBHT 38/350? This was a document
11 produced by the Directorate of Surgery, 5th March 1992,
12 so after you had been made the offer of the job by the
13 University, before the Heart Foundation had given you
14 the chair, before you took up your post, a proposal to
15 the South West Regional Health Authority to develop
16 cardiac services at the Bristol Royal Infirmary.
17 If we did go -- we do not need to -- to page 357,
18 take it from me this document has Mr Wisheart's name at
19 the end of it; okay?
20 A. All right.
21 Q. If we go to 351, please, paragraph 2.5, if you go to the
22 top of the paragraph, first of all, "Strategy for
23 development of cardiac surgery by UBHT --
24 A. I am sorry, 2.5, is it?
25 Q. Yes, 2.5:
0032
1 "Paediatric cardiac service will be united in
2 Bristol Royal Children's Hospital, and provision for
3 this is included in the proposal."
4 If we go to 352, page 5.1:
5 "The Facilities Required:
6 "It is the advice of the SWRHA and the intention
7 of the UBHT to reprovide the Bristol Royal Children's
8 Hospital, including the paediatric open-heart surgery.
9 This development is planned to commence in 1996/97."
10 So it might appear from that document that the
11 plan was to reunite or to move paediatric cardiac
12 surgery to the Children's Hospital in the context of the
13 redevelopment of the Children's Hospital as a whole from
14 1996/97?
15 A. That is possible. I never saw this document: this would
16 have been five years after my appointment.
17 Q. What I want to explore is your knowledge of the attitude
18 of the cardiologists and the cardiac surgeons on the one
19 hand and the attitude of the Trust on the other, or the
20 Regional Health Authority on the other.
21 Was it your impression that Mr Wisheart and his
22 colleagues, who were in post when you took up your job,
23 were anxious to move cardiac surgery on children to the
24 same building as the cardiology for children?
25 A. I was never part of any of this conversation and I was
0033
1 never part of any working party which was looking into
2 this particular aspect. Therefore, I do not have any
3 inside information.
4 I can only give you my feeling, my gut feeling,
5 which was that certainly there was no urgency from the
6 Trust Board or indeed from some of my colleagues,
7 perhaps with the exception of Mr Dhasmana. Mr Dhasmana
8 always made a very strong case that he wanted the
9 children to go in the Children's Hospital, but perhaps
10 with that exception, I do not think there was really any
11 sense of urgency, of moving the children to the
12 Children's Hospital, and on various occasions, when
13 I raised this issue, I was always told that the main
14 problem really was the financial side; moving the
15 children to the Children's Hospital would have been very
16 expensive. And I was told this by several people.
17 Q. Do you remember who told you that?
18 A. Dr Roylance; the Manager of General Surgery, Janet
19 Maher. I think just these two people. At least, the
20 ones I remember. But it was common knowledge, and in
21 fact I think there was a document at some stage which
22 was circulated amongst all the people in the directorate
23 which was highlighting three different possibilities.
24 Among these three possibilities, there was the move to
25 the Children's Hospital, but this was considered to be
0034
1 too expensive.
2 Q. Did you know that there was a plan to redevelop the
3 Children's Hospital at Bristol?
4 A. A new hospital?
5 Q. A new hospital.
6 A. I was aware that there was talk about that, but I have
7 no idea of the fine details of this plan.
8 Q. But that was a plan that was in the pipeline when you
9 took up your job?
10 A. I cannot say that, actually. I have seen so many plans
11 coming and going without being realised, that --
12 I cannot say that. Certainly, I do not think it was in
13 my job description.
14 Q. You would agree, would you, with the proposition that
15 Mr Wisheart was always concerned that paediatric cardiac
16 surgery ought to be moved to the Children's Hospital?
17 A. I would say, then, whereas I agree on the fact that
18 Mr Dhasmana was very vociferous that he wanted the
19 children to be moved to the Children's Hospital, in the
20 case of Mr Wisheart I would say he was lukewarm.
21 Q. But he was the author of this type of proposal?
22 A. I never saw this. You asked me for my feeling and this
23 is my feeling.
24 THE CHAIRMAN: Professor Angelini, help me a little bit. If
25 you do not go to meetings, as you said you are not
0035
1 a meetings person, how are you aware of what is being
2 said in meetings, for example, urging one position or
3 another? You may be unaware of things that were
4 advocated in such meetings, may you not?
5 A. Absolutely. I did not go to these meetings not because
6 I did not have the time but because I was never
7 invited. It is a different story from attending the
8 hospital medical meetings. I was never part of any
9 working party in paediatric surgery, so I do not know
10 what was going on at those levels.
11 What I find surprising is that there was a very
12 strong determination in trying to appoint a Professor of
13 Paediatric Surgery in 1992 and it transpires now, as
14 then, from Mr Elliott, that the main reservation to
15 accepting was the fact that they had a split site.
16 If this was the main issue, I think the UBHT
17 should have done everything possible and impossible to
18 guarantee to Mr Elliott that this was going to happen,
19 if not right away, within a year or two. This is, if
20 you like, my feelings relating to perhaps the
21 interpretation of those events.
22 Q. What was your understanding of the reason why children
23 were eventually moved to the Children's Hospital for
24 paediatric cardiac surgery?
25 A. Pressure. Just general pressure on the Trust Board from
0036
1 public opinion, from everybody inside the hospital, from
2 evidence which had been produced by data from Dr Bolsin
3 and various other people. Again, I do not know if there
4 was a plan all the way along because I was not part of
5 those discussions. If you are asking me what is my
6 perception, I can only tell you that my gut feeling was
7 that the appointment of the new paediatric surgeon, as
8 well as the move to the Children's Hospital, was very
9 much speedier by the pressure put upon the Trust by the
10 way the events developed.
11 Q. We will come to the way the events developed, but
12 Dr Bolsin did not make his audit data known to you until
13 the autumn of 1993?
14 A. That is correct.
15 Q. I think he did not make it known to Professor Vann
16 Jones, according to Professor Vann Jones, until a little
17 later the same year; is that right?
18 A. I would not know that.
19 Q. You were an adult surgeon. What was the position of the
20 demand for adult surgery at the BRI in 1993? Was there
21 an excess of supply or an excess of demand?
22 A. The unit was doing about, I think, 500 cases, and I am
23 sure there was a demand for more operations, as indeed
24 was demonstrated by the fact that from there on there
25 was an increase in the workload effectively until last
0037
1 year, every year.
2 Q. What were the constraints upon the performance of an
3 increased number of operations on adults?
4 A. The main constraint was really the intensive care. The
5 intensive care beds.
6 Q. Not enough of them?
7 A. There were not enough, or they were occupied, maybe by
8 a sick patient for a very long time, so sometimes you
9 had to cancel patients and not do more patients because
10 there was not a bed available to put the patient into.
11 Q. It was not uncommon for adult patients to be cancelled
12 at short notice because there was no bed available?
13 A. I would not say it was all that common. For example,
14 I had worked in other places where it was more common,
15 like Cardiff. This is part and parcel of the NHS as it
16 is. Even now, very often we have to cancel cases
17 because we have some sick patients and therefore we do
18 not have available beds.
19 Q. Having only adults in the Intensive Care Unit as opposed
20 to adults and children would improve the situation as
21 far as adult surgery was concerned?
22 A. Absolutely.
23 Q. So moving paediatric cardiac surgery to the Children's
24 Hospital would be a means of increasing the throughput
25 of adult surgery, would it not?
0038
1 A. Absolutely.
2 Q. Was that not the rationale for the ending of the split
3 site rather than the exertion of pressure, as you put
4 it?
5 A. Let us say it was a combination of the two things.
6 Q. Can we look at JDW 3/303, please? This document is
7 December 1993. It does not say so there, but that is
8 its date. Can you have a look, please, at the first two
9 paragraphs of that document? It is dated at the foot of
10 the next page 20/12/93. Let us look at paragraphs 1 and
11 2. (Pause).
12 Do you remember being involved in the cardiac
13 surgery planning group?
14 A. This was 1993?
15 Q. December 1993.
16 A. No, not really.
17 Q. "The possibility of transferring the paediatric workload
18 currently being undertaken at the BRI to the Children's
19 Hospital --
20 A. Yes, I mean, these things were discussed all the time,
21 mostly at sort of Directorate meetings.
22 Q. "-- as a means of increasing throughput in adult surgery
23 was discussed."
24 A. Yes, these were issues discussed all the time.
25 Q. So that discussion would be important to the paediatric
0039
1 surgeons and paediatric cardiologists and to the adult
2 surgeons and adult cardiologists?
3 A. Absolutely. It would be relevant to everybody.
4 Q. It would be very relevant to you?
5 A. Yes.
6 Q. You see from the next paragraph:
7 "In principle the Directorate of Children's
8 Services would strongly support the integration of
9 paediatric cardiac services on one site."
10 So the Children's Hospital was happy about this
11 idea?
12 A. I am sure they were, very much.
13 Q. And the adult surgeons and cardiologists would be very
14 happy as well?
15 A. Yes.
16 Q. So is it not the case that by December 1993, perhaps
17 rather earlier than that, all the cardiologists and
18 cardiac surgeons, adult and paediatric alike, were
19 anxious to bring about an end to the split site?
20 A. Yes.
21 Q. The rationale for the acceptance of the proposal that
22 there should be an ending to the split by the Trust in
23 the end was that the funding difficulties of the late
24 1980s were going to be overcome by the increase in
25 throughput in adult work, which would mean that the
0040
1 proposal would be financially sensible and would in
2 a sense pay for itself?
3 A. That is correct. If you look at the last paragraph of
4 this letter, it says:
5 "In 1989 a full feasibility study was carried out
6 on a similar proposal, but a requirement to build an
7 additional main theatre plus an extended Intensive Care
8 Unit at BCH to accommodate the work load made this
9 option cost prohibitive."
10 Q. Let us scan down a little.
11 "A number of changes have taken place which may
12 make it more practical."
13 Then those are explained.
14 So there is no great mystery about the ending of
15 the split site. It is just that that which had always
16 been pushed for by the cardiac clinicians, the surgeons
17 and the cardiologists, which had been unable to be met
18 because of cost considerations, in this new context by
19 the mid-1990s, those problems could be overcome and the
20 split site was duly ended?
21 A. It is possible.
22 Q. And it was not actually anything to do with the hoo-ha
23 about Dr Bolsin's data, because that had not come, even
24 to your attention, even to the preliminary attention of
25 other people, until very late in 1993, when this
0041
1 proposal was already formulated?
2 A. That is correct. What I said was that the events in the
3 way they unfold, they accelerate the implementation of
4 the transferral of the paediatric service to the
5 Children's Hospital.
6 Q. If we go on, please, to UBHT 275/130, this is May 1994.
7 We will come back to this later.
8 "Cardiac Expansion Working Party, consideration of
9 draft report."
10 You see the date of 12th May 1994. There were
11 other things which happened on that date which we will
12 have to discuss.
13 Can we scan down, please?
14 "I enclose a first draft of a report ... which
15 contains contributions from as many Working Party
16 members as possible. Queries should be addressed to
17 Lesley Salmon."
18 You are the first name on the distribution list.
19 Do you see that?
20 A. Yes.
21 Q. Were you a member of that Working Party?
22 A. Not that I know.
23 Q. Do you remember getting that draft?
24 A. Yes, I was getting pieces of paper all the time, but
25 I was never involved in any, how can I say, main
0042
1 decision on whether the children -- I was asked perhaps
2 occasionally my opinion, which was that the children
3 should have gone to the Children's Hospital.
4 Q. But this is not just a piece of paper, is it? This is
5 not in the same category as minutes of a meeting you did
6 not attend and might not be very interested in but you
7 would read like the Sunday papers. This is a Working
8 Party considering the expansion of cardiac services and
9 you are the Professor of Cardiac Surgery?
10 A. Fine.
11 Q. So you would want to read this document.
12 A. Please, because I cannot remember it.
13 Q. If we go to JDW 3/195, this, I think, is the proposal.
14 This is the document. If we go to the foot of the page:
15 "As part of the development of paediatric cardiac
16 surgery, it is planned to appoint a committed paediatric
17 surgeon. The creation of this surgical position would
18 enable progress to take place in the paediatric service,
19 signalling that Bristol is at least the equal of its
20 competitors and is fully committed to employing all new
21 developments in this field."
22 That development would be one that you would have
23 supported?
24 A. Absolutely. Can I ask you, what is the date of this?
25 Q. May 1994.
0043
1 A. May 1994? Yes.
2 Q. You see in the paragraph above that, under the heading
3 "General Considerations":
4 "Important issues need to be addressed regarding
5 both adult and paediatric cardiac surgical services."
6 Do you see that?
7 A. "The proposals should facilitate the ..." I am sorry,
8 what are you referring to?
9 Q. Just take a moment to read those last two paragraphs.
10 A. "As part of the development ... (Pause).
11 Q. This is the proposal that was being put forward for the
12 expansion of cardiac services in 1994. It may be that
13 this is actually the final version of the proposal as
14 opposed to the one circulated in May 1994, but I do not
15 think anything turns on the substance of what is being
16 suggested.
17 This document shows, does it not, that the
18 proposal that there be a new surgeon, a paediatric
19 cardiac surgeon, was being proposed by the cardiac
20 community, if I can put it like that, in May 1994?
21 A. Yes.
22 Q. That does not necessarily mean that the proposal is
23 going to be accepted by the Trust?
24 A. It does not necessarily mean how long it will take.
25 Q. But it does show, does it not, that the cardiac
0044
1 community were making these proposals for an ending of
2 the split site to increase the throughput of adult work
3 and to appoint a dedicated or a committed, as it puts
4 it, paediatric cardiac surgeon, by May 1994?
5 A. They could not appoint --
6 Q. They were proposing --
7 A. They were proposing, yes.
8 MR MACLEAN: We will come back to how that proposal was
9 taken forward.
10 Sir, I am told that it may be time for a short
11 break. It may be that, given that we have had some
12 recent submissions, we break for up to five minutes
13 longer than normal, perhaps 20 minutes?
14 THE CHAIRMAN: Yes. I think it would be appropriate to
15 bring all these pieces of paper to the attention of
16 those who need to see them, so shall we now take
17 a 20 minute break and therefore reconvene at 11.20?
18 (11.00 am)
19 (A short break)
20 (11.20 am)
21 MR MACLEAN: Professor Angelini, we were discussing the
22 proposals that were advanced by the cardiac community
23 for ending the split site and appointing a new surgeon.
24 Can I just go back to you taking up your post?
25 How did you get along with your colleagues in the
0045
1 cardiac surgery unit at the BRI?
2 A. Quite well. Quite well. We always had very cordial
3 relations. I do not think I can ever recollect a single
4 argument between myself and Mr Wisheart over a period of
5 four or five years.
6 Q. You mentioned Mr Wisheart in particular. I was not
7 specifically concerned with him, although he would be
8 part of it. Was the situation different in relation to
9 the other colleagues?
10 A. I had a difference of opinion several times particularly
11 with regard to general matters, how the practice was
12 run, with Mr Hutter, and certainly with Mr Dhasmana, and
13 then related to all sorts of things: for example, just
14 to give you a very simple example, I was very unhappy
15 when I arrived in Bristol on the fact that there were no
16 proper instruments to be used for clamping the tubing of
17 the heart/lung machine, and I made a strong case for
18 that to be changed, which took a significant time.
19 I also argued the case with my colleagues that
20 they were not using disposable towels and gowns in
21 cardiac surgery, but they were resterilising a clean
22 towel, and I remember very forcefully I tried to
23 convince them and it took me more than a year to achieve
24 that.
25 Q. Did you think that there were any of your professional
0046
1 colleagues who disliked you?
2 A. It is possible. I am pretty straight with my approach.
3 Perhaps at the time I was not very diplomatic.
4 I usually say what I think.
5 Q. You were described I think by Professor Vann Jones as
6 a man who saw things in black and white.
7 A. That, I think, is wrong. There is no question in my
8 attitude and my culture is different from many people
9 around me, after all, I am supposed to be Latin, there
10 must be some difference between a South European and
11 a North European. Maybe I raise my hand when I talk,
12 I may be very emotional, but equally, I would say when
13 you were facing a situation like the one we were facing
14 at the BRI, with the paediatric service, it is quite
15 difficult not to get upset at times.
16 Q. When Mrs Ferris gave evidence to the Inquiry, she
17 suggested that you were disliked by some people -- not
18 by her but by other people in the cardiac surgery
19 department.
20 A. I do not have any problem in agreeing with that, but --
21 Q. You agree with that. Who disliked you?
22 A. The people who may dislike me, or did dislike me,
23 probably they were people like Mr Hutter in particular,
24 who is still a colleague of mine, because my approach in
25 general to a problem is different maybe from his.
0047
1 I came to Bristol with a very precise task, which was to
2 set up an institute, and I think I succeeded in doing
3 that, but also I wanted to have a very successful adult
4 and possibly paediatric service. So if there were
5 problems, I was trying to resolve them, and this
6 obviously will inevitably lead to personality clashes
7 and discussion, which at times can be a bit heated, with
8 individuals.
9 Q. So there was a personality clash at least between and
10 you Mr Hutter?
11 A. Oh, yes, there is still nowadays, as we are talking.
12 Q. So when I asked you how you got on with your colleagues
13 and you said you did have not a cross word with
14 Mr Wisheart and you were very amicable and so on, and
15 then I asked you if that applied generally, it would not
16 apply to the position between you and Mr Hutter?
17 A. When I say we clash it does not mean we are punching,
18 abusing or insulting each other. It is just that we may
19 have a different opinion in the way the surgery or the
20 unit is run.
21 I can give you another example, only resolved
22 recently. Since my arrival in Bristol in 1992 I put
23 forward the proposal that we should have had a resident
24 registrar in the Intensive Care Unit because I thought,
25 and the kind of work we do required experienced people
0048
1 at night.
2 For one reason or another, this was never
3 implemented. Mr Hutter was the Associate Director of
4 Cardiac Surgery for three years. This was never
5 implemented. However, recently, like I believe last
6 year, the end of last year, this was now implemented.
7 So you may say that we have had different opinions on
8 how the service was run, but this does not mean we go
9 beyond what is a civilised conversation.
10 Q. You became Associate Director, did you --
11 A. Yes, September 1998.
12 Q. Would you accept that your interpersonal skills were
13 such that you get some people's backs up?
14 A. Not particularly. I would say that I am a very direct
15 person. I do not beat around the bush. I say what
16 I think. But this is never in an offensive manner.
17 Q. Mrs Ferris was generally supportive, I think, of you.
18 She said you had a lot to say that was valid and you
19 were very questioning and very challenging, but she also
20 suggested that you were distrusted by colleagues. Have
21 you ever had the impression that you were distrusted by
22 any of your colleagues?
23 A. Yes. Yes, I have.
24 Q. Who distrusted you?
25 A. In particular, the one who probably distrusted me most
0049
1 was Mr Hutter.
2 Q. So it was not a simple personality clash. It was not
3 a simple honest disagreement about the way forward for
4 the unit. If you are actively distrusted by one of your
5 colleagues, then that is a serious state of affairs, is
6 it not?
7 A. Yes and no, really, because the distrust may be related
8 to how the unit is managed and, as often happened, there
9 will be discussion on how the unit should be managed and
10 some argument may prevail and some other may not.
11 Q. But if somebody distrusts you, then they consider you to
12 be untrustworthy?
13 A. I do not think anybody ever told me I was cheating or
14 I was a liar, or something like that. At least, I do
15 not remember.
16 Q. So at all events, relations between and you Mr Hutter
17 were not of the best?
18 A. They have never been very good.
19 Q. They have never been very good?
20 A. No.
21 Q. What about relations between you and Mr Wisheart?
22 A. They have been very cordial all the time. At least,
23 when he was working at the BRI. As I said, I cannot
24 recollect a single incident where Mr Wisheart and I, we
25 had a meeting and we shouted at each other. I cannot
0050
1 recollect a single episode.
2 Q. Is that because shouting was not his style, or shouting
3 was not your style, or both?
4 A. I guess it is both, is it not, because if I was so
5 hot-headed and lacking temper, even if he was quiet
6 I could still shout. He was not preventing me from
7 shouting.
8 Q. You set up something called the Bristol Heart Institute,
9 did you not?
10 A. That is correct.
11 Q. That is an umbrella for various academic departments
12 which are related to cardiac disease and treatment?
13 A. That is correct.
14 Q. Is that right?
15 A. Yes.
16 Q. And that opened in October 1995?
17 A. That is correct.
18 Q. Can I show you UBHT 229/5.
19 The cardiac surgeons' meeting of 12th October 1995
20 and all the people there are cardiac surgeons, apart
21 from Mrs Ferris, who is the General Manager; is that
22 right?
23 A. Yes, that is right.
24 Q. Have a look at paragraph 1, please.
25 A. "The establishment of the Bristol Heart Institute was
0051
1 welcomed ..."
2 Q. Mrs Ferris took the minutes of that meeting?
3 A. Yes.
4 Q. She said, Day 27, page 114 of the Inquiry's transcript,
5 she remembered that meeting. She said it was a very
6 innocuous minute which did not reflect the fact that
7 this was a very difficult meeting and that item 1 about
8 the Bristol Heart Institute represented a very difficult
9 discussion, and that there was a fear expressed that the
10 creation of the Heart Institute would mean that the
11 Cardiac Services Directorate would be absorbed into the
12 Heart Institute and there was a management structure
13 with Professor Angelini as the person in charge of both
14 the academic Department of Cardiac Surgery and the
15 clinical service, and there was a view that people did
16 not want this?
17 A. It is totally wrong. Am I allowed an explanation?
18 Q. Please.
19 A. The Bristol Heart Institute was conceived with the
20 approval of the University. In fact, even as we are
21 speaking, the Bristol Heart Institute is a Research
22 Centre within the University, nothing whatsoever to do
23 with the NHS. It has two functions. One is to bring
24 under the same umbrella all the cardiovascular research
25 done in Bristol. This comprises as well as clinicians,
0052
1 biochemists, pharmacologists, physicians and so forth.
2 It has an executive board made of various members,
3 clinical and non-clinical, who meet once or twice
4 a year. The purpose of this is to give strength to any
5 proposal which comes from Bristol, because there is
6 a large body of research groups working in that area.
7 This is particularly relevant nowadays, because, for
8 example, the MRC would not consider any proposal from
9 individual people.
10 As a second aspect, I wanted the Bristol Heart
11 Institute to be a separate, if you like, entity in
12 clinical terms and the reason was because I was very
13 concerned as early as the end of 1994, that the
14 performance of the adult cardiac surgery was
15 substandard.
16 As a result of this, I did not want to incur the
17 same problems as the paediatric, and somehow I wanted to
18 distance myself from the rest of the unit. As
19 a demonstration of this, in 1994 and 1995 the Bristol
20 Heart Institute produced an annual report which not only
21 had research achievement, but also clinical results.
22 The clinical results were elaborated by Mr Bryan, who
23 was my senior lecturer, and we presented all our
24 mortality and morbidity in a very open manner. It was
25 the first time that institution, the Bristol
0053
1 institution, had produced data which was open to the
2 general public.
3 Q. Let me stop you there. You and Mr Bryan were
4 University-based?
5 A. Yes.
6 Q. You were the Professor and he was the senior lecturer?
7 A. Yes, that is correct.
8 Q. The other cardiac surgeons were UBHT employees?
9 A. Yes, that is correct.
10 Q. You have explained what the purpose of the institute was
11 and that it was nothing to do with the NHS side --
12 A. It still is nothing to do with the NHS.
13 Q. Having said that, was there a fear among the UBHT
14 consultants that they were somehow being taken over by
15 the institute and that you were going to be in charge?
16 A. Yes, I understand what you say. I think this was
17 entirely a matter of semantics; they could not stand the
18 idea that we were the Bristol Heart Institute, and I was
19 told that what they wanted to have on the headed paper
20 was "Bristol Heart Institute, Research Centre", to which
21 I objected because I said that the Bristol Heart
22 Institute is a research centre, but it also has clinical
23 duties which are carried out by myself and by Mr Alan
24 Bryan.
25 Q. I asked Mrs Ferris:
0054
1 "You make it sound as though there was a fear in
2 some quarters that Professor Angelini was perhaps
3 engaged in some sort of coup d'etat against the Cardiac
4 Services Director. Would that be putting it too
5 strongly?" She said, "There was a fear of Professor
6 Angelini taking over."
7 Do you agree with that?
8 A. Not at all. In fact I never had any interest in being,
9 if you like, the associate director of cardiac surgery,
10 and in fact I only took up this position in 1998, in
11 September, on the condition -- and I presented
12 a business plan and I was going to do this for no longer
13 than 18 months. Therefore, to think that I wanted to
14 take over as early as 1995 is absolutely wrong.
15 Q. Mrs Ferris made the point that at this meeting you and
16 Mr Bryan were trying to reassure Mr Hutter, Mr Wisheart
17 and Mr Dhasmana that the Heart Institute was an umbrella
18 for the academic service.
19 A. That is right.
20 Q. And would not swamp or take over the cardiac services
21 directorate?
22 A. Which I never did.
23 Q. I am trying to get at the impression, the fear, the
24 feeling of the other consultants. Did they fear at that
25 stage, so far as you were aware, that you were trying to
0055
1 take over?
2 A. I am sure they may have, but I cannot tell you that
3 because how do I know? I am not in people's minds.
4 Q. Were they critical of this proposal?
5 A. Absolutely.
6 Q. Sharply critical of it?
7 A. Very critical.
8 Q. If we have a look at UBHT 21/125, this is a meeting of
9 the Executive Committee of the Trust Board. Obviously
10 you are not at that meeting. Dr Roylance is and
11 Mr Wisheart is, amongst others, also, Dr Laszlo. Do you
12 see?
13 A. Yes.
14 Q. If we go to 127, please, at the foot of the page:
15 "The Professor of Cardiac Surgery [you] had
16 created a Bristol Heart Institute. He understood -- ",
17 I am sorry, I think this is Mr Wisheart who is saying
18 this.
19 "[Mr Wisheart] understood that it was intended to
20 include NHS clinical facilities within the institute.
21 Dr Roylance pointed out that it was not possible to
22 subcontract clinical care to the University and he could
23 not allow annexation of part of the service in this
24 way. The Trust Board gave its support to the Chief
25 Executive that he should take up this issue with the
0056
1 Professor of Cardiac Surgery."
2 Are you saying that Mr Wisheart had got hold of
3 the wrong end of the stick?
4 A. Absolutely. There are several of these institutes
5 within the hospital. There is a Neurology Institute.
6 There is now an Institute of Endocrine Neuroscience.
7 These are created by the University. This institute was
8 set up following a request from the then Dean of the
9 Medical School for me to group all the cardiovascular
10 research in Bristol. It was not even my idea in the
11 first instance. There are many other institutes within
12 the UBHT, but it does not mean they are going to
13 contract us to do the operation. We just have an
14 honorary status with the Trust. We do the operation the
15 same as any other NHS consultants.
16 Q. Did the Chief Executive take it up with you?
17 A. Never ever.
18 Q. Let us move on. SLD 2/3, please. This is Private Eye,
19 8th May 1992. The relevant article is the one in the
20 left column going over to the top of the middle column.
21 Perhaps we could have those, please. We will blow them
22 up for you, Professor.
23 If we just look down to the third paragraph, do
24 you see the reference there to "killing fields"?
25 A. The third paragraph?
0057
1 "In 1988 the mortality was so high the unit was
2 dubbed the 'killing fields'."
3 Q. Do you remember seeing this article?
4 A. Yes. This is the first one I saw. I did not see the
5 second one. I do not remember if it was this or the
6 other. I saw one article in Private Eye. I know there
7 was another one later on which I do not think I ever
8 saw, but I think this is the one I saw.
9 Q. Do you remember any discussion of these Private Eye
10 articles at Bristol, once you took up your post in
11 October 1992?
12 A. No.
13 Q. You never discussed them with anyone?
14 A. No.
15 Q. And no-one discussed them with you?
16 A. No.
17 Q. Did you have any notion of where the information came
18 from that appeared in Private Eye?
19 A. No idea. I think I know now because I read this book,
20 "Trust me, I am a doctor" of Phil Hammond.
21 Q. Phil Hammond was the one who wrote the article, but I am
22 asking you about who provided him with the information.
23 A. I have no idea. I was not in Bristol at that time.
24 Q. So you never had any discussion about that subsequently?
25 A. No.
0058
1 Q. You first saw data from Dr Bolsin, what has become known
2 as the "Bolsin audit", when?
3 A. This was September 1993, I think.
4 Q. Can we look at UBHT 61/90. Can we go over the page?
5 Can you tell me if you recognise this document?
6 A. Yes, I do.
7 Q. What is it?
8 A. I think it is just something which was sent to me as an
9 annex by Dr Bolsin to the rest of the data and he was
10 also looking at -- there he says how many patients were
11 looked at, what was the age. It was just an analysis.
12 Data collection and analysis which had been carried out
13 by Dr Bolsin, I believe with the help of Dr Black.
14 Q. Can we go over the page?
15 A. I think it is part of the same document.
16 Q. And again, please, the next one? Let us go over the
17 next page, please.
18 A. Yes. This is also part of the same stuff which related
19 to bypass time, cross-clamp time, effectively how long
20 the children were in the intensive care and on the
21 ventilator and in hospital.
22 Q. Let us go through the next few pages as well, please.
23 95: this is now looking at specific operations.
24 A. Yes.
25 Q. Tetralogy of Fallot under 1 year, over 1 year, and then
0059
1 total?
2 A. The total, and then looking at AV canal and VSD.
3 Q. It is looking at the total number of operations, is it?
4 A. Yes.
5 Q. And again, the next page.
6 A. Yes.
7 Q. And again, AV canal this time.
8 A. Yes.
9 Q. UBHT 61/98, please? VSDs.
10 A. Yes.
11 Q. Let us look at this page. What does the top bit of that
12 page tell you?
13 A. VSD under 1 year. This is presumably referring to the
14 fact that this data was all wrong.
15 Q. You tell me what this data shows, first of all. What
16 does it tell you?
17 A. Not much, because you have to show me the rest of the
18 data as well. What is 1 and what is 2?
19 Q. Did you discover what they meant?
20 A. There was some other information together with this.
21 I cannot remember. One probably was either alive or
22 dead; one was dead and two were alive.
23 Q. Let us look at the next page.
24 A. You cannot show me just a piece of data without the rest
25 of the information.
0060
1 Q. Okay. Let us look at this one: tetralogy of Fallot.
2 Is this easier?
3 A. 4 dead, 8 alive, total 12 cases.
4 Q. Bypass times?
5 A. 161. Extubation time is 7 -- I believe this is days.
6 ITU time is days and hospital time is days.
7 Q. If we go over again, the same type of table with VSD?
8 A. Yes, this is the one that was wrong.
9 Q. Let us look at this. Consultant 1 and consultant 2,
10 17 alive versus 22 alive out of a total of 23 and 22.
11 A. Yes.
12 Q. Let us complete it and look at the next page.
13 A. AV canal, 6 out of 10; 2 out of 12, yes.
14 Q. And there might be one more page. [UBHT 61/102]
15 I think you have seen that already?
16 A. Yes.
17 Q. Is that the data that Dr Bolsin showed you?
18 A. This, together with something else.
19 Q. What else?
20 A. Which is in my file, called number 5, which I had
21 wrongly labelled in my file.
22 Q. Is that UBHT 61/80?
23 A. Are you asking me?
24 Q. Let us look at it.
25 A. Yes, I think it is. Can I see the next page?
0061
1 Q. Let us look at the bottom of this page, first of all.
2 There are references there: Bolsin SNC, Personal
3 communication 1994.
4 A. I have no idea what the "SNC personal communication" is.
5 Q. Let us go over the page.
6 A. Yes, that is it.
7 Q. Dr Bolsin showed you that, did he?
8 A. Yes.
9 Q. When?
10 A. Again, I think it was September -- it cannot be
11 September 1993. I cannot remember. Maybe it was in --
12 no, this was something they did later together with
13 Black, where they were trying to do some statistical
14 analysis. This must have been --
15 Q. This cannot be what you were shown in September 1993,
16 because there would have been no personal communication
17 in 1994?
18 A. That is right. This is the first one I saw.
19 Q. Is it the first one?
20 A. I think so.
21 Q. You do not seem very sure.
22 A. No, I am getting confused. Yes, I think this must have
23 been the middle of 1994.
24 Q. You tell me what your recollection is of what you were
25 shown by Dr Bolsin?
0062
1 A. My recollection is that it was the first set of data he
2 showed me.
3 Q. What did you draw from that data you were shown?
4 A. I drew the main conclusion that -- this was just the
5 final piece of the jigsaw, if you like. I had seen,
6 having been there now for about a year, that things were
7 not as I was accustomed to from my previous experience,
8 and when I was shown this data, I was concerned about
9 some of the mortality. I did not pick up the VSD
10 mistakes at all, but things which were also concerning
11 me, which was going in line with what I could see every
12 day, or it was discussed at occasional audit meetings,
13 was the fact that there were complications like, for
14 example, these children were ventilated for many, many
15 days. As I said, the intubation time was very
16 prolonged. The bypass time, for example, was in the
17 order of two or three hours. The cross-clamp time was
18 on average of the order of two hours.
19 So I had by that time made a general picture which
20 was not entirely based on what I had been provided by
21 Bolsin but all the rest of the information which I had
22 had the opportunity to look at --
23 Q. You said this was the first --
24 A. -- in the previous year, that there was a problem, and
25 the problem was predominantly with the fact that the
0063
1 surgery was carried out with a lot of what I call
2 "morbidity", and as a result of this, there was what
3 I thought was high mortality.
4 Q. You said this was the final piece in the jigsaw?
5 A. Yes.
6 Q. Was this the first time you had seen aggregated data
7 dealing with these particular conditions?
8 A. Yes, it was, because the only aggregated data I saw, the
9 only other time I saw aggregated data was prior to the
10 de Leval visit, where, for the first time, the surgeon
11 had collected data which was aggregated data over
12 a period, I believe, of four years, 1992 to 1995, for
13 all the operations and 1990 to 1995 for the switch
14 operation, and that was the first time that cumulative
15 data over a period of time, not just related to one
16 year, had been presented. Before, I had seen data
17 relating for example to the annual return of the
18 Society, and this was data which was not
19 surgeon-itemised.
20 Q. The data that was sent to the register, which was not
21 surgeon-specific: you would have got Bristol's return to
22 that register each year, would you not?
23 A. Yes. I saw the first one, I think -- obviously I never
24 saw anything prior to my appointment. I took my job at
25 the end of October 1992, so I never saw anything before
0064
1 that. I saw the return for 1993 and 1994 and I guess
2 even for 1995, but this was related to that specific
3 financial year.
4 Q. You saw the return and the return included adult and
5 paediatric surgery alike?
6 A. Yes. But this was cumulative data for the two
7 surgeons.
8 Q. So you were shown data by Dr Bolsin in September 1993.
9 To what extent did you seek to verify that data, form
10 your own opinion about it?
11 A. I had no means to verify that data, and as I said, what
12 I did subsequently to that was not based solely on that
13 data.
14 Q. Did you believe the data to be accurate?
15 A. I did. I thought it was as accurate as it could have
16 been, knowing what the sources of the information were,
17 which I think were the book of the perfusionist, a book
18 which was held by Helen Stratton and some other
19 information from theatre. But there was, if you like,
20 no data provided directly by the surgeon on this
21 collection of data by Dr Bolsin and therefore it could
22 not have been perfectly accurate. As a matter of fact,
23 as it turned out, with the exception of the VSD, the
24 data was very correct.
25 Q. Did the VSD data not strike you as being surprising?
0065
1 A. I am afraid it did not, but as it did not strike me, it
2 did not strike anybody else, because this was picked up
3 only two years later by everybody.
4 Q. I am not sure that is quite right, because Professor
5 Vann Jones came and gave evidence last week. He said
6 that when he was presented with the same or similar data
7 by Dr Bolsin, the VSD figures, as it were, leapt out at
8 him, and even although he was an adult cardiologist, his
9 recollection, his general knowledge as such is that he
10 looked at it and thought it cannot be right?
11 A. He said he never said this to me, and I certainly did
12 not pick up from the data that the VSD was wrong. I can
13 only say I did not.
14 Q. Do you accept, looking at that VSD data now, it would be
15 very surprising if that data were true?
16 A. Yes, but it would also be very surprising to see the
17 rest of the data where you had a mortality on average
18 twice as high, so really, it was not all that
19 impossible.
20 Q. Let us just look at the VSD data for a moment. If, on
21 looking at it carefully, it would be surprising if that
22 data were accurate --
23 A. It would be, yes.
24 Q. -- if you had looked at the data carefully and had come
25 to that conclusion, which was a conclusion Professor
0066
1 Vann Jones came to, namely that it would be surprising
2 if the VSD data were true, would that not cast a shadow
3 over the rest of the documentation?
4 A. Absolutely. The fact of the matter is, I do not have
5 any evidence than Professor Jones pointed out to me, or
6 anybody else, for the same sake. With hindsight, it is
7 very easy to say the VSD is wrong. The fact of the
8 matter is that it took a considerable time before it
9 became an acknowledged fact that this piece of
10 information was wrong.
11 Q. Let us look at WIT 73/87. This is Professor Vann Jones'
12 comment on your statement. He is commenting in
13 paragraph 16 of your statement, which we do not need to
14 go to at the moment. Paragraph 2, the second line:
15 "It was because my initial view of the figures
16 produced by Dr Bolsin suggested that some of them were
17 flawed that I wanted them to be substantiated. Although
18 Professor Angelini is also primarily concerned with
19 adult cardiac services [as is Professor Vann Jones, of
20 course] I am surprised that his initial examination of
21 the figures did not lead to a similar conclusion."
22 Do you accept that implied criticism?
23 A. I accept it. It is a criticism, but I can tell you
24 this: if, for example, we look at the AV canal, the data
25 was two or three times more than what was accepted
0067
1 nationally or internationally. The same thing could
2 well have applied to the VSD. We know that the VSD was
3 wrong, but the AV canal, the Fallot, was correct.
4 Q. So it transpired. But when you got this data, you did
5 not look at it very carefully at all, did you?
6 A. This data, for me, was just part of a general picture
7 which I had built, and in fact --
8 Q. So you did not look at it very carefully?
9 A. I did look at it carefully.
10 Q. If you looked at it carefully you would have seen that
11 the VSD was wrong.
12 A. Let us take two things: the VSD and the AV canal. In
13 AV canal, the mortality reported is three times what
14 I am accustomed to. The VSD, the mortality reported is
15 also three times what I am accustomed to. If one, you
16 say, is wrong, in theory the other one should have been
17 wrong as well. I had no means to verify this data
18 because I had no access to any of the data.
19 If there was a concern --
20 Q. Let us pause there for a minute. When Professor Vann
21 Jones saw this data, he was surprised by it.
22 A. Why did he not tell me?
23 Q. He took the view that he wanted persuading that
24 certainly the VSD data was accurate and wanted it to be
25 substantiated, so he says --
0068
1 A. So he says.
2 Q. -- in this statement.
3 A. It is his words against mine. In a way, all I am saying
4 is, if he was so concerned that this data was not
5 accurate, why he never raised this with me.
6 Q. If you accept the implied criticism of Professor Vann
7 Jones that you, had you looked at this VSD data
8 carefully, would have come to the same conclusion that
9 he came to, that it was very surprising and he would
10 need persuading that they were true, you could not have
11 looked at them carefully?
12 A. Can I ask you something again, actually? So if he was
13 so concerned about the VSD because he was so far out
14 from what he regarded as accepted mortality, why did he
15 not express the same concern about Fallot and AV canal
16 because they were also so far out on what he was
17 accepting on mortality?
18 Q. I am asking you.
19 A. All I can say is I looked at the data. If and you want
20 me to say I looked at it superficially with regard to
21 the VSD, I did. I do not have any problem admitting
22 that.
23 Q. I do not want you to say anything. Let me make that
24 quite clear. I want you to tell me the answers to the
25 questions. I want you to tell me how carefully you
0069
1 looked at this data.
2 A. Very carefully. As carefully as I could and I missed
3 the point.
4 Q. Was it not the case that this data was grist to your
5 mill and that you already had a preconceived notion that
6 the surgery at Bristol was not up to scratch and so you
7 took on board without question the material that
8 Dr Bolsin showed to you, which turned out to be, as far
9 as VSDs were concerned, materially flawed?
10 A. No, I did not have any preconceived idea, and I did not
11 perceive the offer of Mr Bolsin as a means for me to
12 achieve any mileage. When I saw this data I was very
13 upset and I think anybody who has any insight and sees
14 data like this should be not just concerned but very,
15 very concerned.
16 Q. Who did you understand this data had been shown to by
17 Dr Bolsin?
18 A. I believe it had been shown to Professor Vann Jones,
19 Professor Farndon, because I had a conversation with
20 Professor Farndon, Professor Prys Roberts and
21 Dr Roylance.
22 Q. Who was Professor Prys Roberts, just remind us?
23 A. The Professor of Anaesthesia.
24 Q. So that is the Professor of Surgery?
25 A. The Professor of Anaesthesia, the Professor of Cardiac
0070
1 Services, Professor Vann Jones.
2 Q. You as Professor of Cardiac Surgery?
3 A. Myself. I believe it also was shown to the Dean of the
4 Medical School, Professor Dieppe, I believe.
5 Q. And you mentioned Dr Roylance?
6 A. And Dr Roylance.
7 Q. Who did you understand had shown the data to
8 Dr Roylance?
9 A. From Dr Bolsin and conversation with Professor Vann
10 Jones, who told me that the relevant people had been
11 informed and had the data.
12 Q. Did Professor Vann Jones tell you in terms that
13 Dr Roylance had the data?
14 A. When he said the "relevant people", if the Chief
15 Executive is not a relevant person, I do not know who
16 else should be.
17 Q. You assumed that must include --
18 A. Yes, I assumed that. I do not know whether he meant
19 that.
20 Q. Did Dr Bolsin tell you in terms that he, Bolsin, had
21 shown the data to Dr Roylance?
22 A. No, he did not.
23 Q. So again, that was an assumption on your part; is that
24 right?
25 A. Yes, that is correct.
0071
1 Q. So let us be clear: who did Dr Bolsin say, in terms, he
2 had shown the data to?
3 A. To me, he said he had shown the data to Prys Roberts,
4 Professor Farndon and Professor Vann Jones. And that is
5 all. I was not even aware, until a later stage, that he
6 had shown the data to Professor Dieppe, the Dean of the
7 Medical School.
8 Q. So at that stage you were one of four people --
9 A. Yes, correct.
10 Q. -- who Dr Bolsin told, as it were from his own mouth;
11 you were one of four?
12 A. Yes.
13 Q. Prys Roberts, Farndon, yourself and Vann Jones?
14 A. That is correct.
15 Q. Did you understand this data to have been shown to
16 Mr Wisheart or Mr Dhasmana?
17 A. No. I do not think Dr Bolsin showed it to them.
18 Q. So you understood that it had not been shown; is that
19 right?
20 A. Yes.
21 Q. Did Dr Bolsin indicate to you whether he was or was not
22 going to show it to Mr Wisheart or Mr Dhasmana?
23 A. No, he did not.
24 Q. Did he indicate that he was going to not show it to
25 them?
0072
1 A. No, he did not either.
2 Q. Was it made clear to you that you ought not to show it
3 to them?
4 A. No.
5 Q. Did you in fact, yourself, take it to Mr Wisheart or
6 Mr Dhasmana?
7 A. No, I did not, although I had this data available,
8 together with Professor Farndon, on 23rd December when
9 a meeting took place in my office between myself,
10 Professor Farndon and Mr Wisheart.
11 Q. We will come to that in just a moment. Did you compare
12 the data that Dr Bolsin had given you with the returns
13 to the cardiothoracic register?
14 A. No. I cannot remember if I did. Probably I did not.
15 Q. Could you have done so?
16 A. Yes, I could, but I did something even better than that.
17 Q. Which was what?
18 A. I went to see Mr Stark at Great Ormond Street because
19 I was aware of the fact that Mr Stark had information on
20 what the performance of various units in the country
21 were, and this was for two reasons: (1) because somehow
22 he had been part of some government panel; (2) because
23 he had recently given a speech at the European
24 Association of Cardiothoracic Surgeons. He was the
25 honorary guest of the President, where he had presented
0073
1 data, albeit anonymous, on cardiac surgery in the United
2 Kingdom and he had specifically pointed out how centres
3 which were not doing enough cases had worse performance
4 and so forth. So he really was the person, in my view,
5 who knew everything of what was going on in the UK in
6 paediatric cardiac surgery.
7 Q. So you went to see Mr Stark at Great Ormond Street?
8 A. Yes.
9 Q. I think you said at the GMC that that was in November
10 1993?
11 A. Yes, that is correct, 17th November, something like
12 that.
13 Q. Did you actually physically show him the data Dr Bolsin
14 had shown you?
15 A. No, I did not.
16 Q. Why not?
17 A. First of all because I did not think it was fair to take
18 stuff which in a way had been given to me in a sort of
19 confidential matter, and also because I knew that
20 Mr Stark was fully informed of what was going on. He
21 had pictures of information of all the United Kingdom
22 data.
23 Q. You said that this data had been given to you in
24 a confidential matter?
25 A. Yes. I mean, "confidential"; "do not take it out of
0074
1 your own institution and show it to everybody" at that
2 stage would have been the appropriate thing to do.
3 Incidentally, even at a later stage I was accused of
4 having done this.
5 Q. How did you know how confidential the data was that
6 Dr Bolsin gave you?
7 A. I mean, I guess it was relatively confidential because
8 if it had been given to 5 or 6 people, I do not know,
9 how can you describe "confidential"? But I thought that
10 it was really not appropriate at that stage to take it
11 out of what was our institution. I had gone to see
12 Mr Stark to ask advice from a senior paediatric cardiac
13 surgeon who was well informed of what was going on
14 nationally on how I should act, if anything, in trying
15 to resolve this problem.
16 Q. Did you discuss with Dr Bolsin how secret this data was?
17 A. No.
18 Q. Did you tell Dr Bolsin you were going to see Mr Stark?
19 A. I do not think I did until I came back. When I came
20 back, I told Dr Bolsin and I told Professor Farndon, and
21 my senior lecturer, Mr Bryan.
22 Q. What did Mr Stark say?
23 A. The conversation took place in his office and
24 effectively I said to him that I have come to him for
25 some advice as a senior person, since he was a very
0075
1 senior person in the business. I said that there had
2 been data suggesting that the mortality was high. Also,
3 my perception, after having spent a year in Bristol by
4 that time, was that mortality and morbidity was a much
5 different story to what I was accustomed to. He said
6 that he was aware of those problems. Indeed, he showed
7 me some of the slides which he had presented at the
8 European meeting, saying "You are not telling me
9 anything new because I have done an analysis" and
10 demonstrated that centres which do not do a great volume
11 of work, like Bristol, will have worse results than
12 specialised centres which do a lot more operations.
13 We discussed these aspects, after which I said to
14 him, "What would you advise? You are a senior man, what
15 would you advise me to do?" He said he thought the best
16 way would have been for me to go back to Bristol, to my
17 head of department --
18 Q. Who was?
19 A. -- the Professor of Surgery, Professor Farndon, and in
20 a way present him with the problem, telling him I had
21 discussed things with Mr Stark, and he said, "I am sure
22 you can resolve this matter in-house. Failing that, you
23 may have to ask for some external help".
24 There were some other issues discussed --
25 Q. Just pause there a minute. What did you understand by
0076
1 "external help"?
2 A. I mean somebody senior like Mr Stark coming in and
3 having a look at what we were doing.
4 Q. Did he mention anything about sending patients from
5 Bristol to Great Ormond Street in the meantime?
6 A. No. What he said I think it was that if we have
7 a problem with a patient that needed urgent treatment,
8 certainly this could have been done at the GOS.
9 Q. Did he mention the ability of clinicians in Bristol to
10 go with those patients to GOS?
11 A. I think he said that, also because in the case of
12 Mr Dhasmana, he had already worked for a year at the
13 GOS.
14 Q. Can we have a look at WIT 73/111, please.
15 This is an e-mail that was sent yesterday
16 afternoon which reached me in the course of the
17 morning. It is from Mr Stark. I want to look at the
18 third paragraph, please, Professor:
19 "I do recall [Mr Stark says] that I have suggested
20 that my colleagues and myself would be happy to operate
21 children with the diagnosis with which the Bristol team
22 was experiencing problems. I have mentioned, if they
23 decided to send some patients to us, the surgeons or any
24 other members of the team would be most welcome to come
25 with the patient to see the way we handle such problems
0077
1 at the GOS."
2 A. Yes. What he did not mention -- I am sorry, what we did
3 not discuss -- I have not seen this yet, I am seeing it
4 now. What we did not discuss, which was highlighted at
5 the GMC trial, was the fact that he never offered to
6 retrain people and I stand to what I said: there was
7 never any offer from him to retrain people. What he
8 said is correct --
9 Q. Have a look at the previous paragraph, Professor, that
10 may help.
11 A. "It is correct that I did not offer formal retraining",
12 yes, that is right, I am glad he said that.
13 Q. So are you and Mr Stark on the same wavelength?
14 A. I think so, yes. I do not have any problem with this.
15 Q. The suggestion that patients and clinicians might go to
16 Great Ormond Street, that Mr Stark made to you, to whom
17 did you communicate that offer in Bristol?
18 A. To Professor Farndon, but if you read this through, this
19 does not mean the surgeons go there and they do the
20 operation. The surgeon and their staff go there and see
21 what the people in the GOS do, which to a certain extent
22 is the same that happened when Mr Dhasmana and some
23 other member of the surgical team went to Birmingham.
24 Q. All right, take it slowly. To whom did you communicate
25 this suggestion?
0078
1 A. I think to Professor Farndon, but quite honestly, I do
2 not know if I did.
3 Q. You did not do it in writing, did you?
4 A. No.
5 Q. You did not communicate it to Mr Wisheart?
6 A. No.
7 Q. Mr Dhasmana?
8 A. No.
9 Q. Dr Roylance?
10 A. No. I did not see any point in sending patients to the
11 GOS with everybody going in and observing. Quite
12 honestly, I do not think that would have helped Bristol
13 in any way whatsoever.
14 Q. But is it not the case that going to observe a centre
15 that is a recognised centre of excellence can assist
16 a surgeon to --
17 A. Yes, that is correct.
18 Q. -- to retrain. For example Mr de Leval and the "Cluster
19 of failures" and the arterial switch operation?
20 A. Yes, but also what we say in surgery is "Watch, do it
21 and teach it". Watching on its own is not a solution to
22 the problem. You can take your Registrar and ask him to
23 help you on a million cases. The first time he does it,
24 there will not be much difference if he helps you on
25 a million cases or 100,000 cases. Therefore, what I am
0079
1 reading in this letter is that although they were
2 prepared to take this patient in the interests of the
3 children, they were not going to do anything to really
4 retrain the people because they could not retrain the
5 people.
6 Q. So you had no faith in the ability of Great Ormond
7 Street or anyone else to retrain the Bristol surgeons?
8 A. No, I did not say that. To retrain people, you have to
9 take these people, not just to watch. Training means
10 you are standing on the side of the assistants and the
11 trainee does the operation. That to me is training.
12 Otherwise just watching by itself is not what I regard
13 as training. That is part of the training, but it
14 cannot be the whole training, if you are not allowed to
15 do things at the first operating surgeon.
16 Q. You took it upon yourself to sweep Mr Stark's offer
17 under the carpet?
18 A. I do not know what you mean.
19 Q. You did not tell anybody about it?
20 A. Fine. I made a mistake.
21 Q. You accept that was a mistake?
22 A. Absolutely.
23 Q. Because did you consider Great Ormond Street to be
24 a better centre than Bristol for paediatric cardiac
25 surgery?
0080
1 A. Yes, absolutely, but I also considered that Birmingham
2 was a much better centre, particularly for the switch,
3 than the GOS.
4 Q. Later on we will see that you were suggesting, at the
5 time of the Loveday operation, that if it was truly
6 urgent, the case might be sent to Mr Brawn in
7 Birmingham, for example?
8 A. That is correct.
9 Q. Is that right?
10 A. Yes.
11 Q. Might there not have been patients between your visit to
12 Mr Stark in November 1993 and Joshua Loveday's operation
13 in January 1995, who, in your opinion, would have
14 benefited from being operated on elsewhere?
15 A. Absolutely.
16 Q. And Mr Stark's offer would have provided for that?
17 A. Yes.
18 Q. Would it not?
19 A. Yes. Why did not I refer the offer? Very simple:
20 because my main concern was to stop the surgery from
21 taking place in Bristol, because in Bristol we were no
22 good at this kind of surgery; therefore it should not
23 have been carried out. I do not think that I was in any
24 position to influence anybody's decision for these
25 children to be sent to another institution because in
0081
1 fact, as demonstrated, even in the last switch case,
2 nobody gave a toss about what I was saying. Therefore,
3 they were not listening.
4 I accept with you that I should have related this
5 particular information that Mr Stark had given to me to
6 the surgeon and to the cardiologists, and it was
7 a mistake on my part not having done so.
8 Q. This is not a case of not listening, this is a case of
9 not hearing because you were not telling them?
10 A. In this case, that is correct.
11 Q. Who else did you speak to when you came back from the
12 meeting with Mr Stark? What was the next event, as far
13 as you were concerned?
14 A. The next event was speaking with Professor Farndon.
15 Q. Is that the meeting with Mr Wisheart?
16 A. No, before.
17 Q. What did you say to him?
18 A. We had several meetings with Professor Farndon in his
19 office, several, 4 or 5, I do not know how many, where
20 we discussed the whole situation of the paediatric. He
21 was aware that there had been problems even prior to my
22 arrival, it was nothing new to him, and we decided to
23 have a meeting with Mr Wisheart, who after all was the
24 most senior person, not only as a surgeon, also as
25 Chairman of the Hospital Medical Committee, and the
0082
1 purpose of this was to discuss with him a way out, if
2 you like.
3 In our view, I believe both of us, Farndon as well
4 as myself, the way out was first and most of all the
5 appointment of a new paediatric cardiac surgeon who was
6 experienced with modern cardiac surgery.
7 Q. The same sort of suggestion that was made in the May
8 1994 Working Party report that we saw before the break?
9 A. Yes.
10 Q. So you, like Mr Wisheart and many other people in the
11 Cardiac Services Unit, thought it would be important to
12 appoint a Professor of Paediatric Cardiac Surgery?
13 A. Absolutely. This was my main objective to a certain
14 extent, to facilitate the appointment of a paediatric
15 cardiac surgeon, a competent modern cardiac surgeon.
16 Q. That was going to take some time, was it not?
17 A. It depends how quickly the Trust was prepared to act.
18 The fact of the matter is that although there were all
19 these wonderful recommendations and plans, my perception
20 was that the Trust was not acting very quickly.
21 As a demonstration of this -- forgive me if I am
22 taking you a few steps ahead -- was the fact that the
23 Chairman of the Trust came to me asking me if I could
24 make some suggestions, and in a letter which was signed
25 by myself and Professor Vann Jones, we made a suggestion
0083
1 that a new paediatric surgeon should be appointed.
2 At that stage, we both -- at least from the
3 content of that letter you can read, certainly my
4 impression was that the Trust was not prepared, as yet,
5 to appoint a paediatric surgeon because they did not
6 have the money. And equally, they were not prepared to
7 move the service to the Children's Hospital at that
8 stage because it was going to be too expensive.
9 Q. That was the management of the hospital?
10 A. Yes.
11 Q. As opposed to the clinicians in cardiac surgery?
12 A. The clinicians were all happy. People had been talking
13 about moving for a long time.
14 Q. The clinicians had wanted to appoint Mr Elliott, who was
15 a paediatric cardiac surgeon?
16 A. I do not know if they wanted to appoint Mr Elliott,
17 because I was not there at the time.
18 Q. You have seen from the correspondence it was more than
19 footsie they were playing with Mr Elliott?
20 A. Yes, but that was not something that was related to
21 my -- I was not part of that decision; I was not part of
22 that process.
23 Q. You had a meeting with Professor Farndon in your office
24 with Mr Wisheart on 23rd December 1993; is that right?
25 A. That is correct.
0084
1 Q. Was the data that you had seen from Dr Bolsin actually
2 presented and discussed at that meeting?
3 A. The data was sitting on the table between myself and
4 Professor Farndon who were on one side facing
5 Mr Wisheart. We did not go through in detail with the
6 data because my and Professor Farndon's impression --
7 incidentally, I hardly ever spoke at that meeting.
8 Q. I am sorry?
9 A. I hardly ever spoke at that meeting, because Professor
10 Farndon did most of the talking. I do not think there
11 was any question that we were discussing the fact we
12 were aware of the data of Dr Bolsin, we had looked at
13 the data of Dr Bolsin, and we wanted to find a way
14 forward on this and again, the way forward which was put
15 forward by Professor Farndon, which in a way had been
16 discussed with me before, was the appointment of a new
17 paediatric cardiac surgeon.
18 Q. So the focus of the meeting was about the desirability
19 of a new appointment of a consultant paediatric cardiac
20 surgeon?
21 A. Yes.
22 Q. And were you suggesting that that should be done by way
23 of a consultant senior lecturer within the University
24 department?
25 A. Not at that stage. What was suggested at that stage was
0085
1 to look at various options from which the money could be
2 raised, because the main issues seemed to have been all
3 the time: there is no money to fund this post.
4 So we were exploring various possibilities, and
5 among these various possibilities there was the one of
6 a University appointment, because we thought we would
7 raise some money either with the British Heart
8 Foundation or with some other charitable body, but only
9 for a short period.
10 Q. So that was one of the options?
11 A. Yes.
12 Q. In your statement to the GMC, GMC 14/3, please, the
13 bottom half of the page is all to do with the meeting.
14 The paragraph is going on 23rd December, do you see
15 that?
16 A. Yes.
17 Q. From there on, you are talking about this meeting?
18 A. Yes.
19 Q. You say, four lines from the bottom:
20 "The meeting was conducted most diplomatically and
21 was not confrontational."
22 A. Absolutely.
23 Q. What do you mean by that?
24 A. Professor Farndon is a much more diplomatic individual
25 than I am, and he can go around, putting it in the
0086
1 vernacular, he can beat around the bush, which I cannot,
2 so effectively he was trying to put to Mr Wisheart --
3 I mean, this was an extremely difficult meeting, because
4 we were confronting the senior paediatric surgeon, who
5 was the Chairman of the Hospital Medical Committee, and
6 effectively we were trying to tell him that his results
7 were not very good, so it was a difficult meeting where,
8 I must say, Professor Farndon handled it very well. He
9 was trying to get the message that things were not quite
10 right, but he was not in a confrontational matter.
11 Q. If Mr Wisheart had seen the "Bolsin data", if I can call
12 it that, which included the VSD data which Professor
13 Vann Jones found surprising, he would have been expected
14 to have taken issue with that, would he not?
15 A. Yes.
16 Q. And there would have been a confrontation, would there
17 not?
18 A. Everybody says the surgeons never saw the data, but what
19 I can reply to that is, if there were all these rumours,
20 all this data circulating, why did the surgeons not
21 produce their data? When I say their data, I mean their
22 comprehensive data over a period of four or five years?
23 The only time this was produced was in 1995.
24 So the thing is two ways. You cannot say "We did
25 not see the data therefore somebody was trying to hide
0087
1 things from us". We never saw the comprehensive data
2 itemised per surgeon or over a period of three or four
3 years as presented by the surgeons.
4 Q. This statement to the GMC does not suggest that
5 Dr Bolsin's data was physically present at the meeting
6 with Professor Farndon and yourself and Mr Wisheart.
7 A. I do not know what else we could have been discussing if
8 not the data in the results. If you are trying to tell
9 somebody that his results are not very good, you cannot
10 just make a hypothetical consideration: you have to
11 discuss some of the facts, which is what Professor
12 Farndon did, although he did not go specifically into
13 things like, "Mr Wisheart, your AV canal data is
14 such-and-such". It was more of a sort of generic
15 conversation where he was trying to approach for the
16 first time with Mr Wisheart the concept that the results
17 were no good.
18 Q. Was the data in the meeting --
19 A. Yes, it was there.
20 Q. This statement does not say that.
21 A. Fine. I did not say that. I apologise for not having
22 said that.
23 Q. But surely if the data had been present, Mr Wisheart
24 would have wanted to have discussed it?
25 A. Fine. He did not.
0088
1 Q. Wouldn't he?
2 A. He did not.
3 Q. Or take a copy of the data so that he could consider
4 it.
5 A. Mr Wisheart, regardless of whether we discussed the data
6 at that time, it is my understanding, by talking with
7 Professor Farndon, Vann Jones and other people, that
8 Mr Wisheart had seen the data. Admittedly, I understand
9 he was never provided with the data by Dr Bolsin.
10 Q. Would you accept the characterisation of Mr Wisheart as
11 a careful man?
12 A. Absolutely.
13 Q. The sort of man who, if he saw on a table at a meeting
14 he was at, some data which was critical of his surgery,
15 would at the very least want to take a copy away so he
16 could study it and respond to it?
17 A. No. If Mr Wisheart was so careful, as he seemed to be,
18 why did he not have, at his fingertips, the results of
19 his surgical operations?
20 Q. Because he thought that he was going to a meeting to
21 discuss the appointment of a paediatric cardiac surgeon,
22 a suggestion he was in favour of and had supported for
23 several years.
24 A. Not at all. The meeting was to highlight the fact that
25 there was concern from myself and Professor Farndon that
0089
1 the results were substandard. The appointment of
2 a paediatric surgeon was a way to resolve this problem.
3 The meeting was not called to appoint or to discuss the
4 appointment of a paediatric cardiac surgeon. As
5 a matter of fact, the meeting ended with no decision
6 whatsoever on the appointment of any paediatric cardiac
7 surgeon. There was no decision taken whatsoever. As
8 I said -- I do not know if I said this to the GMC --
9 when we left, I felt like we had been lectured by the
10 headmaster, and Professor Farndon and I, we looked at
11 each other and we said "We have been lectured by the
12 headmaster".
13 Q. I think your reference to being lectured by the
14 headmaster was in a different context in relation to
15 a different person?
16 A. No, it was in that context.
17 Q. We may have to come back to that.
18 THE CHAIRMAN: Professor Angelini, I cannot find it in the
19 transcript, I think it is at 85 -- well, it is somewhere
20 earlier on, you said that the basis of the meeting --
21 these are my notes -- was to consider the appointment of
22 a paediatric cardiac surgeon. But in talking to
23 Mr Maclean a moment ago, you said that that was not
24 really the basis of the meeting. Which is --
25 A. One is a consequence of the other. The purpose of the
0090
1 meeting was first of all to express our concern; second,
2 the appointment of the paediatric surgeon was the
3 resolution to the concern. It was not the other way
4 around.
5 THE CHAIRMAN: Thank you.
6 MR MACLEAN: How long did the meeting last?
7 A. A good three-quarters of an hour, perhaps even an hour.
8 Q. It was held over lunchtime, was it?
9 A. I think so. It was in my office. I cannot remember if
10 it was lunchtime or afternoon. I cannot remember that.
11 Q. Can we have a look at WIT 73/104, please? This is
12 Mr Wisheart's comment on your statement which I think
13 you have had a chance to look at over the previous
14 break?
15 A. I did not, but I will look at it now.
16 Q. "I contacted Professor Farndon and a meeting took place
17 with Mr Wisheart."
18 That is a quote from your statement.
19 A. Yes.
20 Q. His comment:
21 "The meeting took place on 23rd December 1993 for
22 a short time at lunchtime. The point of the meeting, as
23 I recall it, was that Professor Angelini wished to
24 create an appointment of a consultant paediatric cardiac
25 surgeon and to do so as a consultant senior lecturer
0091
1 within his department. Although I, too, wished to
2 appoint a new paediatric cardiac surgeon, and we did so
3 during the next year, I did not feel this was the best
4 way to go about it. There was no reference to any
5 specific figure or to Dr Bolsin's audit. There was no
6 presentation of any figures."
7 Professor Farndon told the GMC -- Day 15, between
8 pages 73 and 74, and later the same day -- that the
9 meeting which he held with you and Mr Wisheart was to
10 discuss the appointment of a cardiac surgeon; and that
11 was the purpose of the meeting?
12 A. I stand by what I said.
13 Q. And that no data was produced at that meeting.
14 A. It is correct that we did not go through any data, and
15 there was no discussion on specific data like VSD,
16 AV canal or whatever. The meeting was not a short
17 meeting and it lasted at least three-quarters of an
18 hour. The first part of the meeting was Professor
19 Farndon in a very diplomatic way trying to get across
20 the message to Mr Wisheart that the results were not up
21 to scratch.
22 The second part of the meeting was to discuss
23 various options for the appointment of a consultant
24 paediatric cardiac surgeon, one of which was
25 a consultant senior lecturer for a very sport period,
0092
1 followed by an appointment from the NHS.
2 In fact, there was even a third suggestion, which
3 this time came from Mr Wisheart, which was to take
4 a young senior registrar and send him to be trained
5 somewhere else, possibly outside the United Kingdom.
6 This was one of the suggestions which incidentally was
7 made by Mr Wisheart.
8 Q. What was the purpose of having the data on the table at
9 the meeting?
10 A. It just was there.
11 Q. Like a magazine would be there, lying on the table?
12 A. The way meetings can be conducted can be in different
13 manners. As I said, from the word go I did not say much
14 because I felt I was too junior in a way to tackle
15 a sensitive issue like that. Most of the talking was
16 done by Professor Farndon, and it was not a direct talk,
17 like "Here we have some data which says your mortality
18 on AV canal is high, how do you answer this?" It was
19 nothing remotely like this. It was simply, "James, we
20 are concerned that the results of this unit are not up
21 to scratch". So effectively, it was just a more polite
22 manner to put forward our concern.
23 My impression was that the data was sitting there;
24 we never went through page by page with the data. My
25 impression was that Mr Wisheart was fully aware of the
0093
1 work done by Dr Bolsin.
2 Q. Is not the position that, whether the data was in the
3 room or not, Mr Wisheart was certainly never told that
4 the data was in the room, and was never invited to look
5 at the data?
6 A. Mr Wisheart was never told any specific reference to
7 specific data of Dr Bolsin, like: "Your results are no
8 good in the VSD or the AV canal". This was never said.
9 Q. But he was not told that there was data present at the
10 meeting which referred in part to his performance
11 because if he had been, he would have asked to see it?
12 A. No, he was, and he was told, even to him, that Dr Bolsin
13 had done this audit. Everybody knew this. By December
14 1993, the whole hospital knew of what Dr Bolsin had
15 done.
16 If we are trying to say that since the whole
17 hospital knew and Mr Wisheart did not, it may be the
18 case, but I find it very hard to believe that.
19 Q. What became of this meeting? What was the result of
20 this meeting?
21 A. Absolutely nothing. The result was that we left -- my
22 perception was, we were standing on two different
23 positions in a way that, as many other times in the past
24 and in the future, the interpretation of the data and
25 the interpretation of what was going on in the unit was
0094
1 completely different.
2 On one side there was Mr Wisheart and some other
3 people who were arguing that the mortality and the
4 morbidity of the unit was in line with modern cardiac
5 surgery. On the other side there were people, including
6 me, who were saying that the performance of the unit was
7 not even remotely in line with what was the accepted
8 performance of modern paediatric cardiac surgery.
9 Q. You were asked at the GMC -- the reference is 317 -- how
10 your concerns were received by Mr Wisheart at that
11 meeting. You said:
12 "Generally my feeling was that he did not agree
13 with the data".
14 A. Yes.
15 Q. "He also did not agree with the fact that it was a major
16 problem ..."
17 A. This was the main thing.
18 Q. Do I understand your evidence to be that in fact there
19 was no discussion at the meeting of any specific data?
20 A. No, there was not. There was no specific like, "This is
21 the AV canal, there are so many dead, so many alive".
22 That was not discussed.
23 Q. You were shown some further data later by Dr Bolsin.
24 Perhaps I could just deal with this point and then it
25 may be time for another break. I am not sure.
0095
1 THE CHAIRMAN: Would it help if I responded to that
2 straightaway, Mr Maclean, by saying why do not we see if
3 we can go to 1 o'clock, and then take a break?
4 MR MACLEAN: Professor Angelini, you were shown some data
5 later by Dr Bolsin, some of it relating to the switch
6 operation, and then some further data relating to the
7 AV canal?
8 A. That is correct.
9 Q. Did you ever show either of those series of data to
10 Mr Wisheart?
11 A. No, I did not.
12 Q. Why should you want to place before him in the meeting
13 with Professor Farndon the first sets of data, but not
14 the second or the third?
15 A. Because that was the first time we were tackling the
16 problem with Mr Wisheart. We had several other
17 discussions at audit meetings on mortality and morbidity
18 and we were, I am afraid, talking two completely
19 different languages.
20 As a result of this, I thought that I was getting
21 nowhere by talking to Mr Wisheart, or indeed to
22 Mr Dhasmana, and as a result of this, as you know,
23 I went to see the Chief Executive of the hospital, so
24 I went to the next chain of command.
25 Q. Let us turn to Dr Roylance, then. How well did you know
0096
1 Dr Roylance at the end of 1993?
2 A. Hardly at all.
3 Q. Had you had any professional dealings with him?
4 A. No, I met him on the same day as my interview for
5 literally 10 minutes and we merely exchanged
6 courtesies. I never had anything professionally to do
7 with him in terms of clinical work. I saw him entirely
8 in the context of my concern of the paediatric surgery,
9 at least at the beginning. Later on there were other
10 issues, but ...
11 Q. How many meetings did you have with Dr Roylance?
12 A. I cannot recollect, but I guess at least two from the
13 end of 1993 to March 1994 -- at least two.
14 Q. Who was present at those?
15 A. At the first one there was nobody except myself and
16 Dr Roylance. At the second one there was Dr Monk and
17 after that, there were several other meetings, but with
18 many other people present, like all the cardiac
19 surgeons; or another one, we had a meeting towards the
20 August of 1994 with Mr McKinley in his office, Professor
21 Farndon and myself, and Mr McKinley called Dr Roylance
22 in. So there were several meetings, but always with
23 lots of other people involved.
24 Q. Let us look at the period in the early months of 1994,
25 shall we, before the letter that you and Professor
0097
1 Farndon wrote to Mr Durie. Can we confine ourselves to
2 the meeting between --
3 A. I think there were definitely two meetings, one on my
4 own and one in the presence of Dr Monk.
5 Q. I think you told the GMC that you had at least two
6 meetings on your own?
7 A. I cannot remember. It may have been one or two. I do
8 not have any evidence to support one or the other.
9 Q. There is no written material evidencing what was
10 discussed at any of these meetings; is that right?
11 A. Correct.
12 Q. No contemporaneous correspondence either from you or
13 Dr Roylance?
14 A. No, I only learned later on to write a letter. In fact
15 the first letter I wrote on this matter was when Peter
16 Durie asked me. Then I became very acute of the need to
17 write a letter and I wished I had written twice as many.
18 Q. We will come to that letter.
19 A. I was very naive.
20 Q. Dr Monk was the Clinical Director of Anaesthesia?
21 A. That is correct.
22 Q. Whose idea was it for Dr Monk to be present at the
23 meeting with Dr Roylance?
24 A. Mine.
25 Q. Why take Dr Monk with you?
0098
1 A. Dr Monk and I had discussed this problem at length,
2 particularly in November 1993. We had gone to operate
3 in Trinidad, at the University of West India where we
4 helped them to set up a cardiac unit, and we had
5 literally a week together, shoulder to shoulder,
6 including a couple of 10-hour flights, where we
7 discussed the question of paediatric surgery really to
8 exhaustion. I told him what I had done, what I was
9 planning to do and later on, when I had the impression
10 that I was not really being listened to by people, like
11 for example Dr Roylance, because I was always considered
12 like a junior professor, troublemaker, and stuff like
13 that --
14 Q. Just pause there a minute. You had not had any
15 professional dealings to speak of with Dr Roylance
16 before the end of 1993?
17 A. No, but I had at least one meeting at the beginning of
18 1994 in Dr Roylance's office, which preceded the one
19 with Dr Monk.
20 Q. All right. Tell me about that meeting.
21 A. The reason why I took Dr Monk with me was to give
22 some -- how can I say -- "officiality" I do not think is
23 the right word.
24 Q. "Weight and formality" is what you said at the GMC
25 hearing.
0099
1 A. That is correct, yes. Also because Dr Monk was the
2 Clinical Director of the anaesthetic service; therefore,
3 he was quite a senior figure in all of this. He was
4 sharing my concern.
5 Q. He had seen the Bolsin data, had he?
6 A. Yes.
7 Q. Either at the meeting with yourself and Dr Roylance, or
8 at the meeting attended by Dr Monk as well, did you show
9 Dr Roylance the Bolsin data?
10 A. No, I do not think I did. Certainly we never discussed
11 anything in detail again, like "This is the VSD". I am
12 pretty sure that both of us, we did have the data with
13 us, Monk as myself, when we had the meeting with
14 Roylance, but we never went through any specific data.
15 The reason being that the attitude of Dr Roylance was,
16 "This is a matter for the clinician", effectively he
17 was saying, "I do not want to know anything about this".
18 Q. Did you offer the data to Dr Roylance?
19 A. No, I did not, because I thought he had it. This data
20 had been circulating for the last seven months. He was
21 at least in the hands of the Professor of Surgery, the
22 Professor of Anaesthetics, the Director of Cardiac
23 Services and the Dean of the Medical School. If they
24 had not given it by that time to the Chief Executive,
25 then we had a big problem.
0100
1 Q. You could have checked?
2 A. I did not check it.
3 Q. You could have said, "Here you are, Dr Roylance, I am
4 sure you have got six copies of this already, here is
5 a seventh"?
6 A. I did not check it and I apologise not to have done
7 that. Having said that, he did not give us much
8 opportunity to discuss anything anyway because his main
9 line of reply was, "These are matters for the
10 clinicians", so effectively, the conversation was almost
11 over in 10 minutes; nothing whatsoever was discussed.
12 Q. What view of matters did Dr Monk take?
13 A. I am sorry?
14 Q. What attitude did Dr Monk have to all of this?
15 A. I think Dr Monk was genuinely concerned about this.
16 Although he was the Director of Cardiac Anaesthesia, he
17 was a very young consultant, and therefore he had, how
18 can I put it, perhaps fear is not the right word, but he
19 had concern because we were discussing data which were
20 related to people who were occupying very senior
21 positions within the Trust, when we were, if you like,
22 the most junior people who had just arrived on the
23 block, so to speak.
24 Q. Who is that a reference to?
25 A. To Dr Monk and myself.
0101
1 Q. Who are the most senior people you are referring to?
2 A. Mr Wisheart, Dr Roylance.
3 Q. So Mr Wisheart was mentioned by name at this meeting?
4 A. Oh, yes.
5 Q. "We are concerned about Mr Wisheart's figures"?
6 A. Absolutely.
7 Q. Did you suggest to Dr Roylance that any particular
8 surgeon should be stopped from operating on children, or
9 very young children?
10 A. No, I did not.
11 Q. Did you suggest that any particular surgeon should be
12 stopped from operating on any particular procedure?
13 A. Not at that stage.
14 Q. When we were discussing Mr Stark earlier and whether or
15 not you took up the suggestion, and what you did with
16 that, that people should go and observe operations at
17 Great Ormond Street, I think, my memory is, I will be
18 corrected if I am wrong, that you said that your main
19 aim was to get the surgery stopped on the children.
20 Here you are in the Chief Executive's office with
21 Dr Monk beside you. Here is your chance and you did not
22 suggest that the surgery be stopped or that any
23 particular surgeon be stopped from performing any
24 particular procedure?
25 A. Before you --
0102
1 Q. That is right, is it not?
2 A. Can I elaborate on this? Before you say to somebody
3 "You must stop this", you have to demonstrate or
4 convince your counterpart, then you have a problem, and
5 you have to be given the chance, unless you want to
6 shout, as I did later on with Dr Roylance, you have to
7 be given the chance then, the other party is listening
8 to what you have to say. All Dr Roylance had to say,
9 repeatedly, was: "This is not a matter for me; this is
10 a matter for the clinician". He was not prepared to
11 engage in any conversation on whether we had a problem,
12 or indeed how the problem could be resolved.
13 So the discussion, I am afraid, was aborted even
14 before it had a chance to take off.
15 Q. If he had seen the shocking, as you saw it, data from
16 Dr Bolsin, that there was three times as high mortality
17 as one would expect from the various procedures,
18 Dr Roylance might have taken a different point of view
19 and realised things were more serious?
20 A. If he had not seen the data by that time, he was not
21 doing his job properly.
22 Q. Was it not obvious from the way Dr Roylance conducted
23 the meeting that he had not seen the data?
24 A. No. He just did not want to engage in any
25 conversation. He just said "This is not a matter for me
0103
1 to discuss; this is a clinical matter". This is all he
2 said, repeatedly. He was not prepared to engage in any
3 constructive conversation on this issue.
4 Q. So if he did not discuss the data, if he did not go
5 through the data, the Bolsin data with Dr Roylance, what
6 exactly did you discuss? What precisely did you
7 discuss?
8 A. We went there, we said we had come to see him, as I had
9 done before on my own, to tell him that we were very
10 concerned about the way that the paediatric service was
11 run. We wanted him --
12 Q. Was run?
13 A. Was run. I mean, the operations were done, and
14 everything else. We were very concerned about this, and
15 since I felt I had failed to persuade Mr Wisheart to act
16 and do something in his position as surgeon as well as
17 Chairman of the Hospital Medical Committee, I had now
18 come to him as the next line of command, as the Chief
19 Executive of the hospital, the man who could take the
20 decision, to put forward the problem. If he was
21 prepared to listen to me, hopefully, we would have gone
22 into the details of the problem and maybe even on the
23 way to resolve the problem. The fact of the matter is,
24 we were never given that chance, so unless I physically
25 restrained him on a chair and I said what I wanted to
0104
1 say, I was not given that opportunity.
2 Q. The way to resolve the problem was to appoint the
3 paediatric cardiac surgeon and to move the surgery to
4 the Children's Hospital?
5 A. Absolutely, but the problem is, this was the solution.
6 Before, you have to agree that you have a problem. If
7 we do not agree we have a problem, there is no point in
8 discussing what the solution is.
9 Q. But it was not true that at this stage you had a desire,
10 in the meantime, before the surgery was moved to the
11 Children's Hospital, before the paediatric cardiac
12 surgeon was appointed, to actually stop any operations
13 that were still carrying on?
14 A. No. The reason being that, for example, the results of
15 the switch were not made available until later in that
16 meeting.
17 Q. Mr Dhasmana had stopped doing neonatal surgery --
18 A. But that was nothing to do with me. It had happened
19 even before my arrival.
20 Q. I think it happened in October 1993?
21 A. No, it happened before. I think the infants were
22 stopped before. I do not remember the exact date. But
23 the comprehensive figure on the switch was not available
24 until, I believe, August 1994, so it was a few months
25 after the meeting I had in Dr Roylance's office with
0105
1 Dr Monk.
2 Q. You see, Professor, I have a bit of a difficulty in
3 understanding how it was that if, when you got
4 Mr Stark's advice, you were anxious to stop the surgery
5 on children, or to stop the carrying out of particular
6 operations --
7 A. No, I was anxious -- may I interrupt you? I was anxious
8 to convince the people that first of all we had
9 a problem; point 2, I was anxious to appoint
10 a paediatric cardiac surgeon with experience with modern
11 cardiac surgery. This was my anxiety. In the majority
12 of the cases, there was no agreement on the fact that we
13 did have a problem, let alone on the implementation to
14 solve the problem.
15 Q. Did you ever suggest to Dr Roylance that cardiac surgery
16 in general or paediatric cardiac surgery in particular
17 might be subjected to a review conducted by external
18 experts?
19 A. No, not really, not at that stage. No, I never
20 suggested it until the last switch operation, that we
21 should have -- let me rephrase it.
22 There were some other meetings in the second part,
23 after the switch operations were presented, the switch
24 data was presented, there were several meetings, and
25 there was a meeting with Mr McKinley prior to that in
0106
1 which Professor Farndon and myself, we went to see
2 Mr McKinley, and the purpose of that meeting was
3 virtually to canvass some support for the appointment of
4 Mr Pawade.
5 At that meeting, if I remember, McKinley asked for
6 Dr Roylance to come in. One of the things which was
7 discussed -- I do not remember whether it was my
8 suggestion or Professor Farndon's -- was that if we had
9 a problem with the interpretation of the data, perhaps
10 we should have asked for some external help. This was
11 never defined as an individual, an organisation like the
12 Royal College or anything like that. It was just
13 a fairly loose statement.
14 Q. So you did not make the suggestion to Dr Roylance at
15 that stage?
16 A. No, not until later, after the last switch operation.
17 Q. At the GMC, you were asked about this meeting. When you
18 were asked "What did you say to Dr Roylance was the
19 problem?" you said that you had said to Dr Roylance:
20 "I thought there was a serious problem with regard
21 to the way paediatric cardiac surgery was conducted.
22 I had been presented with the figures which in my view
23 showed an unacceptably high mortality and morbidity.
24 I did not have any figures of my own. Nevertheless,
25 I thought there was reason for concern and I wanted him
0107
1 to give some time to this concern."
2 You said that you did not personally show the
3 figures to Dr Roylance.
4 A. No, I do not think I did. I know we both had the data,
5 myself and Dr Monk, but as I said, we never had the
6 chance to go into details of the data.
7 Q. You said that at the GMC you were of the impression that
8 he already was in possession of the figures?
9 A. I am absolutely 100 per cent certain he was.
10 Q. But you did not ask him whether that was true?
11 A. No. As I said, if by that time he did not have the data
12 in his hands, he was not doing his job properly, and
13 a lot of other people would not have done their job
14 properly, starting from the Director of Cardiac Services
15 who should have given the data to the Chief Executive.
16 Q. Did you yourself ever actually tell Dr Roylance what
17 data was available?
18 A. Yes. He knew that Dr Bolsin had done this data
19 collection.
20 Q. Did you yourself --
21 A. I said that. I am sure I said that.
22 Q. Did you yourself ever tell Dr Roylance that there was
23 data floating about from Dr Bolsin, or did you simply
24 assume that he must have seen it?
25 A. I honestly cannot say. If I say yes, I may be lying; if
0108
1 I say no, I may be lying too. I cannot recollect it.
2 Q. You cannot confirm that you told Dr Roylance about this
3 data from Dr Bolsin?
4 A. No, I cannot, although the data was in my hands in
5 Dr Roylance's office. I cannot remember the specific
6 terms of the conversation.
7 Q. So this was another meeting where the data was actually
8 there?
9 A. No, this was the meeting with Dr Monk. We both had the
10 data.
11 Q. But it was not shown specifically to Mr Roylance?
12 A. No.
13 Q. A bit like the meeting with Mr Wisheart earlier?
14 A. Yes.
15 Q. At the GMC you said that you never made him,
16 Dr Roylance, aware that there were such figures.
17 You said:
18 "No, I made him aware there were such figures on
19 multiple occasions."
20 A. Of course I made him aware as Dr Bolsin had done an
21 audit. The whole hospital knew about this. Even the
22 porter. Even the porter knew Dr Bolsin had undertaken
23 an audit which was branded by everybody as a secret
24 audit. Everybody. Absolutely everybody knew. This had
25 been discussed even at consultant meetings, and there
0109
1 was a big outcry because this data had been collected
2 without the authorisation, rightly or wrongly, of the
3 surgeon.
4 Q. I want to separate your perception that everybody knew
5 down to the porter on the one hand and what you and
6 Dr Roylance discussed specifically on the other.
7 I understood you to say a minute or two ago that
8 you could not remember whether you did or did not,
9 yourself, specifically refer Dr Roylance or mention to
10 Dr Roylance that there was data from Dr Bolsin, as I put
11 it, "floating about". That was your evidence a moment
12 ago?
13 A. Yes.
14 Q. At the GMC, when asked the same question:
15 "You never made him aware there were such
16 figures?"
17 You said:
18 "No, I made him aware there were such figures on
19 multiple occasions."
20 Both those statements cannot be true?
21 A. This is becoming very semantic, is it not. The issue
22 is, I walked with Dr Monk into Dr Roylance's office and
23 we went to express to him our concerns on the basis of,
24 amongst other things, the information we had been
25 provided by Dr Bolsin.
0110
1 Whether we specifically said "What we have got in
2 our hands is Dr Bolsin's... can we discuss it or not?"
3 honestly I cannot say, but there is no question
4 whatsoever that we said to him that on the information
5 that we had, on the comprehensive information which was
6 just not Dr Bolsin, what is wrong in all these issues,
7 and it was asked to me at the GMC and you in a way are
8 doing the same thing, is that my opinion was not formed
9 on Dr Bolsin's data only; my opinion was the result of
10 what I was seeing every day of the week in the intensive
11 care. At audit meetings where there was almost
12 inevitably either a dead child or a child with
13 complications. So Dr Bolsin's data was something which
14 reinforced my belief, but it was just part of a bigger
15 picture I had built up. When I was going to talk to
16 people, I was never referring to, "This is like the
17 gospel, Dr Bolsin's data, and this is the reason why
18 I am not happy". I was telling the people I was not
19 happy on the grounds of all the information I had over
20 a period by that time of one and a half years. There
21 had already been many meetings, audit meetings, where
22 mortalities were occurring and children who had died in
23 very strange circumstances had been discussed.
24 MR MACLEAN: Sir, I think maybe it will shortly be time to
25 move on to another topic. Perhaps that could best be
0111
1 done after lunch?
2 THE CHAIRMAN: Yes, I think that is right. Let us now break
3 for three-quarters of an hour, and reconvene at 1.45.
4 (1.00 pm)
5 (Adjourned until 1.45 pm)
6 (1.45 pm)
7 MR MACLEAN: Professor Angelini, before lunch we were
8 discussing the meeting that you had with Dr Monk and
9 Dr Roylance in March 1994. You mentioned in your last
10 answer that your attendance at many meetings included
11 many meetings where mortality was discussed?
12 A. Yes.
13 Q. Each month, I think, there was a meeting?
14 A. Yes. They were fairly irregular, not properly
15 structured meetings until the end of 1994/94 when
16 Mr Bryan took over the role of organising the meetings.
17 Even before that, there were audit meetings at which the
18 activity of the month was presented. This was relating
19 to adult as well as paediatric, so it was not
20 uncommon -- in fact I would say it was almost all the
21 time when there was a case of a child who had either
22 died or with complication, and those cases were
23 discussed, not just by me, by the whole audience of
24 people attending the meeting.
25 Q. On a month by month basis?
0112
1 A. Yes.
2 Q. Those would be attended by --
3 A. They would be attended by consultant surgeons, juniors,
4 we would have some nurses, although the practice of
5 widening it to the nurses, the perfusionists and the
6 anaesthetists started when Mr Bryan took over at the end
7 of 1993/94.
8 Q. So people like Dr Bolsin after that stage would be able
9 to go to those meetings?
10 A. Even before. Before it was more confined to the
11 surgeons.
12 Q. But Dr Bolsin's data, the work that he was carrying out
13 in analysing the results of paediatric cardiac surgery
14 was never discussed at those meetings?
15 A. No. Most of these meetings were never comprehensive
16 meetings; they were meetings relating to the activity of
17 the last month, and there was never, as I said -- we
18 never had -- at the end of each year, probably there
19 would be a presentation on that year, general figures
20 and this was in relation to adult as well as paediatric,
21 but only for that year, not cumulative over a period of
22 three, four or five years.
23 Q. There were annual returns which were drawn up by,
24 I think, Mr Wisheart and Mr Dhasmana?
25 A. Really each individual surgeon had so to speak a duty to
0113
1 come up with his own figure which were eventually put
2 all together in a return which had on one-page the adult
3 and on the other two or three pages the paediatric.
4 Q. And the return was sent where?
5 A. To the Cardiothoracic Society.
6 Q. Where it was then anonymised by the --
7 A. I am not sure how these worked, but I think the return
8 has something like a code or the only people who were
9 allowed to know what each unit was doing was the person
10 who was collating the results from all the units and
11 perhaps, I guess, the Secretary of the Society.
12 Q. But each surgeon in Bristol would have had his own input
13 into the collating of Bristol's own return?
14 A. Certainly I can speak for myself and Mr Bryan, and
15 I guess everybody else would get his own data, so the
16 data was coming from us. It was not validated by
17 anybody, except by us, which in good faith we were
18 producing the data.
19 Q. But at each audit meeting where the previous month's
20 cases, deaths for the previous month, for example, would
21 be discussed, there would be the opportunity for each
22 surgeon to at least know which surgeon had lost patients
23 that month?
24 A. That is correct.
25 Q. Let us turn to the dinner with Dr Monk and Mr Wisheart,
0114
1 and Dr Bolsin.
2 It is right that the four of you went for dinner
3 in early April 1994?
4 A. Yes.
5 Q. To a restaurant no longer with us in Bristol, called
6 Bistro 21?
7 A. Yes.
8 Q. What was the purpose of that dinner?
9 A. That dinner was organised by Dr Monk and the idea of
10 that dinner was to have Mr Wisheart and Bolsin together
11 to try to reconcile some of their differences. I was
12 invited, I guess, I do not know, as a sort of honest
13 broker, or outside -- I do not know what to call it, but
14 the dinner was organised by Dr Monk.
15 Q. Was the dinner the place where Mr Wisheart asked
16 Dr Bolsin and yourself if you would share your concerns
17 with him and Dr Monk about the paediatric cardiac
18 surgery?
19 A. No.
20 Q. It is right, is it not, that Dr Bolsin did not take any
21 data to that dinner?
22 A. Correct.
23 Q. You did not take any data?
24 A. No, I was just the guest at a meeting organised by
25 somebody else.
0115
1 Q. No data was produced, if I can put it like this, from
2 Mr Wisheart's side?
3 A. No.
4 Q. So it must follow that presumably if Dr Monk did not
5 bring any data there was no data discussed at the
6 dinner?
7 A. Again, the purpose of this meeting, everybody seems to
8 emphasise the need to have these pieces of paper in
9 front of you with the data. The fact of the matter was
10 that we were at a stage where we were trying to get
11 across the message that some of us in the unit were not
12 happy with what was going on in paediatric cardiac
13 surgery.
14 On the other side, there were people like
15 Mr Wisheart who were not prepared to accept that there
16 was a problem. So effectively, any conversation was
17 almost dead before it started, because we could only
18 agree to disagree. Therefore, there was never the
19 opportunity to expand and go into details of "Let us
20 look at the VSD, whether a mistake has been made; let us
21 look at the AV canal", because there were two opposite
22 views. One view was what was going on was acceptable
23 surgical practice; the other view was that what was
24 going on was not acceptable surgical practice. These
25 two things were impossible to reconcile. As a result of
0116
1 this, there was never any proper conversation which
2 could try to analyse the problem or, if so, how to
3 resolve it.
4 Q. Dr Monk had accompanied you to the meeting with
5 Dr Roylance?
6 A. Yes, just a few days or weeks before.
7 Q. He was also at this dinner with you and Dr Bolsin and
8 Mr Wisheart?
9 A. Yes.
10 Q. Did he try to bridge the gap between Mr Wisheart on the
11 one side and Dr Bolsin on the other?
12 A. I think Dr Monk was concerned about all of this because
13 of his position, and also because he was genuinely
14 concerned, but again, as it had happened for other
15 people, it was very difficult for him to get the message
16 across.
17 Q. Across to whom?
18 A. To Mr Wisheart. I mean, everybody, even the Professor
19 of Surgery who was in a much more senior position, was
20 always finding himself almost embarrassed in having to
21 say to a colleague, a friend, somebody very senior, that
22 his results were not up to scratch. It was always the
23 sort of psychological barrier, if you want to call it,
24 where people could not just get the message across. One
25 reason was that there was apprehension, because as
0117
1 I said, Mr Wisheart was a very influential individual
2 within the Trust. But there was also --
3 Q. So does that mean that there was the fear that there
4 would be repercussions?
5 A. I do not know if "fear" is the right word, but let us
6 say apprehension.
7 Q. Apprehension of what?
8 A. Yes, even apprehension of what it would be, your future
9 career.
10 Q. What was going to happen?
11 A. I do not know. Perhaps your career, internal promotion,
12 would have been curtailed down, really.
13 Q. How would that come about?
14 A. How would that happen? At the end of the day the people
15 who were running the hospital can have a profound effect
16 in the way your practice or your individual practice is
17 run. They may not be so sympathetic when you go and ask
18 for something like, you know, you want to go and improve
19 something in the service, or even on personal grounds.
20 Q. Was Mr Wisheart, so far as you are concerned in the
21 spring of 1994, one of the people who was, as you put
22 it, running the hospital?
23 A. More or less, yes. I do not know if he was running the
24 hospital, but as the Medical Director he was in the
25 Trust Board. Maybe he was not the Chairman of the
0118
1 Hospital Medical Committee at that stage. Before that
2 stage he had been Chairman of everything that moved in
3 hospital, the Division of Surgery, cardiac surgery,
4 everything. We had an Associate Director of Cardiac
5 Surgery, Mr Dhasmana, who could never take a decision.
6 He never ever took a decision because whatever decision
7 he took was going to be turned down or changed by
8 Mr Wisheart.
9 Q. So were you scared of Mr Wisheart?
10 A. Not particularly, no.
11 Q. Not particularly?
12 A. No.
13 Q. A little bit?
14 A. No. And I can tell you why.
15 Q. So not at all?
16 A. I would say not at all, yes, but despite of the fact
17 I was not scared, I was feeling very uncomfortable all
18 the time, because it is not very pleasant to confront
19 a colleague who happened to be senior to -- I mean,
20 Mr Wisheart could have been -- he is the same age of the
21 person who trained me. He could have been my trainer.
22 And now I was there, confronting him, trying to tell
23 him, "Look, your results are not good". This is very
24 uncomfortable.
25 Q. But you did not confront him, because paediatric cardiac
0119
1 surgery was never mentioned at the dinner?
2 A. But many times before. That dinner was not organised by
3 me, I was simply there as an observer. I did not
4 organise the meeting, I was not responsible for the
5 talking of anything. I had spoken to Mr Wisheart about
6 the results of paediatric cardiac surgery in a very
7 polite fashion many, many times.
8 Q. I think you said, possibly at the GMC, that you
9 discussed the arts, you discussed Manchester United?
10 A. Everything. Football, Italy, all sorts of things. One
11 of the difficulties people have to talk to Mr Wisheart,
12 not only because he is a very senior person and is
13 a very authoritative person, but also, he is very
14 fluent. You start a conversation on a subject, you end
15 up with something totally different, you do not know how
16 you got there. He has a very good ability of discussing
17 in the fashion he wishes, and therefore wriggles out if
18 he does not like the kind of conversation that is taking
19 place.
20 Q. If that is the perception that you had of Mr Wisheart,
21 does that not make it all the more odd that you should
22 not have made full use of the meeting that you had with
23 Dr Roylance in March when Dr Monk was with you, when
24 there was a chance, with somebody who was higher up the
25 management tree even than Mr Wisheart, indeed, at the
0120
1 top, and you and Dr Monk pulled your punches with
2 Dr Roylance?
3 A. I think you British say "you need two to tango". If the
4 other one is not prepared to listen, as I said, short of
5 pinning him down on a chair, I do not know what else
6 I could have done, and so with Dr Monk. Dr Roylance was
7 not interested whatsoever in this kind of conversation.
8 It was like listening to a tape-recorder: "This is not
9 a matter for me. This is a matter for the clinician."
10 This was the message over and over and over. Even when
11 I went to see Dr Roylance, before I spoke to him, before
12 and after the last operation, even after the last
13 operation, this was the same recorded message.
14 Q. But it was a matter for the clinicians, was it not?
15 A. You are asking me?
16 Q. The Chief Executive cannot force people to talk about
17 a subject over dinner if they do not want to talk about
18 it?
19 A. No, but the Chief Executive can call all the involved
20 parties in a room around the table, which should have
21 happened, and said, "Right, concern has been expressed
22 in the hospital by various sides. I would like first of
23 all to see, if I have not seen it, the data of Dr Bolsin
24 that everybody is talking about"; second, I would have
25 instructed the two surgeons, Mr Wisheart and
0121
1 Mr Dhasmana, to produce their data to be confronted with
2 the one of Mr Wisheart (sic) and then, once the facts
3 were concerned, all the people, not just the surgeons,
4 the anaesthetists and everybody else, discuss this
5 matter, then we decide if we have a problem. If we have
6 a problem, we decide how we are going to solve it. If
7 we do not have a problem, the people who said we had
8 a problem will have to apologise. This never took
9 place.
10 Q. There were attempts, were there not, after a meeting
11 with Professor Farndon, for there to be a meeting
12 involving different disciplines towards the end of 1994?
13 A. Yes.
14 Q. And the meeting never took place; is that right?
15 A. Yes, but I need to elaborate a little bit on that, if
16 you allow me.
17 There was a meeting in Mr Wisheart's house in
18 November 1994 and what was discussed --
19 Q. Attended by ...
20 A. Attended by the four cardiac surgeons: myself,
21 Mr Hutter, Mr Wisheart -- five then -- Mr Dhasmana and
22 Mr Bryan.
23 Q. Surgeons only?
24 A. Surgeons only. This was in Mr Wisheart's house. At
25 that meeting, with some significant difficulties, not
0122
1 only because I was in somebody else's house as a guest,
2 I pointed out to Mr Wisheart that I was now concerned
3 about the adult practice. I said I would like to avoid
4 a repeat of the situation that we had with the
5 paediatric and perhaps we should have a good look at all
6 our data, not only adult, to avoid this. Again, I was
7 plainly accused of just trying to now switch the
8 attention to a different matter, the adult, create
9 unnecessary fuss, as I had done with the paediatric.
10 I therefore went to see Professor Farndon and
11 I said "John, I am afraid we may be facing the same
12 problem, not the same extent we had with the paediatric,
13 but there are concerns which have now been expressed by
14 various people in the hospital, that our adult practice
15 is not up to scratch". We both agreed that it was now
16 necessary to have a meeting with everybody concerned:
17 the cardiologists, the anaesthetists and the surgeons.
18 He took the task of speaking himself to Mr Wisheart and
19 organised that meeting.
20 Q. Can we just pause there? Have a look at UBHT 61/252.
21 We have slightly jumped in time a bit, but we have
22 between us raised this point. Let us deal with it now.
23 A. You led me there.
24 Q. I did. 18th November 1994. It is a letter, if we scan
25 down, from Professor Farndon to Mr Wisheart.
0123
1 A. I have seen this letter. I think it was even cc'd to
2 me, actually.
3 Q. "I will speak to Gianni. I really do believe the best
4 way forward is for an internal discussion to begin
5 initially with the five cardiac surgeons ..."
6 You see what is said in the next line?
7 A. I am familiar with this letter.
8 Q. This was a sensible suggestion?
9 A. Absolutely.
10 Q. It was the sort of open discussion you would like to
11 have seen in the paediatric --
12 A. This was related to adult.
13 Q. Yes. This is the sort of development you would like to
14 have seen with the paediatrics as well?
15 A. The fact of the matter was that now I was learning, so
16 I know how to prevent what was going to happen and in
17 fact, the first thing I suggested was that I wanted
18 everybody around the table with the figures, something
19 which I had not been able to achieve before, so it is
20 like, once you have done it once, the second time you
21 know well to avoid the mistake you made the first time.
22 Q. So here is an attempt by you and Professor Farndon and
23 Mr Wisheart to, having had the discussion among the
24 surgeons, the plan is to broaden it out and have
25 a discussion with cardiology and cardiac anaesthesiology
0124
1 as well?
2 A. Yes.
3 Q. Is that not exactly the clinicians sorting out, or
4 planning to sort out the problems among themselves in
5 the way that Dr Roylance would have wanted?
6 A. But this meeting never took place, as a matter of fact,
7 so it was exactly deja vu of what had happened with
8 paediatric.
9 Q. Let us take it slowly. Up to this point, the planning
10 of the meeting, is not this exactly the sort of thing
11 that Dr Roylance had in mind? Is this not the
12 clinicians beginning finally to get their act together
13 to sort out the problems?
14 A. Dr Roylance had nothing in mind. Every time I went to
15 talk to Dr Roylance I was just a minor irritation.
16 Q. But he was irritated perhaps because the clinicians
17 could not have got to this stage previously?
18 A. All right. The clinicians cannot agree, as indeed they
19 did not agree the second time around with the adult, it
20 is the duty in my view of the Medical Director, which
21 incidentally was Mr Wisheart, so we had to go a step
22 further, which was the Chief Executive to say, "Right,
23 you cannot sit around the table by yourself; I will make
24 you sit around a table on my specific order and you will
25 have to discuss this matter".
0125
1 This is what Dr Roylance failed to do with the
2 paediatric and in fact, even with the adult. It was
3 only after myself hammering him over and over and over,
4 then he agreed to an internal inquiry, which was the
5 Bullimore Inquiry, which was, if you allow me to be
6 a bit colourful, farcical.
7 Q. I think, if you do not mind, we will not get into the
8 Bullimore Inquiry into the adult work at this stage.
9 Can I take you back to May 1994? A letter was
10 written, was it not, signed by you and Professor Vann
11 Jones and sent to Mr Durie?
12 A. That is correct.
13 Q. UBHT 61/246. The background to this is that you had
14 been to see Mr Durie, is it not?
15 A. No. Mr Durie had come to see me, which is rather
16 different.
17 Q. When Mr Durie gave evidence to the Inquiry -- Day 30,
18 page 91 -- the letter was shown to him and he said:
19 " ... signed by Professor Angelini and Professor
20 Vann Jones. Yes".
21 Then the letter was read to him and he said:
22 "I have been shown the letter before yesterday and
23 I do not remember seeing it at the time."
24 It is right that there is no reply from Mr Durie
25 to this letter, is there not?
0126
1 A. He resigned like -- he ended his term like a couple of
2 weeks later. I think my understanding is that the
3 letter was received in the Trust, was it not? When he
4 ever read it, I cannot say.
5 Q. You say that if it is suggested, as it was in Mr Durie's
6 statement, I think, that you had been to see him, that
7 is the wrong way round?
8 A. No, that is a lie and can be confirmed by looking at my
9 diary and speaking with my secretary. I had met
10 Mr Durie before that time only once. It was at a dinner
11 function organised by the Chairman of the Hospital for
12 the University. Subsequently I had no contact
13 whatsoever with Mr Durie until, at short notice, my
14 secretary said that Mr Durie's secretary had phoned and
15 he wanted to see me to discuss the expansion plan for
16 the Academic Department on level 7. I said, "Fine, tell
17 him to come along."
18 He came along, to my surprise, with Margaret
19 Maisey. Quite honestly, I do not know what she was
20 there for in terms of discussing the academic plans.
21 Q. Who was Margaret Maisey?
22 A. I think she was Head of Nursing, I do not know how you
23 call it within the UBHT. She was an executive member of
24 the UBHT and Director of Nursing.
25 Q. She worked closely with Dr Roylance?
0127
1 A. I have no idea. It probably was the first time I met
2 the woman.
3 Q. You tell me about Mr Durie.
4 A. They came into my office. I did not organise the
5 meeting. They came to me. The conversation on the
6 academic department expansion lasted about 30 seconds.
7 I must say, I was not expecting him to raise the issue
8 of paediatric. What he said was that he was very
9 concerned about what he had heard and he had an
10 impression or an opinion or whatever you want to call it
11 that the paediatric service was substandard.
12 Q. What did he say he had heard and from whom?
13 A. I think he just said "The service is not good".
14 I cannot recollect the precise words, but the message or
15 gist of it was "I am very unhappy at what I have heard
16 that the paediatric service is not up to scratch". What
17 his exact words were, I do not know. I cannot
18 recollect.
19 Q. What did you say?
20 A. I said then, I share his sympathy in full. He asked me
21 whether I had any solution and I said then in my view,
22 the solution was to try to appoint a new paediatric
23 cardiac surgeon.
24 Q. What did he say to that?
25 A. He said would I be kind enough to put this in writing,
0128
1 and could I be kind enough to go and see Professor Vann
2 Jones to discuss this with him, and make sure that he
3 was in agreement with this concept and send him
4 a letter, and he would have done something if he could.
5 Q. Why did he tell you to go and see Professor Vann Jones,
6 do you think?
7 A. Because Professor Vann Jones was the Director of Cardiac
8 Services. Presumably he was trying to suggest to me to
9 go through the established channel of command.
10 Q. Professor Vann Jones -- these are not his words but
11 I think this is a fair summation of how he put it --
12 suggested that Mr Durie told you to go and see him, Vann
13 Jones, because he, Vann Jones, was seen by Mr Durie as
14 being essentially a wise head and somebody who would
15 take account of --
16 A. I am sure Professor Vann Jones is a wise man, who avoids
17 as much as he can any form of confrontation, as was
18 amply demonstrated in the course of events with the
19 paediatric and subsequently with the adult. If that is
20 a sign of being wise, he is a lot wiser than I am.
21 Q. He was asked how widely spread was the debate amongst
22 those involved in cardiac surgery, and paediatric
23 cardiac surgery specifically, about results at this
24 stage.
25 A. You mean Durie or Vann Jones?
0129
1 Q. Vann Jones.
2 A. I went to see, just an hour after --
3 Q. Just a minute. Professor Vann Jones last week was
4 asked:
5 "Can you tell us how widely spread was this debate
6 [that is the debate about the results] amongst those
7 involved in cardiac surgery and paediatric cardiac
8 surgery specifically, at this time?"
9 Can I ask you the same question?
10 A. Mr Bryan knew of all the results, I had discussed it
11 with him. Professor Farndon knew. The Professor of
12 Anaesthetics, Prys Roberts knew. Chris Monk knew.
13 I had had several discussions with Mr Hutter. I mean,
14 almost everybody knew.
15 Q. Professor Vann Jones said this debate was everywhere by
16 that stage.
17 A. He is just confirming what I am saying, I think, or what
18 I was trying to say earlier on when you gave me the
19 impression that nobody knew anything about it.
20 Q. He said that it was a major topic of conversation by
21 everybody in cardiac circles.
22 A. I see.
23 Q. You agree with that?
24 A. Absolutely. I agree with what he says all the way
25 along, and not even inside cardiac surgery, outside
0130
1 cardiac surgery.
2 Q. The circumstances in which it came to be written,
3 Mr Durie suggested you should go and see Professor Vann
4 Jones and you did so?
5 A. I did indeed.
6 Q. What did you discuss with him?
7 A. I went to see Professor Vann Jones in his office and
8 I referred to the conversation I had with Mr Durie, and
9 I said, "Right, what should we do?" To my astonishment,
10 given the fact that he never had taken any position
11 before, or indeed after, he said, "I think we have to
12 put an end to this saga, I will dictate a letter".
13 He took the dictaphone and started dictating a letter.
14 Halfway through the dictation, I said "I have to go back
15 to my office because I have another appointment. You
16 send me the letter and if I approve it, I will sign and
17 return it to you".
18 Half an hour later I got this letter on headed
19 paper from Professor Vann Jones, with his name and
20 mine. I agreed on everything he said. I put my
21 signature, I gave it back to his secretary who was
22 waiting outside my office, and I understand he sent this
23 letter to Mr Durie and kept a copy of it.
24 Q. Did you understand Mr Durie had seen a copy of the
25 Bolsin data by this time?
0131
1 A. Oh, months before.
2 Q. You said earlier that Mr Durie sent you to see Professor
3 Vann Jones because Professor Vann Jones was Director of
4 Cardiac Services?
5 A. Yes, that is correct.
6 Q. You thought that was an appropriate person to go and
7 see?
8 A. I think so, yes.
9 Q. So it was your impression that the Clinical Director of
10 Cardiac Services was, together with the General Manager,
11 managerially responsible for paediatric cardiac surgery
12 being carried out at the BRI?
13 A. I am not sure about the specific details since, was he
14 or was he not? I think in my view the issue is more
15 than that: there was a moral issue. If you are
16 a director of a service, you have to be able to take
17 your own responsibility and face the music. If there is
18 a problem in your directorate and you are the director,
19 you are morally, as well as by bound duty of your
20 position, to look into this problem.
21 Q. So if it is right that there is a problem with
22 paediatric cardiac surgery, assuming that is right for
23 the moment, that would be something which Professor Vann
24 Jones would be, in some shape or form, obliged to look
25 into?
0132
1 A. Absolutely. On top of that, he was a University
2 Professor, albeit a personal chair, and he was one of
3 the most senior cardiologists in town.
4 Q. So the letter was written in the circumstances you have
5 discussed?
6 A. The letter was entirely dictated by Professor Vann
7 Jones. I did not add anything. I was, quite honestly,
8 absolutely astonished when he put these things in
9 writing, actually.
10 Q. Pleased or not pleased?
11 A. Very pleased.
12 Q. Delighted?
13 A. Delighted, pleased? It does not make much difference.
14 Q. You agree with everything that is in the letter?
15 A. Absolutely.
16 Q. So although it is not your writing, you can adopt it as
17 your position at the time?
18 A. Yes, I put my signature right away. I just could not
19 believe he had written this letter.
20 Q. "If paediatric cardiac surgery is to survive in Bristol,
21 the surgical side certainly needs a very major
22 shake-up."
23 Was the "very major shake-up" what you go on to
24 refer to in that paragraph about the appointing of
25 a senior lecturer to do paediatric cardiac surgery?
0133
1 A. No, this is nonsense. The problem here was, all the
2 time, to appoint a paediatric cardiac surgeon familiar
3 with modern cardiac surgery. All the time I, or other
4 people, put forward this option, the position of the
5 managers was: there is not the money to appoint
6 a consultant NHS. So an alternative solution which
7 I proposed, was, "I am prepared to go to the BHF and
8 cap-in-hand beg for some money, to give us the money for
9 a year or two as a senior lecturer". At that stage,
10 I needed a senior lecturer like a hole in the head in
11 paediatric, given the shambles paediatric was, but that
12 was a way by which I could have found some money,
13 appoint somebody with the understanding that then later
14 on the Trust would have picked up the bill and turned
15 that job into a proper NHS consultant job.
16 I had never any interest to have a senior lecturer
17 who was accountable to me or whatever. As I said,
18 I needed a lecturer in the middle of that shambles like
19 a hole in the head.
20 Q. What was going to happen to the two adult part-time
21 paediatric surgeons?
22 A. If you want to know what I would have liked to see,
23 I would like to have seen Mr Wisheart giving up
24 completely paediatric surgery and Mr Dhasmana playing,
25 if you like, a supporting role to the main paediatric
0134
1 cardiac surgeon.
2 Q. It does not say that in this letter.
3 A. How many things do you want to put in a letter?
4 Q. Did you think that Mr Durie would have known that that
5 was your view?
6 A. It is interesting, actually, because Mr Durie, something
7 he said to me when we had this meeting -- I never
8 understood, incidentally, why he came to see me.
9 I would not be surprised if I was sort of set up on
10 this; it was like a fact-finding mission, you know,
11 perhaps with the blessing of the Chief Executive or the
12 Trust, they said, "Go and have a listen to the
13 Professor, what he has in mind and what he is planning
14 to do".
15 Q. Did you ever ask or enquire what Mrs Maisey was doing at
16 this meeting?
17 A. It never occurred to me in fact until very recently,
18 like yesterday evening. It is still something I cannot
19 explain.
20 Q. Mrs Maisey, I think, has been described as Dr Roylance's
21 "eyes and ears" around the hospital?
22 A. I could not disprove or confirm that, because I probably
23 met Mrs Maisey in all the time she was at the BRI twice,
24 so, really, I do not have an opinion.
25 Q. Might it not be that Dr Roylance had picked up concerns,
0135
1 on the grapevine or however he picked them up, and had
2 suggested to Mrs Maisey that she might pick up Mr Durie
3 and go and find out what was going on?
4 A. Very possible.
5 Q. But you cannot say?
6 A. No, I cannot say. In fact it never occurred to me until
7 you suggested something like this.
8 Q. I am not suggesting it.
9 A. No, but you put it as a possibility.
10 Q. You accept it as a possibility?
11 A. Yes, but I never talked about it before.
12 Q. If the Chief Executive had heard of rumours on the
13 grapevine, let us say, about paediatric cardiac surgery,
14 and had heard that you were involved in them, or you had
15 some knowledge of them, do you think sending the
16 Executive Director of the Trust and the Chairman to talk
17 about problems with paediatric cardiac surgery would be
18 a sensible step to take?
19 A. No, because he should have done that himself and not
20 with me: with everybody else in the directorate. I was
21 just somebody that for one reason or another, he was in
22 the middle of all this shamble, not out of choice, but
23 out of default from all the other people. I was not the
24 right person or I was not the person who was supposed to
25 resolve the problem of paediatric cardiac surgery.
0136
1 I just happened to be the one because a lot of people
2 were coming to me --
3 Q. You are not being asked to solve the problem. You are
4 being asked by Mr Durie to write him a letter
5 highlighting the problem so the matter could be taken
6 forward?
7 A. Wouldn't it have been easier for Dr Roylance to call
8 a meeting with all the anaesthetists and cardiologists
9 to discuss the matter, widely open to everyone for
10 constructive criticism? What was the point of going one
11 by one behind people's backs? It was very simple, he
12 was the boss of the hospital. That is what I would have
13 done if I was in charge of the hospital.
14 Q. This letter: was it deliberately overstating the
15 position in order to emphasise it and highlight it and
16 to provide Mr Durie with some ammunition to allow him to
17 do something about paediatric cardiac surgery?
18 A. I cannot comment on that because I did not dictate
19 a single word of this letter. There are even
20 expressions which I did not even know in English, like
21 "half-baked fashion". This is not my English. I wish
22 I could write as good as this, actually. So I did not
23 contribute in any way to even a comma of this letter,
24 but I fully approved it. And I do not think he was
25 over-emphasising anything. In fact, he was stating
0137
1 pretty plainly what the general view of many people was,
2 but most of these people did not even have the courage
3 to say this in words or in writing.
4 Q. Let us look at the first four lines. You refer to
5 "fashion". There is a reference here to "half-baked
6 fashion", "certainly for all the time that I have been
7 here". The "I" in the context of the letter must be not
8 you but Professor Vann Jones?
9 A. Yes.
10 Q. Then, it says:
11 "I think we accept the reality of the position and
12 that it is unlikely that paediatric cardiac surgery will
13 move to the Children's Hospital for the foreseeable
14 future."
15 A. That is an interesting statement, is it not?
16 Q. What was the basis of that statement?
17 A. He wrote this letter. I read it after. The Director of
18 Cardiac Surgery says it is unlikely that the children
19 will move to the Children's Hospital, but everybody in
20 the Management Board says "We are all working actively
21 to move everything to the Children's Hospital". It is
22 like the right-hand does not know what the left one is
23 doing.
24 Q. Is there not a bit of licence being taken in this
25 letter?
0138
1 A. The simple explanation is that although there were these
2 big plans, there was nothing firm on paper. If I can
3 give you an example, unfortunately, this is the way the
4 NHS works I am afraid, and this is reality.
5 Let me give you an example, if I can digress for
6 a second. Five years ago the Directorate of Cardiac
7 Services proposed a plan for the expansion of adult
8 cardiac surgery which involved transferring all the
9 cardiac and the cardiological beds on level 6 at the
10 BRI. It was approved and everything. Five years has
11 passed and nothing has happened. It does not take long
12 for everybody to have a memorandum saying "We are going
13 to move the children, appoint this and that", but I am
14 afraid to say the determination of achieving that is
15 a very long shot.
16 Q. So in other words, it is one thing to make proposals;
17 it is another to bring them to fruition?
18 A. Absolutely.
19 Q. We mentioned earlier that this letter was written on the
20 same day the draft Working Party report was circulated,
21 12th May 1994?
22 A. I cannot remember --
23 Q. You remember this morning?
24 A. Yes.
25 Q. Can we look at UBHT 84/129, please? This is a Cardiac
0139
1 Services Management Board on 25th April 1994. You did
2 not attend this meeting?
3 A. No. I did not attend this meeting for the various
4 reasons, because I think later on I was -- I was never
5 a member of this Cardiac Service Management Board.
6 However, at a later stage Professor Vann Jones asked me
7 to be part of it as representing the academic side,
8 either myself or a deputy of mine, but I was never part
9 of this.
10 Q. I am not suggesting you should have been at this
11 meeting, nor, indeed, that you should not have been.
12 Let us look at page 130, paragraph 6:
13 "The option of moving paediatrics to the BCH was
14 still being considered."
15 That is before the letter to Mr Durie. This is
16 April 1994?
17 A. Obviously Professor Vann Jones knew something I did not
18 because if in this statement it says the option is still
19 considered and then he writes a letter and says the
20 possibility of the children being moved is rather
21 remote, he obviously knew something I did not.
22 Q. You would not have seen the minutes of this meeting?
23 A. I may have seen the minutes of this meeting, but the
24 minutes of a meeting, this is just a wish expressed by
25 the clinicians and it does not mean by any chance that
0140
1 this is the wish of the Trust Board.
2 Q. It is not a wish, is it? It is saying that a proposal
3 has been made to do something --
4 A. Can you go back to the beginning of this letter?
5 Q. Yes, page 129.
6 A. This is the Cardiac Service Management Board: nothing
7 whatsoever to do with the Executive of the UBHT. These
8 are the clinicians who are running the cardiac services,
9 and they are making some proposal. Whether this
10 proposal will be ultimately accepted by the Board is
11 pure speculation.
12 Q. I understand that entirely --
13 A. If I can finish, these people had their heart in a good
14 place. They wanted the service to be moved. What I am
15 saying is that the Trust Board was not so keen. That is
16 all I am saying. That is all I have been saying all
17 morning.
18 Q. There was a representative of the Trust Board at the
19 meeting, Margaret Maisey?
20 A. Okay, fine.
21 Q. Let us look at the next one, 24th May 1994,
22 UBHT 84/145. Again, you are not there?
23 A. Yes. This is something I had access to, because this
24 was open to everybody.
25 Q. Page 147, paragraph 14:
0141
1 "Cardiac planning group (paediatric and adult
2 services).
3 "Mr Dhasmana reported that a paper setting out the
4 options for the future would be sent to Dr Roylance by
5 the end of the week. The unanimously preferred option
6 of the planning group was to move paediatric open-heart
7 surgery to the Bristol Children's Hospital."
8 We see the reference to the job description which
9 was not going to be purely a paediatric one, which was
10 something Professor Vann Jones was not happy about?
11 A. Yes.
12 Q. Can we look at UBHT 189/120, please. This is 18th July
13 1994. We see you are present by this stage?
14 A. Yes.
15 Q. You could have attended any of these meetings?
16 A. No, no. I could not. I was not part of the Cardiac
17 Surgery Management Board until I was invited by
18 Professor Vann Jones. The Cardiac Surgery Management
19 Board, the Executive, was made by people who were the
20 Director of Cardiac Services, the Associate Director of
21 Cardiac and Cardiology, some anaesthetists and other
22 things. I was eventually invited to that, but this was
23 the elected officers.
24 Q. Let us look at page 121. It is the paragraph at "7",
25 July 1994:
0142
1 "Professor Vann Jones reported that at a meeting
2 held last week, Dr Roylance had made it clear that the
3 costs of moving paediatric surgery had to be reviewed
4 again and reduced if the move was to go ahead. There is
5 a greater sense of optimism that this could be done and
6 a further meeting was to be held on the 20th, with the
7 costings to go to Dr Roylance the following week."
8 A. This is very much what I have been saying all the time:
9 that the Trust Board was reluctant with this move
10 because it was expensive. However, when the pressure
11 built up, everybody speeded up the process of action and
12 there is a clear distinction between what the clinician
13 wanted to see happen and what the Trust or the Executive
14 of the Trust Board were prepared to achieve.
15 Q. If we just go back a page --
16 A. Incidentally --
17 Q. This is 18th July?
18 A. -- this is two months after that meeting with Durie.
19 Q. And it is two days before the letter from Dr Doyle which
20 we will come to in a minute. So is this your
21 understanding: that through April and May, the Cardiac
22 Surgery Management Board, the Cardiac Services
23 Management Board, in fact, the wider group, were anxious
24 that there should be a new appointment of a surgeon who
25 was at least in large part concerned with paediatrics;
0143
1 is that right?
2 A. Absolutely. Let me tell you something else.
3 Mr Dhasmana was in favour of this from the word go from
4 1993 -- 1992.
5 Q. I think you said that earlier. That the children's
6 surgery ought to be moved to the Children's Hospital,
7 but that by July 1994, there were still from the
8 management of the Trust, concerns about the cost of the
9 proposal?
10 A. That is correct.
11 Q. So the proposal in July had neither been accepted nor
12 rejected?
13 A. Absolutely.
14 Q. But that the cost was going to have to be brought down,
15 as Dr Roylance is reported as saying here, if it was to
16 go ahead; is that right?
17 A. Yes.
18 Q. We will see that the position changed, did it not, quite
19 rapidly over the next few weeks?
20 A. Very rapidly, absolutely, because another factor
21 intervened.
22 Q. Before we come to the other factor that may have
23 intervened, Mr Durie said, in giving his evidence to the
24 Inquiry, that he did not remember seeing the letter that
25 you and Professor Vann Jones sent. You presumably
0144
1 cannot tell us whether he saw it or whether he did not?
2 A. No, but I believe the letter has been filed within the
3 Trust, so if it is filed within the Trust, either he was
4 not shown it by the secretary or he did not bother
5 reading it. I do not know. The letter was sent.
6 Q. Let us not get too hasty in the explanation of Mr Durie,
7 because I am going to tell you his explanation in
8 a minute. You cannot tell us whether he did or did not
9 see it?
10 A. I have no idea.
11 Q. What he actually said, at Day 30, page 93, was:
12 "I have been shown the letter before yesterday and
13 I do not remember seeing it at the time. I could have
14 seen it at the time. I certainly would have expected,
15 when I spoke with Gianni Angelini, to say 'Go and talk
16 about it, please, with Professor Vann Jones', in the
17 same way I reported to the Chief Executive, but I have
18 a habit, which was nearly 100 per cent -- and you have
19 seen it somewhere else -- that when I read a document
20 I tended to put my initials on it with either a comment
21 of what should happen or the word 'Seen' and the date.
22 I cannot find it on this document. At the time the
23 letter would have arrived at Trust headquarters
24 I actually was abroad, so it could have been that,
25 rather than wait, it was moved on. I just do not recall
0145
1 at the time having seen the letter."
2 He was asked:
3 "Where would it have been moved on to?"
4 He said:
5 "It would have been given to the Chief Executive
6 to work on, I guess."
7 Then he was asked:
8 "If you had got the letter at the time [so if he
9 had got it] you would have taken the concerns expressed
10 in it to the Chief Executive as well?
11 "I would.
12 "So by whatever route, either missing you out or
13 not, matters would have got to the Chief Executive?
14 It would have."
15 That is dealing with his practice. You will not
16 be able to help us with whether he initialled letters or
17 did not initial letters?
18 A. No.
19 Q. Did you have any comeback on this letter from
20 Dr Roylance or his office?
21 A. No.
22 Q. Mr Durie, shortly afterwards, resigned as Chairman and
23 was replaced by Mr McKinley?
24 A. Correct.
25 Q. Did you have they dealings with him specifically about
0146
1 the letter?
2 A. Not about the letter, but very much along the same
3 lines.
4 Q. You were actually not responsible for sending the letter
5 to Mr Durie?
6 A. No. His secretary brought it to my office. I read it,
7 I signed it as she was waiting and I gave the letter
8 back to Professor Vann Jones' secretary.
9 Q. So did you not think it was a bit odd that there was no
10 response to this letter? After all, the Chairman had
11 gone to all the fuss of coming to see you, saying
12 "Please write me a letter, this is jolly important".
13 You wrote the letter with Professor Vann Jones; you sent
14 it off. Then there is a deafening silence. Did you not
15 think that was strange?
16 A. He retired right away or something like that.
17 Q. You could have chased it up with his successor?
18 A. We did, immediately. In fact we had a meeting with his
19 successor in July/August together with Professor
20 Farndon. I could not be quicker than that. Within
21 three weeks or whatever I was talking to the new
22 Chairman.
23 Q. It is not three weeks; the letter is May, I think.
24 A. All right, the end of May.
25 Q. 12th May.
0147
1 A. When did Mr Durie resign, the end of June?
2 Q. As I recall it was 30th June, but I do not want to be
3 held to that?
4 A. In July I went on holiday for three weeks. I think I am
5 allowed to go on holiday. After that, I had a meeting
6 with a new Chairman who had just taken up his position,
7 escorted by Professor Farndon. So, all right, it took
8 me a month; I am sorry.
9 THE CHAIRMAN: Professor Angelini, if it would help, I am
10 sure you are entitled to three weeks' holiday, and
11 perhaps we could just take the temperature down a little
12 bit. We are here really to learn and we will learn
13 more, the more the conversation can flow relatively
14 without any of us feeling in some way attacked.
15 PROFESSOR ANGELINI: My apologies.
16 THE CHAIRMAN: Not at all, no apology is called for.
17 MR MACLEAN: At about this time, you were shown some data
18 about the switch, were you not?
19 A. I am not quite sure. It was towards the end of August,
20 I think, July/August.
21 Q. Can we look at UBHT 61/46. Is that the data?
22 A. Yes, it is.
23 Q. Was that the first aggregated switch data that you had
24 seen?
25 A. Yes, that is correct.
0148
1 Q. But of course these cases would have been discussed at
2 the audit meetings?
3 A. Occasionally, because quite a significant number of
4 these were done prior to 1992. Therefore I was not
5 there.
6 Q. And before Mr Bryan's --
7 A. Before my arrival, as well. In fact, quite
8 a significant number.
9 Q. At just about this time -- this is dated 13th July
10 1994 -- there was a letter, was there not, from
11 Dr Doyle, UBHT 52/287.
12 Dr Doyle had been in Bristol earlier that week, on
13 the Tuesday?
14 A. That is correct.
15 Q. You had met him there?
16 A. Yes, in completely different circumstances, nothing to
17 do with paediatric cardiac surgery.
18 Q. It was something to do with money the anaesthetists were
19 trying to get?
20 A. Yes, Dr Bolsin and Dr Black had put a proposal to the
21 Department of Health for a new system of risk adjusted
22 mortality and morbidity and there was an official
23 presentation to the Department of Health, meaning
24 Dr Doyle, and as the Professor of Cardiac Surgery, I was
25 invited to lend some support. This was the first time
0149
1 I met Dr Doyle. After the presentation we had some
2 buffet lunch and after that, on the way to my office or
3 in my office, I am not exactly sure about that, he told
4 me that he had received some expression of concern about
5 the paediatric cardiac surgical practice in Bristol, and
6 I should expect very soon a letter from him.
7 Q. Did he say anything more specific about who had told him
8 what?
9 A. I am sure it had been Dr Bolsin, but he was not that
10 specific to me. He did not even say, "I am referring to
11 this operation..." or the other; he said "If you do not
12 mind, I will be in touch with you shortly" and that was
13 it.
14 Q. Dr Bolsin, as an anaesthetist, would have been at the
15 same function?
16 A. He had organised the meeting together with Dr Black.
17 Q. So he would have been Dr Doyle's host, that day,
18 effectively?
19 A. Yes.
20 Q. So why was it that Dr Doyle wrote to you and not, for
21 example, to the Medical Director -- that is perhaps
22 a bad example -- the Chief Executive of the Trust, or
23 Professor Vann Jones or Professor Farndon? Why choose
24 you?
25 A. It is an interesting question. I do not know.
0150
1 I honestly do not know. I can only speculate, but I do
2 not know.
3 Q. You are familiar with this letter. I do not think it is
4 necessary to --
5 A. No, I am very familiar.
6 Q. It is not necessary to read it out.
7 A. I mean, effectively he said he had been presented with
8 some data, he was concerned and things were not right,
9 did I have anything to offer in order to solve this
10 problem.
11 Q. In this second paragraph, after the initial
12 pleasantries, when he turns to the substance of the
13 letter, he talks about concerns for mortality rates for
14 paediatric surgery, "especially in young children"?
15 A. Yes.
16 Q. He talks about she sort of audit, which may or may not
17 be a reference to the Bolsin audit, "which confirmed
18 a greater than expected mortality rate for certain
19 procedures."
20 What did you understand that to be a reference to?
21 A. He was referring to the AV canal, to the Fallot, by that
22 time I think to the switch as well and maybe to the VSD,
23 the data which was wrong, but there were at least three
24 surgical procedures by that time in which the results
25 were no good: AV canal, Fallot's tetralogy and switch.
0151
1 Q. Dr Doyle is seeking reassurance, is he not, looking at
2 the fourth paragraph, that steps are being taken to
3 remedy any problems that have been identified.
4 Looking at the next paragraph, he is saying,
5 essentially, if you, Professor Angelini, could not
6 reassure him that the matter was in hand, then he would
7 have to take the matter further?
8 A. Yes, that is correct.
9 Q. So it is a warning shot across Bristol's bows, if I can
10 put it like that, to get its house in order?
11 A. Yes and no, really. I personally do not think, even
12 following the conversation I had later on with the
13 Department of Health, then they did not want to really
14 have any inquiry. My perception was, "All right, let us
15 put our heads together and try to resolve this problem
16 without necessarily making too much noise". Perhaps you
17 can take it as a little bit of a subtle threat,
18 I suppose, yes.
19 Q. Well, it is not a threat, is it? He is just saying "If
20 you cannot sort it out, I may"?
21 A. Fine. I do not have any problem with this.
22 Q. What was your reaction to the letter?
23 A. I discussed this letter with several people, and I think
24 with Professor Farndon, with my senior lecturer, I think
25 also with --
0152
1 Q. That would be Mr Bryan, would it?
2 A. Mr Bryan, and then Professor Vann Jones and Dr Roylance.
3 Q. In what circumstances did you bring this letter to
4 Dr Roylance's attention?
5 A. I went to his office and I said "Right, this matter has
6 now reached the Department of Health. Are we going to
7 do something or not?" Although he was not terribly
8 accommodating, when I suggested that I had to write
9 a reply, would he have a look at what I had to reply and
10 at least in principle agree, he said so. I wrote this
11 letter, I showed it to at least three different people:
12 Vann Jones, Roylance and probably even Farndon.
13 Q. Pause there. At the GMC Professor Vann Jones was asked
14 about the letter which you sent in reply to this one,
15 which we will come to in a minute. He was asked whether
16 he recalled receiving a copy of that letter, of your
17 reply to this letter from Dr Doyle.
18 He said he did not get a copy at the time.
19 A. So when did he get it?
20 Q. He had only seen it for the first time two or three
21 weeks before the GMC hearing.
22 A. Obviously there is a habit of letters getting lost in
23 the UBHT.
24 Q. Dr Roylance has no recollection of having seen
25 Dr Doyle's letter to you, although he did see the reply
0153
1 after it was sent, as we will see in a minute.
2 A. So he saw the reply, but he was not interested to see
3 the original letter. That is very strange, is it not?
4 Q. I just want to find out what your evidence is, Professor
5 Angelini.
6 A. I am sorry.
7 Q. Your evidence is that this letter was taken by you
8 personally --
9 A. Personally, in hand and this time it was not on the
10 table, it was in front of the face of these individuals.
11 Q. And those individuals are Dr Roylance and Professor Vann
12 Jones?
13 A. And I am not sure about Professor Farndon. I am not
14 100 per cent sure about that, but certainly Dr Roylance
15 and Professor Vann Jones, with no shadow of doubt.
16 Q. To the extent that neither of those two recollect seeing
17 the letter, you would take issue with that?
18 A. I suppose it is their word against mine. What is
19 strange is that this letter was even cc'd to them.
20 Again, they may not have received it.
21 Q. Let us turn over the page, page 288. This letter was
22 not cc'd to anybody?
23 A. This one of Doyle's? No, this was not, my reply.
24 Q. Your reply, 61/273. This is nearly a month after
25 Dr Doyle had written to you?
0154
1 A. Yes, the reason for the delay was because, as I said,
2 I went on holiday, but that was the real excuse. The
3 reason was that I wanted to have some kind of
4 consultation with all the people who matter, like the
5 Chief Executive, the Director of Cardiac Services.
6 There was no point in me sending a letter to Doyle on my
7 own bat, authority, since I did not seem to have much
8 authority with anything, anyway.
9 Q. Let us have a look at the first page of the letter,
10 please, first of all. Again, you are familiar with this
11 letter?
12 A. Yes, very much so.
13 Q. If we go over to page 274, we see it is copied to
14 Professor Vann Jones and to Dr Roylance. There is
15 a tick beside it, which may indicate that this version
16 which the Inquiry got, was the one that Dr Roylance had.
17 If we just go back over the page to the beginning,
18 there is a manuscript annotation which I am pretty sure
19 reads:
20 "James, could I have your comments, John."
21 A. I have never seen this before.
22 Q. I am not suggesting you would have done. If we go to
23 UBHT 61/276:
24 "Dear John", 4th September. You will recall that
25 your reply was dated 19th August.
0155
1 "Dear John,
2 "Gianni's letter of 19th August to the DoH.
3 (1) This letter rightly emphasises that the
4 problem is with one procedure only. The rest of the
5 work is entirely acceptable or better.
6 (2) The letter is on the whole supportive.
7 (3) It might be useful for you to write
8 indicating the limited nature of the problem, your
9 awareness of it and the steps which are being taken,
10 i.e. (i) new cardiac surgeon in paediatrics, (ii) the
11 Trust [underlined] has decided to move paediatric
12 cardiac surgery to the Children's Hospital.
13 (4) Confidence for the future.
14 (5) A quick chat between you and Gianni about
15 such a letter might help to build up Gianni's confidence
16 in the Trust setup.
17 (6) I have discussed it with Gianni and I shall
18 discuss the source of information with the Department of
19 Health with you on my return.
20 Yours, James."
21 If we take it that the "James" is Mr Wisheart and
22 the "John" was Dr Roylance, as they obviously are, does
23 not the fact of the annotation on the reply and those
24 comments rather suggest that Dr Roylance had not seen
25 any draft of your reply and had not seen your letter
0156
1 until after it was sent, when he then farmed it out to
2 Mr Wisheart for comment?
3 A. No. Absolutely not. I went to Dr Roylance, to his
4 office, and I showed him the letter from Dr Doyle as
5 well as my reply. On top of that, my reply was cc'd to
6 him. Whether he ever got it or not, I cannot put my
7 life on that.
8 Q. He did get it because he scribbled on it, as we have
9 just seen.
10 A. You are saying he got it before I sent it to --
11 Q. No, I am not making myself clear.
12 A. I am sorry, I do not understand you.
13 Q. I am suggesting that Dr Roylance did get your reply,
14 273 --
15 A. Yes, but not the original letter from Dr Doyle.
16 Q. Not the original letter from Doyle, and he did not get
17 your reply until after it had gone to Doyle.
18 A. I mean, first of all, if he got my letter, if he had any
19 sense, he would have asked me for the original of Doyle
20 if he had never seen it before. How could he make out
21 what I was saying in the letter if he did not know what
22 the letter from Doyle was saying? That is a bit
23 strange, is it not?
24 The second thing is, I definitely discussed this
25 letter not only with Dr Roylance but also with Professor
0157
1 Vann Jones.
2 Q. If Dr Roylance had had input into your reply --
3 A. No, they did not have any input. He just looked at it
4 and said "Fine, so be it". He did not contribute to any
5 change in the letter or do anything.
6 Q. Let us look briefly at your reply, and then it may be
7 time for another break. Let us scan down the page. You
8 say, in the third paragraph:
9 "We have been able to advertise a new position for
10 a full-time paediatric consultant surgeon and there were
11 interviews undertaken on 20th September."
12 You make some optimistic noises, if I can put it
13 like that, about the appointment of the surgeon.
14 Then you go on to say in the next paragraph, the
15 second line:
16 "The view of all the medics involved in the work
17 anaesthetists, surgeons and cardiologists, is that the
18 present facility should be moved from the BRI to the
19 Children's Hospital, and it is my understanding that the
20 Trust has been looking in this direction."
21 We have seen that correspondence and paperwork.
22 A. That is correct.
23 Q. "The appointment of a full-time paediatric surgeon and
24 the move of the activity to the Children's Hospital
25 would greatly strengthen our unit and address the
0158
1 shortcomings pointed out in your letter ..."
2 Over the page:
3 "... there is no doubt in my mind that the problem
4 we have been experiencing is something which we can
5 address. I am sure that in the next six months I will
6 be able to write to you again and present you with
7 evidence that the changes have taken place as desired by
8 you, and indeed by everybody else concerned here in
9 Bristol. I will keep you informed all the way along."
10 So the two suggestions made there are that there
11 is going to be an appointment made, interviews set and
12 secondly, that the split site is going to be rectified?
13 A. No, I said in fact there is a paragraph where I say this
14 decision is not in my hands.
15 Q. You are quite right, I entirely accept that. You say
16 there are interviews on 20th September and all the
17 clinicians hope --
18 A. Are favourable.
19 Q. -- that the split site will be ended. You cannot speak
20 for the Trust Board, but you hope that will go through?
21 A. Yes.
22 Q. Those are the only two suggestions that are made in that
23 letter, and you say that taking those two steps would
24 address the concerns that Dr Doyle had raised?
25 A. It would. In fact, I think he was quite happy with my
0159
1 reply.
2 Q. There is nothing in that letter about what was going to
3 happen in the meantime, is there?
4 A. No, there is not.
5 Q. And that is because your focus was not on what was going
6 to happen in the meantime; your focus was on the medium
7 term appointment of the surgeon and the ending of the
8 split site?
9 A. Yes and no. What you say should have been in that
10 letter as well is to say any neonatal operation or any
11 high risk operation in the meantime will not be done --
12 THE CHAIRMAN: Professor Angelini, Mr Maclean is not
13 suggesting anything. That is not his job.
14 A. No, I am saying maybe I should have said that in that
15 letter, but I did not think it was really necessary,
16 because if we were going to appoint a paediatric
17 surgeon, to me it was quite obvious and this had been
18 discussed in various meetings, that we had to try to
19 contain the problem, do the operation we were reasonably
20 good at, and trying to stay away as much as possible
21 from the operation we were not good at, as indeed was
22 expressed, this view by me, not to Dr Doyle but
23 certainly to my colleagues in a couple of meetings,
24 including at the end of an audit meeting some time in
25 October or November.
0160
1 Q. Let us, just before we finish on this point, go back to
2 the first page of the letter, 273. Let us just look at
3 the second paragraph. The second line:
4 "I have to admit that indeed there have been
5 audits carried out which have shown a greater mortality
6 than perhaps could be expected in a particular surgical
7 procedure."
8 A. Yes.
9 Q. Just leave that for a minute. The next paragraph; the
10 last sentence:
11 "Of course, it all depends on the quality of the
12 applicants, but I can tell you that from the interest
13 this position has generated, we will certainly have at
14 least one or possibly two very experienced candidates."
15 I have read the wrong sentence. The one before:
16 "I can assure you that we will do our best to
17 appoint a suitable candidate. It is our desire to find
18 someone familiar with the surgical procedure for which
19 our results have been least satisfactory."
20 Taking them in reverse order, which procedure were
21 you referring to as the "one for which our results have
22 been the least satisfactory"?
23 A. I think we spent several hours in the GMC as to whether
24 I should have put an s or not. What I was referring to
25 was very simple. There were at least three procedures
0161
1 which were bad and those were Fallot tetralogy
2 correction, switch, AV canal. As a matter of fact, by
3 that time in my view, there were problems all across the
4 board with neonates and these were related even to
5 procedures for which the numbers were not big enough,
6 like truncus, total anomalous pulmonary venous
7 drainage. It was a total collection of things in which
8 you did not have enough numbers to say you could apply
9 some kind of statistics, but if you were to take all the
10 neonatal surgery together, there was very little we were
11 any good at, at all.
12 Q. Which procedure was the one at which you were the least
13 satisfactory?
14 A. The switch AV canal. At that time, the switch was the
15 most unsatisfactory procedure.
16 Q. So the third paragraph, the specific reference to the
17 one procedure --
18 A. No, as I said, I may have made a mistake, instead of
19 saying "procedures" I said "procedure", but I was
20 referring to virtually the fact that the neonatal
21 surgery was substandard as a whole.
22 MR MACLEAN: I hope we may be able to move on from this
23 letter. Perhaps we could have a short break while
24 I consider whether we will or not move on?
25 THE CHAIRMAN: Shall we take 15 minutes and reconvene at
0162
1 20 past?
2 (3.05 pm)
3 (A short break)
4 (3.20 pm)
5 MR MACLEAN: Sir, just before we come back to Professor
6 Angelini, I should say that today we had originally
7 planned to hear from two witnesses, from Professor
8 Angelini and from Mrs Janet Maher. We will not be
9 hearing from Mrs Maher this afternoon. I will conclude
10 my questions with Professor Angelini and when I have
11 done so Miss Grey will appear as if by magic and address
12 you further on the timetable for witnesses tomorrow and
13 subsequently.
14 THE CHAIRMAN: And she will tell me why.
15 MR MACLEAN: She may be in a position to enlighten you
16 further, but Mrs Maher will not be giving evidence
17 today.
18 Q. Professor Angelini, we were looking at your reply which
19 you gave to Dr Doyle, if you scan up the page to the
20 top, on 19th August 1994, and we were discussing briefly
21 before the break the reference to a particular surgical
22 procedure and so on in the second and third paragraphs.
23 I showed you briefly those comments which
24 Mr Wisheart had made on this letter, apparently at the
25 behest of Dr Roylance, UBHT 61/276.
0163
1 You might not be able to help me with this. The
2 first comment from Mr Wisheart there:
3 "This letter rightly emphasises that the problem
4 is with one procedure only. The rest of the work is
5 entirely acceptable or better."
6 Which one procedure only do you think
7 Mr Wisheart's reply is referring to?
8 A. I am sure he was referring to the switch procedure.
9 Q. Why are you sure about that?
10 A. To say "only one procedure", the one which was standing
11 out more than anything else at that time was the switch,
12 although we knew then the results from the AV canal and
13 the tetralogy of Fallot were also not very good.
14 This statement is obviously wrong because two
15 months later we were presented with the figures for the
16 AV canal which were as bad as the switch with
17 a mortality around 70 per cent, so to say the rest of
18 the work is entirely acceptable or better is just plain
19 lies, really.
20 Q. You do not agree with that statement?
21 A. No, it is just a lie, because there was a mortality on
22 the AV canal of 70 per cent, which was presented two
23 months later. Maybe we did not know at that time, but
24 I would argue since the mortality of the AV canal was
25 related to Mr Wisheart, either he did not know what his
0164
1 results were or he was at least economical with the
2 truth.
3 THE CHAIRMAN: Professor Angelini, we do have to be quite
4 careful about the use of the word "lie".
5 PROFESSOR ANGELINI: I am sorry about that.
6 THE CHAIRMAN: You should not be sorry, you should use
7 whatever word you wish, but make sure whenever you use
8 a word as strong as that, you have some evidence to back
9 it up.
10 PROFESSOR ANGELINI: In this case the evidence was that the
11 mortality in the AV canal was 70 per cent. I think this
12 has been accepted by everybody.
13 MR MACLEAN: So as far as you were concerned, to suggest
14 that apart from the switch the rest of the work was
15 entirely acceptable or better, was completely
16 unjustified as a statement?
17 A. Absolutely.
18 Q. The second comment Mr Wisheart makes is that your letter
19 was on the whole supportive. That is true, is it not?
20 A. I suppose so, yes. I was trying to give a quite good
21 picture that we were now in a position to be able to put
22 our house in order, since the appointment of the new
23 paediatric surgeon was going to take place very soon,
24 and I had the feeling then that the move to the
25 Children's Hospital was also achievable.
0165
1 Q. You were trying to reassure Dr Doyle?
2 A. Yes, I suppose so.
3 Q. Can we go to 61/273, again, the reply, your own letter
4 [UBHT 61/273], at the bottom of the page. You say that
5 you were not in a position to comment any further than
6 whether or not the move to the Children's Hospital would
7 in fact take place. If we go, then, to Dr Roylance's
8 letter, which is 61/278, this is a letter that
9 Dr Roylance wrote to Dr Doyle, which essentially makes
10 the point that Mr Wisheart's comments to Dr Roylance
11 suggested might be made.
12 Further down the page?
13 A. Yes, where he says that a decision has already been
14 taken by the Trust Board.
15 Q. So did you see that letter at the time it was written?
16 Was it copied to you?
17 A. I cannot remember. I do not think it was. But I cannot
18 remember. I certainly saw this letter at the GMC
19 Inquiry, but I do not remember whether there was cc'd to
20 me.
21 Q. That letter from Dr Roylance to Dr Doyle is
22 12th September. If we go to page 279, there is a letter
23 from Dr Doyle to Dr Roylance, 20th September:
24 "Thank you for your letter, and your reassurances
25 that the Trust has action in hand to remedy the
0166
1 concerns ... very relieved to hear from Gianni Angelini
2 that a change in the service had been planned. Under
3 the circumstances, I think it is best to leave the Trust
4 to effect the proposed changes as quickly as possible."
5 So if not "problem solved" from Dr Doyle, at least
6 it was in hand?
7 A. Yes.
8 Q. If we look down the page, there is a stamp there,
9 a Chief Executive's office stamp?
10 A. This was sent to me, yes.
11 Q. It looks as if it was sent for information to
12 Mr Wisheart and to you?
13 A. Yes.
14 Q. In your reply, when you say that these two important
15 steps have to be taken, appoint a new paediatric cardiac
16 surgeon and moving the children's surgery to the
17 Children's Hospital, both of those things have now come
18 to pass. You said that those two changes would address
19 the shortcomings, in your reply to Dr Doyle?
20 A. That is correct.
21 Q. Is it your opinion that those two changes have in fact,
22 as it turned out, addressed the shortcomings?
23 A. It was like from night to day. It was a totally
24 different service from the one we had. We have got now,
25 if you allow me some advertising, possibly one of the
0167
1 best paediatric units in the country or in the rest of
2 Europe.
3 Q. But as I think I mentioned earlier, your reply to
4 Dr Doyle, which is at 273, does not make any provision
5 for what was going to happen with paediatric cardiac
6 surgery before the new surgeon was appointed and before
7 the surgery goes to the Children's Hospital?
8 A. That is correct. But it does not mean that I discussed
9 with my colleagues the fact that we had to avoid
10 operating on high risk children, particularly neonates.
11 I did not state this in this letter, but I had
12 a conversation with my colleagues on this precise point.
13 Q. Which colleagues did you have those discussions with?
14 A. Mr Dhasmana, for example.
15 Q. Who else?
16 A. Mr Hutter; Mr Bryan.
17 Q. You never suggested to Dr Roylance, before the operation
18 on Joshua Loveday was imminent --
19 A. Yes, I did. At a meeting in which McKinley was also
20 there, and Professor Farndon was also there. In fact,
21 it was Bob McKinley who said something like, "I come
22 from aerospace. If we had a situation like this, we
23 would have stopped the whole lot. I want to stop
24 paediatric surgery altogether", and I said I did not
25 think he had to close the shop altogether; he had just
0168
1 to rationalise the system in such a way that the
2 operation we were no good at was not going to be carried
3 out, but ordinary routine cases could continue to take
4 place.
5 Q. When did this meeting take place with Mr McKinley?
6 A. I think it was prior to the appointment of Mr Pawade, so
7 it would be about August 1994, and this was because we
8 had gone to canvass some support, John Farndon and
9 I, from the new Chairman with regard to the appointment
10 of Pawade, because to a certain extent, Professor
11 Farndon and myself, we thought that this was far the
12 best candidate in terms of experience, and he was
13 somebody who could come in and from the word go turn the
14 service around.
15 Q. Can we look at your statement very briefly, WIT 73/17,
16 paragraph 68. You mention in paragraph 68 that you
17 raised the issue with the Chief Executive of the
18 hospital.
19 A. That is correct.
20 Q. And you had conversations with Mr Durie, the Chairman of
21 the hospital, and his successor, Mr McKinley?
22 A. That is absolutely correct. I stand by this.
23 Q. I do not think -- I stand willing to be corrected --
24 that you referred in your statement in any detail to any
25 particular meeting with Mr McKinley?
0169
1 A. I think there is a reference in my statement, or if not
2 in my statement, in the GMC cross-examination, and
3 I think even in the statement I provided to the
4 Inquiry.
5 Q. This is the statement to the Inquiry. Paragraph 68 has
6 a reference to Mr McKinley. If we go to page 19 --
7 A. But it is probably then in my statement to the GMC.
8 Q. We will look at that in a minute. Paragraph 79:
9 "I subsequently spoke at length with Professor
10 Vann Jones and with all my cardiac colleagues, with
11 Dr Roylance and with Mr McKinley."
12 A. Yes. The meeting I am referring to with Mr McKinley was
13 also in the presence of Professor Farndon, so it was not
14 just me.
15 Q. So it was in the presence of Professor Farndon?
16 A. Yes, and at the end of the conversation McKinley asked
17 Roylance to come in.
18 Q. So it was in Mr McKinley's office?
19 A. Yes, it was in Mr McKinley's office. In fact
20 Mr McKinley had just arrived, literally weeks before.
21 Q. What did you say to Mr McKinley?
22 A. We told him that we were very keen for Mr Pawade to be
23 appointed.
24 THE CHAIRMAN: Paragraph 55 of Professor Angelini's
25 statement may help both of you.
0170
1 MR MACLEAN: I am much obliged. Carry on, Professor, I am
2 sorry.
3 A. We said to Mr McKinley then, we were looking to some
4 support from him, since he was going to be the Chairman
5 of the employment committee on the appointment of
6 Pawade, the reason being that Pawade had had a rather
7 unusual, if you like, sort of training; he was now
8 a consultant in Australia for the last two years, and we
9 were concerned that somebody may have raised issues
10 like, he has not been in this country for the last three
11 years.
12 Q. He did not have the accreditation?
13 A. At that time accreditation was not required, but to cut
14 a long story short, we knew Mr Pawade, he was working
15 with somebody who had trained with me. This was my
16 man. And not only my man, there were other people like
17 Farndon, Alison Hayes, one of the cardiologists, even
18 Mr Dhasmana was very supportive of the Pawade
19 appointment. So we went to McKinley and we said, "Look,
20 this is what we want to do, will you support us?"
21 Q. So you were slightly concerned that Pawade might be
22 missed?
23 A. Yes.
24 Q. And you went to McKinley and said, "This is the chap we
25 want, he is the best for the job and we do not want him
0171
1 to slip through our fingers"?
2 A. "We do not want to lose him".
3 Q. That was the reason for --
4 A. That was the reason for that meeting.
5 Q. If we go to DOH 1/9, you will not have seen this
6 document. It is a memo from Dr Doyle -- we see that on
7 the right-hand side.
8 A. Yes.
9 Q. To Dr Winyard, I think the Deputy Chief Medical Officer
10 and Dr Scally in the South West region.
11 If we look down the page a little, paragraph 2:
12 "Earlier this year, [Professor Angelini] became
13 very concerned about the audit results ... Professor
14 Angelini persuaded the Trust to appoint a new paediatric
15 cardiac surgeon and to transfer the service to the
16 Children's Hospital. It was also agreed that no further
17 neonatal or infant cardiac surgery would be performed
18 pending the arrival of the new appointee. (See attached
19 correspondence)."
20 We will have to see Dr Doyle about the
21 correspondence that was attached to this memo. Are you
22 aware of any correspondence which stated that there had
23 been an agreement that there be no further infant or
24 neonatal cardiac surgery?
25 A. There was nothing in writing, at least as far as I know.
0172
1 Q. You remember in your reply to Dr Doyle you promised to
2 keep him fully informed, keep him in touch with events
3 as they unfolded. Did you do so?
4 A. By telephone. We had several telephone conversations
5 all the time and those intensified towards January when
6 there was the last switch operation planned.
7 Q. Joshua Loveday.
8 A. But we were in quite regular contact.
9 Q. Did you tell Dr Doyle that no further neonatal cardiac
10 surgery would be performed?
11 A. No, I do not think I said that, and I did not put that
12 in writing anywhere, at least so far as I can recollect.
13 Q. Was it your impression that there would be no further
14 neonatal cardiac surgery?
15 A. Absolutely, and I had stated this in various meetings
16 with various people and indeed, there was no switch for
17 several months.
18 Q. Dr Doyle gave evidence at the GMC. 23rd October 1997,
19 page 111 of my version of the transcript.
20 "What did you believe to be the position as
21 respects the undertaking of paediatric cardiac surgery
22 until Mr Pawade arrived?"
23 Dr Doyle said:
24 "Both of the letters and also the phone
25 conversation I had with Professor Angelini around the
0173
1 end of August, I was certainly given the strong
2 impression that no complex paediatric cardiac surgery
3 would be performed at the Bristol Royal Infirmary
4 pending the two changes that had been highlighted".
5 That is the point that had been highlighted. The
6 first was the appointment of Mr Pawade, the second was
7 the moving of the service to the Children's Hospital.
8 He referred at page 119 of the same date to having
9 been given verbal assurances by Professor Angelini,
10 "...and I certainly took the assurances from
11 Dr Roylance's letter, albeit possibly falsely, that the
12 undertakings had been given that no 'risky' operations
13 would be performed pending Mr Pawade's letter, so at
14 that stage I was content that the matter had finally
15 been grasped and that it would now be appropriate for me
16 to take more of a back seat."
17 So Doyle was reassured?
18 A. Yes. I never put this in writing myself, and I really
19 do not think that I had any authority to say no neonatal
20 procedure can be carried out, because whether people
21 would listen to me or not, it was entirely up to them.
22 I did not have the authority to make that statement.
23 Q. In the latter part of 1994, you saw some further
24 AV canal data from Dr Bolsin?
25 A. Yes.
0174
1 Q. Can we look at UBHT 54/3? Is that the data you saw?
2 A. Yes, that is it.
3 Q. Dated 31st October. It is referring to one surgeon
4 only, and the surgeon is JDW: Mr Wisheart?
5 A. That is correct.
6 Q. There is a 30 per cent mortality on the table and
7 a minimum 70 per cent mortality for the period 1992 to
8 1994.
9 A. That is it.
10 Q. If we scan down a little, Dr Bolsin's signature at the
11 bottom: is that his writing, or your writing?
12 A. No, that is mine, "from Dr Bolsin".
13 Q. "SB data from Dr Bolsin", that is your writing?
14 A. "SB data" is not my writing but "from Dr Bolsin" is my
15 writing. Presumably "SB" is just him signing it and
16 "from Dr Bolsin" is my comment.
17 Q. So this is definitely the one you saw?
18 A. Yes.
19 Q. "Data also demonstrated one surgeon was statistically
20 worse than the other."
21 Did you know that Mr Wisheart had not done any
22 AV canal work since August 1994?
23 A. Yes, which was just a month or two before this.
24 Q. If we scan up the page --
25 A. The last one was 25th August or something like that.
0175
1 Q. There it is there, "died on table".
2 A. Yes, that is correct.
3 Q. He had done no more since then?
4 A. He had not, no.
5 Q. And he was not going to do any more?
6 A. I am sorry, yes. After these results, I would be
7 surprised he had not stopped before.
8 Q. That is a different point, but did you know in October
9 1994 that there were not going to be any more of these
10 operations carried out by Mr Wisheart?
11 A. Put it this way: there was nobody who ever said, "From
12 this operation onwards, Mr Wisheart is not going to do
13 any more AV canal". There was no memo, there was
14 nothing written down by anybody, whether this was
15 Mr Wisheart or anybody else.
16 Q. Did you discuss this specific data with anyone else,
17 apart from Dr Bolsin who showed it to you?
18 A. Yes, lots of people. Again, Mr Bryan, Mr Hutter,
19 Mr Dhasmana. In fact, we had quite a confrontational
20 meeting some time a few weeks after this, where I was
21 trying to say that the service should be rationalised.
22 This data was seen by all sorts of other people, but
23 certainly, I showed this to Professor Farndon. This
24 was, at that stage, whereas perhaps the first time
25 Dr Bolsin's data was circulated in a more circumspective
0176
1 way, this was much more open. Everybody had these
2 almost overnight.
3 Q. You did not discuss this specifically with Dr Roylance,
4 however?
5 A. I cannot remember.
6 Q. I think at the GMC --
7 A. I probably said I did, but I cannot remember now. These
8 are really five or six years ago events. I have a head
9 full of numbers and names. I have seen these people
10 millions of times.
11 Q. What you said at the GMC, in my version page 4110:
12 "Did you specifically discuss that data with
13 Mr Roylance?
14 Answer: I did not specifically discuss the data
15 in the way 'look how many are dead, look how many are
16 alive' but I vividly remember we had a meeting where
17 I pointed to the fact that after all, my concern which
18 I had regarding the AV canal may have been vindicated by
19 this newly available data which showed things had not
20 got better but, if anything, had got worse."
21 Is that still your evidence?
22 A. Yes, I stand by that.
23 Q. I do not know, logically, the next event was the meeting
24 at Mr Wisheart's house and the surgeons' meeting with
25 Mr Farndon. We have dealt with that I think.
0177
1 A. Yes.
2 Q. Can we come to the final area, the operation on Joshua
3 Loveday? Can I ask you to look at the notes of the
4 meeting which Mr Wisheart had with Professor Farndon on
5 17th November 1994, GMC 4/80, please? This was
6 a meeting of just the two of them, you were not there?
7 A. No, I was not.
8 Q. This is a typed up verse of the note, it is not
9 perfect. We have the handwritten version. You were
10 asked at the GMC about this?
11 A. I was shown a little extract of this, not the whole lot.
12 Q. This is a typed up version of Professor Farndon's note.
13 Let us go to GMC 4/81. The second paragraph, the last
14 sentence:
15 "It is also noted that he [Dr Bolsin] developed
16 a referral --
17 A. I am sorry, where are you looking?
18 Q. The second new paragraph beginning "JW". The next
19 sentence which begins also on the third line:
20 "It is also noted that he [Dr Bolsin] developed
21 a referral agency without telling people that they were
22 named, e.g., James W, Oxford ?? [double question mark],
23 et cetera" and somebody has written the word "Westaby".
24 Can I show you UBHT 118/15. Before we look at it
25 any further, you would have been 40 years old in 1993?
0178
1 A. That is right, yes.
2 Q. Have a look at this document:
3 "The following consultant surgeons and
4 anaesthetists will be undertaking the provision of
5 medical care for the patients referred from the Regional
6 Consortium for Purchasing Cardiac Services based at the
7 UHW, Cardiff."
8 It is on the headed notepaper of Whitechurch
9 Medical Services Ltd Cardiff and the Head Office is
10 36 Westbury Lane, Bristol.
11 If we scan down the page, at the bottom there is
12 a paragraph about Dr Bolsin. If we go further down, can
13 we go to the very bottom of the page, please. Let us go
14 back to Professor Angelini's paragraph. There is
15 a paragraph about you there. Can you help us with what
16 this is all about?
17 A. I never saw this. It is full of mistakes. First of
18 all, my name is spelled wrong. Secondly, I never worked
19 at the Middlesex Hospital.
20 Q. Let us look at page 118/11, please. Can we see this
21 whole page, please, first of all? Let us look at the
22 first and second paragraphs.
23 Are you able to shed any light on what --
24 A. Yes, I think I am. I never saw this, incidentally, nor
25 the other one, because otherwise I would at least have
0179
1 changed the spelling of my name and the inaccuracy.
2 I never worked at the National Heart or Middlesex
3 Hospital. This, I suppose, is a good indication that
4 I never saw it. I seem to remember, then -- when is
5 this letter dated?
6 Q. We reckon it is November 1993, or thereabouts.
7 A. Dr Bolsin -- I did not even know he had a company or
8 whatever this is, but Dr Bolsin was trying to recruit
9 patients, either private patients or patients coming
10 from various Health Authorities as part of the waiting
11 list initiative to be done at the BUPA hospital in
12 Bristol.
13 He had asked us whether, if there were such
14 patients, we would be happy to operate. I am sure we
15 all said "Yes, by all means". But that just was about
16 all I know. I certainly never operated on anybody who
17 was referred by Dr Bolsin at the BUPA hospital, or
18 indeed, anywhere else.
19 Q. If we go right down to the bottom of this page -- it is
20 not going to be there. Can I tell you on the very
21 bottom of that page on the hard copy which is in front
22 of me, it says: "Registered in England" and there is
23 a company number for the company. Then there is an
24 address. Then it says "Managing Director, Janet E
25 Seager, BA Hons", the person who has written the letter,
0180
1 and then it says "Company Secretary, SNC Bolsin BSc,
2 MBBS, FRCA", so it would appear that Dr Bolsin was the
3 Company Secretary of this company.
4 You cannot take it any further?
5 A. Not any further than I just told you. I do not think he
6 ever managed to get any contract with anybody, so far as
7 I know.
8 Q. Can we go to 13. This is a letter, if we look over the
9 page to UBHT 118/14, from Dr Bolsin. Back then to
10 UBHT 118/13. It is a letter to the University Hospital
11 of Wales, negotiating a reduction in the price of what
12 I think are adult operations. If we go down the page,
13 you see you are mentioned in the paragraph beginning
14 "The cardiac surgery service ... also now including
15 Professor Gianni Angelini."
16 A. I do not think I ever saw this. Surely this must have
17 been negotiated together with the BUPA hospital, is it
18 not?
19 Q. Well, I certainly do not know, Professor Angelini.
20 A. Neither do I. I am totally unaware of all of this.
21 Q. So this is a mystery to you?
22 A. Yes. I mean, it is not a mystery in the way I explained
23 it to you. This is all I know.
24 Q. I understand. All you know is that --
25 A. He was actively trying to get patients as part of -- at
0181
1 the end of every financial year, all the various health
2 authorities are in a sort of panic state. They are
3 trying to have patients done right and left because they
4 have got surplus money. We have done this before at the
5 BUPA and at the BRI. We did it all in the last four
6 months last year. Every Saturday a team of people would
7 operate on an NHS patient waiting list initially from
8 Cornwall. We all did the operation, we were all paid
9 outside our normal hours, and I suspect the purpose of
10 this was exactly the same. But that is all I can tell
11 you.
12 Q. Back to the actual surgery at the BRI at the time.
13 You discovered that Joshua Loveday was in the list for
14 January 1995?
15 A. That is right.
16 Q. You spoke to Dr Martin, I think, did you not?
17 A. Amongst other people, I spoke to a lot of people.
18 I spoke to Professor Farndon, I spoke to Mr Bryan,
19 I spoke to Mr Hutter, I spoke to Dr Martin.
20 Q. You spoke to Dr Martin?
21 A. Yes, I did.
22 Q. In person?
23 A. No, on the telephone.
24 Q. Where was he?
25 A. He was doing an outpatient clinic somewhere in the South
0182
1 West. I do not know where. His secretary tracked him
2 down for me and we had a conversation on the telephone
3 which may have lasted 15 or 20 minutes.
4 Q. You questioned the carrying out of the operation?
5 A. I questioned to him the wisdom of doing this case in the
6 BRI. I also told him that this was not an urgent case
7 and there was no need to do this operation and if he
8 felt that the child needed an operation, we could
9 have sent him to Birmingham, to Bill Brawn, who was
10 perhaps the best surgeon in the land, to do this
11 operation safely.
12 Q. Did Dr Martin agree that the operation was urgent or
13 not? Or did he agree it was not urgent?
14 A. He agreed it was not urgent.
15 Q. So what did you understand his justification being for
16 carrying out the operation?
17 A. His justification was since this child was not
18 a neonate, the results on the non-neonate were much
19 better than the results on the neonate, therefore he was
20 justified to go ahead with the operation.
21 Q. Does that explain why the operation had to take place in
22 January 1995?
23 A. I do not think I understand your point.
24 Q. Dr Martin was saying the results for non-neonates are
25 okay?
0183
1 A. Yes, so there is no reason to send this child somewhere
2 else or to postpone him. That was his argument.
3 Q. Why carry out the operation before Mr Pawade took up his
4 post, if it was not urgent?
5 A. I think you have to ask that question to Dr Martin.
6 Q. Did you ask that question?
7 A. Yes.
8 Q. What was the answer?
9 A. "The child has been waiting; why wait not a little
10 longer?" I cannot exactly remember the specific words
11 he said, but in his view the competence of the surgeon
12 to do this operation in a child of the age of the child
13 we were dealing with was adequate. Of course, I totally
14 disagreed with this.
15 Q. So you agreed to differ?
16 A. Absolutely. I said that this was a very bad decision
17 and I am afraid I was in total disagreement.
18 Q. Can we have JDW 7/30, please? This is a letter from you
19 to Mr Wisheart. 10th January.
20 A. Yes.
21 Q. You had spoken to him previously?
22 A. I spoke to him previously in his office. I tried to
23 persuade him, as well as many other people, of how
24 unwise it was to go ahead with this operation, and
25 I wrote this letter, really as the final attempt to see
0184
1 whether by putting my concern in writing this could have
2 somehow convinced them or -- I do not know what -- but
3 it was literally the final attempt. I had spoken with
4 Dr Roylance. I had spoken with Dr Doyle at the
5 Department of Health. Dr Sheila Willett, Professor
6 Farndon, you name it. I did not have anything else
7 I could do except writing this letter, and that is the
8 last thing.
9 Q. You wrote to Mr Wisheart and headed it "Medical
10 Director"?
11 A. Yes. It was a deliberate statement because I wanted to
12 make him responsible as Medical Director and not as the
13 surgeon, also given the fact that he was not going to do
14 the operation anyway. He was the Medical Director, he
15 could have stopped his own patient.
16 Q. You had spoken to him a few days before?
17 A. Yes.
18 Q. Did you tell him you were going to contact Dr Doyle at
19 the Department of Health to stop the operation?
20 A. Yes, I did, and I believe Dr Doyle contacted the Trust
21 anyway.
22 Q. You did speak to Dr Doyle before the operation?
23 A. At least two or three times. In fact, I asked for his
24 help and following my telephone conversation, I am
25 absolutely certain he spoke with Dr Roylance.
0185
1 Q. You had spoken to Dr Roylance as well?
2 A. As well.
3 Q. What did he say?
4 A. Dr Doyle?
5 Q. Dr Roylance, to you?
6 A. The usual type, the 'recorded message': "This is
7 a matter for the clinical people".
8 Q. Did not Dr Roylance say, "Well, the surgeon is
9 Mr Dhasmana and he is happy to go ahead and the
10 cardiologist, Dr Martin, he is happy to go ahead"?
11 What was Dr Roylance to do?
12 A. By that time, there had been no meeting of all the
13 people involved because the meeting took place the night
14 before the operation, so that was after I had spoken
15 with Dr Roylance. But the issue was a more fundamental
16 one here. The people who were trying to take the
17 decision on whether to go ahead or not, not only were
18 making a decision 12 hours before an operation, but
19 somehow they were all emotionally involved in this
20 business of the switch operation. They were not in any
21 position to take any sensible decision.
22 The reason I went to see Mr Wisheart and then
23 Dr Roylance was simply to say to them, "You are senior
24 people, you are in a position to stop this operation
25 which is not urgent. Why do you not just think about
0186
1 this. Why do we not assess this with a cool head before
2 embarking and doing the surgery which may end
3 catastrophically for the child, and then what we have
4 proved?"
5 So the people who were taking the decision were
6 too much emotionally involved in what was going on.
7 I think that was a wrong decision, and the Chief
8 Executive and the Medical Director should have
9 appreciated that the decision should not have been left
10 to these people. If I was the surgeon, under no
11 circumstances would I do an operation where a body of
12 people has decided 12 hours before whether I am fit or
13 not to do it? Can you imagine the pressure on you when
14 you have to do an operation with everybody, with a gun
15 aiming at you? And in fact I am told, because I was not
16 in the operating theatre, when the right coronary of the
17 child was inadvertently cut, that was the end of the
18 operation. I was not in theatre, but this has been
19 reported to me by the assistant who was helping in the
20 operation.
21 Q. In other words, a surgical mistake was made early on?
22 A. Call it what you want. In my view, it is like scuba
23 diving, when you are 60 metres underwater and you cut
24 your air supply.
25 Q. But a meeting did take place the night before the
0187
1 operation, attended by --
2 A. It did.
3 Q. Attended by, amongst others, Dr Bolsin, and everybody
4 present agreed, did they not, that there was no medical
5 ground for not proceeding with the operation?
6 A. The interpretation of the data was completely wrong by
7 a group of people who were emotionally involved in this
8 problem. They all had -- I am not a psychologist,
9 forgive me, but they all had a sort of collective guilt,
10 because everybody has been in one way or another
11 involved at some stage with this process of the switch.
12 They were not in a stable mind, position, to take this
13 decision. If you look at the data --
14 Q. Can we do that? Can we look at UBHT 126/51.
15 You were not at this meeting?
16 A. No, I was positively excluded.
17 Q. As you understand it, is this the data that was
18 discussed at that meeting?
19 A. Yes, I think it is.
20 Q. If we scan down the page, please, it is the second
21 table, is it?
22 A. That is correct, the one in the middle.
23 Q. "Mortality, JPD patients only"?
24 A. Yes, neonates, non-neonates below 1 year and above
25 1 year.
0188
1 Q. So 9 of 13 neonates had died?
2 A. Yes.
3 Q. 69 per cent. The total of non-neonates who had died was
4 3 out of 15, 20 percent, of whom two were under 1 year,
5 in other words, between 1 month and 1 year old, and one
6 was over 1 year; is that right?
7 A. Yes.
8 Q. So the justification, if that is what it was, for doing
9 the operation as you understood it was arrived at by
10 comparing the 69 per cent figure for the neonates with
11 the 20 per cent figure for non-neonates?
12 A. Yes.
13 Q. And saying 69 per cent was too bad, but 20 per cent was
14 okay?
15 A. Yes. Can I explain to you what my view is? If you give
16 me this data and you allow me to change the time we
17 start counting or divide, for example instead of saying
18 1988 to 1989 we look at 1988 to 1990 or whatever, I can
19 make anything you want of this data, and I am sure the
20 Chairman who is an academic will understand what
21 I mean. I can make anything you want to read into this
22 data. The fact of the matter was that neonate was
23 a mortality which was far, far beyond any place in the
24 UK.
25 One of their arguments was, if you were to compare
0189
1 this data -- and I think if you go below, they compare
2 it with the UK, but forget about that for a minute.
3 They were saying, if you compare the data of above
4 1 year, so not only they have divided the neonate and
5 non-neonate, but now they have divided the non-neonate
6 above 1 year and below 1 year. Obviously statistics is
7 a very fine science but it is very open to manipulation
8 as well.
9 The conclusion is above 1 year, 13 per cent, we
10 can do these operations. So we go back to the neonates,
11 they were bad. It was even something which was worth
12 discussing. You look at the non-neonate. The overall
13 mortality was 33 per cent. If you take the data which
14 was available at the time in the United Kingdom, it was
15 varying between one unit and another and according to
16 the risk of the transposition between 10 and 30 per
17 cent.
18 If you look at the overall mortality here, it was
19 what, 46 per cent. Even if all these cases were the
20 worst possible case taking place in the United Kingdom,
21 they still had a mortality of 15 per cent higher than
22 the highest risk on their own than the rest of the
23 United Kingdom.
24 If you let me finish a second, I will give you
25 another explanation as well.
0190
1 The results of the United Kingdom when they talk
2 about mortality, they also have the mortality from
3 Bristol so if you want to make a comparison, you have to
4 take out the mortality from Bristol.
5 If you look at this, it was trying to justify
6 action which, on my view, could not be justified.
7 Q. You think it is, if I can put it like this, suspicious
8 that you were not at the meeting?
9 A. I was excluded. I had no doubt whatsoever.
10 Q. It was, in a sense, nothing to do with you: you were an
11 adult surgeon, Professor of adult cardiac surgery?
12 A. Yes, who had shown a key interest in everything that was
13 going around. Can I add something else? If my opinion
14 was not requested, why, two or three hours later, did
15 I get a call from Mr Wisheart trying to justify to me
16 why they were going ahead with an operation?
17 Q. I was going to ask you about that. Mr Wisheart rang you
18 that evening and told you that the decision at the
19 meeting was that the operation was to go ahead?
20 A. Yes.
21 Q. He told you that the meeting had unanimously agreed
22 there were no medical grounds for not proceeding?
23 A. I do not know if he said "unanimously". I believe
24 Dr Bolsin had not agreed and Dr Pryn had left the
25 meeting before the decision was taken, so it was not
0191
1 unanimous. Whether he told me it was unanimous or not,
2 I cannot say.
3 Q. You rang Dr Doyle the following day after the child had
4 unfortunately died?
5 A. Yes, in fact I think the day after the child had died,
6 because the day the child died, I was in London at the
7 British Heart Foundation.
8 Q. I think that is right, Professor. It was the 13th. You
9 also spoke on that day to Dr Roylance, did you not, and
10 followed that up with a letter?
11 A. Yes.
12 Q. UBHT 217/138. It is one of the last documents we will
13 have a look at. "Dear John..." [16th January 1995].
14 You refer to a conversation on Friday 13th, the day
15 after the Loveday operation?
16 A. Yes.
17 Q. The second line of the second paragraph:
18 "In view of this, I share your opinion that an
19 enquiry should be held on the paediatric work carried
20 out in the Department of Cardiac Surgery from 1988 to
21 the present day."
22 You say that was a minimum requirement, in your
23 opinion?
24 A. Yes.
25 Q. So Dr Roylance had by this stage decided there should be
0192
1 an enquiry, had he not?
2 A. No, he had not.
3 Q. That is what the letter said?
4 A. It was me putting words in his mouth to force his hand,
5 to have the enquiry.
6 Q. Can we scan down the page --
7 A. This is the reason why I cc'd it to everybody, because
8 I was hoping that now, forcing his hand, he could not
9 wriggle out once more and perhaps we now were going to
10 have a really proper look at the results of paediatric
11 surgery.
12 Q. Then there was a meeting of the Cardiac Surgery
13 Associate Directorate on 17th January, and Professor
14 Vann Jones attended that meeting which he found
15 acrimonious?
16 A. I am sure it was acrimonious.
17 Q. And allegations by this time were flying around of
18 disloyalty and lack of co-operation?
19 A. I cannot remember the specific words. I can tell you
20 I was very, very upset.
21 Q. Then I think the last topic we ought to deal with,
22 I hope fairly briefly, is Professor de Leval and
23 Dr Hunter came to Bristol?
24 A. That is correct.
25 Q. You met them. I think they visited on 10th February
0193
1 1995?
2 A. Yes.
3 Q. There is some documentary evidence for that, but I think
4 there is no dispute about that.
5 A. No.
6 Q. When did you first become aware of their conclusions?
7 A. Suddenly, out of the blue, we were summoned in the Trust
8 headquarters one evening by the then Chairman,
9 Mr McKinley. There were about 10 or 15 people around
10 the table. The Chairman of the Hospital Medical
11 Committee presented some, how can I say, extracts from
12 this de Leval/Hunter report.
13 Q. That was Dr Laszlo?
14 A. Dr Laszlo. Immediately, my feeling was that this was
15 totally unacceptable, and effectively the Chairman was
16 asking us to underwrite this report, to which I said
17 under no circumstances I was prepared to underwrite
18 anything until I had seen the full report. After
19 a longer argument, the people were allowed to look at
20 the report.
21 This was literally for less than five minutes. In
22 my case, with Dr Laszlo looking over my shoulder,
23 I could take no notes whatsoever. I did not have more
24 than five minutes to read it and this created,
25 obviously, a lot of dissatisfaction and complaint.
0194
1 After that, Mr McKinley decided then that the full
2 report was going to be shown to this group of 10 or 15
3 people, and there were two meetings, late in the night,
4 one day after the other -- I do not recollect the exact
5 date -- during which the report was discussed literally
6 word by word. None of us had the opportunity to
7 actually have the report copy in front of us, but there
8 were acetates which discussed the report word by word.
9 Q. I think you have previously said that was 13th and 14th
10 March?
11 A. Yes, I am sure it was.
12 Q. What happened there?
13 A. We discussed the words of this, or most of the
14 paragraph. To me that report was absolutely shocking.
15 In a way, if you like, it was a vindication of what
16 people like me had been saying for a very long time.
17 Despite that report, I felt that particularly myself and
18 Dr Bolsin, we were very much victimised by Mr McKinley
19 and some of the other people present, almost like
20 accused of having been responsible, of having dragged
21 the Trust into this situation and we were responsible
22 for this report and everything else.
23 No really formal decision was taken at that
24 meeting on what was going to happen from then to 1st May
25 when Mr Pawade was supposed to start working, although
0195
1 a few days later, a memo was circulated signed by Dr Nix
2 or Mr Nix, on what we were supposed to do in the interim
3 period.
4 Q. That is HA(A) 146/113.
5 A. At some stage during this meeting, there was a great
6 opposition to my suggestion that no switch should be
7 done. In fact, people wanted to continue and there was
8 the same argument above one year, below one year, infant
9 and neonate, but I think ultimately the memo from Mr Nix
10 stated that no switch operations should be performed
11 until the new surgeon took up the appointment.
12 (Document on screen) That is it, yes.
13 Q. And that is what happened?
14 A. That is what happened, although there were some other
15 cases carried out, in fact one I think up to the last
16 day when Mr Pawade started -- not a switch.
17 Q. Can we look at UBHT 7/27? This is May 1995, a meeting
18 of the Executive Committee of the Trust Board, not
19 a meeting you were present at, of course. If we go
20 to 28, Dr Roylance reviewed the situation -- this is
21 paediatric cardiac surgery:
22 "The Trust Board directed that the Chief Executive
23 should set up an internal confidential conciliation
24 process with independent advice. The process should be
25 completed by the next board meeting so that the Chief
0196
1 Executive could report back."
2 What was your attitude to that decision of the
3 Trust Board?
4 A. This is the first time I have seen this. I am not aware
5 of any particular conciliation process.
6 Q. There was some correspondence between Dr Black, Dr Joffe
7 and various others?
8 A. All right. This is something I was not very much
9 involved in. It was in reply to an article in the BMJ
10 that Dr Joffe published. Dr Black and Dr Bolsin
11 replied, but the Trust took an injunction or something
12 like that, preventing the publication of that report.
13 So really, I cannot comment on any of this. Certainly,
14 to reconcile people and to -- it was a rather difficult
15 task after all that had happened.
16 Q. The timing of this was --
17 A. It would be too late. Too little, too late, I would
18 say.
19 Q. Just to wind up my questions, Professor Angelini, you
20 never raised the concerns about paediatric cardiac
21 surgery at the HMC, did you?
22 A. No.
23 Q. Which you only attended the once?
24 A. Yes, that is correct.
25 Q. Mr Dhasmana said that he was never told to stop
0197
1 operating by anyone. That is paragraph 8(3) of his
2 comments on your statement.
3 You never suggested to Mr Dhasmana that he should
4 stop operating on any particular type of patient?
5 A. Oh yes, repeatedly I told him he should do no switch
6 operations and in fact, he had stopped, so --
7 Q. He had stopped on the neonates?
8 A. Yes, but he had done nothing in the interim. The last
9 switch operation, the switch operation he performed
10 before the last one was something like months before,
11 7 or 8 months before, so it was almost an understanding,
12 and finally he had stopped.
13 Q. Mr Dhasmana says, in his comments on your statement --
14 this is WIT 73/60 -- he says there, in paragraph (iv) at
15 the bottom of the page:
16 "Although neonatal switches were stopped in
17 October 1993, the switch operation in older children
18 continued as my record was quite good in this category."
19 Do you agree with that characterisation?
20 A. Yes, I agree. I do not agree but -- no, I do not,
21 because what does he mean, the record was good?
22 A mortality of above 1 month of 45 per cent is not
23 a good record.
24 At the same time as this discussion was taking
25 place, I provided everybody in the hospital with a paper
0198
1 which was written by the Boston group of Professor
2 Castaneda, published in the paper Cardiovascular Surgery
3 in 1992, this paper was reporting a large series of
4 switch operations, as many as 400 plus, of which almost
5 half of those had a VSD, one of the high risk
6 transpositions. The conclusion of the paper after
7 showing the results was that it was now accepted that
8 a mortality of less than 5 per cent can be achieved in
9 any form of transposition. And here I was trying to be
10 convinced by people that 40 per cent mortality was
11 acceptable. None of the data on switch was acceptable
12 to me.
13 MR MACLEAN: So you take issue with Mr Dhasmana. I do not
14 think there is anything else from beside or behind me.
15 That being the case, those are all the questions that
16 I want to ask you, Professor Angelini. Thank you very
17 much for giving your evidence. The Panel may have some
18 questions for you. Is there anything else you want to
19 say now, anything that I have not covered properly, or
20 have not covered at all, anything I have got wrong?
21 PROFESSOR ANGELINI: I cannot think of anything. Thank
22 you.
23 MR MACLEAN: There will be a chance to reflect on the
24 transcript and come back, if necessary. There may be
25 some questions from the Panel.
0199
1 THE CHAIRMAN: There are no questions from the Panel.
2 Mr Allison?
3 MR ALLISON: No, sir.
4 THE CHAIRMAN: I am grateful to you. Professor Angelini,
5 thank you very much for coming. We are grateful for
6 your evidence. It has been a long day but we have
7 covered a lot of ground and we are very, very grateful
8 to you. Thank you.
9 MR MACLEAN: Sir, if I can just move off stage, Miss Grey
10 can enlighten us about tomorrow.
11 MISS GREY re TIMETABLE
12 MISS GREY: Thank you. Sir, firstly if I could deal with
13 the evidence of Miss Maher, we were to have heard from
14 her today. In fact, she has provided us with two full
15 statements of all the issues that the Inquiry covers,
16 save for the issue of issue N, that is "Concerns".
17 That has come to us in a form that cannot be used
18 by the Inquiry, and which, in particular, cannot be in
19 the shape that it is at the present and has not been
20 circulated for comments or rebuttal by other interested
21 parties.
22 I say that in a spirit not of any criticism
23 whatsoever of any party; rather, it has revealed at this
24 stage a need to agree how to manage the presentation of
25 evidence that has already been the subject of inquiry
0200
1 before the GMC.
2 We are addressing that and Miss Maher and those
3 who assist her have kindly agreed to go away and prepare
4 a further statement on that issue. She is to do that,
5 and also to deal with various supplementary questions
6 that have arisen out of her previous evidence. When
7 that has been presented to the Inquiry, it will of
8 course be circulated in the normal way, and then you,
9 sir, the Panel, will no doubt consider, or reconsider,
10 whether to hear from her on a further occasion.
11 I hope that that explains what has happened to the
12 evidence of Miss Maher at this stage, even though, as it
13 happens, we would probably not have been able to deal
14 with it today in any event.
15 THE CHAIRMAN: Miss Grey, that is very kind of you to
16 explain that. Clearly there was a slight
17 misunderstanding and no blame attaches to anyone,
18 perhaps, except to me, that we should have made our
19 procedure even more clear than we thought we had.
20 May I through you convey my thanks to those who
21 advise Miss Maher, for their help in trying to resolve
22 the matter and we look forward to receiving the full
23 statement in due course. Thank you.
24 MISS GREY: Thank you. Turning then to tomorrow, we start
25 tomorrow at 9.30 with the evidence of Mr Kieran Walshe,
0201
1 who is an independent expert in medical and clinical
2 audit. He is the Senior Research Fellow at the Health
3 Services Management Centre in the University of
4 Birmingham. He will be assisting us by painting the
5 national scene of development in this area at the
6 beginning of tomorrow's session.
7 We will then hear from Dr Trevor Thomas, who was
8 the Chairman of the Medical Audit Committee in the Trust
9 during part of the period of our terms of reference.
10 Mr Kieran Walshe will, we hope again, be able to provide
11 commentary and assistance on that evidence towards the
12 end of tomorrow's session.
13 THE CHAIRMAN: Thank you, Miss Grey. Then we adjourn until
14 tomorrow morning at 9.30. Good afternoon, everyone.
15 Thank you, Miss Grey.
16 (4.20 pm)
17 (Adjourned until 9.30 am on Wednesday, 13th October
18 1999)
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2 I N D E X
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6 APPLICATION BY MR LISSACK .......................... 1
7 REPLY BY MR CHAMBERS ............................... 7
8 RESPONSE BY THE CHAIRMAN ........................... 13
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10 PROFESSOR GIANNI DAVIDE ANGELINI (Sworn)
11 Examined by MR MACLEAN ....................... 14
12
13 MISS GREY re TIMETABLE ............................. 200
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001