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Daily transcripts
Hearing summary
14th October 1999
The Bristol Royal Infirmary Inquiry oral hearings focus this week on
the issue of concerns raised about the adequacy of paediatric cardiac surgery and the
subject of medical and clinical audit.
Today the Inquiry heard from Dr Alan Bryan, Consultant Cardiac Surgeon
at the Bristol Royal Infirmary (BRI) and Honorary Senior Lecturer at the University of
Bristol. Dr Bryan came to the academic Cardiac Unit at the University of Bristol in 1993.
He said that his role was to assist Professor Gianni Angelini in establishing the academic
unit at the University as well as carrying out surgical responsibilities at the BRI. He
expressed his opinion of the Bristol unit, particularly emphasising the medical cover
arrangements within the Intensive Care Unit. He described the creation of the Cardiac
Services Directorate and Mr Janardan Dhasmana’s (consultant cardiothoracic surgeon)
role as Associate Clinical Director for Cardiac Surgery. He commented on the influence of
Mr James Wisheart (consultant cardiothoracic surgeon and Medical Director) over Mr
Dhasmana. Dr Bryan then discussed audit activity and the annual returns made to the
Cardiothoracic Register and the circulation of the results within the cardiac unit. He
commented on problems with paediatric surgery highlighted by the 1994 returns and what he
said were explanations for the high mortality figures for several procedures put forward
by the surgeons. He then discussed his impression on seeing Dr Steven Bolsin’s audit
data and the reaction to it within the BRI. He described a series of meetings called to
discuss the issue of mortality following paediatric cardiothoracic surgery and commented
on the actions proposed by Mr Wisheart and Mr Dhasmana to restrict their cases following
the appointment of a dedicated paediatric surgeon. He concluded by commenting on the
decision to perform a switch operation on Joshua Loveday in 1995, which prompted the
review of the cardiac unit undertaken by Professor Marc de Leval and Dr Stewart Hunter in
1995.
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FULL TRANSCRIPT
1 Day 63, 14th October 1999
2 (9.20 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Mr Maclean.
5 MR MACLEAN: Good morning, sir. I am sorry we are starting
6 a little later than we might have done. The reason for
7 that was simply that today's witness Mr Bryan was
8 reading some of the comments made by others on the two
9 statements he has made to the Inquiry.
10 This morning we have only one witness, Mr Alan
11 Bryan, who is represented by Miss Tina Freeman who sits
12 behind me.
13 Could Mr Bryan come to the witness chair, please?
14 Would you stand, Mr Bryan, please, to take the oath?
15 MR ALAN BRYAN (AFFIRMED):
16 Examined by MR MACLEAN:
17 Q. An easy one to start, Mr Bryan: can you give us your
18 full name, please?
19 A. May name is Alan James Bryan.
20 Q. You are a consultant cardiac surgeon at the UBHT?
21 A. That is correct.
22 Q. Can we look, please, on the screen in front of you, at
23 WIT 81/1? If we blow that up a little, is that the
24 first page of the first of two statements that you have
25 made to the Inquiry?
0001
1 A. Yes, it is.
2 Q. If we go to page 12, is that your signature?
3 A. It is.
4 Q. And that is the first statement dated 12th July of this
5 year?
6 A. Yes.
7 Q. You have made a second statement, have you not, if we go
8 to page 17?
9 A. Yes.
10 Q. That is a statement that deals specifically with the
11 issues of audit and with the issue of concerns about
12 standards of care?
13 A. It is.
14 Q. The final page, I think, of that statement, is page 33:
15 again, your signature and the date of that statement?
16 A. That is, yes.
17 Q. Have you read those two statements through recently?
18 A. Yes, I have.
19 Q. Is there anything in them that you want to change at
20 this stage?
21 A. No.
22 Q. And they are true to the best of your knowledge and
23 belief?
24 A. They are.
25 Q. As you know, Mr Bryan, there have been a number of
0002
1 comments on your statements. Can I just check that you
2 have seen that which you ought to have seen?
3 In respect of your first statement there has been
4 a comment from Mr Dhasmana, page 13, please. You have
5 had a chance to see this, have you?
6 A. Yes, I have, briefly.
7 Q. I think you had a comment, did you not, on
8 paragraph 1 here?
9 A. Yes. Paragraph 1, line 3: it is incorrect that
10 Mr Dhasmana was the senior registrar in the same unit.
11 When I worked there, he was a consultant.
12 Q. Just to put that in a little context, you trained in
13 Bristol and in Cardiff, did you not, between 1982 and
14 1987?
15 A. No, I would say I did my general surgical training
16 really in Bristol and Cardiff, and my time spent in
17 cardiac surgery in Bristol was at a very junior level,
18 a Senior House Officer level. I would not really call
19 that part of my cardiac surgical training. I went on to
20 do cardiac surgical training in Cardiff, Papworth,
21 Cambridge, and St Louis in the United States.
22 Q. So you did have some experience as SHO in Bristol around
23 1985?
24 A. That is correct.
25 Q. That would have been a period of what, four months or
0003
1 thereabouts, would it, in cardiac surgery?
2 A. I think it was four or five months, yes.
3 Q. At that stage, Mr Wisheart and Mr Dhasmana were both
4 consultants?
5 A. Yes.
6 Q. Mr Dhasmana only shortly being appointed as consultant?
7 A. Yes, I am not sure when that was, but he was definitely
8 a consultant at that time.
9 Q. Mr Hutter was there as well, was he not, as senior
10 registrar?
11 A. Yes, our paths crossed only briefly in 1985 in that
12 I think he was appointed as a senior registrar in
13 something like April 1985 and I left in May, so I did
14 come in contact with him at that stage, but only for
15 a very brief time period. I cannot remember whether
16 those were the exact dates, but it was something like
17 that.
18 Q. It may not matter much, but the point is that you
19 recollect that when you were an SHO in Bristol,
20 Mr Dhasmana was a consultant; and he is saying here he
21 was the senior registrar?
22 A. Yes, that could easily be clarified.
23 Q. So Mr Dhasmana has commented on your first statement.
24 There have been a number of comments attracted by your
25 second statement. I think you have had a chance to see
0004
1 the comments respectively of Professor Farndon,
2 Mr McKinlay, Mr Dhasmana, the UBHT, Peter Durie,
3 Dr Bolsin and Mr Wisheart?
4 A. Yes, I have.
5 Q. We will refer to bits of some of those in due course.
6 When you were in Cardiff, you would have worked
7 with, amongst others, Professor Henderson, would you?
8 A. Yes. I think I was a Registrar in Cardiff. Professor
9 Henderson was a Professor in cardiology. I think my
10 relationship with Professor Henderson would be summed up
11 as I knew who he was, but I am not sure he would know
12 who I was.
13 Q. You also worked there with Gianni Angelini?
14 A. That is correct.
15 Q. At that stage, he was what?
16 A. He was a Registrar, then Senior Registrar, then he went
17 to Rotterdam and he was then an intermediate fellow with
18 the British Heart Foundation, I believe.
19 Q. Shortly after he came back from there, he then went off
20 again, I think?
21 A. To Sheffield.
22 Q. Your paths, you and Professor Angelini, as he became,
23 crossed again, did they not, in the latter part of 1993
24 when you were appointed Consultant Senior Lecturer by
25 the University of Bristol?
0005
1 A. I think our paths had never really diverged that much,
2 really. I also regarded myself as quite a close
3 research associate of his. I had worked with him for
4 some years by that stage. I was quite friendly with
5 him. I had written papers with him whilst he was at
6 Sheffield, so whilst we were working in different places
7 I always maintained links with him. I always had it at
8 the back of my mind if he was appointed to a chair that
9 working as a senior lecturer would be something I would
10 want to consider quite seriously, but I had not really
11 anticipated he would be appointed to a chair quite as
12 soon as he was, so ...
13 Q. What was your opinion of Professor Angelini as a cardiac
14 surgeon, first of all?
15 A. I think that I have always considered him to be a very
16 competent adult cardiac surgeon, really with a great
17 deal of innovative skills and ideas, and an ability to
18 develop new things that I would perhaps in a way envy,
19 in that I am rather more cautious in my approach. He
20 has always had, if you like, more abilities in terms of
21 pushing clinical skills forward than I would have
22 myself.
23 So I would say to a certain extent I always
24 perhaps viewed him with some esteem, really.
25 Q. You saw him as an innovator?
0006
1 A. Yes.
2 Q. What about the academic side of his work?
3 A. He helped me a lot in my career. He set me up with some
4 research that subsequently led to an MD thesis. I have
5 been a co-author on many papers with him. I think
6 I would regard it as what I might call a symbiotic
7 relationship in that over the years we have helped each
8 other quite a lot, so I do not think it has been one-way
9 traffic, but has certainly been a very close
10 relationship. I would regard it rather more as a sort
11 of fraternal relationship than perhaps a friend of mine,
12 really.
13 Q. And what about in terms of interpersonal skills, to use
14 the modern jargon? Professor Angelini has been
15 described as someone who tends to see things in black
16 and white?
17 A. It is always difficult to comment on people that are
18 close friends and that you have known for very many
19 years. I have known him for so long, I think he does
20 have quite a direct manner, but I think I would put it
21 to you that if you come to this country in 1982 as
22 a young Italian with very little experience in cardiac
23 surgery and by 1992 you are a British Heart Foundation
24 Professor of Cardiac Surgery, it would be surprising if
25 you were not an individual with a large amount of drive,
0007
1 will to succeed, and, you know, personal ambition.
2 Those kind of people tend to be direct sort of people.
3 I think it rather more goes with the territory,
4 really, and I would not see it as a criticism myself.
5 Q. So you have for many years been a friend of Professor
6 Angelini?
7 A. That is correct.
8 Q. Perhaps even a close professional friend?
9 A. Yes, that is true.
10 Q. So, as it were, it his directness does not bother you?
11 A. No, it does not, because I know him very well.
12 Q. Does it tend to bother others who know him less well?
13 A. I think people can find his manner intimidating, but
14 I would clarify that by saying people find my manner
15 intimidating. I have to say that we are talking about
16 cardiac surgery in the professional workplace.
17 Stressful situations can arise. If you are in charge,
18 as you are if you are the consultant cardiac surgeon,
19 you have to direct matters and that means you have to
20 direct things to people of all grades and therefore I do
21 not necessarily think that it is a criticism.
22 What I would say is that it really goes with the
23 territory. There are not too many cardiac surgeons that
24 are known for hiding their lights under bushels, really,
25 it just does not go with the territory.
0008
1 Q. You have described the respect that you had for
2 Professor Angelini's talent as an innovator in his
3 field. Was that something that was going to be taken
4 forward in his new chair at Bristol when you joined him
5 as Consultant Senior Lecturer? Was that going to be an
6 outlet for his innovative skills?
7 A. He always had ideas and good ideas, really, both in the
8 technical sense and in terms of getting things going.
9 He has lots of ideas and some of those are very good
10 ideas and some of those are not such good ideas.
11 I think that one of the sort of helpful contributions
12 that I have made over the years is if you like helping
13 him with deciding what is going to be good and what is
14 perhaps not so good, really, so I perhaps regarded
15 myself as a rather more sort of, how shall I put it,
16 sort of thoughtful -- in other words, I do not jump to
17 conclusions easily. I would perhaps, if he came up with
18 ideas that I perhaps did not like, I would tell him, so
19 perhaps I would view myself as being rather conservative
20 and, if you like, would -- I do not know how to put it,
21 really.
22 Q. Would it be fair to say that you acted almost as
23 a filter, filtering out the wheat from the chaff?
24 A. That would perhaps be a bit too much, but if he came up
25 with an idea that would sound like a very good idea,
0009
1 I would perhaps think it through in a very reasoned
2 manner and give him a view on it. The view might be
3 that it was a good idea and he should proceed with it
4 and I would help him, or I did not think it was a good
5 idea. I think that was useful to him over a number of
6 years.
7 Q. The academic chair that Professor Angelini had and your
8 post originally was Consultant Senior Lecturer employed
9 by the University?
10 A. Yes.
11 Q. The idea was to set up an academic unit of cardiac
12 surgery, which had never existed before?
13 A. That was the purpose, yes.
14 Q. So it was a development of something new which Professor
15 Angelini and you were taking the lead role in?
16 A. Yes, that is correct.
17 Q. So would it be fair to say that the University posts
18 that you both occupied were fertile ground for
19 innovation at that stage?
20 A. I think so, yes. Mainly through him.
21 Q. Both of you I think were spending a good part of your
22 time in the hospital operating as well?
23 A. It is traditional with a University post that you fulfil
24 what is called a "whole-time equivalent". In other
25 words we were supposed to fulfil a clinical commitment
0010
1 of a single full-time NHS consultant as I am now, but in
2 practice academic departments tend to do more work than
3 that of a single person because of circumstances,
4 really, so we would perhaps do the work of one and
5 a half times an NHS consultant as judged by the number
6 of cases, but certainly it was imperative there was
7 adequate time for academic work, and that is not just
8 doing operations.
9 Q. When you came, Professor Angelini had been there for
10 something less than a year?
11 A. I think he arrived in October 1992, although you would
12 have to clarify that.
13 Q. He did. How would you describe the atmosphere in terms
14 of willingness to embrace innovation, change or new
15 developments among the NHS consultants with whom you and
16 Professor Angelini were now working?
17 A. I think that there was always discussion about new
18 ideas. I think that there were certainly a number of
19 things in the clinical arena that I would have regarded
20 as fairly routine at that stage, in, if you like,
21 national and international terms but which, in my view,
22 were regarded in Bristol as being some kind of
23 innovation. I suppose I was a bit surprised by that,
24 really. In other words, many of the things I regarded
25 in my clinical practice as being routine parts of my
0011
1 practical surgery were not really routine in Bristol.
2 Q. Give us some examples of that.
3 A. Things like myocardial protection, which is the way we
4 protect the heart while we are doing heart operations.
5 The techniques which I was using routinely were not
6 really being used routinely. The post-operative
7 management in terms of the intensive care was not really
8 very -- I was not very happy with the routine manner of
9 doing that, really. I thought it was, to use the best
10 word, "old-fashioned".
11 Q. You were an adult surgeon?
12 A. That is correct.
13 Q. Those comments are in the context of the treatment of
14 adults rather than children?
15 A. Yes, they are, that is correct.
16 Q. Can you elaborate a little as to your impressions of the
17 Intensive Care Unit, the care provided there?
18 A. It was a mixed Intensive Care Unit with adults and
19 children, which I have to say that I did not then think
20 was a good idea, and, you know, I no more think now that
21 it was a good idea than it was then, really. I think
22 that the intensive care worked quite well on the whole.
23 I had reservations particularly which I expressed
24 at the time that the level of medical cover as far as
25 I was concerned on a routine basis was not at a high
0012
1 enough level of seniority in that the resident doctor at
2 that time was a Senior House Officer and those Senior
3 House Officers could range from people who had no
4 previous experience in cardiac surgery to people who had
5 quite a lot. The experience of that grade of doctor is
6 very variable in terms of their intensive care
7 management, and I felt that in what we are talking
8 about, 1993, many units at that stage had what I would
9 call a resident Registrar, a more senior doctor, and
10 I was uncomfortable with the notion that the patient's
11 first line of care within the hospital was a Senior
12 House Officer and that the other more senior doctors may
13 not be in the hospital.
14 I think I was uncomfortable with that, with the
15 adult patients, but although I did not have any direct
16 contact with the paediatric patients, I was more
17 uncomfortable with the idea that they were looked after
18 by that grade of doctor primarily.
19 Q. You had been in that position some years before, in
20 Bristol?
21 A. I had, yes.
22 Q. When you were the Senior House Officer?
23 A. Yes, and that is part of the reason I was unhappy with
24 it. I was a Senior House Officer in cardiac surgery
25 looking after paediatric cardiac surgery patients in
0013
1 1985, and at that time I had done six months of
2 paediatric surgery in the Children's Hospital in
3 Bristol. Despite the fact I had six months of
4 experience in paediatric surgery, my initial exposure to
5 cardiac surgery left me feeling very exposed and, you
6 know, I clearly recollect at the time feeling very
7 uncomfortable that I was the primary doctor looking
8 after babies after operations when at that stage I did
9 not really understand what had been done.
10 Q. You use the expression in the first statement --
11 WIT 81/2, paragraph 5 -- that you initially felt "out of
12 your depth"?
13 A. Yes, I think that is a good term for that.
14 Q. Was it your impression that the other SHOs who were
15 there as well as you felt similarly? Or was it just
16 you?
17 A. I do not know that I specifically talked about it to
18 them. Feeling out of your depth is a question of
19 perception and insight, so some people may have been out
20 of their depth but may not have realised it, so I think
21 it was not discussed between the other doctors, but
22 certainly, some of them had much less experience than
23 I had, so therefore I would have been surprised if they
24 were not more out of their depth than I was.
25 Q. If we look at paragraphs 7 and 8, there you talk about
0014
1 the point you have mentioned about the seniority of the
2 resident staff.
3 You say in paragraph 8 you believe that the
4 limiting factor in not being able to have resident
5 Registrars has been lack of space to provide
6 accommodation. However, there was also never agreement
7 among the consultant surgeons that this was necessary.
8 So aside from space constraints, what was the
9 argument advanced by some consultant surgeons that
10 resident Registrars were not necessary, even if there
11 were sufficient space?
12 A. I do not know that there were really any arguments ever
13 advanced to say that it was not necessary. I do not
14 think that there was ever any counter argument as to why
15 it was not necessary. I think there was Professor
16 Angelini and myself saying that we thought that this
17 should happen, but I do not remember anybody saying that
18 it should not happen. In other words, there was
19 inaction rather than disagreement, if you see what
20 I mean. I do not think anybody ever said to me, "We do
21 not want resident Registrar".
22 Q. There was no --
23 THE CHAIRMAN: Just for the record, it says "I do not think
24 there was ever any counter argument as to why it was not
25 necessary". I think you probably meant, Mr Bryan, that
0015
1 it was necessary?
2 A. I am sorry, I missed that point. Shall I say what
3 I think, and then -- I do not believe that anybody ever
4 advanced a counter argument to say that it was not
5 necessary. I think that the situation was that this was
6 a proposal which was advanced on a regular basis over
7 a number of years and nothing ever happened.
8 MR MACLEAN: Can I have a shot? Professor Angelini and you
9 felt this was important?
10 A. Yes.
11 Q. It was high up your list of priorities?
12 A. No. I do not know that it was high up my list of
13 priorities, but it was certainly in my list of
14 priorities.
15 Q. There was no positive hostility to it elsewhere?
16 A. No, there was not.
17 Q. But others did not feel as strongly as you and Professor
18 Angelini?
19 A. No, I think there was the emphasis that others did not
20 think it was necessary, really.
21 Q. Mr Dhasmana, in his comments at WIT 81/14, paragraph 2,
22 towards the bottom of that paragraph, says that there
23 was some discussion with the anaesthetist, do you see
24 about 10 lines from the bottom, as to whether they could
25 provide the resident cover but it had failed to
0016
1 materialise and he said the reason for that was the same
2 reason the surgeons had, namely lack of numbers because
3 of the split of cardiothoracic surgery among the three
4 sites -- the Children's Hospital, the BRI and the
5 Frenchay hospital where the thoracic surgery was; junior
6 doctors' working hours; and the tightness of
7 accommodation?
8 A. I think all these things have been problems in the
9 organisation of departments in the last few years, but
10 these are sort of -- if you want something to happen,
11 there are a series of rooms in the clinical department
12 and you just have to decide your priorities for using
13 those rooms. If there is a will to use one of those
14 rooms for an on-call room for a resident Registrar, you
15 have to say to the Registrar, "You are now resident and
16 that is your room".
17 As a sort of prelude to that, we did -- I would
18 need to go back through the medical personnel, because
19 going back to the appointment of the Registrars in 1993,
20 that would be one of our Registrars, Malcolm Underwood,
21 I think we insisted in his job description he would be
22 resident on call, even though at that time there was no
23 provision for it. The reason for that was that we were
24 still arguing that the Registrar should be resident. If
25 you know anything about contracts, if you do not sign
0017
1 a contract saying that you are resident, nobody can
2 subsequently make you resident.
3 So while we were consistently arguing we wanted
4 the Registrars resident, we did make the provision we
5 could ask them to be resident later on.
6 So there was a consistent dialogue on this matter,
7 but it did not happen until Professor Angelini became
8 Associate Clinical Director and that happened within
9 a month and that was because there was a will on his
10 part to advance that, and it happened very easily. We
11 just said "That room is now the resident Registrar's
12 room". It was easy.
13 Q. When you arrived in Bristol, the Directorate of Cardiac
14 Services was in the pipeline, but I think not fully
15 fledged until the spring of 1994; is that right?
16 A. Yes. I think the Directorate of Cardiac Services was
17 being formulated around the time I arrived. I do not
18 remember cardiac surgery ever being part of general
19 surgery, so it was about the middle to the end of 1993.
20 Q. And the Associate Clinical Director of Cardiac Surgery
21 was whom?
22 A. I think it was probably Mr Dhasmana at that stage. It
23 was certainly -- I am not sure when Mr Dhasmana took
24 over from Mr Wisheart.
25 Q. Let us look at WIT 81/4.
0018
1 A. You would need to help me on that. I do not really know
2 when Mr Dhasmana started as the Associate Clinical
3 Director.
4 Q. Paragraph 17. Can I start at the end of the paragraph?
5 You say:
6 "As an associate directorate during the period
7 1993 to 1995 I felt that decisions taken at the level of
8 associate directorate were of limited value, which led
9 to frustrations for all of us, including Mr Dhasmana."
10 A. Yes, I would stand by that. That is why I wrote it.
11 Q. Is that because the directorate did not have power to do
12 anything important, or that its decisions were not being
13 taken forward?
14 A. No, I think that there was always a feeling in the
15 directorate, because Mr Wisheart was in a very senior
16 position within the Trust, that he was playing a major
17 role in determining the strategy of the Trust, and also,
18 as I have said there, in what he saw as the best
19 strategic direction for cardiac surgery.
20 So there was a feeling that the views expressed
21 within the associate directorate were not having much
22 impact at Trust level because at Trust level people were
23 consulting with Mr Wisheart, which was not that
24 surprising, really, if you think about it.
25 Q. So when the cardiac services directorate became fully
0019
1 fledged, I think Professor Vann Jones was the Clinical
2 Director of that directorate, Mr Dhasmana was the
3 Associate Clinical Director of Cardiac Surgery.
4 Mr Wisheart held no position of responsibility within
5 that directorate?
6 A. No. Well, except as a consultant member, but no
7 formal --
8 Q. Except as a consultant member, but he of course held
9 very senior positions in the Trust?
10 A. That is correct.
11 Q. And so people, both within and without the directorate,
12 would essentially look to him to provide the de facto
13 leadership of cardiac services; is that right?
14 A. I think there was that perception, yes. Certainly by
15 me.
16 Q. You say there that Mr Dhasmana found it difficult to
17 lead, to manage conflict and to make decisions and
18 appeared to have difficulty acting independently of
19 Mr Wisheart.
20 Why was that? Was that something in Mr Dhasmana's
21 personality, or something in Mr Wisheart's? How did
22 that come about?
23 A. I think Mr Dhasmana had worked with Mr Wisheart for many
24 years as a junior doctor and as a consultant associate
25 and that -- I have found this myself, with people in my
0020
1 career. When you have worked with people at a junior
2 level, to a certain extent you perhaps find it hard when
3 you are at an equivalent level ever, if you like, to
4 treat them anything other than as -- the analogy that
5 one might use is that if you are a pupil in a school and
6 then you eventually become a teacher, you still always
7 treat the headmaster as the headmaster, really. It is
8 difficult to erode the sort of pupil and teacher
9 relationship over a period of time. I think he did
10 particularly find it difficult to do things which
11 Mr Wisheart did not agree with.
12 Q. Mr Dhasmana has commented on this paragraph at
13 WIT 81/15, paragraph 4. He says that he agrees with you
14 that he did not have the support and co-operation from
15 his colleague, especially during the second half of his
16 time.
17 Is that something that is part of your evidence:
18 that he did not have the support and co-operation of
19 colleagues, or is your evidence that he just was not
20 very good at leading the meetings?
21 A. I think that his statement is unfairly self-deprecating,
22 really. I do not think that we did not support him;
23 I think that what I would say is that we recognised
24 that -- it is not really in a nasty sense, it is just
25 that we recognised this was not his forte; he was
0021
1 a clinical cardiac surgeon. I think his communication
2 skills were not that great, he was not that good at this
3 job.
4 While it might sound like a criticism, I would not
5 like it to go down as an awful criticism of him; he was
6 doing his best. I think if there were a greater choice
7 of people to have done that job, then he probably would
8 not have advanced himself as a great candidate. I think
9 if he was honest with himself, as he usually would be,
10 he would say himself that was not really his forte.
11 I think he did it because it was his turn to do it,
12 because Mr Wisheart had done it before, he was the most
13 senior person and he saw it as his job to then be the
14 Associate Clinical Director; that as managerial things
15 would advance, we would ask "Is he actually suited to
16 doing this role?", and we would perhaps have concluded
17 that he was not suited to doing that role and he would
18 not have done it.
19 Q. Can we turn to your second statement, please? It starts
20 at page 17. Let me deal with the question of audit.
21 You refer in paragraph 2 to Royal College of Surgeons
22 Guidelines on Surgical Audit, which you say were issued
23 in approximately 1990.
24 Can I show you RCSE 1/50? I will just ask you if
25 that is the document you are referring to.
0022
1 A. Well, it would not actually have been, because it says
2 at the bottom "Revised June 1995", so that would not be
3 the actual document I am referring to, but it would be
4 the revision of the original document.
5 Q. The first revision in 1989?
6 A. You say it was 1989. It may not have been 1990 but it
7 was somewhere around that time. The reason I remember
8 it is because when we set up audit at the University
9 Hospital of Wales in cardiac surgery, that was the
10 document I used as my model.
11 Q. I am not particularly interested in whether it was 1989
12 or 1990, I just wanted to establish that this was the
13 document in its revised form that you had in mind?
14 A. Yes, it is.
15 Q. This was a template, if you like, for the work you did
16 in Wales?
17 A. Yes.
18 Q. By virtue of the fact that it was revised in June 1995,
19 it remained, did it, the basic template for clinical
20 audit in surgical practice until the end of the period
21 the Inquiry is concerned with, which ends in 1995?
22 A. I think it would, yes. There are many other audit
23 documents, but I have always used that as the main
24 template.
25 Q. You saw that as the starting point?
0023
1 A. I think so, yes.
2 Q. If we go to WIT 81/18, paragraph 6, this deals with the
3 question of audit practice when you started at the BRI
4 in 1995 --
5 A. 1985?
6 Q. I am sorry, 1993. At this stage, the practice was that
7 all the surgeons would collect their own data which
8 would then be collated by Mr Dhasmana and sent off to
9 the Cardiothoracic Register each year?
10 A. That is correct.
11 Q. And you yourself, as we have discussed, were an adult
12 surgeon, so your practice would be to put together your
13 own data, send it to Mr Dhasmana, and then you would be
14 provided with a copy, would you, of Bristol's return to
15 the register?
16 A. That is correct, yes. I would slightly -- I did the
17 returns for the academic department, so that was not
18 just me, that would be the Professors' returns as well.
19 Q. Yes. I think there is a document where you write to
20 Mr Dhasmana saying "Here are my and Gianni's figures for
21 the year, keep them all together", and then the
22 important point is that the return would be circulated
23 among all the contributors?
24 A. Yes, that is true.
25 Q. There would be, would there not, an annual presentation
0024
1 of the register return at one of the surgical review or
2 audit meetings?
3 A. Yes, there would.
4 Q. And that would be conducted by whom?
5 A. 1993 to 1995 it was always Mr Dhasmana, because he
6 collated the return. I must say, I do not remember
7 there being a meeting in 1993; there probably was but
8 I just do not recollect there being one.
9 Q. But you do recollect there being a meeting in 1994?
10 A. Yes, and subsequently.
11 Q. You say at paragraph 10 over the page that it was the
12 1994 return to the register that highlighted your
13 concerns about Bristol's mortality.
14 Before we look at that, Mr Dhasmana has said that
15 the presentation of the register returns was always done
16 by him in an open and honest way.
17 Would you agree with that?
18 A. Yes, I think I would agree with that, yes.
19 Q. A "cards on the table" approach?
20 A. Yes, I think so.
21 Q. Let us look at WIT 81/48. This is an extract from your
22 GMC evidence. If we go down the page to letter F,
23 please, you say:
24 "As I said, when paediatric cardiac surgical
25 information was presented, certainly any mortality and
0025
1 morbidity related to his patients, he [Mr Dhasmana]
2 always presented in a very open and sensible manner and
3 it was always discussed fully and, as I said, perceived
4 deficiencies I think were acknowledged ..."
5 A. Yes.
6 Q. Why was it that the 1994 return struck you particularly?
7 A. I think what you have to understand is that these are
8 quite complex statistics, in a way. There is a large
9 number of diagnostic categories. I am sure you are all
10 familiar with the UK register returns, and therefore,
11 when you perhaps look at them superficially, you do not
12 always pick up what might be regarded as, you know,
13 aberrant figures and things like that, but it was
14 clearly -- the one figure that struck me was the figure
15 for open-heart surgery in the under 1 year olds, which
16 I think was something like 14 deaths in 50 children, or
17 14 deaths in 48 children.
18 Q. Can I help you? UBHT 217/99: this is the front page of
19 the register.
20 A. That is the one.
21 Q. If we go to page 108 --
22 A. That is the one.
23 Q. It is the right-hand column, is it not, "under 1 year"?
24 A. Yes. I obviously looked at this kind of information
25 with the knowledge that I had always had concerns about
0026
1 the paediatric cardiac surgery, even before I had taken
2 the job in Bristol. I also looked at it in the
3 knowledge that Dr Bolsin had already presented some
4 figures to me which, well, at the very least, caused me
5 to be concerned. So if you like, this was something
6 else which I felt was -- I mean, I looked at these
7 figures, and as you will appreciate, I am not
8 a paediatric cardiac surgeon, but I am a cardiac
9 surgeon, so I do feel I have quite an understanding of
10 paediatric cardiac surgery and what I used for my
11 reference source for these statistics, I calculated the
12 percentage and said "That is 28 per cent". I thought,
13 that is quite a high figure.
14 I went to the previous UK register, because as you
15 will appreciate, when you submit these you do not have
16 the reference statistics for that particular year, so
17 I went to the figures which would be 1991 to 1992, and
18 1990 to 1991, and it did not compare well with those
19 figures. I think it is something like 14 or 15 per cent
20 mortality.
21 I think there were a number of things at that
22 stage, and this would be the middle of 1994 that led me
23 to be concerned, really.
24 The difficulty is in the difference between
25 results which are not very good in small numbers and the
0027
1 difference between figures that are clearly
2 unsatisfactory and figures that are not very good but
3 acceptable.
4 But I think these undoubtedly fuelled my concern.
5 Q. In Mr Wisheart's comments on your statement, which is
6 WIT 81/60, page 61, commenting on paragraph 10 of your
7 statement he says:
8 "I believe it is entirely appropriate that
9 aggregated figures such as these are regarded as
10 sufficient to raise a concern or ask a question.
11 However, they are not a sufficient basis upon which to
12 make a judgment. In order to do so, the difficulty
13 created by the relatively small numbers involved needs
14 to be dealt with, and more information is needed so that
15 case mix and risk stratification can be taken into
16 account."
17 A. Yes.
18 Q. Is that a fair comment?
19 A. I think that I would not have any major reason --
20 I think the difficulties in that statement are that risk
21 stratification is a difficult problem in paediatric
22 cardiac surgery and has not been resolved, and it has
23 not been resolved still in the UK. There is, to my
24 knowledge, no regular practice of risk stratification,
25 it is all based on diagnostic categories.
0028
1 So I think the difficulty is -- and this was
2 a consistent problem -- the two problems that have been
3 highlighted in his answer by Mr Wisheart are relatively
4 small numbers and he is quite right, it is not possible
5 to make a judgment and I did not, for that very reason.
6 The other thing is case mix.
7 So, you know, the difficulty, there were
8 relatively small numbers and they were bad cases,
9 because that is the justification for not very good
10 results, it is very easy to say in a meeting,
11 "Oh well -- ". I cannot remember a specific occasion
12 when this kind of thing happened. I cannot say on
13 this. But, for instance, in that document, the
14 AV canals in 1993 to 1994, the sort of thing that would
15 happen in the clinical workplace is that somebody would
16 say, "Oh well, the results were better than that last
17 year".
18 So, as one who has come through the door in 1993,
19 if you say AV canals in the under 1 year age group --
20 you will need to show me again but I think it is
21 something like 4 out of 6 deaths; if you are in
22 a clinical meeting and somebody says "Those results are
23 not good but they are better than last year" and you do
24 not have the results of last year, human nature is such
25 that you accept what somebody is telling you, and you do
0029
1 not say in a meeting like that, "Can you show us the
2 results for last year because we are not certain that is
3 true?"
4 So I find myself in the position of looking at
5 these things and saying, "Yes, they are small numbers
6 and I know we cannot draw a conclusion, but they are not
7 very good. I do not know what they were before, but if
8 they were a 'bit better' last year, what were they the
9 year before, and yes, they were small numbers last
10 year".
11 So it is difficult in this environment to draw
12 conclusions: were the results just not very good but
13 acceptable, or were they definitively bad, and in that
14 case, should not have continued?
15 So I think that is a dilemma which has dogged this
16 whole thing throughout, because those results were not
17 really available.
18 In other words, yes, the results were presented
19 openly and I do not doubt that, but the results that
20 anybody can draw a meaningful conclusion from were not
21 available, because as Mr Wisheart has pointed out, there
22 were not numbers available to do so.
23 Q. So the dispute, if you like, is not that data was not
24 presented or the returns were not presented in an open
25 and honest fashion; the discussion and the debate is
0030
1 about what conclusions it was possible to draw?
2 A. Precisely.
3 Q. To the extent that arguments were advanced that the
4 numbers were small -- obviously numbers may have been
5 small; one can tell how many numbers there were -- but
6 what about the risk stratification point? To what
7 extent was anyone in a position to say, "Our cases are
8 more difficult than the centre down the road"?
9 A. It is always easy to say that, and it is always, in my
10 view, difficult to justify it.
11 Q. How could one go about justifying it?
12 A. You can risk stratify the adult patients, as we did.
13 I think that no such system was in place for paediatric
14 cardiac surgery at the time, to my knowledge. You may
15 correct me, or Mr Wisheart may correct me, but it was
16 not something that was done, really.
17 In terms of risk stratification in the early
18 1990s, this applied to adult cardiac surgery; it was not
19 used in paediatric cardiac surgery. There would be
20 recognised risk factors for paediatric operations: in
21 other words, you would say, for instance, high blood
22 pressure in the pulmonary arteries, pulmonary
23 hypertension was generally regarded as being a bad
24 thing, an adverse risk factor, but to my knowledge there
25 was no regular process by which paediatric cardiac
0031
1 surgeons looked at these diagnostic categories in more
2 detail, apart from I think it has been more obvious --
3 it is just not dealt with in the same way, so it is
4 perfectly reasonable to say that risk stratification was
5 not taken into account, but it was not by anybody at
6 that stage, really, and still is not now. It is a bit
7 like, you know, "He says it is a bad case; I do not
8 think it was", the way we would say, if you are
9 a cardiac surgeon and any case dies, it is a bad case.
10 There are two approaches. I have observed that,
11 having worked in a number of cardiac surgical centres,
12 there are different ways in which people deal with the
13 death of their patients. Some people are very
14 self-analytical and they will say, "Well, this patient
15 died, I do not think that patient should have died. We
16 made a mistake and we must try to correct that". Other
17 people will reconcile it by saying "This case is a bad
18 case. Although the risk stratification data does not
19 indicate so, it was a bad case and it was not a surprise
20 to me that it died".
21 So while there are objective ways of assessing
22 these, it does depend on your personal insight into what
23 you do, as well as objective criteria.
24 Q. In order to advance an argument that the reason why our
25 headline figures are worse than somebody else's is
0032
1 because of case mix, you would have to, would you not,
2 first of all stratify your own cases, and secondly, be
3 in a position to compare your stratified cases with
4 somebody else's stratified cases?
5 A. Yes, I think that is right.
6 Q. The first of those two was not being done anywhere, for
7 paediatrics?
8 A. In paediatrics, not to my knowledge, no.
9 Q. You talked about the different ways in which people deal
10 with losing patients. What was your impression of the
11 way that the paediatric cardiac surgeons in Bristol, in
12 1993/94/95, dealt with unfortunate results of losing
13 patients?
14 A. I think I have said it in the statement, actually.
15 I thought about the way I wrote it, so if you could find
16 it in my statement, I said that there was a culture of
17 explaining not very good results. I am not saying this
18 so well now, so if you could find it in my statement,
19 I quite like the way I wrote it.
20 Q. WIT 81/20, paragraph 15.
21 A. I think I would stand by that statement. In my view, at
22 that time, a culture existed of explaining or justifying
23 what I would see as mediocre or poor results on the
24 basis of case severity, rather than directing attention
25 to producing better results.
0033
1 Q. There were two paediatric cardiac surgeons?
2 A. I think that I would not really say that necessarily
3 applied to just paediatric cardiac surgery. I would say
4 that applied to cardiac surgery: adult and paediatric.
5 Q. In Bristol?
6 A. Yes, I believe it did, yes.
7 Q. Did it apply generally throughout the consultants who
8 were there at that time, or is there anyone you would
9 absolve from such a culture?
10 A. Not really. I think I would stand by that.
11 Q. Did that apply to Professor Angelini?
12 A. No, I think I am talking about -- he obviously did not
13 write this. You see, what happened in 1993, and I think
14 that this is important, was that a group people and
15 a significant number of people came from outside
16 Bristol. That had not happened for some years. A group
17 of people who had been practising both in surgery and in
18 anaesthesia in a number of major centres throughout the
19 world, all in different areas, and they would be
20 Professor Angelini, myself, Dr Davies the anaesthetist
21 and Dr Pryn.
22 This was a group of people who all had had
23 experience of contemporary cardiothoracic surgical
24 practice in quite major international centres, and knew
25 what could be achieved in cardiac surgery both in adults
0034
1 and in children. They were familiar with contemporary
2 cardiac surgical practice. I believe that the people
3 that were working in Bristol at the time were not that
4 familiar with what could be achieved, because many of
5 them had been there for some years, many of them had not
6 had experience in contemporary cardiac surgical
7 practice.
8 I did not have very much experience in paediatric
9 cardiac surgical practice, as I have said, but I knew
10 the flavour of it. I had worked in Cardiff when a new
11 surgeon had started off. I knew the way it should be
12 and what could be achieved.
13 Q. You had worked in Cardiff when the paediatric surgery
14 was getting under way?
15 A. That was when Francesco Musumeci took up his post, at
16 the University Hospital of Wales. I think he took up
17 his post in the middle of 1991. During his first year
18 of activity I was the then Senior Registrar in Cardiff.
19 Q. How would you characterise his results, so far as you
20 were aware?
21 A. They were excellent. I was very aware that they were
22 very good.
23 Q. So you had recent experience of a centre whose
24 paediatric results were, as far as you were aware, very
25 good?
0035
1 A. Yes, and I had observed in St Louis the audit data that
2 they were producing. I think the difficulty in that it
3 is obviously, if you have contact with what I would call
4 a major international centre, then if you are coming
5 back to work in what I would call, not denigrating it,
6 but a provincial British centre, you are going to accept
7 there are going to be differences in outcomes between
8 say the Boston Children's Hospital and perhaps Great
9 Ormond Street and Bristol. You might accept there will
10 be some lag in adopting new techniques and the level of
11 performance.
12 Q. This sentence in your statement which you quite rightly
13 wanted me to take you to when I asked you about it: is
14 this something you thought carefully about writing?
15 A. I think so, yes.
16 Q. Mr Wisheart's comment on this paragraph, which is at
17 WIT 81/62 paragraph 4, he sets out the quotation from
18 your statement, and then he says:
19 "All the clinical meetings relating to paediatric
20 cardiac surgery were consciously directed to improving
21 the quality of the work. Mr Bryan did not attend any of
22 these meetings because he was an adult surgeon.
23 Therefore, I do not think he is in a position to make
24 the comment quoted above."
25 A. It is quite fortunate in that case that I prefaced this
0036
1 by saying I thought it applied to adult and paediatric
2 cardiac surgery, because I would acknowledge that I did
3 not attend any of the paediatric cardiac surgery audit
4 meetings, but as you will remember, I said I thought it
5 applied generally across the board to cardiac surgery.
6 So I would think that it is a reasonable thing to say.
7 I think he may not agree with it, but I would stand by
8 the comment. It is obviously a perception, but
9 obviously the purpose of this Inquiry is to do with what
10 people's perceptions were as well as what were facts.
11 Q. I should show you what Mr Dhasmana says about the same
12 paragraph, WIT 81/38, paragraph 4. He disputes the
13 existence of the culture and he says that he is sure
14 that you are aware of his "self-critical approach and
15 persistent effort" to improve his results in paediatric
16 and adult cardiac surgery.
17 A. Yes, I am. Mr Dhasmana was always self-critical and he
18 did make efforts to improve his results in adult cardiac
19 surgery. I think we have established over the course of
20 the last few years there was no criticism of
21 Mr Dhasmana's adult cardiac surgery because of the
22 external inquiry, and I have always found myself
23 somewhat confused by the outcome of the various
24 inquiries into paediatric cardiac surgery, as to whether
25 the conclusion was that there was any fault found with
0037
1 Mr Dhasmana's paediatric practice, apart from the switch
2 operation.
3 Q. If it is right that he had a self-critical approach and
4 made persistent efforts to improve his results in
5 paediatric and adult cardiac surgery, then he would not
6 be somebody who was seeking to explain or justify
7 mediocre or poor results on the basis of case severity,
8 would he?
9 A. I think it is a question of insight. You have to
10 understand how to improve the results. In other words,
11 you can try for 100 years to improve your results, but
12 if you do not kind of understand the way it should be,
13 it is like I do not doubt that he tried very hard, but
14 if we take the switch operation as an example, I have no
15 doubt that throughout the whole of his professional
16 life, Mr Dhasmana gave everything he had to all the
17 patients under his care. There is no question of that
18 in my mind. He was a very conscious doctor that always
19 tried his best, but ultimately, you are either good at
20 things and you can do them or you cannot. It is not
21 a question of effort.
22 But I think perhaps I would think that that
23 criticism was perhaps more applicable to Mr Wisheart
24 than Mr Dhasmana, really. But I would stand by it.
25 Q. The culture one, you mean?
0038
1 A. Yes. Could I make one more point? If you are
2 confronted with a result which is not very good, then
3 there are two responses to that. You can either, if you
4 like, say "The results are not very good and they should
5 be better, we must be doing something wrong, we have to
6 get this right and improve things", or the other
7 response is to say that "Actually the results are not
8 very good but it is because they are bad patients and we
9 cannot be expected -- we are working under difficult
10 circumstances and we are doing our best".
11 So I think that that, to me, is --
12 Q. And you would, if forced -- resist this if you do not
13 agree with me -- put Mr Dhasmana in the former category
14 and Mr Wisheart in the latter, albeit that Mr Dhasmana's
15 concerns to improve ultimately in the switch operation,
16 so far as he were concerned, were unsuccessful.
17 Is that fair?
18 A. I think the culture was wrong, somehow. I do not think
19 that there was ever any suggestion about the commitment
20 of Mr Wisheart, Mr Dhasmana, to giving 100 per cent to
21 all of their patients under their care. They never gave
22 less than 100 per cent. They worked very long hours,
23 but I think particularly in the under 1 age group,
24 ultimately I think that the results were unsatisfactory.
25 Q. The commitment point is a different point?
0039
1 A. Yes.
2 Q. The fact that people should be doing their best. What
3 we have been discussing is the insight that people have
4 when the outcomes are not good?
5 A. Yes. I think precisely, and that is what is difficult
6 here, because it is a difficult area, it is different
7 shades of grey. I understand what you are trying to --
8 these are sort of very personal things. It is very
9 difficult to nail this down, really, because there are
10 many factors interacting, the results and exactly how
11 bad they were, there are people's responses to...
12 But what I would say is that the results were
13 always there, and that the difficulty in this: the
14 results were being presented but they were not results
15 that people could draw conclusions from. There were
16 always things, if you like, obfuscating the issues, in
17 other words, "Oh yes, but there were two bad cases in
18 this". All right, there were two bad cases.
19 Q. You say they were not results people could draw
20 conclusions from. They were results that people could
21 not draw robust conclusions that would stand up to
22 scrutiny in a published journal?
23 A. That is right, but gradually they created a flavour. In
24 other words, there was Dr Bolsin pointing out
25 deficiencies in the service. There were my own
0040
1 observations in relation to the everyday practice of
2 paediatric cardiac surgery in relation to the previous
3 experience that I had, which was limited, and then there
4 were the figures that were available to me from the
5 register.
6 The way I would put it to you is that I gradually
7 came to the conclusion that the results in patients
8 under the age of 1 year, undergoing open-heart surgery,
9 were not satisfactory.
10 That is a distinction between being not very good
11 but acceptable, and unsatisfactory. That is a difficult
12 distinction to make. I would have thought some of the
13 other people you would have interviewed would have
14 actually highlighted that, like the paediatric experts.
15 Q. Can I take you back a bit, because we have had this
16 discussion we were having over insight into deaths and
17 so on. Can I take you back a bit to something you said
18 earlier. You said you always had concerns even before
19 you took the job in Bristol?
20 A. Yes, I did.
21 Q. About paediatric cardiac surgery. What was the source
22 of those concerns?
23 A. When I was a Senior House Officer in 1985, at that time
24 I was a junior doctor but I had not gone away with
25 a very favourable impression of paediatric cardiac
0041
1 surgery from here. I think at that stage, since it was
2 my first exposure to it, I did not know that much about
3 it, to be frank with you, but I had gone away thinking
4 that really the mortality was quite high, although I was
5 not counting in 1985, and I had already made up my mind
6 that I did not want to operate on children myself and
7 that was nothing to do with my experiences in Bristol or
8 anywhere, really; I just have always not enjoyed
9 treating children.
10 That is a side issue. But I had not, shall I say,
11 been impressed with paediatric cardiac surgery as
12 a Senior House Officer; I had not liked children dying
13 when I was involved in their care and that may be a flaw
14 in me. Personally, I do not like treating children with
15 the prospect of them dying.
16 But also, there was a general sort of flavour
17 which I suppose has been pointed out is hearsay, that
18 the reputation of Bristol in terms of paediatric cardiac
19 surgery was never good. Throughout my time in
20 paediatric cardiac surgery, it is difficult -- people
21 would say "Who said that?", "When did they say it?".
22 This is not the culture of paediatric cardiac surgery.
23 This is like any other profession. There are places
24 perceived as being good and places not perceived as
25 being good. Information is transmitted amongst the
0042
1 trainees at meetings and that kind of thing. You cannot
2 really identify what creates these impressions about
3 places. I cannot say to you that Dr X on 13th June 1989
4 told me that Bristol was not good at paediatric cardiac
5 surgery. You just formulate an impression. It may be
6 unfair, but nevertheless, I had that impression, rightly
7 or wrongly.
8 When I was doing my fellowship in St Louis in
9 1992, one of my colleagues in Cardiff sent me the
10 statement, the bits out of Private Eye and told me, "You
11 may wish to worry about this" because this was tied up
12 with the time when there was discussion as to whether
13 Professor Angelini was going to be appointed to a chair
14 in Bristol, I think, although I do not remember the
15 exact time-scale, and people in Cardiff knew if
16 Professor Angelini was appointed to a chair in Bristol
17 I would be a candidate who would be interested in the
18 senior lecturer job.
19 Q. There was a Private Eye article in May 1992?
20 A. Yes.
21 Q. Which was after Professor Angelini was offered a job by
22 the University, but before the British Heart Foundation
23 offered him --
24 A. I do not remember the date, and I do not remember the
25 article, but it was a critical article.
0043
1 Q. Did it concern you, people sending you articles from
2 Private Eye saying "What do you think of that?"
3 A. Yes, it did. I do not read Private Eye myself, but I do
4 know they do not tend to publish things -- it is my view
5 they do not publish things unless there is some element
6 of truth in them. As I remember from -- you may not,
7 but some of the more senior members of the Panel may
8 remember it better than I, but I well remember, I think
9 I am right in saying -- it has nothing to do with
10 this -- but all the John Poulson and Maudsley affair to
11 do with the city architect in Birmingham where I grew up
12 was originally exposed through the pages of Private
13 Eye. I must say, I thought it was a bad thing for that
14 to be published. T Dan Smith and Poulson, but Maudsley
15 was the city architect.
16 Anyway, the point about it is the notion that
17 things that were published in Private Eye were things
18 that they thought carefully about before they were
19 published, and there was always an element of truth. So
20 before I took up the post, I had briefly discussed the
21 question with Professor Angelini -- no, I am sorry, not
22 before I took up the post. Before I applied for the
23 post I did discuss that question with Professor Angelini
24 along the lines of, "Isn't your requirement more
25 a paediatric cardiac surgeon?" Although I cannot
0044
1 remember the conversation, the gist of the thing was,
2 "Look, what I want to do is to set up an academic
3 department and that is the purpose of your appointment".
4 Q. I am just going to see if we can show you the Private
5 Eye articles. There were various ones throughout 1992.
6 SLD 2/3, which is May 1992. If we blow up the left-hand
7 column and the top of the middle column, this is the one
8 that was shown to Professor Angelini the other day. You
9 see there is reference made to mortality rates at
10 Bristol of 20 to 30 per cent in the top of the middle
11 column.
12 Do you remember if that is the one that was sent
13 to you around this time?
14 A. I am sure it was, because obviously one tends to
15 remember -- I do not remember it in detail, but you
16 obviously remember "The Killing Fields"; it is the sort
17 of phrase that sticks in your mind. I do not remember
18 the detailed content of it, but I do remember that
19 particular phrase.
20 Q. As we see in the left-hand column, this is the article
21 that uses that expression?
22 A. Yes. I do not know whether that features in any other
23 articles, but I am sure because of that one phrase it
24 probably was, but I do not remember the details of it.
25 Q. So your general attitude, whether you are discussing
0045
1 housing in Newcastle or cardiac surgery in Bristol, is
2 that this type of thing in Private Eye is to be treated
3 under the "no smoke without fire" basis?
4 A. No, I would not say that. I would not say it is
5 necessarily no smoke without fire, but certainly if
6 I was working in a department where that kind of thing
7 was appearing in Private Eye, I would certainly want to
8 establish whether there was any basis in fact for that
9 kind of article appearing. Since I was not there, I do
10 not know how that article was treated, but it certainly
11 gave me some cause for concern.
12 MR MACLEAN: Sir, we have been going for an hour and
13 a quarter or thereabouts. This may be a convenient
14 moment, before I move on to something else, for a short
15 break?
16 THE CHAIRMAN: Mr Maclean, yes, thank you. Let us take 15
17 minutes and therefore reconvene at 10.45.
18 (10.30 am)
19 (A short break)
20 (10.45 am)
21 MR MACLEAN: Mr Bryan, just before the break we were talking
22 about the concerns that you had had about Bristol before
23 you came to work here again as Consultant Senior
24 Lecturer in 1993.
25 You had explained again, going back to your time
0046
1 as an SHO in Bristol in 1985, you are not in a position
2 to say that suddenly on a particular day you received
3 some information which led you to think that there might
4 be something not quite right with the paediatric cardiac
5 surgery in Bristol, but that a general flavour was
6 generated and an impression was formed over time that
7 there was something not quite right.
8 Is that a fair summary?
9 A. I think that is correct, yes.
10 Q. In 1985, when you had this unease that you described,
11 did you think about how that unease, how those concerns
12 could be addressed? What did you think ought to be
13 fixed?
14 A. I think that would be far overstating my sort of
15 perceptions. At that stage I had no previous exposure
16 to paediatric cardiac surgery or cardiac surgery in
17 general, so I did not really know how it should be. But
18 I think I went away with a perception that if that is
19 how it was, then I did not like it much. I think that
20 would sum up my feelings.
21 Q. This general perception that Bristol's paediatric
22 cardiac surgery was not of the best was presumably
23 reinforced by the Private Eye article that was sent to
24 you in the early 1990s?
25 A. Yes. I think that would be correct, yes.
0047
1 Q. Had there ever been a time in-between when you had
2 reason to think that your initial impression was
3 erroneous?
4 A. I did not really have any contact with Bristol between
5 1985 and 1993.
6 Q. When you spoke earlier about the development of
7 impressions about places or organisations, you made the
8 point that sometimes impressions can develop about
9 a place which impressions are unfair?
10 A. Yes.
11 Q. When you got to Bristol in 1993, knowing about the
12 existence of this impression as you have described it,
13 did you consider that the impression was unfair?
14 A. I think that I obviously had a certain amount of
15 preconceived view on this, and I would acknowledge that,
16 but I think when I came in 1993 I did try to, if you
17 like, formulate my own opinion.
18 Obviously the extent to which I did that and the
19 extent to which that view was coloured by my
20 preconceptions is hard to separate, but I did genuinely
21 think when I came in 1993 it was a view that, "Let us
22 just see how things are", since I really could not do
23 anything else at the time. It was a situation created
24 by circumstance rather than --
25 Q. So you tried to approach it with an open mind?
0048
1 A. Yes, I did, or I believe I did.
2 Q. And having done so, was the impression that you received
3 previously confirmed or not confirmed?
4 A. I think you have to set it in the context of starting
5 a consultant job: you know, here I am, coming back from
6 America, July 1993, wife seven months pregnant with
7 a third child, living in temporary accommodation, trying
8 to write an MD thesis to get a higher degree, trying to
9 set up an consultant practice, trying to set up an
10 academic department. When there are a lot of things
11 going on in your life, you have priorities and I must
12 say that in the latter part of 1993, and certainly the
13 early part of 1994, assessing paediatric surgery was not
14 my number 1 priority, for the reasons I have said.
15 Q. By the time that we discussed earlier the presentation
16 of the 1993/94 register figures, the alarm bells were
17 ringing a bit more loudly, were they?
18 A. I think it was because that was the first real time when
19 I had sat down and looked at data which was independent
20 of what Dr Bolsin had shown me, which led me to say,
21 "Well, look, that is a worry".
22 Before, you see I had had Dr Bolsin come to me and
23 produce to me some data which I was concerned about, but
24 then I recognised that there are inherent difficulties;
25 he had collected the data himself under rather difficult
0049
1 circumstances. I was worried about it but I wanted to
2 formulate my own opinion. I gradually formulated an
3 opinion based on a flow of information, so I had these
4 preconceptions. I tried to have an open mind.
5 When I came into the building in July 1993,
6 Dr Bolsin came to me later on in 1993 and raised his
7 concerns, so that was another piece of information.
8 Then I thought, well, you know, he has collected this
9 data, there are always difficulties in coding these
10 patients. I do not know, although I did discuss with
11 him at the time, the way he had collected the
12 information, but I think I wanted to formulate my own
13 opinion.
14 Looking back in time, it was really, as I say, an
15 evolution of opinion on my part as, say, was this all
16 right, was it just not very good or was it just
17 unacceptable? And as more information became available,
18 I gradually formulated the opinion that open-heart
19 surgery, particularly in young children, that is the
20 under 1's age group, the outcomes were overall not
21 satisfactory.
22 Q. When you say "not satisfactory", you mean not as good as
23 they should have been?
24 A. I think so, yes.
25 Q. Unacceptably below standard?
0050
1 A. Yes.
2 Q. So in the end, with this accumulation of different
3 pieces of information, the impression you had had before
4 you came to Bristol in July 1993 was reinforced?
5 A. Yes. I think it was, in the young age group. I would
6 want to make it clear that as far as I was concerned,
7 I was not really worried about open-heart surgery in the
8 older children. I thought that overall the results as
9 viewed from the figures, as far as I could see, were
10 perfectly reasonable.
11 Q. As far as you were aware, this impression that was
12 created about Bristol which you have spoken about,
13 in the late 1980s and early 1990s, before you came to
14 Bristol, which was that Bristol's paediatric cardiac
15 surgery was not all it might be: was that impression one
16 that covered all paediatric work, or was it related only
17 to the very young?
18 A. I think that that would be far overstating the
19 specifics, as to what was the general impression.
20 It was a general impression. You have to understand
21 that the nub of paediatric cardiac surgery in the
22 evolving, late 1980s and 1990s, is complex neonatal
23 surgery. That is what paediatric surgery is. There is
24 obviously paediatric surgery in older children, but
25 where the hub --
0051
1 Q. That is where it is at, is it?
2 A. That is a good expression. That is where it is at.
3 Q. That is what defines it and sets it apart?
4 A. I think so. That is what defines the successes and
5 failures. The way I would see it is, yes, you can close
6 atrial septal defects in a five year old and of course
7 it is fine, and the currency really in the late 1980s
8 and early 1990s was, you know, the switch operation.
9 That was, if you like, a barometer of almost the
10 performance of paediatric cardiac surgery units.
11 It is hard to define those kind of things, but
12 almost, if you like, "the word on the street" would be
13 about paediatric cardiac surgeons when you go along to
14 meetings and talk with your junior colleagues: "Is he
15 any good at the switch operation? Yes, he is really
16 good at that". That is the culture which is not
17 necessarily -- "the word on the street" would be the
18 expression I would use.
19 Q. So that was the badge that all paediatric cardiac
20 surgeons who were up-to-the-minute would want to wear?
21 A. I would not want to overstate that, but as a doctor
22 training in paediatric cardiac surgery, I would say that
23 was the badge people would want to wear, yes.
24 Q. So if a centre was doing the arterial switch and was
25 doing it well, that would be an indication that this
0052
1 centre was up with the best of them?
2 A. It would, yes, in my view.
3 Q. With the corollary of that being that a centre that was
4 not doing the switch or was doing the switch poorly
5 would be seen as not being up with the latest
6 developments?
7 A. Yes.
8 Q. You have mentioned Dr Bolsin and I have not, so far,
9 really developed this part of your evidence at all.
10 WIT 81/23, paragraph 28, is where you deal with
11 Dr Bolsin coming to see you?
12 A. Yes.
13 Q. Fairly shortly after you had taken up your appointment
14 in the autumn of 1993?
15 A. Yes.
16 Q. I think it is right, is it not, Mr Bryan, you cannot
17 precisely remember which pieces of paper you were shown
18 by Dr Bolsin, but he presented you with data involving
19 certainly tetralogy of Fallot and VSD?
20 A. That, I believe, is correct, yes.
21 Q. What about the AV canal?
22 A. I think he presented that to me later when he presented
23 to me some data with regard to switch operations as
24 well.
25 Q. From this paragraph, paragraph 28, the data that you
0053
1 were shown by Dr Bolsin discriminated between one
2 consultant and the other?
3 A. I believe it did, but he did show me a series of pieces
4 of information. I am not sure whether the first one --
5 I think there are two things I am not clear on. I think
6 the first piece of information he showed was purely
7 related to mortality, and it discriminated between the
8 two surgeons and it compared their outcomes to the UK
9 register in tetralogy of Fallot and ventricular septal
10 defect.
11 I think subsequently he presented data to me on
12 the same diagnostic categories but also including what
13 I would term "morbidity" but you would have down as
14 "intensive care and bypass time", that kind of
15 information, but I have a feeling that they were
16 presented separately. But I do not really remember,
17 actually.
18 Q. We went through some of this with Professor Angelini
19 earlier this week. I do not propose to take you to the
20 document, the Bolsin data, unless you want me to, but
21 paragraph 28, am I right in thinking that the two
22 messages you took from this data were first of all that
23 Mr Wisheart's mortality was above that of Mr Dhasmana,
24 and secondly that that mortality was significantly
25 higher than the UK register figures?
0054
1 A. Yes.
2 Q. Do you remember whether or not those figures, which did
3 not of course include the switch, gave you any cause to
4 think that Mr Dhasmana's mortality, whilst lower than
5 Mr Wisheart's, was nonetheless higher than the average
6 would suggest it should have been?
7 A. No, I think he told me specifically that Mr Dhasmana's
8 mortality was in line with what might be expected in the
9 UK. Can I just read that again? Yes. I think that is
10 right. What I do not say there is that he led me to the
11 impression that outcomes for patients under the care of
12 Mr Dhasmana in the diagnostic categories that we are
13 talking about were in line with UK outcome.
14 Q. So as far as it went, this data and however reliable it
15 may have been, there was no cause for concern with
16 Mr Dhasmana?
17 A. Not with those diagnostic categories. That was
18 certainly the impression I got, yes.
19 Q. In your earlier answer a few minutes ago, when you were
20 talking about Dr Bolsin presenting you with this
21 data, am I right in thinking that I detected an air of
22 perhaps scepticism about the Bolsin data, or at least
23 a desire on your part to form your own view?
24 A. I think that if you have an academic background,
25 whenever you are presented with data you would naturally
0055
1 expect that you would question whether it is true or
2 not.
3 I think that the two things that need to be
4 highlighted in relation to this data are first of all
5 I have tried myself on a number of occasions to collect
6 retrospective clinical data about patients in Health
7 Service hospitals, not to do with paediatric cardiac
8 surgery, and it is very difficult to get the medical
9 notes of dead patients and it is very difficult to get
10 a comprehensive -- if you are trying to look for the
11 notes of 40 patients you get the notes of 38 patients
12 and you cannot find out whether the last two are dead or
13 alive, so I knew that to collect this kind of data would
14 not have been easy for Dr Bolsin. He did talk to me
15 about the way he collected it and I knew from my own
16 experience it would not have been easy.
17 Also, I knew from my own limited understanding of
18 paediatric cardiac surgery that coding these patients
19 would not be easy because, as I am sure you will have
20 learned from the various people who have given evidence,
21 the anatomical classification of these lesions, what is
22 wrong with the heart, is actually quite complicated.
23 I know you have had Professor Anderson here. He is one
24 of the people who have tried to simplify it but it is
25 complicated.
0056
1 At the time, I did ask him that coding these
2 diagnostic categories is difficult and was he sure that
3 was correct? I think he quite clearly satisfied me that
4 he had done his best in what were difficult
5 circumstances to collect data conscientiously, to, if
6 you like, support his hypothesis which seemed to be that
7 outcomes for patients having open-heart surgery in
8 Bristol was worryingly unsatisfactory.
9 Q. When you talk about "difficult circumstances", what were
10 the difficult circumstances?
11 A. I think firstly the difficult circumstances, I would
12 say, is collecting any data in the Health Service
13 retrospectively. That is difficult. I would put it to
14 you as somebody who has tried to do that on a number of
15 occasions, it is difficult for the reasons I have
16 highlighted. You cannot find the notes and the funny
17 thing is that the most difficult notes to get hold of if
18 you are looking through the medical notes are the notes
19 of dead patients. That can make a real difference,
20 because if you are collecting the notes of 30 or 40
21 people and you end up with three deaths and then you
22 cannot find two sets of notes, you do not know whether
23 those two patients whose notes you cannot find are dead
24 or alive. In an area where small numbers of deaths can
25 make quite a difference, it is quite important.
0057
1 So I think difficult circumstances first of all in
2 relation to the actual collecting of the information,
3 and he had obviously done this, if you like, on his own
4 and I think for reasons that I do not really understand,
5 he felt under pressure, really. I think you would need
6 to ask him the reasons why he felt under pressure, but
7 he always gave me the impression that this was not
8 something that -- I do not think I ever got the
9 impression that he was -- the use of the term "secret"
10 has been used quite often. I do not think I ever got
11 the impression he was doing it secretly. He was doing
12 it independently. He was doing it because he was
13 concerned.
14 Q. What pressure did you think Dr Bolsin was under? Who
15 did the pressure come from?
16 A. I only know from him, really, and when he presented this
17 data to me, he told me that he had highlighted his
18 concerns about paediatric surgery to the Chief Executive
19 of the hospital in the early 1990s, and I am sure you
20 have that letter. I do not know the substance of the
21 letter. But as a consequence of that, he told me
22 that -- not exactly -- he been told if he pursued that
23 line of argument, that that would be bad for his future
24 career in the hospital. I assume that his approach to
25 this was dictated by that -- in fact, he told me that:
0058
1 his concerns about it and his approach to this were
2 dictated by previous pressure that he had felt under as
3 a result of his initial expression of his concerns.
4 Q. So your impression was -- it is not something you had
5 direct knowledge of --
6 A. No, certainly it is an impression.
7 Q. Your impression was that Dr Bolsin had been "warned off"
8 by senior management in the hospital?
9 A. I think that he did give me a detailed description of
10 this but I do not remember exactly what he said, but the
11 description was that he was told that this was not
12 something which he should pursue.
13 Q. Who did you think told Dr Bolsin that?
14 A. I think it was either Dr Roylance or Mr Wisheart.
15 I think -- I do not really know; I would be making it
16 up.
17 Q. I do not want you to make anything up. If you do not
18 know, you do not know.
19 A. All right. Well, I do not know. He did tell me but
20 I do not remember.
21 Q. Did you have anything else, any other knowledge from
22 elsewhere, to support what you were told by Dr Bolsin,
23 that he, Bolsin, had been essentially told this was not
24 something that would be good for his career?
25 A. Could you repeat that, please?
0059
1 Q. What I am trying to get to is whether there was anything
2 else you knew about which would tend to confirm what
3 Dr Bolsin had told you?
4 A. No, there was not.
5 Q. So it was only what Dr Bolsin had said?
6 A. Yes.
7 Q. Was it your impression when Dr Bolsin showed you this
8 data that he was showing it to other people as well?
9 A. I knew that he was.
10 Q. Who did you know he had shown it to?
11 A. I knew he had shown it to Professor Angelini.
12 Q. How did you know that?
13 A. Because, well, I suppose -- I do not really remember,
14 but because we had adjoining offices, I mean, Dr Bolsin
15 was somebody that we worked with on a regular basis.
16 I suppose the reason I knew he showed it to him was
17 because I talked to Professor Angelini about it so we
18 had both seen it but not at the same time.
19 Q. Did you yourself talk to anyone else about the Bolsin
20 audit in a formal way?
21 A. It depends what you mean by "a formal way". You have
22 obviously chosen that word quite specifically. I would
23 say that I did not speak to anybody in a formal way,
24 although Professor Angelini is of course my head of
25 department and therefore you could argue that I had
0060
1 discussions about the concerns that that data aroused in
2 me with my head of department. But I would not, in
3 retrospect, while I would say to you, yes, I discussed
4 it with my head of department, I did not go into
5 Professor Angelini's office and say "Hello Professor
6 Angelini, I want to raise formal concerns with you about
7 the data Stephen Bolsin has shown me". It was not like
8 that.
9 Q. And you did not do it with anybody else either?
10 A. No. I suppose the only formal conversation I had with
11 this was with Professor Farndon. The only way I would
12 regard it as formal is because Professor Farndon was the
13 head of division, I suppose I regarded any conversation
14 with him as formal. He is "not a mate of mine", is the
15 expression that I would use, he was a senior figure
16 within the hospital, whereas I would categorise the
17 other people like Professor Angelini and Dr Bolsin,
18 Dr Monk and Dr Davies as friends of mine, really.
19 Q. Those four names you have just mentioned, if we go to
20 your witness statement at 81/24, the bottom of the page,
21 paragraph 32, we see what you say in the last three
22 lines.
23 Over the page:
24 "Dr Bolsin's concerns were echoed by others. This
25 matter was the common topic of conversation in 1994.
0061
1 Where was it the common topic of conversation?
2 A. Pretty much everywhere, really, in the hospital.
3 Q. The whole hospital?
4 A. I think so. It was the current topic of conversation
5 everywhere. I would say it was difficult to get off the
6 subject of this problem when you are having dinner in
7 other people's houses. You might like to ask my wife
8 sitting over there. I am sure she can imagine dinner
9 parties where nobody talked about anything else,
10 really. I think that is a sort of measure of -- it was
11 not just something that -- people talked about nothing
12 else, really.
13 Q. It was not restricted to the --
14 A. The key thing about this is that there were people --
15 obviously people were talking about this in corridors
16 and everywhere, in the pub, in the operating theatre,
17 but, if you like, there were divisions. In other words,
18 you only talk to people about delicate matters like this
19 who are likely to be receptive.
20 So I think that human nature is that there were
21 some people -- I cannot understand the idea that there
22 were some people who were talking about this non-stop,
23 and there were other people that were not really aware,
24 for a period of time, that this was being talked about
25 at all, because human nature is that you choose to talk
0062
1 to people about things that are concerning you with
2 people who are likely to be receptive, and therefore you
3 would not necessarily go along to somebody whom you
4 identified as being unreceptive to your concerns and
5 say, you know, "Hey, what do you think about this?"
6 because you would know from, if you like, the setup of
7 the department, who those people would be.
8 Q. Just bear with me a second. It is just a little point,
9 it is not going to detain us long. The transcript says:
10 "I think that human nature is that there were some
11 people", and then you are recorded as saying "I cannot
12 understand the idea that there were some people who were
13 talking about this non-stop..."
14 Did you mean to say that you can understand the
15 idea that there were some people who were talking about
16 this non-stop and there were other people who were not
17 really aware for a period of time?
18 A. I think so. I think certainly for a period of time. It
19 is hard to define what that period of time was, but
20 I can certainly believe that, yes.
21 Q. The people you identify in this paragraph -- Dr Bolsin,
22 Professor Angelini, Dr Davies, Dr Monk and yourself --
23 to the extent that you were having discussions about the
24 problem as you saw it, therefore there was an element of
25 each of you preaching to the converted?
0063
1 A. Yes, I suppose there would be, yes.
2 Q. You yourself, in this statement, say: "In late 1994
3 I was aware that all the principal senior clinicians
4 involved in this area were aware of people's concerns"?
5 A. Yes.
6 Q. That would include at that stage Mr Wisheart and
7 Mr Dhasmana, would it?
8 A. No, I do not think -- I think the times that I would say
9 that believed that those people were made aware of
10 concerns in this area were two and they were not
11 concerns expressed by me. I think other people have
12 said, I find it hard to believe -- I still find it hard
13 to believe that they were not aware of these concerns --
14 Q. Who?
15 A. I am sorry, I am getting confused here.
16 The two times when I was fairly convinced that
17 these matters were broached with Mr Wisheart and
18 Mr Dhasmana were specifically a meeting that took place
19 between Professor Farndon, Mr Wisheart and Professor
20 Angelini. That actually must have been in late 1993,
21 was it, some time around -- when was it?
22 Q. Let us take that one first, WIT 81/26, paragraph 36.
23 Is that paragraph dealing with the meeting you
24 have just mentioned?
25 A. Yes, but I do not know the date of that meeting.
0064
1 Q. On Tuesday, when Professor Angelini was here, we
2 discussed a meeting involving himself, Professor Farndon
3 and Mr Wisheart on 23rd December 1993.
4 A. Okay, so it was not 1994, but I think that would
5 probably be the meeting we were talking about.
6 Q. You were not at the meeting?
7 A. That is quite correct; I was not at the meeting.
8 Q. How are you able to tell us about what happened at that
9 meeting? Where does your information come from?
10 A. It comes from Professor Angelini.
11 Q. Did it come from Mr Wisheart?
12 A. No, it did not.
13 Q. Did it come at all from Professor Farndon?
14 A. No.
15 Q. Can I take you to WIT 81/34. We are interested in the
16 manuscript annotations. It is paragraph 36. This is
17 Professor Farndon's response to your statement:
18 "It is not my recollection that the meeting
19 discussed concerns about outcomes in paediatric surgery,
20 but to do with strategy for a new appointment for a new
21 surgeon".
22 Then, if we go to Mr Wisheart's comments on your
23 statement -- this, I think, should be page 68 -- the
24 meeting on 23rd December 1993, so there is nothing
25 between Mr Wisheart and Professor Angelini about that.
0065
1 You pointed out you were not present?
2 A. Yes.
3 Q. "The main point of the meeting concerned the creating of
4 the appointment of a Consultant Senior Lecturer in
5 Paediatric Cardiac Surgery. I do not remember there
6 being any specific discussion of outcomes of paediatric
7 cardiac surgery".
8 A. Yes.
9 Q. So Professor Farndon and Mr Wisheart would appear to be
10 as one as to what that meeting was about?
11 A. Yes. And I would tell you that my involvement of this
12 is that my office was next-door to Professor Angelini's
13 office because we had a suite of offices, and all I can
14 tell you is that Professor Angelini came to my office
15 after the meeting, as he often did, because we were
16 colleagues and said "John Farndon and I have just had
17 a meeting with James in which we have tried to point out
18 to him that the results of paediatric cardiac surgery
19 were not satisfactory", and the comment from him --
20 I remember it very clearly because it is an interesting
21 one, he said "He spoke to us [meaning Mr Wisheart] like
22 a couple of schoolboys". That is what he said about the
23 meeting. I can only tell you that was what he said to
24 me in my office after the meeting, so I was not present
25 at the meeting but it was immediately after the meeting;
0066
1 we are talking about an average working day when I am
2 sitting in my office and the Professor of Cardiac
3 Surgery comes and relates what has happened in
4 a meeting. I do not know whether it is correct or not,
5 I can only relate what he said to me, but it is
6 second-hand information.
7 Q. So we looked at that. You said there were two events --
8 A. The other thing was the well-trodden ground of the
9 consultants' meeting after the audit meeting late in
10 1994, which would be the consultants' meeting with
11 Mr Dhasmana, Mr Hutter, myself and Professor Angelini
12 present.
13 Q. So these two events, the first one, the one we have just
14 discussed, the "Farndon meeting" if I can call it that,
15 Mr Wisheart was present but not Mr Dhasmana?
16 A. I believe that, but I do not know that, really. I mean,
17 I do not know who else was present. Professor Angelini
18 only mentioned Professor Farndon and Mr Wisheart; he did
19 not say whether anybody else was present.
20 Q. I do not think anybody suggests anyone else was present.
21 A. I do not know.
22 Q. At the November 1994 meeting, after the end of the audit
23 meeting when the surgeons were there: Mr Wisheart was
24 not at that meeting but Mr Dhasmana was; is that right?
25 A. That is correct.
0067
1 Q. There had been, if I can just deal with this now,
2 another meeting, had there not, in September 1994, the
3 meeting where the 1993/94 register returns were
4 discussed?
5 A. Yes.
6 Q. By that stage, had you been shown some further
7 information by Dr Bolsin?
8 A. I had been, but I cannot really date that. He showed me
9 some results for the AV canals and switch operations at
10 some stage, but I cannot date that.
11 Q. How did you react to being shown the switch data?
12 A. I think one has to set this in context and say that
13 while I worked in the BRI, to my knowledge three switch
14 operations were performed from July 1993 until 1995, so
15 from my personal contact with that operation done in the
16 BRI, most of the information presented to me is
17 presented from a period when I was not in the building.
18 I think it was generally accepted that the results
19 of the switch operation, particularly the neonatal
20 switch operation, were unsatisfactory. I do not think
21 Mr Dhasmana ever gave anybody any other impression, and
22 he always acknowledged it quite openly, really.
23 I think what was always at issue with this was
24 what action should be taken. There remained that
25 discussion until the Joshua Loveday operation.
0068
1 Q. You were asked about this at the GMC, about Dr Bolsin's
2 switch data.
3 A. Yes.
4 Q. You were asked:
5 "Did you not think at any time to say to
6 Mr Dhasmana, 'Look, Steve is compiling these figures.
7 One set is James's operations and the other set is
8 yours'?"
9 You said:
10 "I think in relation to the arterial switch
11 operation, there was ample evidence that Mr Dhasmana was
12 concerned about the outcome of these operations
13 himself."
14 You have said much the same today?
15 A. Yes.
16 Q. "Since I knew he was concerned about the outcome of
17 these operations himself, looking back on it, I think
18 this is one reason why I did not confront him with it or
19 discuss it, because it was obvious to me that he was
20 concerned about the outcome of switch operations
21 himself. So in a sense I do not see how I would go to
22 him and say 'Janardan, I am worried about the outcome of
23 switch operations', since he had made it perfectly
24 obvious that he was worried himself. I think the point
25 at issue is whether I should have gone to Mr Dhasmana
0069
1 and said to him, 'Janardan, I think we should stop doing
2 switch operations'."
3 A. Yes.
4 Q. Was that suggestion that switch operations should no
5 longer be carried out something that was discussed in
6 the 1994 meeting, because by that time --
7 A. The 1994 -- which meeting are we talking about?
8 Q. The meeting in September at which Professor Angelini and
9 Mr Dhasmana were?
10 A. I do not believe that switch operations specifically
11 were discussed at that meeting. Do you want me to
12 discuss my perceptions of that meeting?
13 Q. Yes, which was something I think you were not invited to
14 do at the GMC, but --
15 A. I was just checking! There were four people present,
16 and I have to say it was an acrimonious meeting. It did
17 not start so. Mr Hutter and I did not really play any
18 significant part in the meeting, apart from being
19 slightly taken aback by the fact that there was a lot of
20 arguing, really, between Professor Angelini and
21 Mr Dhasmana.
22 I should set it in context by the fact that this
23 meeting followed a period in the summer and I cannot
24 date the clinical cases, but I am sure it would be
25 possible to date them, whereby there was a period, a run
0070
1 of several small children that had been operated on by
2 Mr Wisheart when Mr Dhasmana was on his holidays. There
3 had been a bad outcome for a number of children during
4 that period.
5 What happened in these situations was that when
6 those kind of situations arose, then everybody or
7 a number of people would go running to Professor
8 Angelini's office to complain about the paediatric
9 service.
10 Q. Who would do that?
11 A. Well, I do not know specifically. I mean, first of all
12 Dr Bolsin would do that. Secondly, there would be
13 nursing staff, there would be Helen Stratton, whose
14 title I cannot remember, would be raising concerns about
15 it. But they would not be running to the paediatric
16 surgeons to raise their concerns with the paediatric
17 surgeons.
18 So the difficulty was here that you had people
19 confronting -- you know, Professor Angelini thought or
20 perceived that there was a problem, as I did. He was
21 the Professor of Cardiac Surgery. A problem would
22 arise. People would present that problem to him as
23 a problem: "What are you going to do about it?" He
24 would be put in the position of having to resolve that
25 problem, or deal with those concerns, which was not
0071
1 comfortable for him because he was being confronted with
2 a problem which was not in his clinical area of
3 practice. But he was the Professor of Cardiac Surgery
4 and he therefore had to take some action.
5 I do not think that, when confronted with this
6 kind of information from Dr Bolsin -- complaints from
7 other people -- he could not take no action, really.
8 So this meeting was conducted in an atmosphere
9 where a number of people had complained about this
10 period in the summer when Mr Wisheart had operated on
11 a series of children with unfortunate outcomes, and I am
12 sure that Mr Wisheart was not aware that those people
13 had made those complaints.
14 We were then placed in a position -- and the main
15 "gripe", if I can call it that, of Mr Dhasmana at the
16 time was that he perceived that Professor Angelini had
17 been, if you like, making undiplomatic remarks about the
18 outcomes for paediatric surgery to one of the surgeons
19 at Great Ormond Street.
20 Q. Mr Stark?
21 A. That is my understanding, yes. I mean, I do not know
22 that Mr Dhasmana specifically meant that, but I knew
23 Professor Angelini had sought advice from Mr Stark.
24 So the meeting was conducted in an atmosphere
25 where a load of people had complained to Professor
0072
1 Angelini about the outcomes during the summer when
2 Mr Wisheart had undertaken some surgery on a group of
3 young children. I cannot remember the diagnosis or
4 exactly what the outcomes were, but I am sure you could
5 go back.
6 So it was conducted -- there was a sort of
7 background of, you know, unrest, to that meeting.
8 Q. What was your understanding of the reason why Professor
9 Angelini had discussions with somebody at Great Ormond
10 Street who you believed to be Mr Stark?
11 A. My understanding was -- it says it clearly in the
12 statement, I can say it again -- that Mr Stark was
13 a senior figure in paediatric cardiac surgery and if you
14 perceived that there was a problem, then to go and ask
15 Mr Stark for some advice as to whether first of all
16 there was a problem and secondly how to deal with the
17 problem would seem to me to be a reasonable thing to do.
18 The difficulty is that most of us in our clinical
19 careers had never been confronted with a problem like
20 this. They are not easy problems to deal with, as can
21 be seen from this matter. My perception, gleaned from
22 Professor Angelini, was that he went to ask Mr Stark as
23 a senior figure in paediatric cardiac surgery for his
24 advice. And obviously, inherent in that discussion, he
25 would have to tell Mr Stark what he felt the problem
0073
1 was.
2 So that, if you like, to me sets some scene on the
3 difficulty here. On the one hand I can fully understand
4 why Mr Dhasmana would view this kind of, if you like,
5 action as unsolicited and unfair interference by
6 Professor Angelini in the paediatric cardiac surgical
7 service, but equally well, Professor Angelini is
8 confronted by a whole bunch of people complaining about
9 it and he had to do something. You cannot say "Go away
10 out of my office, it is not my business, paediatric
11 surgery", because you are the Professor of Paediatric
12 Surgery.
13 Q. This meeting is the one that took place after the audit
14 meeting in November 1994?
15 A. Yes, that is correct.
16 Q. Was the discussion there about contact with the
17 Department of Health?
18 A. I do not recall. I think there was some discussion
19 about that, actually, now you mention it. I do not
20 remember exactly, but that was brought up at the
21 meeting, yes.
22 Q. Did you know, before matters came to more general
23 attention, that there had been contact with the
24 Department of Health by Professor Angelini, amongst
25 others?
0074
1 A. My understanding was that that contact was established
2 by Dr -- it is Mr Doyle, is it, or Dr Doyle?
3 Q. Dr Doyle.
4 A. I went to a meeting with Dr Doyle. Dr Bolsin had
5 contact with Dr Doyle, something to do with audit, and
6 I remember going to a meeting with Dr Black, Dr Doyle,
7 Dr Bolsin, Professor Angelini and I think I went along
8 as well and had a sandwich or something. It was
9 a lunchtime meeting to discuss an audit project that
10 Steve Bolsin was doing. I do not remember the details
11 of it. That was the first and only time I ever met
12 Dr Doyle.
13 Q. You yourself did not correspond with Dr Doyle?
14 A. I do not think I actually spoke to him. I was just
15 listening to what Steve Bolsin presented at that
16 meeting, really.
17 Q. By November 1994, you said there were only three switch
18 operations in your time.
19 A. Yes.
20 Q. Would that be including Joshua Loveday?
21 A. That might have been the fourth one. I cannot remember.
22 I have looked at it in the schedule of events but
23 I cannot remember. There was one that took place the
24 day I started work at the BRI. But it was a very small
25 number: 3 or 4.
0075
1 Q. Did you know that Mr Dhasmana had stopped doing neonatal
2 switch operations in October 1993 and had done no more
3 since?
4 A. I think I knew that he had not done any more, but I had
5 never seen it written down or said by him that he had
6 stopped doing them. I think I had seen the letter
7 written by the anaesthetists to say that they would --
8 I cannot remember the wording of it, but the impression
9 I got is that they were withdrawing the anaesthetic
10 service for neonatal switch operations. I did not see
11 that letter signed, I saw it in a draft form, but my
12 understanding was that they would stop as a result of
13 the anaesthetists refusing to anaesthetise the patients,
14 but I do not remember Mr Dhasmana saying that he was
15 stopping them, no. I got the impression that rather
16 than him stopping them, the anaesthetists had declared
17 they were not prepared to anaesthetise the patients.
18 Q. In November 1994, what was it that Professor Angelini
19 wanted to happen about paediatric cardiac surgery at
20 that stage, in the short term?
21 A. The word I have used before -- I think I am quite clear
22 on this -- is that he wanted to rationalise it.
23 Q. That is the word you use at paragraph 38 of your
24 statement, WIT 81/27.
25 A. The conflict, you see here, is here we are in a regional
0076
1 centre, trying to provide a service for an area and we
2 are not wanting to -- we have already, I think,
3 appointed at that stage Pawade --
4 Q. Yes.
5 A. -- so we are trying to rationalise the service so that
6 we do not put children's lives unnecessarily at risk,
7 but the things we were good at -- and there were things
8 we were good at and the results were fine -- it was felt
9 we could do, really.
10 So my understanding of Professor Angelini's
11 position was that he wanted the service to continue, but
12 could we try and rationalise it and have some agreement
13 as to first of all what operations we will do, and
14 secondly, who will do them, because there was a very
15 clear perception at that stage that the outcome for
16 young patients in the under 1s were not good for
17 Mr Wisheart.
18 Therefore I think my understanding of what
19 Professor Angelini was saying was, "Look, can we
20 rationalise the service? Can we get you to do those
21 things in the neonates which you are good at, and can we
22 not do the things we are not good at and can we get
23 Mr Wisheart not to operate on any young children --
24 Q. Just to pin that down a bit, rationalisation of the
25 service would include Mr Wisheart doing, what, no more
0077
1 under 1s, or no more children at all?
2 A. At that meeting, I do not think the specifications of
3 it -- we are talking about a meeting where there were
4 two people shouting at each other. We are not talking
5 about refinements in diagnostic categories. It was not
6 one saying "Can you be sure, is that a switch with a VSD
7 or is that under 1 month or between 1 month and 1 year?"
8 What we are talking about is an earnest discussion
9 between two professional colleagues. It was not
10 refined.
11 But that was the clear message I took away.
12 Q. The message was, was it that Mr Wisheart should stop
13 doing some operations at least that he had been doing,
14 and that Mr Pawade would take up his post -- presumably
15 he would do any paediatric cardiac operations?
16 A. Yes, because he was viewed as somebody with extensive
17 training in complex neonatal heart surgery.
18 Q. And Mr Dhasmana would do some but not others?
19 A. I think really that what Professor Angelini was saying
20 to Mr Dhasmana at that meeting was that he was
21 acknowledging that he was running the service. He was
22 saying, "Look, Janardan, you are a close friend,
23 a long-time associate of Mr Wisheart. You are the man
24 who is running the service. But what I would say to you
25 is, can we rationalise the service?"
0078
1 The idea was that if Professor Angelini could not
2 get anybody to rationalise the service, then
3 Mr Dhasmana, who was, if you like, the lead paediatric
4 surgeon, could talk to Mr Wisheart and ask Mr Wisheart
5 perhaps to do cases where he was getting good results.
6 Q. You have used the expression here -- just look at the
7 screen, Mr Bryan, the top of the page. You talk about
8 the "unpleasant argument" and so on, matters
9 degenerating.
10 "Mr Dhasmana rejected outside interference in the
11 service."
12 Did Mr Dhasmana, so far as you were aware,
13 perceive Professor Angelini as being one of the
14 outsiders interfering with the service?
15 A. Yes, I think he did. I think that is specifically what
16 I mean.
17 Q. Why was Professor Angelini perceived as being an
18 outsider? Were you perceived as being an outsider?
19 A. I think so, yes.
20 Q. Any adult surgeon would be perceived as being an
21 outsider?
22 A. I think so, yes.
23 Q. So Mr Hutter would be an outsider, too?
24 A. I think so, yes.
25 Q. So there were only two insiders?
0079
1 A. Yes. Mr Dhasmana, I think, would quite rightly say that
2 there was, if you like, a team running paediatric
3 cardiac surgery and he would regard the anaesthetists
4 doing the paediatric anaesthesia and the cardiologists
5 investigating the patients as the paediatric cardiac
6 surgery service, so it would perhaps be incorrect to say
7 there were just two of them. I think he would view it
8 as a sort of body of professional activity.
9 Q. So Dr Joffe and Dr Jordan -- he had retired by then,
10 I think -- Dr Joffe, Dr Hayes and Dr Martin, they would
11 be insiders?
12 A. Yes.
13 Q. Dr Bolsin anaesthetised for paediatric cardiac surgery,
14 so he would be an insider?
15 A. That comes down to those people that you perhaps -- I do
16 not know whether I could comment on that.
17 Q. He would qualify under the definition?
18 A. Yes, he would qualify as an insider.
19 Q. Was he treated as an insider by the other insiders?
20 A. I do not know. Dr Bolsin and certainly -- I think
21 certainly before the adverse publicity in late 1994/95,
22 people got on generally well in the department. I think
23 Dr Bolsin and Mr Dhasmana got on very well, really. So
24 I do not think there was any suggestion that Dr Bolsin
25 was an outsider, he was just part of the team.
0080
1 Q. Is your clear recollection, at all events, that this was
2 a meeting which was unpleasant?
3 A. Yes, certainly.
4 Q. And a meeting at which Professor Angelini was pushing
5 Mr Dhasmana to take steps, as Angelini put it, to
6 rationalise the service?
7 A. Yes, I would say that, but there were two sides to it in
8 that Mr Dhasmana was very upset with Professor Angelini
9 for what he would say would be discussing paediatric
10 cardiac surgery with a senior colleague outside Bristol.
11 Q. Can we look at WIT 81/38, the bottom of the page,
12 Mr Dhasmana's comments on your paragraph 38, the one
13 which deals with this meeting. I do not want to ask you
14 anything about that page, but that is where it starts.
15 If we go over the page, the fourth line:
16 "The whole meeting related to raising concerns
17 about my surgical work outside Bristol without first
18 discussing them with me [the Mr Stark point].
19 Unfortunately the meeting turned into an acrimonious
20 exchange. There was no discussion by Professor Angelini
21 on the rationalisation of the paediatric service at this
22 meeting."
23 I take it you disagree with that?
24 A. I do, yes.
25 Q. Are you clear in your own mind that there was such
0081
1 a discussion?
2 A. Yes, I am, yes.
3 Q. Are you quite sure?
4 A. I am, yes. Can I just -- it is a minor point, can you
5 go back to the previous page? It says that the meeting
6 was convened by me after the audit meeting.
7 One thing that is worth pointing out is that, as
8 a consultant body, the time when we used to hold
9 consultant meetings was after the audit meetings,
10 because it was protected time when we were not doing
11 operations. So we regularly would hold consultant
12 meetings after the audit meeting.
13 So I just kind of go away with the impression from
14 that statement that this was some extraordinary general
15 meeting of the consultant body to specifically address
16 the concerns that Mr Dhasmana had. It was not really
17 that. I mean, we had regular consultant meetings. I do
18 not remember receiving an agenda, but we regularly held
19 them after the audit meetings. I am sure Mr Dhasmana
20 went along to the meeting with a specific intent to draw
21 Professor Angelini's attention to the fact that he was
22 unhappy about it, but I do not really believe that was
23 the sort of sole reason for holding the meeting.
24 Q. At about the same time, rather confusingly, there was
25 another meeting of the cardiac surgeons at Mr Wisheart's
0082
1 house, was there not? Do you remember that?
2 A. Can you say it again?
3 Q. A meeting at about the same time at Mr Wisheart's house?
4 A. That is correct, yes. I do not remember the date.
5 Q. You were there?
6 A. Yes, I was.
7 Q. What was that about?
8 A. Professor Angelini asked for a meeting to discuss
9 outcomes for adult patients, because I think he
10 perceived that the outcomes for patients under
11 Mr Wisheart's care were causing him concern. He wanted
12 to discuss how we could address that, or whether there
13 was a problem or not.
14 Q. What was the follow-up action after that meeting? Do
15 you remember?
16 A. I think the only action I can remember was that we all
17 took some patients from Mr Wisheart and I remember
18 taking something like two or three cases from his
19 waiting list which were deemed to be cases where he was
20 being subjected to a larger number of re-operations
21 because of his age and because of the length of
22 practice.
23 Q. Can we look at UBHT 164/96? Do you remember seeing
24 this? We see the signature. It is Mr Wisheart's?
25 A. I have never seen this before.
0083
1 Q. Sent to you, amongst others?
2 A. Yes, I mean, I may well have seen it but I do not
3 remember it.
4 Q. "There should be some redistribution of heavy cases from
5 myself ..."
6 Is that the memo evidencing the action following
7 the meeting at Mr Wisheart's house?
8 A. I do not remember seeing that. It does not say that
9 that was -- I just do not remember.
10 Q. The memo refers to Mr Wisheart being in discussion with
11 Chris Monk about the meeting with anaesthetic colleagues
12 which was down for -- they were looking at dates in the
13 second and third week in January. Do you remember if
14 such a meeting ever took place?
15 A. I do not know. I would not know that, really. I do not
16 think it did.
17 Q. Events, perhaps, in the early part of January 1995
18 rather overtook such a meeting, did they?
19 A. I have no recollection of it.
20 Q. Let us look at A(2) in that memo. The other matters
21 which it was agreed to take action about were:
22 "... that we should prospectively gather more
23 information about these high risk cases so we have
24 a better understanding of the types of patient contained
25 therein, and where the difficulties may seem to lie.
0084
1 "If you are in agreement, I propose to be involved
2 in this myself in collaboration with Alan [that is you,
3 I presume] if he is agreeable."
4 A. Yes.
5 Q. That is about the adult risk stratification, is it?
6 A. I do not really know anything about that.
7 Q. That paragraph would suggest that it is about an adult
8 risk stratification project.
9 A. Yes.
10 Q. And there was such a project, was there?
11 A. Not that I recollect, no.
12 Q. Does any of this memo suggest to you that there was
13 anything to do with paediatric cardiac surgery discussed
14 at that meeting?
15 A. No, there was nothing discussed to do with paediatric
16 cardiac surgery at that meeting. There was only one
17 statement by Professor Angelini at the meeting, which
18 was an indirect statement. Because he called the
19 meeting, he prefaced the meeting by saying something
20 along the lines of that we all knew of his views in
21 relation to paediatric cardiac surgery.
22 Apart from that, there was no specific discussion
23 about paediatric cardiac surgery.
24 Q. What was your understanding about whether there was or
25 was not an agreement or a decision that complex
0085
1 paediatric cardiac surgery would or would not take place
2 before the arrival of Mr Pawade?
3 A. My un