Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts Hearing summary 21st October 1999 The Inquiry oral hearings focus this week on the concerns raised about paediatric cardiac surgery at the Bristol Royal Infirmary (BRI) between 1984 and 1995 and actions taken during the period to resolve those concerns. The Inquiry will also hear evidence which will illustrate the national scene and address the subject of post mortems and tissue retention. Today the Inquiry heard evidence from two Senior Medical Officers from the Department of Health (DOH), Dr Peter Doyle and Dr Jane Ashwell. Dr Doyle explained that one of his current responsibilities at DOH is to act as the Medical Secretary to the National Specialist Commissioning Advisory Group (NSCAG), formerly Supra Regional Services Advisory Group (SRSAG), which commissions specialist services nationally. He commented on whether DOH had the authority to restrict hospitals from providing specific services and the opportunities presented by the introduction of contracting and commissioning to define NHS services. He said the SRSAG contracts stated that services should meet local health authority quality standards. Dr Doyle told the Inquiry about an anaesthetic audit meeting he attended in Bristol in 1994 hosted by Professor Gianni Angelini and presented by Dr Steven Bolsin. He explained that following the meeting Dr Bolsin raised concerns with him about audit figures he had relating to mortality following complex paediatric cardiac surgery at the Bristol Royal Infirmary (BRI). He said Dr Bolsin asked for advice about what to do with this data. Dr Doyle indicated that he should follow well known procedures and bring his concerns to the attention of senior staff within the United Bristol Healthcare NHS Trust (UBHT). Dr Doyle explained that he raised Dr Bolsin’s concerns in a letter to Professor Angelini, who, he said responded by reassuring him that steps were being taken to resolve the issue. He also said that he received confirmation from Dr John Roylance, Chef Executive, UBHT, that the matter was in hand. He said that he was under the impression that complex paediatric cardiac surgery would be suspended at the BRI until the appointment of the new surgeon. Dr Doyle concluded his evidence by commenting on action that he took before and after the last switch operation, which took place in January 1995. Dr Jane Ashwell told the Inquiry about her role as a Senior Medical Officer at DOH in the late 1980s and 1990s. She commented on an audit meeting she attended in 1992 at which she met Dr Bolsin, who expressed his concerns to her about his audit figures for complex paediatric cardiac surgery at the BRI. She explained that she passed on these concerns to Professor Farndon, Clinical Director for Surgery at the BRI and commented that she subsequently heard no further comments about Bristol until a letter from Dr Bolsin in 1994 thanking her for her assistance.

FULL TRANSCRIPT

   1                     Day 67, 21st October 1999
   2   (9.30 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF: Good morning, sir. Sir, this morning we have
   6     first of all Dr Doyle, and then Dr Ashwell of the
   7     Department of Health.
   8        Dr Doyle, would you please stand to affirm?
   9            DR PETER DOYLE (AFFIRMED):
  10            Examined by MR LANGSTAFF:
  11   Q. Dr Doyle, you are Peter Doyle?
  12   A. That is correct.
  13   Q. A Senior Medical Officer in Health Services
  14     Directorate 2 of the NHS Executive?
  15   A. Correct.
  16   Q. And as such, you have a responsibility as the Medical
  17     Secretary of what is known now as NSCAG: the National
  18     Specialist Commissioning Advisory Group, is it?
  19   A. That is correct.
  20   Q. Which was the successor to the Supra Regional Services
  21     Advisory Group?
  22   A. That is correct.
  23   Q. May we have on the screen, please, WIT 337/1? Is that
  24     the first page of a statement which you have made for
  25     the purposes of this Inquiry?

   1   A. It is.
   2   Q. Can we go over, please, to page 3? Although your
   3     signature does not appear in writing, that is
   4     effectively your signature, is it?
   5   A. It is, and there should be a hard copy, a signed copy,
   6     somewhere in the system. I have sent one.
   7   Q. And you adopt that statement as your evidence?
   8   A. I do.
   9   Q. Tell me, as a Senior Medical Officer in the Department
  10     of Health, did you, in 1994 or 1995, have any authority
  11     to stop a hospital doctor carrying out a procedure in
  12     any part of the country?
  13   A. I had no authority to stop any independent contractor
  14     doing anything under the NHS, directly.
  15   Q. I am going to ask you to speak up a little if I may.
  16     It may be that we will have to adjust your microphone,
  17     but let us see how we go for a moment or two.
  18        Did anyone else, as you see it, in the Department
  19     of Health, leave aside for the moment the Secretary of
  20     State, have such a power?
  21   A. Not that I am aware of.
  22   Q. Was it your view at the time that the Secretary of
  23     State, herself or himself, had such a power?
  24   A. Not directly.
  25   Q. If there was no direct power, what was, as you saw it,

   1     the indirect power?
   2   A. Increasingly, through the then contracting, now
   3     commissioning process, the services that individual
   4     provider Trusts were contracted to deliver was
   5     increasingly precise, and has been gradually better
   6     defined over the last few years.
   7        Clearly, if a provider Trust is not contracted to
   8     provide a particular service for the NHS, and does so,
   9     then the Secretary of State has the power to ask that
  10     Trust, and can if necessary direct that Trust not to
  11     provide that service.
  12        As you know, in this country clinicians are
  13     supposed to have so-called "clinical freedom". The
  14     decision to intervene in an individual clinical decision
  15     on an individual patient basis, that power I do not
  16     believe lies to me or any other person, including the
  17     Secretary of State.
  18        The indirect form of control is what services
  19     a unit, a Trust, are expected to provide.
  20   THE CHAIRMAN: May I seek, Dr Doyle, clarification of your
  21     original response to Mr Langstaff, when you said:
  22        "I had no authority to stop any independent
  23     contractor doing anything under the NHS."
  24        Quite what did you mean by "independent
  25     contractor" there?

   1   A. I have to be careful about the general language.
   2     Strictly speaking the independent contractors are GPs,
   3     but consultants are seen to be an independent practice,
   4     which is slightly different. Consultants are normally
   5     I think perceived as having the freedom to treat
   6     patients referred to them as they think best, and it is
   7     not for other clinicians necessarily to question those
   8     clinical judgments. Certainly, it would not be for me
   9     to question the clinical judgment of another senior
  10     clinician.
  11   MR LANGSTAFF: So we have, do we, the curious position, as
  12     it may seem to some, that if a treatment or procedure is
  13     carried out by a doctor which results in damage or harm
  14     to the patient, litigation may follow. The professional
  15     competence or conduct procedures may follow, but there
  16     is no power in advance to stop the anticipated
  17     procedure, no matter what the general clinical view is
  18     of it?
  19   A. This is a much broader question, an area where I do not
  20     have particular expertise. I think in general, if an
  21     individual consultant or an individual GP in this
  22     country wishes to treat a patient in a particular way,
  23     take a particular clinical decision, it is very
  24     difficult, on a case by case basis, to find any means of
  25     preventing them carrying out that clinical decision.

   1        Then, if things go wrong, clearly it then raises
   2     questions of going through the various procedures you
   3     have outlined. Clearly there are instances,
   4     particularly in the case of junior doctors in training,
   5     where more senior members of staff can heavily influence
   6     their decisions, but even in the sort of directorial
   7     system you have in the States or Australia, the director
   8     of a unit cannot necessarily automatically stop an
   9     individual consultant going ahead with an operation if
  10     that is their decision.
  11   Q. In any event, your own view, in 1994/95, which is the
  12     period of time that I shall be asking about in
  13     particular, was, as I understand it, that nothing could
  14     be done in advance directly to prevent any proposed
  15     procedure taking place. The most that could be done was
  16     by way of influence.
  17        Does that sum it up?
  18   A. Yes. I mean, there is no doubt that colleagues could
  19     try to influence the decision of a consultant,
  20     particularly the colleagues that that consultant had to
  21     work most directly with who might even be involved in
  22     the procedure. But as to influence from without the
  23     hospital, without the Department, that would be
  24     extremely difficult.
  25   Q. And the indirect route that you talk about is

   1     a question, is it, of the purchaser or the Secretary of
   2     State exercising such powers as there may be arising out
   3     of the purchaser/provider split? You are nodding to
   4     that. The reason I have to say that is because
   5     otherwise it does not go down on the transcript.
   6   A. Yes.
   7   Q. Which is an indirect pressure that is likely, is it, to
   8     take effect some time after any event which may be
   9     harmful to a patient?
  10   A. The question of what services a particular provider does
  11     or does not deliver at any time can come before or
  12     after. In other words, the more directive the
  13     commissioning process in terms of who provides services
  14     so that you prevent proliferation, it could conceivably,
  15     in certain circumstances, prevent those not as
  16     experienced from setting up a new service.
  17        It may, in certain instances, stop providers from
  18     providing a service. Clearly the commissioning process
  19     is not an instrument for the control of clinicians and
  20     clinical work; it is for ensuring that only those
  21     increasingly -- it is really only in the last few years
  22     that the commissioning process has become as clearly
  23     cut, as directional as it is now doing, by trying to
  24     ensure that only those Trusts with the facilities, and
  25     staff with the appropriate experience provide specific

   1     services. Clearly that is an element in trying to
   2     ensure the quality of those services. That is
   3     a relative new development.
   4   Q. For services which are supra-regional services, or were
   5     supra-regional services, and now come under the umbrella
   6     of the National Specialist Commissioning Advisory Group,
   7     the Department of Health is, is it, effectively the
   8     purchaser?
   9   A. The commissioner, yes -- now commissioner.
  10   Q. Yes, was purchaser, is now commissioner.
  11   A. Yes.
  12   Q. Does that then give it a power in such cases that would
  13     be absent in the case of a procedure carried out in
  14     a district hospital where there was a purchaser, in the
  15     old days the district, or a commissioner in the
  16     district?
  17   A. There is a difficulty here because there are two
  18     parallel processes going on, which historically are
  19     interlinked, which means that the position in the last
  20     few years is very different from the position as was,
  21     say, ten years ago.
  22        Clearly the responsibilities of -- whoever was,
  23     some years ago, contracting for a service -- when
  24     supra-regional services started there were Regional
  25     Health Authority purchased services or directed

   1     services, the local health authority, and gradually the
   2     system has changed and the responsibility for first
   3     contracting after 1991 and then more latterly
   4     commissioning services still falls to a number of
   5     bodies.
   6        In theory, the responsibility of each of those
   7     bodies responsible for determining what services are
   8     provided at what level are the same.
   9        I think it is fair to say that certainly in the
  10     1980s, the concern was purely in terms of determining
  11     what services -- following the determination Griffiths
  12     had to start to manage the NHS much more towards the
  13     direction of those services that the people needed
  14     rather than just allowing the thing to develop. The
  15     focus has gradually changed over the last 15 years or so
  16     in trying to be more and more specific about what
  17     services individual groups of patients, individual
  18     authorities, care groups need, and how those are best
  19     delivered. This has been a very gradual process of
  20     changing the focus.
  21        In the early days of commissioning and managing
  22     services, it was purely cost and volume: how much we
  23     were getting, how many procedures were done. The
  24     quality questions were entirely matters for the
  25     profession and professional self-regulation.

   1        The need to manage the service and to be able to
   2     manage better the health care workers in Trusts and
   3     others to deliver the sort of services for which you
   4     were being contracted was, if you like, the focus of the
   5     management change, so increasingly, tools have been
   6     developed to enable health authorities and providers,
   7     including Trusts once they were developed, to employ and
   8     manage the staff to deliver specific services, and that
   9     process has gradually been refined, and was being
  10     refined during the whole of this period.
  11        So, certainly -- I cannot speak for the early days
  12     of the SRSAG, I was not involved, but even when I took
  13     over the secretaryship of SRSAG, it was still then
  14     a matter that we were primarily financially responsible
  15     for the funding, and to ensure that the activity was
  16     delivered.
  17        The questions about which units should be
  18     designated, which were so-called centres of expertise
  19     and whether there were any problems were matters that
  20     the group sought advice from the appropriate
  21     professional body, the Royal College or professional
  22     association.
  23        That position has not really changed today. Now,
  24     as Secretary of NSCAG, if we have questions raised about
  25     the capacity of a unit to deliver a part of the service,

   1     the group as a whole will still seek the advice of the
   2     appropriate professional body or college, to go and
   3     whatever, inspect the unit if necessary, look at the
   4     results and report back to the group to say, "We think
   5     this unit has the right facilities and expertise to
   6     deliver this particular service".
   7   Q. Can I try to unpick that? The question I began with,
   8     that you began answering, was whether or not in the case
   9     of a supra-regional service, the Supra-regional Service
  10     Advisory Group, or NSCAG stood in the shoes of the
  11     purchaser or commissioner, so it had the same powers in
  12     theory, the same influence as the purchaser or
  13     commissioner in other cases would have. Is your answer
  14     to that, in theory that is so?
  15   A. Not exactly. There are some differences. Specific, for
  16     example, in the SRSAG contracts was a requirement that
  17     the units providing the service met the quality
  18     requirement of the local health authority. So a certain
  19     amount of the requirement to meet quality standards,
  20     those standards were not set by the SRSAG or, after
  21     1996, by NSCAG. The units themselves were required to
  22     meet the local quality standards, so there were some
  23     differences between the contracting process -- minor,
  24     but some differences -- on the part of the SRSAG and the
  25     contracts required by local authorities.

   1   Q. So far as the monitoring of the quality of outcome is
   2     concerned, during the period in which you were
   3     responsible for SRSAG and after that NSCAG, is it the
   4     case that that was a responsibility of the district
   5     rather than SRSAG or NSCAG?
   6   A. I think initially it was the responsibility of the
   7     clinicians. Following the requirement in 1991 for all
   8     clinicians to participate in audit, which was
   9     essentially local activity, and the sort of activity
  10     that SRSAG and latterly NSCAG would have expected as
  11     part of the quality control procedures to be done at
  12     local level.
  13        However, about the time that I became the Medical
  14     Secretary of SRSAG, the group started to recognise --
  15     and this would be 1994 -- that some at least of the
  16     audit tools required under that circular could in effect
  17     only be provided with help from the SRSAG. So
  18     increasingly, since 1994, the SRSAG and latterly NSCAG
  19     has tried to ensure that those designated units have
  20     appropriate medical audit tools in place to enable them
  21     to assess their own performance and to report back, for
  22     instance to participate in inter-unit audit, where all
  23     the designated units get together and compare results.
  24        That has been, again, part of the process, that
  25     gradually evolving sophistication of medical audit since

   1     the early 1990s, and increasingly, SRSAG looked to try
   2     to fulfil its role in providing those audit tools and
   3     started to include a requirement to participate in an
   4     agreed audit programme in its contracts.
   5        But that requirement was certainly not to my
   6     knowledge, and I cannot speak for that time, but I am
   7     not aware that it was in that sense formally part of the
   8     contracts from the beginning. Do not forget,
   9     contracting only came in formally in 1991. In 1992 most
  10     health authorities and the SRSAG was still struggling to
  11     find an acceptable form of contract and what elements
  12     should be in it, and really -- well, the contract was
  13     still evolving and the format of the annual report the
  14     units were expected to bring back to the SRSAG was still
  15     evolving in 1994/95. This was an evolving process which
  16     gradually became more sophisticated.
  17        I think there may be one point that is helpful to
  18     the Inquiry, if I make it at this point, and it may not
  19     have been clear, and that is that when I visited Bristol
  20     in 1994, this was nothing to do with my role as
  21     Secretary of SRSAG --
  22   Q. I think, with respect, Dr Doyle, you are going off the
  23     point here. I will come to that in a moment, and we
  24     will explore the circumstances that led to your coming
  25     to Bristol, but for the moment, the question I was

   1     asking you was if, indeed, the arrangement was exactly
   2     the same so far as the supra-regional bodies, if I can
   3     call SRSAG and NSCAG that for the moment, were in the
   4     position of purchasers or commissioners, save that
   5     quality of service was a matter which the district had
   6     to resolve with the unit.
   7        What I was asking you was whether or not it was
   8     the district rather than the central bodies that had the
   9     responsibility for monitoring quality -- we will come to
  10     what "quality" means in a moment, but broadly, is that
  11     the position or not, broadly speaking?
  12   A. Quality is a multi-faceted thing.
  13   Q. We will come to the definition of quality in a moment.
  14   A. You see, I do not think your question is capable of
  15     a concise answer. There are elements of quality that
  16     fall to different organisations, each of whom is
  17     responsible --
  18   Q. Let us divide quality if you like, into "hotel" services
  19     on the one hand and outcome on the other. So far as
  20     hotel services are concerned, who would have the
  21     oversight of that, beyond, obviously, the unit itself?
  22   A. It depends on the hotel. I am not an expert in hotels.
  23     I would not care to answer.
  24   Q. So far as quality of outcome, who would have the
  25     responsibility there?

   1   A. I have no idea.
   2   Q. Did the Supra-regional Services, or NSCAG, review the
   3     local unit monitoring of their own quality of outcome?
   4   A. Not in a formal unit-by-unit basis. There is also, do
   5     not forget, a distinct difference between SRSAG, which
   6     is essentially an advisory group relying on external
   7     advice, and a very small secretariat, from the average
   8     two or three people in the secretariat, and the average
   9     Health Authority with 30 or 50 staff responsible for
  10     contracting over a wide area and having contracting
  11     units that were formally monitoring and negotiating
  12     contracts, which is why the requirement in the SRSAG
  13     contract was that the major part of the quality control
  14     for systems was that they had to comply with the local
  15     quality criteria.
  16        The SRSAG Secretariat at that stage normally
  17     visited each unit, both with clinicians and the
  18     administrators responsible for the service, Chief
  19     Executive or whoever, Medical Director, each year, in
  20     order to determine where the service was going and what
  21     sort of developments, if any, were needed the following
  22     year. So there was a constructive dialogue and there
  23     was certainly at that stage strict monitoring of the
  24     performance against contract, that is, in terms of the
  25     numbers and some limited question of outcomes in terms

   1     of the fact that the right number of patients were being
   2     assessed, going through the system, being discharged
   3     from the system and followed up.
   4        The detailed quality appraisal of any unit was
   5     a matter of wherever concerns were raised the College
   6     was asked, and still is asked, to answer specific
   7     questions about quality raised about the unit, and we
   8     would certainly have been concerned if potentially it
   9     had been brought to us that any unit or any us Trust was
  10     not complying with the local health authority quality
  11     criteria. But there were no staff. You are talking
  12     about three staff compared with 30 to 50 in the average
  13     Health Authority. There was no way we were able to
  14     monitor, line by line, detail by detail, every aspect of
  15     the performance. The clear performance parameters we
  16     monitored and were reported back to the group and they
  17     had to report back to us in their annual report. The
  18     annual report was scrutinised to make sure they had
  19     reported back on whatever patient satisfaction surveys
  20     or rather initiatives had been agreed upon in
  21     conjunction with the local Trust.
  22   Q. You were saying that if an issue in relation to quality
  23     of outcome arose, that the group or NSCAG would take
  24     advice from the Royal Colleges. It would, of course,
  25     expect in any event that the standards reached would

   1     meet local requirements.
   2        Is that a fair summary, or not?
   3   A. Yes. As I said before, there are multiple questions
   4     about quality, about the facilities, maintenance,
   5     safety, fire safety, all sorts of regulations which
   6     Trusts have to meet. All those we left to the local
   7     health authority to monitor. If there had been
   8     a question about the specific outcome of a service
   9     brought to our attention, then we would, and still do,
  10     ask the appropriate professional body or College to
  11     properly investigate that question and report back to
  12     the group.
  13   Q. And having sought the advice of the Royal College, the
  14     expectation would normally be that the group would
  15     follow that advice?
  16   A. On the performance of a specific unit, yes.
  17   Q. Before I leave this area and focus on your visits to
  18     Bristol and discussions that you have had, can I just
  19     ask you, so far as controlling the performance or not by
  20     a clinician of a particular procedure, is it your
  21     perception that the Regional Medical Director or
  22     Director of Public Health of a region or district would
  23     have any role to play?
  24   A. At what stage?
  25   Q. In advance.

   1   A. No, but when are we talking about?
   2   Q. In chronological time? From 1994.
   3   A. From 1994, if there were still consultants who retained
   4     regional contracts, then possibly in those circumstances
   5     the Regional Medical Director, up to the time they
   6     became part of the department, may still have had some
   7     residual responsibilities for performance or matters
   8     pertaining to that consultant, as they had -- this was
   9     a hangover from the earlier mechanism.
  10   Q. If it was a teaching hospital, one would not, of course,
  11     have that position?
  12   A. And those Trusts that had taken over the contracts with
  13     their consultants would have taken on, with that, the
  14     responsibility for performance, discipline, et cetera.
  15   Q. So in so far as there was any power to direct
  16     a consultant to do or not to do a particular procedure,
  17     would that seem to you, on reflection, to rest with the
  18     local management, that is, in the case of a hospital,
  19     the teaching unit, the local Trust?
  20   A. The organisation which held the consultants' contracts,
  21     as their employer, clearly had the right to determine
  22     what NHS duties and responsibilities fell under that
  23     contract. If anybody had the power to prevent
  24     a consultant from embarking on what some might consider
  25     injudicious practice, then it is only the employer.

   1   Q. You went down to Bristol on 19th July 1994, you tell us,
   2     and you went there in connection with a meeting, I think
   3     relating to audit. In what capacity did you go?
   4   A. I had three main areas of responsibility. I had just
   5     come into a new post in April which covered not just the
   6     SRSAG but also responsibility for the policy in relation
   7     to cardiac services, liver and renal services, and also
   8     organ transplantation, so the capacity in which I went
   9     down to Bristol was in my wishing to pick up, as fast as
  10     possible, all the key developments in relation to
  11     cardiac surgery and cardiology, which may or may not be
  12     important for the Department of Health to start
  13     developing new policies for, or to amend the existing
  14     policy, because the medical world is continually
  15     changing.
  16   Q. So you attended the meeting as part of your official
  17     duties?
  18   A. Absolutely.
  19   Q. At the time that you went, you were already the
  20     Secretary of the Supra Regional Services Advisory Group,
  21     but we know from the evidence that we have heard that at
  22     the stage that you took over as Secretary, Bristol no
  23     longer was designated in respect of neonatal and infant
  24     cardiac services?
  25   A. That is correct.

   1   Q. Because the services as a whole had been de-designated?
   2   A. That is correct.
   3   Q. So you had no particular responsibility for infant and
   4     neonatal cardiac services?
   5   A. No specific responsibility for those units. Some
   6     general policy interest.
   7   Q. You took over from Dr Halliday?
   8   A. I took over some of Dr Halliday's responsibilities.
   9     I think I actually inherited cardiac services from
  10     Dr Ashwell. Dr Halliday had retired about three months
  11     earlier.
  12   Q. When you read yourself into your new post, did you look
  13     through their files to get a feel?
  14   A. Only the most recent "hot" topics that were still
  15     awaiting some attention. I cannot say I read back,
  16     except in relation to those topics, in detail the
  17     previous files, no.
  18   Q. What, if anything, did you know about neonatal and
  19     infant cardiac services at Bristol before you went on
  20     your visit on 19th July?
  21   A. Nothing at all.
  22   Q. Did you know that there had been a supra-regional unit
  23     at Bristol?
  24   A. I was aware that the neonatal and infant cardiac surgery
  25     had been de-designated recently and that all the units

   1     around the country -- and Bristol was one of those
   2     units, but other than that as a passing fact, no.
   3   Q. The meeting that you went to on the 19th: who hosted it?
   4   A. That is an interesting question. I was clearly given
   5     the impression at the time that Professor Angelini as
   6     the Professor of Cardiac Surgery was hosting the
   7     meeting.
   8   Q. What was the central topic?
   9   A. The developing National Association of Cardiothoracic
  10     Anaesthetists audit system.
  11   Q. And roughly how long were you in Bristol?
  12   A. As far as I can recall, I arrived sort of middle to late
  13     morning. I was there for several hours, presented with
  14     various aspects of the thing, had lunch: probably about
  15     four hours.
  16   Q. Part of your job was making and maintaining contact with
  17     clinicians, was it?
  18   A. Indeed.
  19   Q. So you spoke to a number of people?
  20   A. I spoke to most of the people at that meeting.
  21   Q. Not, I take it, solely about anaesthetic audit?
  22   A. Primarily. Indeed, at that particular meeting, almost
  23     exclusively about anaesthetic audit and the options and
  24     developments and statistical methods that they were
  25     exploring.

   1   Q. Do you recall talking to Professor Angelini personally?
   2   A. I spoke to most of the people there personally at some
   3     stage during the meeting, particularly over lunch.
   4   Q. Do you recall whether he said anything to you which you
   5     now recall as being of importance or relevance?
   6   A. I do not recall anything. I recall saying something
   7     very general to him because he was the first Professor
   8     of Cardiac Surgery that I had met in my new post, that
   9     I would probably be wanting to talk to him at some other
  10     stage about general issues in cardiac surgery, but it
  11     was only about my new role and interest in what
  12     developments were going on in cardiac surgery. But I do
  13     not recall -- I have thought about it -- him saying
  14     anything to me at that time, or me saying anything to
  15     him at that time, other than of a very general nature.
  16   Q. So there was something along the lines of, "I must have
  17     a chat with you about cardiac services"?
  18   A. "What is happening in cardiac surgery", that sort of
  19     thing.
  20   Q. And you meant nationally and generally?
  21   A. Where is cardiac surgery going? What is developing?
  22     What are the new techniques that the NHS is going to
  23     adapt to? Here is a Professor I assumed was at the
  24     forefront of or wishing to be at the forefront of
  25     development in cardiac surgery.

   1   Q. When you finished the meeting, you went back by train?
   2   A. Yes.
   3   Q. What happened on the way to the station?
   4   A. As I was leaving the meeting, Dr Bolsin asked if he
   5     could accompany me to the station. I am fairly certain
   6     we shared a taxi. I cannot exactly remember.
   7   Q. Pausing there, had you met and spoken to Dr Bolsin
   8     before?
   9   A. Not before that meeting. I had spoken to him during the
  10     course of the meeting, but I had had no contact with him
  11     before that.
  12   Q. So as you see it, what would he have known of you? That
  13     you came from the Department of Health?
  14   A. Yes.
  15   Q. That you had a particular interest in anaesthetic audit?
  16   A. No. I had a particular interest in cardiac services and
  17     this audit was particularly important in relation to
  18     cardiac services.
  19   Q. And would he have known, as you think about it, that you
  20     were the Medical Secretary of the Supra Regional
  21     Services Advisory Group?
  22   A. I have no idea, but it is unlikely. He might have.
  23     I have no way of knowing.
  24   Q. So he asked to accompany you to the station. Did you
  25     think that odd?

   1   A. No. In my job, that is almost a normal occurrence.
   2     Wherever I go to meetings, clinicians take the
   3     opportunity to seek my advice on an enormous variety of
   4     subjects, and it is not unusual, in the coffee breaks
   5     before or after meetings that I go to, that individual
   6     clinicians take me to one side to discuss anything. It
   7     can be anything from their own career prospects to
   8     developments in the field: have I heard about...; did
   9     I see this article; anything.
  10   Q. You yourself: had you had any prior clinical involvement
  11     in cardiac services?
  12   A. I had a brief rotation as a Registrar in my surgical
  13     training on the cardiothoracic surgical unit in Glasgow,
  14     where I trained.
  15   Q. How many months?
  16   A. Three months.
  17   Q. And that was it?
  18   A. That was it.
  19   Q. So you had nothing particularly to offer in the
  20     specialty as a clinician, but you did because of your
  21     responsibility given by the Secretary of State?
  22   A. At that time, my, if you like, clinical knowledge about
  23     the subject was limited, yes.
  24   Q. So if a clinician wished to talk to you about cardiac
  25     services, they obviously had in mind the position that

   1     you occupied in the Department of Health. That is why
   2     they were talking to you -- probably?
   3   A. That was certainly a strong possibility, but not always
   4     the case, because I had wide experience in the NHS
   5     before I became a Department officer, in various aspects
   6     of not just the clinical services, but I negotiate for
   7     the BMM and various other things, so that there were, if
   8     you like, areas of my knowledge that were considerably
   9     wider than anything that relates to my work in the
  10     department.
  11        As I say, because I was by then in a position to
  12     have a much broader national view on a whole variety of
  13     issues than some other doctors, then people would come,
  14     for instance, to talk about their own career prospects:
  15     did I think that moving to a particular centre was
  16     a sensible move? It is very difficult to say questions
  17     like that are anything to do with my responsibilities in
  18     the Department. It might have been, because if the
  19     centre, for instance, was a designated centre... So one
  20     always had to make a judgment about why I was being
  21     approached and when I was approached, and particularly
  22     where people asked me to speak to me in the strictest
  23     confidence, which they frequently do, being another
  24     doctor, and therefore bound by the rules of medical
  25     confidentiality, that I reserve, and have always

   1     reserved, the right to say "If this is something serious
   2     I may not be able to preserve that confidentiality,
   3     because of my job within the Department".
   4   Q. In any event, you are in the taxi, then, with
   5     Dr Bolsin. Anyone else?
   6   A. The driver.
   7   Q. What happens?
   8   A. I cannot repeat verbatim, but he said he wanted to
   9     discuss with me a problem they had been having in
  10     Bristol. The substance of the conversation was that he
  11     had conducted an audit and was not happy about the
  12     results and that he had tried to draw those results to
  13     the attention of people in the Trust without a great
  14     deal of success. He was concerned.
  15        This is not an unusual type of question for people
  16     to ask me. There are clearly agreed mechanisms for
  17     resolving that type of issue. This was the first time
  18     I had met the chap. I had no way of knowing what his
  19     background was, other than he had obviously established
  20     some sort of national expertise in audit, so it was in
  21     my --
  22   Q. Just pausing there, how did you know that?
  23   A. Because he was running a national anaesthetic audit
  24     project, so he must have developed some recognition and
  25     expertise in audit. Therefore on the balance of

   1     probability, if he was concerned about audit result, it
   2     was more likely that he had some genuine concerns and
   3     was not, as sometimes happens, one is approached by
   4     disgruntled clinicians who have very different reasons
   5     for wanting to talk to me.
   6   Q. Can I try and split this into two parts. First of all,
   7     what do you remember as a matter of fact being said and
   8     secondly, the way in which you evaluated it, which is
   9     what you are now going on to?
  10        As a matter of fact, you say that he said that he
  11     had concerns because he had conducted an audit, and the
  12     effect of it was that he had spoken, or tried to get
  13     people to listen. Did he say when the audit had been
  14     conducted? Did he say what it was --
  15   A. I cannot remember exactly what he said, but something
  16     about in the early 1990s or something, but he did not go
  17     into great detail. He actually handed me an envelope
  18     which he said contained the audit results. He did not
  19     go on to be particularly specific about what those
  20     results showed or when the audit was conducted. He just
  21     said, "I have done an audit."
  22   Q. "I have done an audit", but nothing that you can recall
  23     about the date?
  24   A. Not specific about the date, no.
  25   Q. What did he say about the difficulties of having his

   1     audit accepted?
   2   A. I explained if there were questions about the -- it was
   3     a matter for the Trust and there were well recognised
   4     mechanisms. He said he had tried to bring the results
   5     to the attention of people in the Trust, so far without
   6     success, so I went on to explain in greater detail about
   7     HC(90)9 and the exact mechanism by which questions of
   8     performance and/or interprofessional disputes -- because
   9     at this stage all I knew was that there was clearly
  10     a dispute here. He was representing one side of the
  11     argument --
  12   Q. What you actually said was --
  13   A. "This is how to solve your problem".
  14   Q. Which was to do what?
  15   A. To follow the guidance set out in HC(90)9.
  16   Q. You had in mind Appendix E, did you?
  17   A. Yes.
  18   Q. So you were suggesting to him, were you, that he should
  19     follow the guidance and get a joint consultative
  20     committee established?
  21   A. Assuming that there was sufficient grounds for that to
  22     be -- yes, exactly that, and that that really, getting
  23     an outside independent view, was the only way to resolve
  24     this type of issue.
  25   Q. If you were recommending an outside independent view,

   1     does that mean that he said to you words to the effect
   2     that the results of the audit were a matter of clinical
   3     or professional dispute?
   4   A. No, that was my judgment. He was convinced that his
   5     audit results were clearly correct. That is only his
   6     word for it.
   7   Q. He handed you, you say, a brown paper envelope.
   8     Sealed?
   9   A. Sealed.
  10   Q. With your name on it?
  11   A. I honestly cannot remember.
  12   Q. Did he say why he was giving it to you?
  13   A. Yes.
  14   Q. Why did he say?
  15   A. He said, "Here is a copy of the audit, my audit
  16     results". I think he said it contained a couple of
  17     letters he had already written.
  18   Q. Did he say what he wanted you to do with that material?
  19   A. No, not specifically, because I in a sense prevented him
  20     from doing so, because I said it would not be
  21     appropriate for me to make any judgment about the
  22     material.
  23   Q. But you took the material, did you?
  24   A. I took it, yes.
  25   Q. The advice you gave him: was it simply to have in mind

   1     the provisions of HC(90)9?
   2   A. I went on to say that the alternative was to discuss his
   3     concerns with other senior members of the profession,
   4     who would have the skills and expertise to judge whether
   5     the findings he had were correct or not. That again is
   6     a not infrequent resort that clinicians have, to turn to
   7     their senior figures and discuss it.
   8   Q. Which is it, senior bodies or senior figures?
   9   A. Senior figures within the bodies, either a College or
  10     the appropriate professional association.
  11   Q. So you were advising him to go to a senior figure in an
  12     association or in one of the Colleges?
  13   A. Indeed.
  14   Q. Or to use the procedure set out in HC(90)9?
  15   A. Primarily to use HC(90)9 because that is the agreed
  16     mechanism that the Department and the profession had
  17     agreed and set out a procedure there to be followed,
  18     which was the way that these things should have been
  19     resolved.
  20   Q. How did the conversation in the taxi end? It would take
  21     you five or ten minutes to get from the Infirmary down
  22     to the station?
  23   A. Something like that. I did indicate to him that I would
  24     also give some thought -- because -- are we now talking
  25     about fact or evaluation?

   1   Q. Fact.
   2   A. I did indicate to him before I got out of the taxi that
   3     I would give some thought as to whether there was
   4     anything else I could do to ensure that the proper
   5     procedures were followed.
   6   Q. Turning from the facts, is there anything else you can
   7     recollect now about the nature of the conversation,
   8     either what you said to him or what he said to you?
   9   A. No.
  10   Q. Did you not, then, say to him: "Have you spoken to the
  11     Chief Executive or the Medical Director about this?"
  12   A. In explaining HC(90)9, I think I indicated that the
  13     original requirement set out in that circular is for the
  14     District Medical Officer to take action in the first
  15     place, but because Trusts had intervened, the
  16     responsible doctor would now be the Medical Director of
  17     the Trust, and if for any reason that was not
  18     appropriate, then you would go to the Chief Executive.
  19        That was only in general terms. I knew nothing
  20     about Bristol or the Trust setup at all at that time.
  21   Q. So do you think you actually said to him that he should
  22     raise the matter with the Medical Director of his Trust?
  23   A. As far as I can recall, I almost certainly said that,
  24     yes.
  25   Q. Do you recall, as best you can remember it, that you

   1     said he should raise the matter with the Chief Executive
   2     of the Trust?
   3   A. I cannot recall at this stage exactly what I said to
   4     him, but knowing the guidance as I did, I would almost
   5     certainly have said to him something like, "Instead of
   6     the District Medical Officer, you should raise the
   7     matter with the Medical Director, or possibly with the
   8     Chief Executive of the Trust", just in those general
   9     sort of terms.
  10   Q. I am pressing you on this for the accuracy of your
  11     recollection. When you say you would have raised it in
  12     those terms, do you think you actually did raise it in
  13     those terms, or is your memory perhaps vague on that?
  14     It is some time ago.
  15   A. It is a long time ago, nearly five years. As I recall,
  16     I simply walked him through the outlines of what the
  17     guidance said.
  18   Q. You knew the guidance well because you had had a hand in
  19     drafting it, had you?
  20   A. Indeed.
  21   Q. So what you had in mind, just so there is no later
  22     misunderstanding about it, may we have on the screen,
  23     please, WIT 37/96, the intermediate procedure from
  24     HC(90)9. This is the part you had in mind, is it?
  25   A. Indeed.

   1   Q. We have been to this on other occasions. I do not need
   2     to take you through it, but it was just so that your
   3     evidence is completely clear.
   4        Your evaluation, then, of what had taken place was
   5     what?
   6   A. Initially, this was a not unusual occurrence, this type
   7     of approach by clinicians with some concern or other.
   8     In all these situations, one has no way of knowing
   9     whether the individual concerned is entirely honest,
  10     correct, and doing it from the best motives, or is
  11     someone who has a grudge and is disgruntled or whatever,
  12     particularly when you do not know the individuals
  13     concerned and have met them for the first time. But it
  14     is not unusual in my job for advice to be sought about
  15     handling a very wide variety of situations.
  16        My first reaction is always to give people advice
  17     as to how they cope with the problem, how they should
  18     solve it, what the agreed mechanisms are, to inform them
  19     how to do it, and that is exactly what I did in this
  20     case.
  21        I was rather more concerned in this case than
  22     I would have been in many others, because of the
  23     seriousness of the allegations he was making. If those
  24     allegations were correct, then clearly there was
  25     a matter of considerable concern here. I say "if" those

   1     allegations were correct.
   2   Q. Could I stop you there? The allegations then went
   3     beyond him saying, "I have had an audit and no-one will
   4     listen". Something was said about the substance of it?
   5   A. He said he had done an audit of the outcomes of
   6     paediatric cardiac surgery and that he felt that the
   7     outcomes were poor. That is what he said he had done
   8     the audit about, during the conversation.
   9   Q. That might mean many things?
  10   A. Of course.
  11   Q. What did you understand him to be saying?
  12   A. That if his figures were correct -- do not forget we are
  13     talking about the very early days of audit, when
  14     statistical methods were still questionable, to say the
  15     least, and even nowadays, expertise in evaluating
  16     clinical audit, particularly when numbers are small, it
  17     is not easy even now. The statistical methods are not
  18     as good as we would wish. At that stage they were
  19     certainly rudimentary. This was one of the reasons why
  20     I was not prepared to look at the statistics myself,
  21     because I am not an adequately trained statistician to
  22     determine whether a particular set of outcomes is
  23     accurate or not.
  24        The question was, here is a man claiming expertise
  25     in audit, who says he has done an audit, who says the

   1     results, the outcomes, are poor. If that is the case,
   2     the implications of what he is saying could be
   3     potentially serious.
   4   Q. You were going to go on with your evaluation.
   5   A. Therefore, I was concerned to see whether there was any
   6     way one could, if you like, "nudge" the process of
   7     resolving this issue. One thing I was clear about is
   8     that he was one side of an interprofessional
   9     disagreement or dispute of some sort. Whether right was
  10     on his side at that stage, I had no way of judging
  11     adequately.
  12        There was clearly a mechanism laid out, one which
  13     I was fairly familiar with, for resolving these
  14     disputes, so the first initial concern on my part was to
  15     make sure that the appropriate mechanism was used, was
  16     expedited to get on with resolving this dispute.
  17        The question was, I have asked myself this many
  18     times, whether I could nudge the process forward and
  19     ensure that the Trust took action fairly speedily to
  20     resolve the dispute and to get to the bottom of the
  21     argument as to whether there was or was not a case to
  22     answer.
  23   Q. The fact that you derived from your conversation that
  24     there was an interprofessional dispute may suggest that
  25     you had been told or it had been indicated to you that

   1     there was one other or one or two others in the clinical
   2     area concerned who took a different view?
   3   A. That was my judgment, that from previous experience,
   4     when somebody comes to you with a story of the sort that
   5     Steve Bolsin did, and this is not unusual, this happens
   6     to me not infrequently, there is always at the basis --
   7     and from my experience in clinical practice before the
   8     Department, these disputes occur and you have to have
   9     some sort of independent mechanism for resolving it.
  10   Q. Because HC(90)9 really deals with disputes relating to
  11     individuals, rather than to systems or units, does it
  12     not?
  13   A. Well, it is intended, and there was a Working Party
  14     report to cover those situations where there was clearly
  15     a breakdown in professional relationships and one side
  16     were claiming one thing and the other were claiming
  17     another. Where that was between two individuals or two
  18     departments, you had to have a mechanism to resolve
  19     those breakdowns in any hospital.
  20   Q. In any event, it is one individual saying something
  21     about the other, and perhaps having something to say in
  22     return?
  23   A. There may be one or two against one or two others, but
  24     it is clearly a dispute on clinical matters between two
  25     parties within a hospital.

   1   Q. So because of your experience, you saw this as
   2     indicating such an area of disagreement in this
   3     department?
   4   A. And one that needed speedy resolution, because of the
   5     potential seriousness.
   6   Q. When you left on the train, you had in your possession
   7     the envelope. Had you looked at it with Dr Bolsin?
   8   A. No.
   9   Q. Did you look at it in the train?
  10   A. No.
  11   Q. Did you look at it afterwards?
  12   A. No.
  13   Q. So the envelope remained sealed?
  14   A. Yes.
  15   Q. How do you know what it contained?
  16   A. Only from what Dr Bolsin told me.
  17   Q. So your knowledge that it contained figures and
  18     statistics and a couple of letters was what he told you
  19     it contained?
  20   A. Exactly.
  21   Q. So he had given you a letter, obviously designed for you
  22     to read, and you never read it?
  23   A. That is correct. As I told him I would not. But he
  24     would not take it back. I could have --
  25   Q. He would not take it back?

   1   A. No.
   2   Q. So you offered it back to him?
   3   A. Yes.
   4   Q. Why did you say you would not take it?
   5   A. As I explained to him, I was not in a position, I did
   6     not have the skills or expertise to come to a judgment,
   7     nor was it appropriate for me to come to a judgment.
   8     There were mechanisms, there were appropriate people, as
   9     set out in HC(90)9, who had the skills and expertise to
  10     examine the material and come to a judgment about the
  11     truth or otherwise of his allegations, and that I could
  12     not make that judgment. It was not within my area of
  13     responsibility. There are other bodies who have clear
  14     legal and other responsibilities for taking a view upon
  15     those matters.
  16   Q. Before we leave the conversation of 19th July, do you
  17     recall what his response to you was when you mentioned
  18     that he might, should, raise the matter with the Medical
  19     Director?
  20   A. I do not recall him saying anything specific, or not in
  21     more general terms, "I have already tried to raise the
  22     matter within the Trust". I do not recall him making
  23     any specific remark about the Medical Director.
  24   Q. But you did, and he --
  25   A. I explained the nature of the circular: that the person

   1     in the case of a Trust who had taken over responsibility
   2     from the District Medical Officer would have been the
   3     Medical Director of the Trust, the person responsible
   4     for implementing HC(90)9. No more than that. That is
   5     a factual matter arising from the circular itself.
   6   Q. Would he have understood from what you were saying that
   7     he had to raise the matter with the Medical Director of
   8     the Trust?
   9   A. I assume so.
  10   Q. And he never said to you anything to identify any
  11     individual as the other side of the argument?
  12   A. No.
  13   Q. So it follows he never said to you, in response to
  14     anything you might have said, "Well, I cannot raise it
  15     with the Medical Director because the Medical Director
  16     is Mr Wisheart and that is where I have my problem"?
  17   A. I do not recall anything as specific as that, no.
  18   Q. So you go back to London, back to the office. You filed
  19     the letter?
  20   A. I filed the envelope in my filing cabinet, yes.
  21   Q. And what happened to it?
  22   A. It sat there.
  23   Q. You still have it?
  24   A. I think so, yes, in the file.
  25   Q. Is it still sealed?

   1   A. No.
   2   Q. So you have looked at it since?
   3   A. Yes. This is jumping forward now. Some months later
   4     when the matter became generally known, after the
   5     January, then copies of all my correspondence and the
   6     papers concerned went on to the file, the official
   7     departmental file.
   8   Q. And you filed it in the office?
   9   A. Yes, with the papers from the meeting, the agenda, and
  10     so on.
  11   Q. So you regarded it, do I take it, as something which had
  12     been handed to you because you had attended the meeting
  13     in your official role as a doctor in the employment of
  14     the Department of Health?
  15   A. I think that is a very grey area. I cannot speak for
  16     why Dr Bolsin had chosen to hand it to me or in what
  17     capacity he was handing it to me. It was for him --
  18   Q. You cannot speak to him. I am asking you about you and
  19     the way you regarded your role in the matter.
  20   A. I was concerned that there appeared to be a problem that
  21     was not being addressed in the way it should have been
  22     addressed.
  23   Q. The question I asked was whether you had filed it in the
  24     office together with the material you had got from the
  25     meeting which you had attended as part of your duties

   1     because you took the view that this had been handed to
   2     you as occupying a role as a doctor in the employment of
   3     the Department of Health?
   4   A. I do not think I was conscious of any such decision at
   5     the time. I just put the papers from Bristol into the
   6     filing cabinet, all of them.
   7   Q. It is just a question of, "I have this, I am not going
   8     to look at this but I will file it"?
   9   A. I just took the papers from Bristol -- I had made my
  10     decision I was not going to look at it in the taxi and
  11     explained that to Dr Bolsin. When I got back to the
  12     office, I simply took the file containing all the papers
  13     from Bristol and put them in my private filing cabinet
  14     in the Department.
  15   Q. Did you speak to anyone else at the Department about the
  16     substance of the meeting you had had on the 19th?
  17   A. In indirect terms, my then head of the section was
  18     Dr Jeff Graham and he just asked me how I got on at
  19     Bristol. I said it had been a very interesting meeting
  20     but there could be a problem down there. I said I had
  21     explained how to sort it out, and he said "Fine", so
  22     I did not go into any specifics with him at all.
  23   Q. How frequent was it to have a conversation of that sort
  24     with him?
  25   A. Fairly frequent.

   1   Q. At any stage in the course of the meeting on the 19th,
   2     was it mentioned to you by Dr Bolsin that he had
   3     approached Dr Ashwell at an earlier occasion?
   4   A. No.
   5   MR LANGSTAFF: I am going to move on from the 19th to what
   6     happened thereafter. Sir, it may be a convenient moment
   7     to take a break?
   8   THE CHAIRMAN: Yes, Mr Langstaff, but before we do, may
   9     I just go back to one response from Dr Doyle?
  10        You said that you understood Dr Bolsin was talking
  11     to you as a doctor and you used the expression "in the
  12     context of medical confidentiality". What does that
  13     mean to you?
  14   A. The strict rules of medical confidentiality, as you
  15     know, relate to patient and patient data --
  16   Q. Some would say those are the only rules. Explain the
  17     other.
  18   A. There was a clear -- there used to be, should I say,
  19     a clear statement on the part of the GMC that one did
  20     not comment in public about one's colleagues and did not
  21     traduce one's colleagues, so many people chose to
  22     interpret medical confidentiality extending to
  23     discussions not just about individual patients but also
  24     about concerns with individual colleagues. As
  25     I explained, I reserved the right, if the issue was

   1     serious enough, not to break that. That confidentiality
   2     was not absolute, if you like, with the patient
   3     confidentiality, but nonetheless, one did treat those
   4     requests, as far as it is possible to do, entirely in
   5     medical confidence or strictly discussing those matters
   6     only with other doctors.
   7   THE CHAIRMAN: Thank you.
   8   MR LANGSTAFF: Sir, if I may just ask a couple of questions
   9     before we take the break, arising out of that exchange?
  10        You say part of your role, and we have heard from
  11     Dr Halliday, that part of his role was networking?
  12   A. Indeed.
  13   Q. In other words, picking up information about what was
  14     going on from chatting to other doctors in corridors,
  15     over lunch, that sort of thing?
  16   A. Our role is, like any doctor, to be as informed as it is
  17     reasonably possible to be, about those areas for which
  18     you have any responsibility. If you are a clinician,
  19     a cardiac surgeon, you should be reading the journals
  20     about cardiac surgery. If I have responsibility for
  21     cardiac surgery services, I need to be informed as I can
  22     about cardiac services, clinical developments, the whole
  23     thing. So the question of networking is primarily one
  24     of trying to ensure that we are aware primarily of
  25     developments in the specialty that may have a big impact

   1     on NHS service in the future.
   2        In order to do that, one has to talk to lots of
   3     doctors, including a friendly relationship with lots of
   4     clinicians, so that they will come to you and explain to
   5     you, or raise questions with you, and send you articles
   6     that are important, so that you keep abreast of your
   7     subject.
   8   Q. Did doctors talk to you about other doctors?
   9   A. From time to time, yes.
  10   Q. From time to time, or frequently?
  11   A. In lots of contexts.
  12   Q. In the context that they did so, chatting about other
  13     clinicians, that would, on the definition you have just
  14     given us, be, on their part at any rate, a breach of
  15     medical confidentiality?
  16   A. It depends what you are talking about. A lot of the
  17     substance of the conversations is "Have you seen the
  18     research so-and-so is doing? Have you seen this?" and
  19     they were not specific conversations where they asked me
  20     to keep confidence, but from time to time, people came
  21     up and said "I wish to talk to you in confidence about
  22     a difficult issue" and that may involve individual
  23     clinicians, treatment of patients, concerns they have
  24     about a particular research programme, or whatever.
  25   Q. Effectively, you are encouraging them because of your

   1     need to know, to say this sort of matter to you, I take
   2     it?
   3   A. One encourages people to talk to you about issues of
   4     importance in cardiac surgery. From time to time,
   5     coming along with that, will be people wishing to seek
   6     your advice in confidence about difficult issues they
   7     face, either personal or professional.
   8   Q. The second matter which arises out of the question the
   9     Chairman asked you is this: you say it was your practice
  10     to explain to those who raised issues with you that you
  11     may not be able to keep it confidential and you may have
  12     to raise it with others?
  13   A. If the matter was such that it impinged on matters that
  14     were clearly important to the department, and I usually
  15     did that as a "health warning" up front from
  16     experience, when people say "I wish to come and speak to
  17     you in confidence", I usually, as I did with Dr Bolsin
  18     on this occasion, offer that health warning.
  19   Q. So does it follow from that answer that Dr Bolsin had
  20     asked to speak to you on a confidential basis?
  21   A. Yes.
  22   THE CHAIRMAN: Shall we break for 15 minutes, and therefore
  23     reconvene at 10 past 11?
  24   (10.55 am)
  25               (A short break)

   1   (11.10 am)
   2   MR LANGSTAFF: Dr Doyle, when you came back, then, to
   3     London, you filed the sealed envelope in your file. Did
   4     you regard what had been told to you as a fairly serious
   5     matter?
   6   A. Potentially very serious.
   7   Q. You wrote two days later in a letter which we see,
   8     UBHT 52/287. If we scroll up to the address, we see it
   9     is addressed to Professor Angelini and if we scroll up
  10     to the top of the page, on Department of Health
  11     notepaper. So obviously you were writing from the
  12     Department of Health.
  13        Let us look at the text.
  14        "Dear Gianni", so you were on first name terms
  15     with him?
  16   A. After the very helpful and pleasant meeting we had had,
  17     yes.
  18   Q. What was the principal purpose of writing this letter to
  19     him?
  20   A. As I said in my earlier statement, I was under the
  21     assumption that he had hosted the meeting, so the
  22     primary purpose of writing the letter, I would have
  23     written a letter to him as the host in any case, to
  24     thank him for his hospitality, so I would have written
  25     the letter in any case.

   1   Q. The second purpose we see beginning to evolve in the
   2     second paragraph. You say:
   3        "It has recently been brought to my attention..."
   4        That is a reference, is it, to the taxi-cab
   5     conversation?
   6   A. It is.
   7   Q. "... that there are concerns about the mortality rates
   8     for paediatric, especially neonatal and infant, cardiac
   9     surgery performed at the BRI. I further understand that
  10     some sort of audit has been carried out which confirms
  11     a greater than expected mortality rate for certain
  12     procedures."
  13        "Some sort of audit": why describe it in those
  14     terms?
  15   A. Because I had no detailed knowledge at that stage of the
  16     exact audit methodology, the type of audit that had been
  17     undertaken.
  18   Q. And you had not looked at the documents?
  19   A. No.
  20   Q. "Which confirms a greater than expected mortality rate
  21     for certain procedures", in the plural.
  22        What had you been told by Dr Bolsin that made you
  23     think it was more than one procedure?
  24   A. Because he had said they had audited the paediatric
  25     surgery and the results, some of the outcomes, were

   1     poor. I had no way of knowing, from his conversation or
   2     any knowledge on my part at that stage, what particular
   3     bits of paediatric cardiac surgery were concerned,
   4     whether it was one procedure or all procedures.
   5   Q. It obviously was not all procedures, was it, because
   6     otherwise you would not have used the words "greater
   7     than expected mortality rate for certain procedures"?
   8   A. This was written almost immediately after the
   9     conversation in the taxi, so I would imagine I was
  10     quoting reasonably accurately the position as had been
  11     put to me by Dr Bolsin in the car. In other words,
  12     I was repeating the substance of the conversation.
  13   Q. You say "dictated" so your habit was to dictate a letter
  14     and have it typed up, was it?
  15   A. Most of these things I dictate rough to my secretary who
  16     sends it back to me and I polish it, and then it was
  17     sent off.
  18   Q. The reason I ask that is that there is no secretarial
  19     reference on this, but that is just the way it was, was
  20     it?
  21   A. No, because depending on what time I was in my office,
  22     if my secretary was there, I would dictate a rough
  23     draft, she would send it back to me for editing and
  24     polishing. If she was not there, I would print it off
  25     myself. If it went back to her, she might or might not

   1     put a reference number on it.
   2   Q. So what had been said to you in the taxi, it would
   3     follow, because this is the nearest one has to
   4     a contemporaneous note, is that it was more than one
   5     procedure, but less than the whole of paediatric cardiac
   6     surgery?
   7   A. Yes.
   8   Q. The next paragraph:
   9        "I am sure you will agree this is a matter for
  10     very great concern".
  11        That really fits with your idea that this was,
  12     indeed, a very serious matter.
  13        "If the position proves to be as reported to me,
  14     the excess deaths are in themselves a tragedy."
  15        What was it that Dr Bolsin had said to you about
  16     excess deaths?
  17   A. This is my assumption, that if his allegations were
  18     correct, it is a matter of concern because there would
  19     have been by definition excess deaths.
  20   Q. So you understood that it was outcomes in terms of
  21     deaths, mortality?
  22   A. In cardiac surgery it normally is.
  23   Q. "If the problem has been recognised and adequate
  24     remedial steps have not been taken, it becomes an
  25     unacceptable tragedy."

   1        What were you trying to say there?
   2   A. That as Steve Bolsin had pointed out, the audit results
   3     were not just immediate. He said in the taxi it was
   4     something like four years. My understanding at that
   5     time was that he had been working on this problem for
   6     three to four years. Clearly if his further allegations
   7     which he made in the taxi, that he had tried to bring to
   8     the attention of the people from the Trust and without
   9     great success so far, were also correct -- and again,
  10     I had no way of knowing, it was only his word at the
  11     moment -- if the Trust had not taken action to address
  12     this situation, then that, to me, was unacceptable,
  13     because the procedures were clearly laid out, the duties
  14     of the Trust were there, they should have acted, if
  15     concerns had been raised.
  16   Q. So what you are saying is the perhaps obvious position,
  17     that if the audit is accurate, then there have been
  18     unnecessary deaths?
  19   A. Exactly.
  20   Q. If the audit is accurate and has been drawn to people's
  21     attention and they have done nothing, then not only are
  22     there excess deaths, but it is completely unacceptable?
  23   A. Absolutely.
  24   Q. Indeed, that would be one of the most serious of any
  25     matters that you would have to deal with?

   1   A. This is, shall we say, fairly strong language from
   2     somebody from the Department to write.
   3   Q. Because you took it so seriously?
   4   A. If the allegations were correct, this was clearly a very
   5     serious problem -- if the allegations were correct.
   6   Q. Yes.
   7   A. It was further my duty to ensure that those allegations
   8     were properly looked into by the appropriate
   9     authorities.
  10   Q. So you go on, and the next paragraph suggests that you
  11     are saying the proper authority to look into it in the
  12     first instance is the profession. By that you meant the
  13     local clinicians, did you?
  14   A. This directly referred to the audit circular, HC(91)2,
  15     which set out the duties locally of clinicians to audit
  16     themselves. If that mechanism had been up in place and
  17     working, then it should have been able to answer the
  18     questions. That circular clearly stated that audit
  19     remained at that stage, a professional matter. It was
  20     for the Trust to give the professional the tools with
  21     which to do the job.
  22   Q. So were you, by the fourth paragraph, saying "Sort
  23     yourselves out and report back to me that a future audit
  24     shows that the problem has gone away"?
  25   A. Exactly. I draw your attention to the last sentence,

   1     where I am clearly, by implication, saying "I expect you
   2     to be able to prove to me in the near future that your
   3     audit results are comparable with any other unit in the
   4     country". Many would assume this is overstepping the
   5     mark.
   6   Q. You were doing this because you saw this as a serious
   7     problem which needed to be addressed?
   8   A. Potentially very serious problem. Possibly, if the
   9     allegations were correct.
  10   Q. If the allegations were correct. The last paragraph of
  11     the page:
  12        "If there is a problem and for any reason you are
  13     not able to reassure me that it has been resolved, the
  14     circumstances are such that I would be obliged to seek
  15     the help of colleagues in the Performance Management
  16     Directorate, who would doubtless raise the matter
  17     formally with the Trust. It is highly likely that some
  18     sort of formal inquiry would follow."
  19        What is the Performance Management Directorate?
  20   A. The climate at the time was that Trusts were independent
  21     and the Secretary of State had very little power to
  22     intervene, but there was a Performance Management
  23     Directorate which ensured the legal obligations of the
  24     Trust were being met in terms of accountability.
  25        If you like, this is a not-too-subtle threat to

   1     say that at this point I was writing to a person who
   2     I assumed was a senior professional, a medic, keeping it
   3     on the confidential medical net. My assumption is that
   4     the Professors of Cardiac Surgery in most institutions,
   5     in my experience, are people of considerable influence
   6     who are normally able to ensure that either through the
   7     academic net or --
   8   Q. Again, could I come back to your motivation in
   9     a moment? I was asking you what the Performance
  10     Management Directorate was.
  11   A. I beg your pardon. The Performance Management
  12     Directorate was an element of the Department which was
  13     responsible for ensuring that the Trusts accounted for
  14     their legal responsibilities. It is primarily
  15     a financial matter.
  16   Q. So the performance is to be understood in the sense of
  17     keeping to financial targets, is it?
  18   A. Primarily financial, but there are also other elements,
  19     other guidances that have gone out to Trusts, so if
  20     there is a clear failure of Trust management in any
  21     issue, then the performance directorate would certainly
  22     want to be involved because in whatever area of Trust
  23     management there is a clear breakdown, this then becomes
  24     the responsibility of the Trust Board, the Chairman, the
  25     Chief Executive, to deliver on those bits of guidance

   1     that have gone out to the Trusts.
   2        So they would certainly want to know about clear
   3     evidence that a Trust had failed in its duties. If
   4     a Trust failed to resolve a situation like this, that is
   5     a failure of Trust management.
   6   Q. So performance management, largely financial but also
   7     other management aspects. What would they do? What
   8     could they do?
   9   A. I think that would depend on the circumstances. Clearly
  10     the Secretary of State has the right to set up any form
  11     of investigation or enquiry.
  12   Q. That is the Secretary of State. What about the
  13     Performance Management Directorate?
  14   A. The Performance Management Directorate is an arm of the
  15     formal mechanisms for managing the NHS.
  16   Q. What could they do to alert the Secretary of State that
  17     you could not?
  18   A. If they had become aware of the problems, presumably
  19     they would have alerted other colleagues in the
  20     Department to the problem.
  21   Q. Why could you not do that?
  22   A. At this stage --
  23   Q. Not why did you not, but why could you not?
  24   A. I could have done.
  25   Q. So the Performance Management Directorate is

   1     a directorate which exists for the purposes you have
   2     mentioned. It had no more power -- I think is what you
   3     are implying -- than you did to act, the acting in
   4     circumstances where there is a failure of management
   5     control consisting of notifying other people who may be
   6     able to apply such pressure as they have at their
   7     disposal?
   8   A. Their formal job within the responsibility of the
   9     Department was to look at the management of Trusts.
  10     Mine were very difficult responsibilities, to look at
  11     policy development in cardiac services. So they did
  12     have a formal requirement to look at the performance of
  13     Trusts.
  14   Q. What was it about the problem as you understood it to be
  15     that made you think there may be a failure of
  16     management?
  17   A. If the Trust failed to tackle a clear issue for which
  18     there was a clear mechanism for dealing with it and
  19     allowed that problem to go unresolved, that, in my book,
  20     is a failure of Trust management.
  21   Q. Let me ask you a general question and then try and bring
  22     it down to the particular. Audit, you have told us, was
  23     in part of its process of evolution at this stage. The
  24     results of any set of figures produced would have to be
  25     interpreted?

   1   A. That is correct.
   2   Q. It was well known, was it, that there was scope for
   3     different interpretations of the same figures?
   4   A. This is a hypothetical question. If there was clear
   5     statistical significance in any set of figures, then it
   6     was difficult to interpret them in any other way. The
   7     problem is that where numbers are small, the confidence
   8     intervals become very large and it is very difficult to
   9     know whether a particular set of statistics is or is not
  10     significant.
  11   Q. That only relates to excluding chance as a reason for
  12     the apparent discrepancy in the figures. It does not
  13     imply one explanation for the discrepancy rather than
  14     another. There may be presumably different views about
  15     that?
  16   A. There may be lots of different views: was case mix
  17     adequate? Were they properly stratified? Was the data
  18     period correct? There are lots of reasons why you can
  19     challenge a statistical analysis, if you are going to
  20     get robust valid outcomes that everybody accepts, and
  21     part of the peer review process is to ensure you have
  22     a comprehensive and complete data set for the specific
  23     question you are asking.
  24   Q. So why would a difference of view about the way in which
  25     particular figures require to be interpreted be

   1     a management problem?
   2   A. Because the argument over those figures, over the
   3     significance of those figures, is an interprofessional
   4     dispute. Ipso facto, if the two sides cannot agree as
   5     to the meaning of those figures and the importance of
   6     those figures, then management has on its hands an
   7     interprofessional dispute. That interprofessional
   8     dispute requires to be resolved. You cannot allow
   9     clinicians in the departments to carry on disputes for
  10     many years. It damages the effectiveness of the unit.
  11        So management has a requirement to bring in
  12     outside independent people who have the skills to look
  13     at that, to peer review in effect what is going on and
  14     to make recommendations.
  15   Q. I will come back to that in a moment. I just want to
  16     explore those last couple of answers.
  17        Suppose that there are two clinicians in
  18     a particular department, both of them, let us say,
  19     surgeons, who in respect of a particular condition have
  20     a disagreement about appropriate treatment, so that one
  21     of them wants the department to adopt a policy of
  22     conservative treatment for a particular condition, the
  23     other wants to advise a policy of operative
  24     intervention.
  25        That is an interprofessional dispute?

   1   A. Indeed.
   2   Q. Is a dispute such as that also a management problem?
   3   A. Clearly. I mean, there were other disputes. The people
   4     here must know about the Wendy Savage inquiry. It is
   5     exactly that kind of professional dispute that came to
   6     a formal inquiry. At that time there were other Trusts
   7     who were more or less successfully using the mechanism
   8     to resolve problems they had with individual clinicians:
   9     one at the same time, at least another cardiac surgeon
  10     in the country. The Trust had used the mechanism and
  11     come to a resolution of the problem.
  12        So we are not talking about an isolated problem
  13     here. We are talking about a problem which had
  14     significant parallels beforehand, several other
  15     enquiries, several consultants, RHAs who were the
  16     employers, if you had gone into the 1980s and asked how
  17     many consultants they had suspended pending these types
  18     of enquiries, it would not be difficult for the Inquiry
  19     to ask how many consultants were suspended on full pay
  20     in the 1980s as a result of some allegations of this
  21     sort, of interprofessional disputes or poor performance.
  22        One of the reasons they were so difficult to cope
  23     with was the reason we had the Working Party in the
  24     1990s to come up with a clearer mechanism for addressing
  25     just this type of problem.

   1        So what I am trying to put in context is that this
   2     was clearly a potentially very serious set of
   3     allegations. But the situation was not unusual in the
   4     sense that, from time to time many health authorities
   5     and/or Trusts or hospitals had had similar problems and
   6     found the one mechanism or other for resolving the
   7     problem.
   8        As I was aware at the time I went down to Bristol,
   9     there was at least one other case currently going on
  10     where a Trust had used the mechanism to resolve another
  11     allegation of poor performance.
  12   Q. Everything you are saying, I think, is consistent with
  13     a view, in this particular case, that there had been
  14     a disagreement between one side and another about
  15     figures. That, I think, underlay your view, from what
  16     you are saying? You are nodding.
  17   A. Yes.
  18   Q. So you understood, did you, from what you had been told
  19     by Dr Bolsin, that whether it was right or whether it
  20     was wrong you did not know, but you had been told he had
  21     discussed his figures with what you might describe as
  22     the "other side"?
  23   A. He told me words to the effect that he had raised the
  24     matter with people in the Trust and so far had not made
  25     a great deal of progress. In other words, up to that

   1     point, nobody had instituted the mechanism as set out in
   2     HC(90)9, a formal action had not been taken by the Trust
   3     up to that time.
   4   Q. You understood from his description of this -- "I have
   5     shown this but not made any progress", coupled with the
   6     events of having a sealed brown envelope handed to you
   7     in a taxi, the private conversation, you being an
   8     outsider -- as indicating that there had been and was an
   9     ongoing dispute between clinical professionals and the
  10     unit?
  11   A. His allegations were sufficient assertion that if there
  12     was any basis in them at all, the other professionals
  13     and the Trust had an absolute duty to resolve that
  14     problem as speedily as possible.
  15   Q. In the last paragraph there, by reference to Performance
  16     Management Directorate, "highly likely some sort of
  17     formal enquiry would follow": is this a form of emphasis
  18     to reinforce your advice that something needed to be
  19     done quickly?
  20   A. What I am indicating is that the consequences of failing
  21     to address and resolve the problem would be serious.
  22   Q. So this is a -- "threat" may not be the appropriate
  23     word, but it was a warning, was it?
  24   A. It was a very strong warning.
  25   Q. This letter as a whole, having looked at the first page:

   1     is that an unusually strong letter for someone in the
   2     Department of Health to write?
   3   A. Very.
   4   Q. How often would you say in your tenure of office have
   5     you written a letter as strong as this?
   6   A. No more than two or three times.
   7   Q. And it would follow that anyone receiving such a letter
   8     should have been in no doubt as to the seriousness of
   9     the position?
  10   A. No doubt at all.
  11   Q. Shall we go overleaf to what we have as UBHT 52/288.
  12        "I recognise this letter may put you in a very
  13     difficult position personally. If there is anything
  14     I can do to help, please do not hesitate to get in
  15     touch."
  16        You were writing, in respect of the concerns, to
  17     Professor Angelini as a Professor of Cardiac Surgery?
  18   A. Correct.
  19   Q. You took it, did you, that he had responsibility of some
  20     sort for the provision of the service?
  21   A. In my experience -- and again, one has to speak from
  22     general experience -- Professors of Surgery and
  23     Professors of Cardiac Surgery are normally persons of
  24     influence, both academically in terms of the academic
  25     performance, this is a major teaching hospital, and also

   1     with the Board and Medical Director.
   2        So if one, shall we say, makes it clear to
   3     a Professor where the duty lies, you would expect them
   4     to be in a position to engage all the other senior
   5     people in the medical school or the Trust with the
   6     required process.
   7   Q. So what you are saying is that you viewed Professor
   8     Angelini as having influence, but not necessarily having
   9     responsibility?
  10   A. Well, I had no knowledge at that time of Professor
  11     Angelini's standing within the Trust. From general
  12     experience, academic Professors usually do have
  13     significant experience, are in a position to give a lead
  14     in matters of audit and performance management. He
  15     would have been the appropriate senior person.
  16   Q. So it is right then to describe your view of him as
  17     somebody who had influence, perhaps considerable
  18     influence, but no control as such?
  19   A. I am not sure my analysis went that far. My assumption
  20     was that he was a senior academic member of staff.
  21   Q. What was going to be difficult about his personal
  22     position?
  23   A. Because he was relatively new, that I was aware of, and
  24     clearly if you come in as a relatively new Professor and
  25     start raising difficult issues, it might not be quite

   1     the best foot on which to start in a new Trust.
   2        On the other hand, as far as I was concerned at
   3     that stage, it is the duty of people like Professors to
   4     take a lead in matters like this.
   5   Q. Did you know where his sympathies might lie in the
   6     dispute that you had perceived as continuing?
   7   A. At that stage, none at all.
   8   Q. That letter, as we have seen, is 21st July.
   9        On 19th August you got a reply, DOH 1/12. This is
  10     now more than three weeks later. You had written on
  11     a matter which you regarded as very serious, one of
  12     those letters you had written only once or twice in your
  13     tenure of office, which related to unnecessary deaths
  14     and possibly a complete failure of management to resolve
  15     a difficult position, if the allegations were true.
  16        Did you raise it with anyone else in the
  17     Department of Health before you got Professor Angelini's
  18     reply?
  19   A. No.
  20   Q. In your statement to us, WIT 337/2, paragraph 10:
  21        "If I think a problem is urgent or serious, it is
  22     part of my responsibilities to alert colleagues to the
  23     situation either within the Department or elsewhere in
  24     the NHS. It is not unusual for me to contact people in
  25     positions of authority to ensure they are aware of

   1     problems and that appropriate action is being taken."
   2        This problem was, as you saw it, serious. Indeed,
   3     you described it as "very serious", so it was part of
   4     your responsibility to alert colleagues to the situation
   5     either within the Department or elsewhere in the NHS?
   6   A. Correct.
   7   Q. You did not alert colleagues in the Department to it,
   8     except by passing reference you made to the problems at
   9     Bristol?
  10   A. Correct.
  11   Q. Which colleagues elsewhere in the NHS did you alert to
  12     the problem?
  13   A. Professor Angelini.
  14   Q. Only?
  15   A. Only.
  16   Q. You say it is not unusual for you to contact people in
  17     positions of authority, which you said to the best of
  18     your understanding he did not occupy, except that he had
  19     an interest?
  20   A. My assumption was that he was in a position of authority
  21     as a Professor of Cardiac Surgery.
  22   Q. Given the provisions of HC(90)9, of which you were aware
  23     having some input in the drafting, did you not think it
  24     appropriate to alert the Chief Executive or the Medical
  25     Director of the Trust to the problem?

   1   A. That would have depended on the response I got from my
   2     first initial warning shot.
   3   Q. How long were you going to give it?
   4   A. In a situation like this, clearly I would not have
   5     expected an instantaneous reply, because, again, if one
   6     assumes what would normally take place following
   7     a letter like that is that the person to whom I had
   8     written would then go and discuss the contents with
   9     a number of colleagues, they would want to determine
  10     what course of action they would have taken, how they
  11     were going to resolve the problem, before writing back.
  12     So I would have expected maybe a month, six weeks,
  13     because what I wanted was a clear reassurance that the
  14     issue was now being tackled according to an effective
  15     mechanism for so doing.
  16   Q. In other words, either the allegations are not true, or
  17     they are true and they were taking steps to resolve it?
  18   A. It set up a process to resolve the problem, to look at
  19     the allegations, to determine what needed to be done and
  20     to take appropriate action: a management action on
  21     behalf of the Trust.
  22   Q. The letter of 19th August, DOH 1/12: was this the first
  23     you heard back from Professor Angelini in response to
  24     your letter?
  25   A. It was.

   1   Q. So there was no phone call. He did not ring you up and
   2     say "What is this all about?"
   3   A. No, but he did -- I think it was either just before or
   4     just after this letter -- ring me to confirm more or
   5     less the contents of the letter.
   6   Q. This letter?
   7   A. This letter, yes.
   8   Q. So that would have been some days after?
   9   A. There were a number of phone calls around that time.
  10     I have to say, I am hazy about exactly their order.
  11     I think it was probably after this that he rang me.
  12   Q. So to the best of your recollection, and I appreciate it
  13     is not always easy to go back five years, but to the
  14     best of your recollection, this was the first further
  15     contact there had been?
  16   A. (Witness nods)
  17   Q. Did you hear anything further from Dr Bolsin?
  18   A. Not at all.
  19   Q. He did not chase you up and say "What are you doing
  20     about the conversation in the taxi?" He just left it in
  21     your hands, or you had left it in his?
  22   A. I had not left it in his, because I had taken the
  23     opportunity --
  24   Q. No, so far as he was concerned?
  25   A. What he did, I have no knowledge.

   1   Q. Indeed, jumping ahead for a moment, did you ever speak
   2     to him again before the events of early Jane 1995?
   3   A. I do not recall speaking to him at all, certainly not on
   4     this subject, until 11th January.
   5   Q. Back to the letter. He says:
   6        "I appreciate your frankness and concern about
   7     some of our paediatric cardiac surgery work. I have to
   8     admit that indeed there have been audits carried out"
   9     I notice that is in the plural, "which have shown
  10     a greater mortality than perhaps could be expected in
  11     a particular surgical procedure", which is in the
  12     singular.
  13        "This has been a matter of concern for us all and
  14     we have tried very hard in the last few months to
  15     implement changes aimed at improving our results."
  16        How did you read this in terms of accepting or
  17     rejecting the audit which you understood had been handed
  18     to you in the brown envelope?
  19   A. The very strong impression given by that second
  20     paragraph is that he and his colleagues have examined
  21     the audits, have recognised there is a problem with them
  22     and that they are now taking steps to resolve the
  23     problem, whatever the nature of the problem was. So the
  24     clear indication from that first paragraph is that in
  25     fact, even before I wrote, the implication is that this

   1     is a matter months, they would already have been
   2     wrestling with the problem, that they were already
   3     taking the appropriate action and that they had now
   4     agreed how to resolve the problem.
   5   Q. Did it cross your mind that the initial conversation had
   6     been, as you described to Professor Angelini, about more
   7     than one audit, revealing problems in more than one
   8     procedure, whereas here you have more than one audit,
   9     each revealing, or both revealing -- it is not clear
  10     which -- problems in a particular surgical procedure?
  11        Did you ever think about the wording?
  12   A. I do not think I went to that degree of analysis. What
  13     he said was that there had been audits carried out, so
  14     that suggested they had repeated, it was not just one
  15     Bolsin audit but several audits and that they had
  16     identified as a result of the audits at least one
  17     problem. In other words, they had taken definitive
  18     action to confirm whether or not there was any basis in
  19     the allegations. They had determined there was some
  20     basis and they were now taking action to resolve it.
  21        Generally in the sort of work I do, that second
  22     paragraph would be extremely reassuring.
  23   Q. He goes on to say what is being done about it and he
  24     talks about the need to find someone familiar with the
  25     surgical procedure "for which our results have been

   1     least satisfactory". He goes on in the last paragraph
   2     to talk about the move from the Bristol Royal Infirmary
   3     to the Royal Hospital for Sick Children. In the middle
   4     of that paragraph:
   5        "The appointment of a full-time paediatric surgeon
   6     and the move will greatly strengthen our unit and
   7     address the shortcomings pointed out in your letter."
   8        You had not, I think, said anything about
   9     shortcomings, apart from there were concerns about the
  10     mortality rates?
  11   A. Yes.
  12   Q. But you understood him to be talking about the same
  13     thing, did you?
  14   A. I understood that they were taking the appropriate
  15     action to correct those unsatisfactory rates and
  16     clearly, one of the questions in anything that is
  17     unsatisfactory is the organisation arrangements. Unless
  18     you put the appropriate team in place with the
  19     appropriate facilities, it is difficult to get results,
  20     so it seemed to me the action they were taking was to
  21     address both the facilities for managing children, the
  22     paediatric cardiac surgery patients, and also to engage
  23     appropriate staff with the appropriate experience.
  24   Q. The very last sentence on that page, Professor Angelini
  25     making it clear he was not in authority to do anything

   1     himself about it, but really confirming your view that
   2     he had influence rather than authority.
   3   A. The decision to move the unit he says "is not in my
   4     hands". I am not sure I would have expected it to be in
   5     the hands of a Professor of Surgery.
   6   Q. If we go overleaf, the second last sentence:
   7        "I will keep you informed all the way along."
   8        You respond to that on 30th August -- we have had
   9     your letter to him of 21st July, his response 19th
  10     August, your response 30th August, which we get at
  11     UBHT 61/275.
  12   A. I am sorry, could I make one other comment about that
  13     letter? The copies at the bottom, because it is not
  14     only reassurance, the substance of the letter is not
  15     only reassuring. The fact he has copied that letter to
  16     me also to Professor Vann Jones, who I assume is the
  17     head of cardiology, I do not know because I did not know
  18     anything about him at the time, and also to the Chief
  19     Executive of the Trust, suggests to me that the Trust,
  20     and all required persons to take appropriate management
  21     action to resolve the problem, are all included.
  22        So if one was ever asking for reassurance that by
  23     now the Trust had grasped the nettle, there was adequate
  24     in this letter.
  25   Q. UBHT 61/275. You respond. The last paragraph: do

   1     I read that as a sign-off? You have done your job?
   2   A. Exactly.
   3   Q. When, in relation to the letter of 19th August, or this
   4     letter, do you think you may have heard from Professor
   5     Angelini on the telephone?
   6   A. He rang me, I think probably just before 30th August,
   7     around then, to let me know that they had managed to
   8     interest Ash Pawade, who again was not a name at that
   9     stage known to me, but he was clearly very enthusiastic
  10     that if they could attract Ash Pawade to the unit, then
  11     it would be an extremely good thing.
  12        So there was certainly a short conversation about
  13     the forthcoming appointment but I do not remember any
  14     other substantive conversations around that time. The
  15     only one I recall is his -- it may be too strong, but
  16     certainly his enthusiasm for at least one of the names
  17     on the short-list.
  18   Q. So Professor Angelini is filling you in on details here?
  19   A. Yes.
  20   Q. Talking to you by telephone. You say there were
  21     a number of phone calls which you find difficult to
  22     place. Did he make more than one phone call? Was this
  23     the only one?
  24   A. The only one I can recall around this time was the one
  25     where he told me they were hoping to get Ash Pawade.

   1     I cannot recall any others.
   2   Q. Did he tell you when Ash Pawade was going to start?
   3   A. No.
   4   Q. When did you think he might, from general experience?
   5   A. General experience is two to three months.
   6   Q. So having been told that around the beginning of
   7     September, you expected him to take up his office
   8     probably December/January?
   9   A. 1st January would probably be the most likely date.
  10   Q. Having signed off on your letter of 30th August, did you
  11     hear again that year, as you recall it, from Professor
  12     Angelini by telephone?
  13   A. I do not recall, certainly not on this matter. I cannot
  14     absolutely exclude a phone call on other research
  15     interests that he had, but I do not recall any reference
  16     to this matter in a telephone call at all during the
  17     remainder of that year.
  18   Q. What Professor Angelini has told us -- it is Day 61/173,
  19     beginning at line 1 -- is that he has suggested to us
  20     that he and you had several telephone conversations all
  21     the time and those intensified towards January when
  22     there was the last switch operation planned.
  23        I will come to that in a moment or two. Is he
  24     right or is he wrong about saying that he and you had
  25     several telephone conversations all the time and were

   1     "in quite regular contact", was another phrase he used?
   2   A. I do not recall.
   3   Q. Do you think you probably would recall if it had
   4     happened?
   5   A. In relation to this issue, yes. Possibly in relation to
   6     cardiac research and other projects that he was
   7     interested in -- I mean, I have had over the years
   8     a number of conversations with Professor Angelini, in
   9     particular about cardiac surgery. I do not actually,
  10     I have to say, recall that autumn having any further
  11     conversations with Professor Angelini specifically on
  12     this matter, or anything else, but I could not rule them
  13     out.
  14   Q. So you could not rule out a conversation on anything
  15     else, but you are how certain that you did not speak to
  16     him about this matter?
  17   A. And I certainly did not speak to him frequently. If
  18     I spoke to him at all, it was one phone call.
  19   Q. So you may have spoken to him more than just the once
  20     around 30th August, but not otherwise?
  21   A. That is right.
  22   Q. That is the best of your recollection; how certain are
  23     you about that?
  24   A. Reasonably certain.
  25   Q. Can we move on to DOH 1/14? It is a letter of

   1     12th September 1994, from Dr Roylance to you. Was this
   2     the first you had heard from Dr Roylance?
   3   A. Yes.
   4   Q. No phone call?
   5   A. No phone call. Unsolicited letter.
   6   Q. He begins by reciting the fact that you picked up from
   7     the end of the previous letter, that he had seen that
   8     letter, and by "the correspondence", that would refer to
   9     the other letters you had written?
  10   A. I am sorry, it needs to ...
  11   Q. I am sorry, can we scroll down, please. (Screen
  12     scrolled)
  13   A. Yes, I mean, my assumption is, if he says "the
  14     correspondence" he has seen my letters.
  15   Q. And there was not a lot of it?
  16   A. Only two.
  17   Q. "I felt I should write to confirm the Trust Board's
  18     awareness of this problem, for which reason we are
  19     seeking to appoint another full-time consultant
  20     paediatric cardiac surgeon ..."
  21        He says the Appointments Committee is due to meet
  22     on 20th September.
  23        "The decision has already been taken by the Trust
  24     Board ..."
  25        Ash Pawade's name at this stage could only have

   1     been one of the candidates?
   2   A. Correct.
   3   Q. So do you think, on reflection, that the conversation
   4     that you remember having with Professor Angelini,
   5     identifying Ash Pawade by name, must have taken place
   6     after 20th September?
   7   A. No, the short-listing takes place weeks before an
   8     Appointments Committee is made. The short-listing is
   9     normally a minimum two weeks before, and often many
  10     weeks before that. So the fact that Ash Pawade was one
  11     of the candidates and was on the short-list would have
  12     been known to Professor Angelini during August/early
  13     September, before this letter was written. It could
  14     have been known to him well before this letter was
  15     written -- only that he was on the short-list, though.
  16   Q. We see how Dr Roylance finishes the letter:
  17        "I will continue to monitor the situation". I see
  18     he has promised to keep you informed.
  19   A. But that letter is crucial. The first sentence of the
  20     second paragraph is vital. He is telling me that the
  21     Trust Board, that is the non-executive directors, the
  22     directors, the Chairman, are aware of the problem: that
  23     the Trust itself is fully informed. Nobody, the
  24     Secretary of State could not have asked for better and
  25     clearer reassurance from the Chief Executive that the

   1     Trust had analysed, understood the problem, taken
   2     effective management action and set in train all the
   3     changes needed to resolve it.
   4        So this unsolicited letter came to me as probably
   5     the strongest reassurance I could have received at that
   6     time that the Trust were now taking appropriate action.
   7   Q. And the "appropriate action", it would appear from the
   8     second last paragraph, is to resolve "the situation for
   9     the future."
  10        To what did you understand the somewhat Delphic
  11     words, "the situation", to refer?
  12   A. You can read a lot in-between the lines. What I read
  13     in-between the lines was that they recognised that their
  14     outcomes were poor; that they were putting somebody in
  15     who would in future perform the procedures, the
  16     implication being until they were in place they would
  17     not undertake any risky procedures, and they would
  18     undertake the management organisation problem. It is on
  19     the basis of common knowledge: one recognises that split
  20     site working is always difficult in any acute specialty,
  21     so concentrating all the work in one centre clearly has
  22     an advantage.
  23        So it seemed to me they were addressing both the
  24     performance question and the facilities question and
  25     taking effective and fairly speedy action.

   1   Q. Where do I get from the second paragraph the statement
   2     explicitly that no further paediatric cardiac operations
   3     were going to be performed until the appointment of
   4     another full-time consultant, paediatric cardiac
   5     surgeon?
   6   A. You do not.
   7   Q. Where do I get it implicitly?
   8   A. I get it implicitly that you would not be going out to
   9     appoint another cardiac surgeon to do the work if you
  10     had not recognised that work was being done
  11     inadequately. If you have identified a problem like
  12     that, you do not, in normal circumstances, in my
  13     experience, compound the problem by continuing to
  14     produce poor results. The implication of that to me,
  15     and that is my interpretation of it, is that you would
  16     not -- I was given a clear understanding in the phone
  17     conversation with Professor Angelini, that they would
  18     avoid the procedure at least, if not procedures, that
  19     were in question until Ash Pawade was in post.
  20   Q. Let me unpick that as best I can. The words used in
  21     this letter, "another full-time paediatric cardiac
  22     surgeon", would suggest there are one or two or three or
  23     four full-time consultant paediatric cardiac surgeons
  24     already in post?
  25   A. Yes.

   1   Q. Plainly it is the concept that another full-time
   2     paediatric cardiac surgeon is needed. That is necessary
   3     from an understanding of the paragraph, is it not?
   4   A. Do not forget, this paragraph follows the letter from
   5     Professor Angelini to say that they were appointing
   6     somebody with experience of the area of cardiac surgery
   7     with which they had a problem. The implication from his
   8     letter was that they had audited it and there were only
   9     problems with one procedure, or possibly certain
  10     procedures. So here you were appointing, according to
  11     Professor Angelini, a consultant paediatric cardiac
  12     surgeon specifically to address the weakness in their
  13     programme.
  14        This is confirmed, albeit not as explicitly in
  15     this letter, that they have recognised the problem,
  16     which I assumed was the same problem as Professor
  17     Angelini was addressing, because that is the natural
  18     assumption and that he is just confirming that the step
  19     required to resolve that problem is to appoint
  20     a full-time paediatric cardiac surgeon.
  21        The strong implication of that to me, from my
  22     experience of medical practice, is that in that area in
  23     which they were weak, they would not risk doing further
  24     cases until they got a person with the appropriate
  25     experience and training in place to undertake the

   1     procedures.
   2   Q. It is equally consistent, is it not, to read it as
   3     saying, "We have had to rely upon part-time consultant
   4     paediatric cardiac surgeons. That is why we need
   5     a full-timer to do the work"? If it read in that way,
   6     there would be nothing necessarily implied in the
   7     paragraph to suggest that the existing cardiac surgeons
   8     should not go on doing what they were doing, is there?
   9   A. It may be open to that interpretation by some people,
  10     but taken --
  11   Q. But that was not the interpretation you had?
  12   A. Taken in the context of following the more specific
  13     points, this is a summary, a brief summary, of the
  14     points made in Professor Angelini's letter. The
  15     implication that I took from it was quite clear.
  16        Clearly, that is my interpretation. Others may
  17     have interpreted it differently, but it is certainly
  18     consistent. What he has written to me here is entirely
  19     consistent with what I had already learned from
  20     Professor Angelini.
  21   Q. You say, in relation to this point, if we just go to
  22     UBHT 61/282 -- it is a later letter that you were to
  23     write to Dr Roylance.
  24        "From information received, including your letter
  25     of 12th September [the one we have been looking at]

   1     I had understood that steps had been taken to rectify
   2     the problem by the appointment of a new paediatric
   3     cardiac surgeon and the transfer of the service to the
   4     Children's Hospital. I had assumed, mistakenly, it
   5     would appear, that (at least high risk) neonatal and
   6     infant surgery would have ceased pending the arrival of
   7     the new consultant and the transfer."
   8        You appear to be accepting in retrospect that your
   9     assumption was mistaken?
  10   A. He told me in retrospect, later, that my assumption was
  11     mistaken, yes.
  12   Q. And you accepted it?
  13   A. Well, my assumption was that in writing the letter, that
  14     is what he was agreeing to. That clearly he claimed not
  15     to have agreed to that, and therefore I could only
  16     conclude that my assumption drawn from his and Professor
  17     Angelini's letter and the conversation was not the same
  18     as his understanding.
  19   Q. You have described your understanding as to what was
  20     impliedly going to stop, a few moments ago, as being at
  21     least the particular procedure they had most problems
  22     with, and here it is the least high risk neonatal and
  23     infant surgery.
  24   A. I was still not aware of the outcome of the audit or
  25     what procedures. All I knew was that they were ones

   1     that carried by their nature a high risk. So in
   2     a sense, because I do not know the specifics, I am
   3     keeping to a fairly broad definition. In other words,
   4     those procedures which by definition you have a problem
   5     with, I would not have expected you to do.
   6   Q. The assumption you made, going back to the letter of
   7     DOH 1/14, it is equally capable, the second paragraph,
   8     of being read, is it not, as saying, "We in the Trust
   9     are going to take care over procedures that we operate",
  10     rather than "We are not going to do any"?
  11   A. Others may interpret it in any way they wish.
  12     I interpreted it as I have explained.
  13   Q. I am not going to take you back for the moment to the
  14     later letter of 25th January which you wrote to
  15     Dr Roylance, but you say in that that from information
  16     received, including your letter of 12th September,
  17     "I had understood that steps had been taken to rectify
  18     the problem."
  19        What was the other information you received?
  20   A. The letters from Professor Angelini and the phone call
  21     and the fact that he had written subsequently to tell me
  22     that Ash Pawade had actually been appointed, not to tell
  23     me anything about his work.
  24        This letter, signed by the Chief Executive of the
  25     Trust, should be all the assurance anybody in the

   1     Department of Health needs to say that effective Trust
   2     management action has now been taken, the problem has
   3     been addressed, the solution is in hand.
   4        Once I got this letter, it appeared to me that at
   5     last, if that was the case, if there had been any delay,
   6     the issue had been tackled, the problem was now in the
   7     process of resolution in the same way that other Trusts
   8     that I was aware of had been managing and resolving
   9     similar problems.
  10   Q. What, if anything, did Professor Angelini say to you to
  11     give you any idea that there was going to be no further
  12     high risk surgery, or no further surgery in a particular
  13     area, or whatever it might be?
  14   A. Again, at this stage, it is difficult to recall exactly
  15     word for word what was said in the conversation. He was
  16     clearly excited that Ash Pawade was arriving. He
  17     implied that, until he arrived -- I cannot remember the
  18     exact words -- they would not be doing any more
  19     difficult procedures.
  20   Q. Implied?
  21   A. Implied. I cannot remember his words, whether he said
  22     to me exactly, "We will not do anything until he
  23     arrives", or whether he said -- I cannot remember.
  24     I cannot remember his words exactly, but I came away
  25     from that, Roylance's letter, what was left in my mind

   1     left me with the clear impression they were not going to
   2     undertake any high risk cardiac surgery until the
   3     changes they had proposed had been put in place.
   4        Again in my experience, I would not have expected
   5     a unit -- I mean, the purpose of audit is to identify
   6     the problem, to find out how to overcome that problem.
   7     You do not perpetuate the problem in normal practice
   8     until you have put in place the changes necessary to
   9     overcome the problem I have identified. That is just
  10     good practice.
  11   Q. Professor Angelini has told us he did not think that he
  12     did say to you that there would be no further surgery in
  13     any particular field.
  14        From what you say, thinking about it to the best
  15     of your recollection, you cannot deny his view on that.
  16     The highest you put it is that that is the implication
  17     you took from what he said?
  18   A. Exactly.
  19   Q. Indeed, I suppose it might be said that he, Professor
  20     Angelini, could only reflect the decisions of others
  21     because you knew that he was the Professor, but you knew
  22     that the Chief Executive and the Trust obviously had the
  23     control over whether operations were or were not done?
  24   A. In the final analysis, clearly. It was a matter for the
  25     Trust. I mean, this letter from Dr Roylance implies

   1     very strongly -- it does not imply, it states
   2     explicitly, that the Trust Board, the whole Trust Board,
   3     is aware of the problem and has taken steps to resolve
   4     it.
   5        As far as I am concerned, that is as much
   6     reassurance as anybody can expect.
   7   Q. We go on to DOH 1/7. It is 20th September, so having
   8     had the letter that you got from Dr Roylance on
   9     12th September, we now have this letter,
  10     20th September. It is the date of the interviews, as
  11     we have been told. You write to Dr Roylance:
  12        "Thank you for your letter .... Pleased to hear
  13     that ... a change in service had been planned. Under
  14     the circumstances, I think it best to leave the Trust to
  15     effect the proposed changes as quickly as possible."
  16        What you are saying here is, "I have done my bit,
  17     you just go ahead and do what you are doing"?
  18   A. Exactly.
  19   Q. So you were giving your blessing to the proposals to
  20     address the problem that had been identified to you.
  21     Even though you had not fully explored the problem
  22     yourself, you regarded these changes as appropriate
  23     action from the appropriate people?
  24   A. No. That is not what this says.
  25   Q. I am asking about what was in your mind.

   1   A. What this says is, the Trust has taken action. I have
   2     been reassured that the Trust has taken action. That is
   3     the Trust's responsibility. They now seem to be taking
   4     on their responsibilities. It is not appropriate for me
   5     to do anything further.
   6        I am not saying that what they actually took was
   7     the right action or not. I had no way, I had no details
   8     of the problem. I had had a reassurance from the Trust
   9     itself that they were aware of the problem, they
  10     understood it and they had taken action. In other
  11     words, at this stage, effective management action on the
  12     part of the Trust had been taken to resolve the issue,
  13     which, to my knowledge at that stage, was still an
  14     interprofessional dispute. The interprofessional
  15     dispute had been confirmed by Professor Angelini that
  16     there was a problem with the service. Steps had been
  17     taken to address it.
  18        Do not forget, I have asked repeatedly in my
  19     letters to be given future audit results, which is again
  20     overstepping the mark, as I have no right to monitor the
  21     outcome of Trusts, but in order to provide a final level
  22     of reassurance, I sought an assurance that future audit
  23     results would show their results were as good as
  24     anywhere else in the country. So there is even
  25     a fallback position that I had really no right to

   1     demand, to say that "I expect in due course to be
   2     reassured that the action you have taken has resolved
   3     the problem and that the audit results are now
   4     acceptable".
   5   Q. On 22nd September, if we see a letter at UBHT 61/280,
   6     this is a report to you of the appointment of Ash
   7     Pawade.
   8   A. That is correct.
   9   Q. You respond to that, UBHT 61/281, 3rd October.
  10        " ... I trust the service will now fulfil its
  11     potential."
  12        Did you, at that stage, think you had done your
  13     job?
  14   A. I did.
  15   Q. Did you hear any more about problems at Bristol before
  16     January 1995?
  17   A. As usual in my job, I heard a bit of gossip here and
  18     there at meetings I attended about the problems there
  19     had been in Bristol. In other words, I heard a lot of
  20     gossip about what had happened in the past, but nothing
  21     to suggest that what they were now doing was not going
  22     through smoothly and working.
  23   Q. When was the next occasion that you heard anything which
  24     caused you to take any particular action?
  25   A. On 11th January when I was phoned first. I cannot

   1     remember which order it was, but both Dr Bolsin and
   2     Professor Angelini, I think it was Bolsin first and
   3     Angelini second, advising me that they felt that the
   4     paediatric cardiac surgeons were about to perform
   5     another high risk operation. And that Ash Pawade was
   6     not in post. I further ascertained it was not an urgent
   7     procedure.
   8   Q. Whichever of them phoned you, I want to deal with the
   9     two conversations you had. Did Dr Bolsin phone you, or
  10     did you phone him?
  11   A. As far as I recall, he phoned me.
  12   Q. There is a suggestion that he was paged by you on
  13     11th January. Could that be right?
  14   A. It is certainly possible if Professor Angelini rang me
  15     first.
  16   Q. That might have happened?
  17   A. That might have happened.
  18   Q. What do you recollect Professor Angelini as having said
  19     to you?
  20   A. I recollect the substance of both phone calls as being
  21     similar and that is that they were proposing an
  22     operation an 18 month old boy, a risky, difficult
  23     operation that they did not think, given their previous
  24     track record, was a risk worth taking.
  25   Q. Did they say who was proposing this?

   1   A. I do not recall they named a specific surgeon at that
   2     stage. I certainly do not recall it. No.
   3   Q. So what did you do?
   4   A. What was immediately clear to me was that the
   5     interprofessional dispute had reawakened. Here again
   6     were Professor Angelini and Dr Bolsin at least concerned
   7     that the Trust -- they were concerned, so the
   8     interprofessional concerns that I thought had been
   9     sorted were now clearly being raised again and that far
  10     from -- well, it may have disappeared for a while, but
  11     the interprofessional dispute was rearing its head
  12     again.
  13   Q. Did you give either Professor Angelini or Dr Bolsin any
  14     advice as to what they should do?
  15   A. Again, I cannot recall exactly the substance of the
  16     conversation. I have a feeling I said they had to take
  17     it to the Trust management, but that I would also --
  18     I undertook to ring Dr Roylance to alert him to the fact
  19     that I was aware that concerns were being raised once
  20     again.
  21   Q. That you were aware, or so that he might become aware?
  22   A. To ensure that he was aware that this interprofessional
  23     dispute had broken out again. Because I had no way of
  24     knowing at that stage whether he knew anything about the
  25     problem, as he had written to me in the past, as he was

   1     a doctor, then as I said previously in my statement,
   2     I do ring people in authority and Roylance was clearly
   3     the authority in this case, to make them aware of
   4     potentially serious situations that are arising.
   5        So I had no hesitation in this case in ringing
   6     Dr Roylance as the Chief Executive of the Trust saying
   7     "Do you know that a potentially serious situation has
   8     arisen in your Trust?"
   9   Q. What do you recall Dr Roylance saying to you?
  10   A. He informed me that, as we spoke -- because I had only
  11     managed to get hold of him in the early evening --
  12     during the course of our conversation, a case conference
  13     had already been arranged to discuss the question and
  14     that he would abide by -- again, I cannot remember
  15     exactly the phrase he used, whether he would abide by
  16     the outcome of that case conference.
  17        Again, that did not seem an unreasonable action
  18     for a Chief Executive to take at that stage, to call in
  19     all the relevant clinicians to sit down and examine the
  20     problem and determine what was the most appropriate
  21     course of action. That is a good way of resolving
  22     a dispute that has arisen.
  23   Q. So he may well have said to you he would abide by the
  24     outcome of the medical conference that was taking place
  25     and from your perspective, that was an entirely

   1     reasonable thing for him to do?
   2   A. Yes.
   3   Q. What else was said?
   4   A. I suggested to him that if, as I had been informed, the
   5     procedure was non-urgent, he always had the opportunity
   6     to get an outside second opinion or something, if there
   7     was a problem. So again the same resort you have, if
   8     you have a difficult clinical issue if the worst comes
   9     to the worst, you can resort to an outside second
  10     opinion. In the case of a child, if you have
  11     a difficult surgical problem, some surgeons will, in any
  12     case, seek a second opinion from a colleague. So it was
  13     a perfectly reasonable course to adopt.
  14        I also suggested that because clearly the, in
  15     inverted commas "row" had broken out again, if anything
  16     went wrong, then the outcome could be serious because
  17     this was clearly -- I did not explain, in my mind at
  18     that time, this would represent a breakdown of Trust
  19     management: that the apparent resolution of the
  20     interprofessional dispute had only been apparent.
  21   Q. Let me just explore that. What you are saying is that
  22     it was entirely appropriate, as you saw it, for
  23     Dr Roylance to await the decision of the clinical
  24     conference that was taking place, and abide by the
  25     outcome of that, whatever it was. Why should it be

   1     a breakdown of Trust management if the child died, but
   2     not a breakdown of Trust management if the child
   3     survived?
   4   A. I did not say that -- it was a failure of Trust
   5     management if they did not come to a conclusion as
   6     a result of that case conference that satisfied the
   7     senior clinical staff, who were clearly concerned.
   8        In other words, if the outcome of his management
   9     of this difficult situation did not resolve the concerns
  10     of the various parties, then that was a failure of Trust
  11     management.
  12        So to some extent, even had the child survived but
  13     certain members of the clinical staff were still
  14     concerned that this was injudicious and it raised the
  15     previous concerns yet again, that still would have been
  16     a failure of Trust management in my view.
  17   Q. So what impression do you think that you left
  18     Dr Roylance with as a result of your phone call?
  19   A. I hoped I had alerted him to the seriousness of the
  20     situation, and that this was a difficult question that
  21     needed very careful handling.
  22   Q. Neither of those matters with which you say you probably
  23     left Dr Roylance, suggest that he should take any
  24     particular action?
  25   A. I offered him alternatives.

   1   Q. Which were what?
   2   A. That he might wish to abide by the findings of the case
   3     conference, but if in doubt, because the case was not
   4     urgent, get a second opinion.
   5   Q. So if not in doubt, if satisfied that he could rely upon
   6     the case conference, it was appropriate --
   7   A. It is not my job --
   8   Q. The advice you were giving him was that it was all right
   9     for him to go ahead?
  10   A. If the case conference resolved the differences of view
  11     between the clinicians. If it did not resolve that
  12     difference in view, then he was embarking on an
  13     extremely high risk course, because whatever the outcome
  14     of the surgery, he had reawakened the interprofessional
  15     dispute.
  16   Q. Is that not something of a cleft stick for him, because
  17     suppose that there are, let us say for the sake of
  18     a purely hypothetical example, 10 people at the case
  19     conference, two are firmly of the view that the
  20     operation should not go ahead and 8 are firmly of the
  21     view that it should.
  22        Suppose that is the hypothesis.
  23        If the operation does go ahead, then inevitably
  24     two are disappointed, because their views have not been
  25     taken. If the decision by the Chief Executive is that

   1     the operation should not go ahead, is not the corollary
   2     that 8 people are disappointed in their view that the
   3     operation should go ahead and that that view has been in
   4     effect trampled on by the Chief Executive?
   5   A. Yes.
   6   Q. So in that situation, is there actually any right
   7     decision that the Chief Executive can take?
   8   A. Yes.
   9   Q. Which is what?
  10   A. What is in the best interests of the patient.
  11   Q. Is there, given that a case conference is, on this
  12     hypothetical example by 10 people, two of whom who think
  13     it is in the best interests of the patient not to
  14     operate and 8, on the hypothetical example, who say it
  15     is in the best interests to operate: there is no, or is
  16     there, any objective way of resolving whether it is or
  17     is not in the best interests of the child to operate?
  18   A. If there is a question mark over the management of
  19     a child, or any patient, then the thing that is in the
  20     best interests of the patient, unless it is a dire
  21     emergency, is to get another second opinion.
  22        Knowing that there had been clearly questions over
  23     the performance of complex operations, yes, anybody is
  24     in a cleft stick, it may be a judgment of Solomon, you
  25     may have to live with the consequences but you are

   1     appointed as the Chief Executive. And there is a Chief
   2     Executive who is a doctor. Whatever his experience as
   3     a doctor, he must have made difficult clinical judgments
   4     in the past himself.
   5        I suggested to him a perfectly normal acceptable
   6     course of action. If there remained some discussion
   7     after the case conference about the management of that
   8     child, the safe thing is to get an independent second
   9     opinion.
  10   Q. So you were taking the view that objectively speaking,
  11     there was risk, avoidable risk, potentially to the
  12     child, even if the majority view at the case conference
  13     was whether the best interests of the child would be
  14     served by continuing the surgery the next day?
  15   A. I had no idea, I had no information in the case
  16     conference who was involved. What I advised him was
  17     that if the case conference did not resolve the problem,
  18     he should seek outside advice. It is a normal prudent
  19     course.
  20   Q. Again, a purely hypothetical example: suppose there had
  21     been a case conference of 30 clinicians, one of whom
  22     said "Do not operate" and 29 of whom had said "Yes, let
  23     us go ahead". Would the advice still hold good?
  24   A. It may. Who are those clinicians? What is their
  25     expertise? What is their track record? If you have in

   1     a room the acknowledged national if not international
   2     experts giving an opinion, you cannot get a better
   3     opinion for that person. If you have not got the
   4     acknowledged best expertise available, then in the
   5     interests of that patient you should go and get it.
   6   Q. So you speak to Dr Roylance. You give him that advice.
   7     You say that you would have regarded it as a failure of
   8     management if, as it turned out, there had been
   9     a possibility of resolving the conflict in the case
  10     conference and the operation had gone ahead with tragic
  11     results?
  12   A. That is not exactly what I said.
  13   Q. I am sorry. If management was not at the case
  14     conference, if it was just clinicians, why would it be
  15     a failure of management if they did not agree?
  16   A. Failure of management is to resolve the differences, the
  17     interprofessional differences that had clearly arisen,
  18     again arising from this case. Failure of management is
  19     to not resolve those differences and seek a course of
  20     action which is acceptable, defendable.
  21   Q. The view you have been expressing obviously depends upon
  22     there being a disagreement at the conference?
  23   A. True.
  24   Q. If there was no disagreement, obviously there is not the
  25     problem you have identified?

   1   A. Assuming that the conference represents the right
   2     authorities. You could have a case conference of
   3     theatre porters who would not necessarily come to the
   4     right -- your case conference has to be properly
   5     constituted.
   6   Q. What then happens? You have spoken to Dr Roylance on
   7     11th January. You heard, on 12th or 13th January, that
   8     there had been a tragedy?
   9   A. Yes.
  10   Q. Who told you?
  11   A. Again, it is difficult to recall at this stage, but it
  12     was either Professor Angelini or Steve Bolsin, or
  13     possibly both. But I certainly had a flurry of phone
  14     calls on or around the -- I think it was the second day
  15     after the procedure. And clearly, that was evidence
  16     that the situation had gone from bad to worse.
  17   Q. Let me take you back for one moment. There is one
  18     matter I should have covered and I have not. You say
  19     that in the conversation you had on 11th January,
  20     Dr Bolsin, you think, had told you that the case was not
  21     an emergency?
  22   A. Yes.
  23   Q. Did anyone else tell you that?
  24   A. I think I asked -- as far as I recall, I asked both
  25     Professor Angelini and Steve Bolsin if it was an

   1     emergency. When I spoke to Dr Roylance, I again said,
   2     or words to this effect: "I understand this is not an
   3     emergency procedure", which he confirmed.
   4   Q. You say that with a little bit of hesitation. How
   5     certain are you that Dr Roylance expressed the view to
   6     you that it was not an emergency?
   7   A. I cannot be certain whether he did. I certainly pointed
   8     out to him that there was time, because it was not an
   9     emergency, to take effective action and he did not
  10     disagree.
  11   Q. You said I think at the GMC that it was difficult to
  12     recall exactly what was said to each of the people you
  13     spoke to by phone. That is so, is it?
  14   A. That is correct.
  15   Q. So I press you just a little on this, in case it should
  16     be a matter of importance: how certain are you first of
  17     all that you mentioned that it was not an emergency,
  18     putting the point to Dr Roylance? Secondly, if you did,
  19     how certain are you that you got a response
  20     acknowledging that that was the case?
  21   A. I am certain that I put the point to Dr Roylance because
  22     of the advice I offered. I said there was time to get
  23     a second outside independent opinion. There would not
  24     have been time to do any of that -- had it been a life
  25     or death operation, because the child was dying, that is

   1     totally different. I would only have gone ahead with
   2     the course of action that I did if it was clear in my
   3     own mind that there was at the very least several days
   4     available to discuss and determine the most appropriate
   5     management of the child.
   6   Q. Back to the next day or the day after. When was it?
   7     Was it the 12th or the 13th, do you think, that you
   8     heard?
   9   A. I cannot answer that, but as far as I recall, it was the
  10     13th. I think it was two days after the --
  11   Q. So the operation would have been a Thursday?
  12   A. The operation was on the 12th.
  13   Q. The Thursday?
  14   A. I must have heard on the Friday, which would have been
  15     the 13th.
  16   Q. Did you speak to anyone else that day about this?
  17   A. I cannot honestly recall whether I spoke that day.
  18     I think it was the following Monday -- the 16th, was it,
  19     that I wrote alerting a large number of colleagues in
  20     the Department.
  21   Q. You wrote on the 16th, yes. Did Mr Wisheart contact you
  22     at all?
  23   A. He contacted me I believe on the morning of the
  24     operation, to explain the outcome of the case
  25     conference. I again reiterated my concerns. On the

   1     13th I spoke to Dr Roylance and I may have spoken to
   2     Dr Wisheart, and I made it clear to Dr Roylance in that
   3     conversation that I would be alerting my colleagues in
   4     the Department to the situation.
   5   MR LANGSTAFF: Now I am going to pick up on what happened
   6     thereafter, after a break, sir. Would now be an
   7     appropriate time for an adjournment for lunch?
   8   THE CHAIRMAN: Yes. Shall we say 40 minutes, then? That
   9     means 20 past 1.
  10   (12.40 pm)
  11            (Adjourned until 1.20 pm)
  12   (1.25 pm)
  13   THE CHAIRMAN: Dr Doyle, forgive me, I have kept us
  14     waiting. I apologise to everyone, but there were
  15     a number of things I had to do elsewhere. Sometimes it
  16     happens. Forgive me.
  17   MR LANGSTAFF: Dr Doyle, just before we leave your phone
  18     call to Dr Roylance finally on the night before the
  19     surgery, you say that you are confident you said to him
  20     words to the effect that it was not an emergency, it was
  21     a case that might wait.
  22        He would presumably be in the position of not
  23     himself knowing the full clinical details until after
  24     the clinical conference?
  25   A. I am sorry, but I am not in any position to determine

   1     what clinical details Dr Roylance was or was not in
   2     possession of. I would have thought it was a matter of
   3     a moment to ascertain whether the child was an emergency
   4     case or not.
   5   Q. It might have been known that the case was elective, but
   6     it might not have been possible to say any more than
   7     that.
   8        Let me go on to your conversation with Mr Wisheart
   9     on the morning of the surgery. He phoned you?
  10   A. As I recall, yes, he did, yes.
  11   Q. And had you spoken to Mr Wisheart before?
  12   A. Certainly not on this subject. No, as far as I can
  13     recall, I had never spoken to Mr Wisheart before.
  14   Q. Did you know who he was and what role he played in
  15     respect of this incident?
  16   A. I knew by then that he was a paediatric cardiac surgeon,
  17     or at least, a cardiac surgeon, and I think I was also
  18     aware at that stage that he was Medical Director.
  19   Q. Did you know that it was not him who was to perform the
  20     operation?
  21   A. I have no idea who was to perform the operation.
  22   Q. The day after the operation, Friday, the 13th, did you
  23     speak again to Mr Wisheart?
  24   A. Certainly either the Friday or the following Monday.
  25     I spoke to him soon after, and Dr Roylance.

   1   Q. Do you recall when it was that you spoke to
   2     Dr Roylance?
   3   A. No, I cannot recall exactly. But in that
   4     conversation -- well, we will come to that.
   5   Q. I think I may be able to help you on the date at which
   6     you spoke to Dr Roylance. It is DOH 1/9: a memo by you
   7     dated 16th January. Notice that date, please. The
   8     second page of it. Page 10, at the bottom [DOH 1/10]:
   9        "I have spoken to Dr Roylance (Trust CE) today who
  10     assures me ..."
  11        There is no reference to any earlier phone call
  12     after the operation in the course of that memo. It is
  13     a memo I am going to come back to, but does that help to
  14     establish the date at which you first spoke to
  15     Dr Roylance after the operation?
  16   A. It is not necessarily the first time I spoke to
  17     Dr Roylance. All it says is that "I have spoken to
  18     Dr Roylance today". As I say, I cannot recall
  19     exactly -- there was a whole flurry of phone calls.
  20     I certainly spoke to several people on the Friday, and
  21     it would not be unreasonable to give Dr Roylance the
  22     weekend to consider exactly what he was going to do and
  23     then speak to him again. But I cannot remember the full
  24     sequence of phone calls at this stage. I certainly
  25     spoke to him obviously on the Monday. Whether that was

   1     as well as, I do not know.
   2   Q. What was the nature of the conversation that you had
   3     with Dr Roylance?
   4   A. To (a) explain to him that I had to alert colleagues in
   5     the Department and that I felt in my view that an
   6     external inquiry was now essential. The nature of that
   7     external inquiry might cover both whether, in the
   8     particular procedure that had taken place, there were
   9     avoidable problems and certainly whether in the context
  10     of the record of the Department, it was an acceptable
  11     decision to have taken to have operated in the first
  12     place.
  13   Q. What was his reaction to your suggestion that there
  14     should be an external enquiry?
  15   A. He agreed to it.
  16   Q. Straightaway?
  17   A. He certainly questioned whether there was any way out of
  18     it. I think he agreed to it reasonably quickly.
  19   Q. So we may take it that the impression you were left with
  20     was that he willingly agreed to such an inquiry taking
  21     place?
  22   A. The impression he was left with was that he had finally
  23     agreed that an inquiry should take place.
  24   Q. Which was it, willingly, or finally?
  25   A. Had finally.

   1   Q. What therefore happened I think was that you, so far as
   2     writing to Dr Roylance is concerned, wrote to him on
   3     25th January, UBHT 61/282. You set out the history in
   4     the first paragraph. The second paragraph, the
   5     understanding which we have dealt with. The third
   6     paragraph:
   7        "As you know, I learned last week that far from
   8     this being the case [that neonatal and infant surgery
   9     would cease] it continued. We spoke on the evening of
  10     11th January about the proposal to perform a switch...
  11     I suggested that under the circumstances it might not be
  12     advisable to proceed. The operation was performed the
  13     following day and the child died."
  14        If you, on the evening of 11th January, were
  15     saying to him that it all depends on the outcome of the
  16     clinical management conference as to whether it is or is
  17     not --
  18   A. I am sorry, that is not what I said.
  19   Q. I am sorry, I thought that you had left him with the
  20     idea that there was a dispute, an interprofessional
  21     dispute that needed to be resolved?
  22   A. I had told him, made it quite clear to him, that the
  23     interprofessional dispute had arisen and that it was the
  24     responsibility of Trust management to sort it out.
  25     I had given him possible options and pointed out that

   1     there was no need to do anything as an emergency.
   2        He had to judge whether the case conference was
   3     properly constituted and whether the outcome of that
   4     case conference was acceptable and would resolve the
   5     interprofessional dispute. Clearly it did not.
   6   Q. You continue to write here about the need to have an
   7     inquiry and in the last sentence you talk about the need
   8     to inform colleagues, or the fact that you will inform
   9     colleagues in the Department.
  10   A. I am sorry, I haven't got it.
  11   Q. It is 61/283. (Shown on screen)
  12        This letter is written on 25th January. You had
  13     had the conversations on the 16th or maybe earlier of
  14     January. Is this a letter to, as it were, record your
  15     position?
  16   A. Well, it is to let him know what my summary of the
  17     situation is, yes: to record my position, and in fact of
  18     course, if one is going to be strictly accurate, I had
  19     already informed colleagues, rather than that I would
  20     have to inform colleagues.
  21   Q. You have a response back on 26th January, UBHT 61/284.
  22     It responds by addressing, it says, three matters which
  23     are set out at (a), (b) and (c), as we can see. Then it
  24     says this:
  25        "The Trust has decided not to perform complex

   1     neonatal or infant open-heart surgery until there has
   2     been resolution of the conflicting professional advice."
   3        That, I think, was what you had been looking at,
   4     if we go back to 61/282, the third paragraph where you
   5     say:
   6        "As you know, I learned last week that far from
   7     this being the case, neonatal and infant cardiac surgery
   8     has continued at the Bristol Royal Infirmary."
   9        The case that was operated on on 12th January was
  10     a case of an 18 month old child, was it not?
  11   A. That is correct.
  12   Q. Neither a neonate nor an infant?
  13   A. Correct.
  14   Q. So what had inspired the flurry of phone calls and the
  15     exchange of letters was an operation on someone who is
  16     outside the technical boundaries of what is a neonate
  17     and what is an infant?
  18   A. Correct.
  19   Q. If we go back in that light to UBHT 61/284, the decision
  20     not to perform complex neonatal or infant open-heart
  21     surgery, as it happens, if it stopped there, would not
  22     have prevented the possibility of another Joshua
  23     Loveday?
  24   A. Yes, but with great respect, these arguments about
  25     definitions were not my concern. My concern was the

   1     interprofessional dispute, and whatever form of surgery
   2     was a matter of concern to the clinicians involved, the
   3     concern was, our job in the NHS is to make sure that
   4     situations are managed properly by the appropriate
   5     persons. This Trust in this instance was failing to
   6     satisfy certain senior clinicians as to the way it was
   7     managing the paediatric cardiac surgical service. It is
   8     not my job to second-guess clinical judgment.
   9        Yes, there were definitions subsequently,
  10     clarification of exactly what for the purposes of
  11     surgery could, should, take place. That was a matter
  12     for the senior clinicians involved with true experience
  13     of the subject, and as you will know, the President of
  14     the British Cardiac Society who was himself a paediatric
  15     surgeon later intervened to clarify and ensure it was an
  16     appropriate thing.
  17        My concern at this stage was to ensure that the
  18     interprofessional dispute was resolved whatever the
  19     basis for that dispute.
  20   Q. You spoke to Dr Parker?
  21   A. Subsequently, yes.
  22   Q. UBHT 61/286, the bottom of the page, please. This is
  23     your letter again, is it not?
  24   A. That is correct.
  25   Q. The last four lines:

   1        "It was also agreed that until the results of the
   2     inquiry were available, the Trust would suspend all
   3     complex paediatric open-heart surgery. This is
   4     a slightly different definition from that contained in
   5     our previous correspondence, but is, we agreed, the
   6     right one under the circumstances."
   7        The agreement is one between you, the Department
   8     of Health, and the Trust, is it?
   9   A. That is correct.
  10   Q. So you, for the Department of Health, were in fact
  11     agreeing upon a particular definition of surgery that
  12     would not be done?
  13   A. Correct.
  14   Q. You have explained that you took advice on it, but --
  15   A. This is following expert advice.
  16   Q. Following your talking to Dr Parker?
  17   A. Indeed.
  18   Q. Indeed, you set that out:
  19        "... advice offered by the President of the
  20     British Cardiac Society."
  21        So definitions were actually a matter of some
  22     importance, even though it might not have been your
  23     primary concern?
  24   A. The importance of the definition is relating to the
  25     agreed management action that will be taken to resolve

   1     the management dispute -- to resolve the
   2     interprofessional dispute. It is clearly appropriate if
   3     you are setting out a management process, to resolve the
   4     issue, to ensure that it tackles exactly the right
   5     issues.
   6        In order to ensure that the right issue is taken,
   7     expert advice was used to arrive at a definition that
   8     covered the risk appropriately. I was then satisfied
   9     that the action being proposed by the Trust did cover
  10     the grounds that were the basis of the interprofessional
  11     dispute.
  12   Q. Can I move on a little to UBHT 61/293, the meeting of
  13     9th March 1995. This is the next document that we have
  14     after the 3rd February letter which I have just shown
  15     you.
  16        What, in your recollection, took place in the
  17     intervening month?
  18   A. Clearly my minute was discussed by colleagues at various
  19     levels in the department, those I circulated and those
  20     I passed it on to and this in effect was after
  21     consultation, with the decision that the situation was
  22     sufficiently severe and sufficiently a matter of concern
  23     and that the Department and the Regional Health
  24     Authority, who were also informed in my minute, should
  25     jointly go down and ensure that the Trust had put in

   1     place appropriate actions to manage the problem.
   2        So this, in a sense, is the sort of formal
   3     approach that might well result from the Department
   4     having concerns about Trust performance and the way they
   5     were managing an issue.
   6   Q. What we do not see there is the Chief Executive of the
   7     UBHT. Is that because he was about to retire?
   8   A. If I recall, he was actually on holiday, in Australia,
   9     I think.
  10   Q. So his deputy comes?
  11   A. So his deputy comes.
  12   Q. The reason, please, for involving the Region was what?
  13   A. The service had, by that stage, gone from -- as we said,
  14     it was de-designated in 1994. It was now still, at this
  15     stage, a Regional Health Authority responsibility.
  16   Q. Can we scroll down, please? Paragraph 3:
  17        "Mr McKinley said that the Trust was facing
  18     a complex issue. He acknowledged that concern had been
  19     expressed for some time about paediatric cardiac
  20     services in the BRI. He believed the Trust had the
  21     situation under control from the middle of 1994, but
  22     following an unsuccessful switch ... earlier concerns
  23     had resurfaced."
  24        Does that represent your recollection of what
  25     Mr McKinley said about concerns?

   1   A. That was a reasonable summary of my understanding of the
   2     position at that time.
   3   Q. You do not know whose minutes these are, do you?
   4   A. I would suspect they were initially done probably by
   5     Billy Flynn for the NHS Executive, and then would have
   6     been agreed by those present. I note there are one or
   7     two amendments on it, so I suspect this is actually
   8     a draft rather than the final version.
   9   Q. Paragraph 4:
  10        "Dr Doyle explained that during a visit to UBHT in
  11     July 1994, his advice had been sought on how to resolve
  12     a long-standing problem over the interpretation of the
  13     paediatric surgical audit results. He had advised that
  14     the matter should be put to the Trust management again
  15     and if necessary outside help should be sought."
  16        That is a reference to your conversation with
  17     Dr Bolsin?
  18   A. And my advice to Professor Angelini.
  19   Q. "He later discussed the proposed action with Professor
  20     Angelini and Dr Roylance and understood an acceptable
  21     agreement had been reached to the effect that, pending
  22     the appointment of a new paediatric cardiac surgeon,
  23     high risk procedures would not be undertaken at the
  24     BRI."
  25        You told us about that. It records there what had

   1     been said about the operation. It says:
   2        "Following the operation, you had again been
   3     contacted by a number of people, including some outside
   4     the BRI."
   5        Who were they?
   6   A. I mean, that is a summary of what I said, but I had been
   7     contacted by another senior paediatric cardiac surgeon
   8     from another centre shortly after the unsuccessful
   9     operation to say was I aware. So if you like, this is
  10     a result of my networking, somebody else ringing me up
  11     to alert me to the fact that there was a serious problem
  12     in Bristol, a fact I already knew and resolved.
  13   Q. Who was that?
  14   A. That was Mr Brawn, from Birmingham. And shortly after
  15     that, of course, Mr Parker was in touch with me. By the
  16     time this meeting was held, I had had a number of
  17     conversations --
  18   Q. So the "somebody" is Mr Brawn and Dr Parker?
  19   A. Yes, essentially.
  20   Q. Anyone else?
  21   A. Not that I can recall specifically at this stage, no.
  22   Q. Can we go overleaf, please, to page 294, down to
  23     paragraph 7:
  24        "Dr Doyle reminded those present that, from
  25     correspondence he had seen, the difference of

   1     professional opinion had existed since at least
   2     1990 ..."
   3        What correspondence are you there referring to?
   4   A. By this time, as I said earlier, the brown envelope had
   5     been opened and put on the official file and that
   6     contained two letters, one written by Dr Bolsin in 1990
   7     and another I believe written in 1992, and I believe
   8     both those letters are a matter of record.
   9   Q. I am told by Mr Moore behind me that what is thought to
  10     be those letters and the enclosure has been traced to
  11     the Department of Health and he will make sure we have
  12     copies together with a statement as to why it is thought
  13     those are the documents. Would you be so kind as to
  14     have a look at them and see whether they ring bells with
  15     you, so you can confirm they are the documents?
  16   A. I can confirm the two documents part of the GMC Inquiry
  17     were the two letters. They are on record as part of the
  18     GMC evidence as well, and I confirmed at that time they
  19     were the two letters I had seen.
  20   Q. Would you read through the rest of that paragraph and
  21     tell me how accurate a reflection it is, you think, of
  22     what you had to say to the meeting? (Pause)
  23   A. The first half is clearly a summary of what I said, and
  24     as far as I can see that agrees with what I said.
  25     Clearly Dr Laszlo's comments, as far as I recall, that

   1     is what he said, but I am not responsible for what
   2     Dr Laszlo said.
   3   Q. It is simply the accuracy of the record I am asking you
   4     about, because this particular minute has been queried
   5     in other places.
   6        Just to confirm again, I think you said your
   7     minute, meaning the Department of Health's minute;
   8     probably Billy Flynn?
   9   A. The one that I sent to colleagues in the department on
  10     16th January, yes.
  11   Q. Forgive me, I have resolved the confusion that there was
  12     on this side of the chamber.
  13        Can we then come back to the two documents I have
  14     not yet shown you, which you will be familiar with,
  15     because they are your own personal minutes, first of all
  16     of 16th January, the Monday following the Thursday of
  17     the operation: DOH 1/9.
  18        This is a memo to Dr Winyard and Dr Scally,
  19     Dr Scally being from the South Western Region.
  20     Dr Winyard being?
  21   A. Deputy Chief Medical Officer and Medical Director of the
  22     NHS Executive.
  23   Q. And the copies are to others, amongst others what you
  24     might describe as "in-house press people"?
  25   A. No. Dr Harvey was personal Secretary of the CMO.

   1     Dr Bourdillon was the SMO and Dr Graham the PMO.
   2     Ms Phillips was my administrative counterpart on the
   3     section and Mr Waterhouse was her immediate superior, so
   4     her equivalent to Dr Graham.
   5   Q. I am grateful. The background that you set out:
   6        "Earlier this year the Professor of Cardiac
   7     Surgery, Professor Angelini, became very concerned about
   8     the audit results for neonatal and infant cardiac
   9     surgery produced by one of the anaesthetists, Steve
  10     Bolsin. After a great deal of discussion in which
  11     I became involved during a visit for other reasons,
  12     Professor Angelini persuaded the trust to appoint a new
  13     paediatric cardiac surgeon and transfer the service to
  14     the Children's Hospital."
  15        You do not, in that recitation of the background,
  16     set out anything about the initiation for your concerns
  17     being Steve Bolsin's talking to you in the taxi?
  18   A. True.
  19   Q. Why not?
  20   A. Because it is a very brief summary. I suppose I was
  21     trying to summarise the situation in the shortest
  22     possible time, because the issue of concern was what had
  23     happened in January.
  24   Q. How do you know that Gianni Angelini "became very
  25     concerned about the audit results"?

   1   A. Because when we had subsequently spoken and in the
   2     exchange of correspondence, he had showed his concern.
   3   Q. Forgive me: speaking I understand, but the
   4     correspondence does not, does it, indicate that he, for
   5     himself, was very concerned, rather than that he was
   6     having to grapple with a problem which was recognised
   7     within the Department? There is a difference, is there
   8     not?
   9   A. There is a difference in the sense that this is a very
  10     brief summary which does not reflect perhaps as well as
  11     one might wish, with hindsight, the exact process that
  12     had taken place during the summer.
  13        What it does interestingly reflect is that in our
  14     discussions, phone calls and letter, again the
  15     impression I had been given by Professor Angelini was
  16     that he was actually far more influential than he might
  17     subsequently claim to have been, and, yes, it is not --
  18     I mean, in three sentences, one cannot produce -- the
  19     important thing is for my senior colleagues to
  20     recognise, there has been a problem since the summer,
  21     which appeared to have been resolved but clearly has
  22     not.
  23   Q. You say in the last sentence of that paragraph that it
  24     was also agreed that no further neonatal and infant
  25     cardiac surgery would be performed -- I have asked you

   1     about that -- but in brackets it says, "(see attached
   2     correspondence)".
   3        Is there any letter that we have not seen?
   4   A. No, that refers to my exchange of letters with Professor
   5     Angelini, the ones we have already covered, my letters
   6     and his letters and Dr Roylance's letters.
   7   Q. So in support, as it were, of your view that those
   8     letters bore that implication properly, you were putting
   9     them forward to your superior and to Dr Scally as
  10     bearing that out?
  11   A. Superiors.
  12   Q. You describe the events of the Wednesday, and again, it
  13     is a question of recollection, because recollection may
  14     be of importance, but when I asked you about this in
  15     evidence, you could not recall whether it was Dr Bolsin,
  16     whether it was Professor Angelini, whether you might
  17     have bleeped Dr Bolsin or not.
  18        Here, five days away from the event, you recall it
  19     as a contact by Dr Bolsin?
  20   A. Indeed.
  21   Q. So is that --
  22   A. That helps clarify my memory, yes.
  23   Q. So is that more likely to be right?
  24   A. I am sure that is right, yes. This is written at the
  25     time of the event.

   1   Q. Your advice that you say you gave, again, not something
   2     you recollect in quite those terms today when we have
   3     been through it, looking at it in the light of memory --
   4   A. I am quite sure that I gave Dr Bolsin that advice,
   5     because it accords with exactly the advice I had given
   6     him earlier, and the advice I subsequently gave him.
   7     Paragraph 4 here again is a useful summary and confirms
   8     exactly what I said earlier: that I pointed out to
   9     Dr Roylance the very serious difference of professional
  10     view that had again developed.
  11   Q. When I asked you about it before the lunch break, you
  12     did not, I think -- the transcript will show whether
  13     I am right or wrong on this -- mention transferring
  14     a child as a possibility. You mentioned getting outside
  15     advice, a second opinion, but not actually transferring
  16     a child.
  17        Do you think you mentioned that transferring the
  18     child to another centre might have been appropriate, or
  19     not?
  20   A. Getting a second opinion is done one of two ways.
  21     Normally with a child of this age, it means transferring
  22     the child to another centre. Occasionally you might ask
  23     a colleague to come and examine the child at the
  24     hospital, particularly if it is difficult to transport
  25     the child. But in normal medical parlance, getting

   1     a second opinion on a child like this would mean sending
   2     the child with the parents to the other centre.
   3        So transfer is implicit in getting a second
   4     opinion, in most cases.
   5   Q. So you may have said no more than, "get a second
   6     opinion"; you may have meant, "transfer the child"?
   7   A. Getting a second opinion would imply transferring the
   8     child to another centre. It normally would.
   9   Q. I am going to press you for an answer in case it be
  10     important. Might you, do you think, have said no more
  11     than "get a second opinion", meaning, as you say it,
  12     that necessarily implied transferring the child?
  13   A. Again, after five years, it is difficult to recall
  14     exactly what I said. On the basis that I wrote this
  15     within a very few days of the event, the fact that
  16     I wrote what I did there might well -- well, almost
  17     certainly means that in the course of the conversation,
  18     which by the nature of our discussions had been
  19     abbreviated, I would have elaborated on getting a second
  20     opinion to the point of "if it is not urgent there is
  21     plenty of time to transfer the patient to another
  22     centre".
  23   Q. You recall Dr Roylance, in this memo, saying he would be
  24     guided by his Medical Director, James Wisheart, "and
  25     also the senior cardiac surgeon! [exclamation mark]".

   1   A. Yes. Again, I wrote this slightly after the event.
   2   Q. You were asked about this when you gave evidence before
   3     the GMC, when it was suggested to you that, guided by
   4     the results of the conclusion of the case management
   5     conference -- and indeed, that was the way you described
   6     it to us in your statement and the way you recalled it
   7     today. Which is it? Is it the case that these words
   8     were definitely said, or is it the case that something
   9     to that effect was said and you were not concentrating
  10     on the difference, if there was one, between this and
  11     the case management conference, or you think your
  12     evidence today is probably right, or what?
  13   A. It is equally probable that both are right. You forget,
  14     this was quite a long conversation and it is entirely
  15     possible, as I say, trying to recall it at this time
  16     that he said he would be guided by the case conference
  17     and guided by his Medical Director in the course of that
  18     conversation, because we repeated some of the points
  19     several times.
  20        The fact that I wrote this a day or two after --
  21     I mean, clearly the statement by Dr Roylance was that
  22     the case conference was going on and that he would be
  23     guided by the outcome. Whether the outcome was relayed
  24     to him by James Wisheart as his Medical Director or not,
  25     I do not know. As I say, I was not concerned at that

   1     stage specifically with the details. The point was that
   2     he had to resolve the interprofessional dispute, which
   3     he clearly did not do.
   4        Writing this slightly in the heat of the moment,
   5     a couple of days after a very tragic event when I felt
   6     that we had to act quickly and to alert my colleagues
   7     quickly to a difficult situation, it is entirely
   8     probable that I started to put some, if you like what
   9     had then become apparent undercurrents as to who was
  10     responsible for managing various aspects of the Trust
  11     business and that seemed to be becoming increasingly
  12     anomalous into my minute, to forewarn them of some of
  13     the potential complications that might arise when we
  14     looked into this matter.
  15   Q. Can we go overleaf, please, on this? You describe in
  16     paragraph 5 the conversation you had with Mr Wisheart
  17     the following morning. You have not told us, in your
  18     recollection, anything of the content of the
  19     conversation that you there, in paragraph 5, record.
  20        Again, this memo, written on the 16th to alert
  21     your seniors to the position, is nearer in time. Is it
  22     accurate?
  23   A. It is as accurate as I could make it at the time. As
  24     I said earlier, I spoke to Mr Wisheart in the morning.
  25     He told me his view. I reiterated my view and gave him

   1     very much the same advice as I had given Dr Roylance.
   2     I would not be changing my advice. The advice is, the
   3     first rule of surgery is: if in doubt, keep out.
   4   Q. I am not going to trouble you with the rest of the memo,
   5     but can I ask you this: this was the first time that you
   6     had formally involved your seniors?
   7   A. That is correct.
   8   Q. Perhaps I should actually just take you back to
   9     paragraph 9 of the memo, and just ask you about that.
  10     Would you just read it through for a moment? (Pause).
  11        The second last question which is raised there:
  12     how can differences of professional opinion or
  13     interpretations of audit data be resolved without
  14     putting patients at risk?
  15        "It would seem that we need a well recognised and
  16     acceptable mechanism for getting independent advice on
  17     such difficult questions."
  18        Why is it that HC(90)9, which you thought earlier
  19     on and had advised Dr Bolsin was the answer, why do you
  20     think it was not?
  21   A. This is slightly different ground, because the audit
  22     circular went out, HC(91)2. We are asking in that, and
  23     in this, the profession to self-regulate themselves and
  24     we are asking the Trust management to give them the
  25     tools to do the job.

   1        What was becoming clear was that the more you get
   2     into audit of this sort and the more you start to do
   3     a systematic analysis of your results, the more likely
   4     some of these issues are going to be raised.
   5        Clearly, what is not allowed for in this circular
   6     specifically is any national means or any outside
   7     independent benchmark, or any way in which, at that
   8     stage, within the current mechanisms we had, we had not
   9     yet defined an appropriate pathway where
  10     a straightforward outcome of audit could be taken to
  11     some higher independent mechanism to resolve the
  12     dispute. In a sense, what I had identified, or seemed
  13     to be coming out of this problem, was a gap in our
  14     current guidance and procedures. Clearly HC(90)9
  15     applied to the resolving of interprofessional disputes.
  16     Clearly HC(91)2 ensured that audit systems were set up,
  17     but HC(90)9 was not really intended to deal with getting
  18     independent opinion on audit outcomes per se, only where
  19     they led to severe questioning of performance or
  20     dispute.
  21        So in other words, we needed some professional
  22     method of assessing these things that fell in that area.
  23   Q. So were you talking then about the differences of
  24     professional opinions or interpretations short of
  25     professional dispute?

   1   A. Yes, where there were differences of opinion that needed
   2     to be resolved at a much earlier stage in a sense, as
   3     soon as any differences start to become apparent.
   4     Because in certain circumstances it might not have been
   5     necessarily a professional dispute arising, there was
   6     just concern that a particular unit did not quite know
   7     how to proceed in the light of the audit results they
   8     found.
   9   Q. Paragraph 8: you are recording what you said to James
  10     Wisheart.
  11        "As you were in possession of many of the facts,
  12     you had to pass them on to your colleagues. We were
  13     obliged to protect the position of the Secretary of
  14     State."
  15        What do you mean by that?
  16   A. Exactly that. The Secretary of State, the NHS authority
  17     was set up under the NHS. The Secretary of State had
  18     overall responsibility for the management of those
  19     Trusts. If there was a clear breakdown in Trust
  20     management and the Trust was not fulfilling its
  21     obligations as set out in the NHS Act, then at that
  22     stage the Secretary of State might well become
  23     responsible, if he failed to act. Clearly, by this
  24     stage, the Department, in the name of the Secretary of
  25     State, had a clear duty to act because it was apparent

   1     to all that they had failed in an aspect of their
   2     management.
   3   Q. So because the Trust has failed in its duty and job to
   4     manage, as you saw it, the Secretary of State would have
   5     to get involved?
   6   A. Absolutely. At that stage.
   7   Q. I was going to move on to the memo which we have
   8     following this, on 24th January, DOH 1/15, paragraph 3:
   9        "... still not clear whether there is a serious
  10     problem with cardiac surgery, or whether this is
  11     a serious breakdown in professional relationships ...
  12     cause for grave concern that the Trust has not taken
  13     action to resolve the problem; that children's lives
  14     might have been put at risk and that rumour and innuendo
  15     have been allowed to spread apparently unchecked."
  16        There is a reflection of those words in what was
  17     said on 26th January to you in Dr Roylance's letter,
  18     UBHT 61/285. Just let us look at that for a moment.
  19     It is the first sentence. (Pause). Having read that,
  20     can we go back to DOH 1/15? Paragraph 3. What did you
  21     mean by "rumour and innuendo"?
  22   A. This is, as you will appreciate, several days later when
  23     now being open to full discussion, all sorts of facts
  24     not known to me at the time started becoming available.
  25     The rumours that these problems had gone back. It was

   1     shortly after this that I became aware, I had never seen
   2     them before, of the articles in Private Eye, for
   3     instance. Also, this postdates my conversations with
   4     Mr Parker, Bill Brawn and others. It was quite clear
   5     from those conversations that a lot of other people,
   6     apart from me, had known of the existence of problems in
   7     that unit and that others were outside the Trust talking
   8     about it.
   9   Q. So you mean that when you spoke to Bill Brawn, he gave
  10     you a reflection of either his view or those that had
  11     been reflected to him of views saying, "Well, there has
  12     been a problem there for a long time", or something
  13     along those lines?
  14   A. That is right: was I aware of the immediate problem and
  15     that had been aware of problems for some time.
  16   Q. What sort of matter was Dr Parker saying?
  17   A. Again, he said that part of the reason for ringing me
  18     was that he felt that the definition I had used, offered
  19     to the Trust -- he had been contacted either by the
  20     Trust or by Mr Wisheart, I do not know, but he rang me
  21     to say he had seen it and his advice had been asked and
  22     he thought the definition I had given was not the most
  23     appropriate. We therefore discussed the most
  24     appropriate definition and came to the agreement, but
  25     again, in the course of that conversation he advanced

   1     the opinion, rather as others had already expressed,
   2     that there was only a problem with certain procedures
   3     and that they were recognised and they were going to be
   4     dealt with.
   5        So again, he gives the very strong impression that
   6     whilst some parts of the service were fine, there was
   7     a problem and it was there and known about.
   8   Q. Did you form any view from what was said to you about
   9     how long others in the profession had perceived that
  10     there was some problem, albeit relying on rumour and
  11     innuendo?
  12   A. Not at that stage. I was still under the impression
  13     that it was four or five years.
  14   Q. The impression, four or five years, initially had been
  15     given to you by Dr Bolsin?
  16   A. That is correct.
  17   Q. And because of the letter you had uncovered in the brown
  18     envelope. Was there anything else that gave you the
  19     idea of the four to five years?
  20   A. No, only what, up to that stage, had been brought to my
  21     attention from various sources. I was still under the
  22     impression that the problem was only from the late
  23     1980s/early 1990s onwards.
  24   Q. Before I leave the whole question of what you were told,
  25     what you knew, what you found out, can I ask you this:

   1     you said on a number of occasions how you received the
   2     envelope and you did not open it. At the GMC you
   3     said -- let me just find the precise page -- that you
   4     had the letter. You opened it in the taxi, looked at
   5     what was inside and put it away again.
   6        Can you explain to me how that difference might
   7     arise? I will get your exact words in a moment. I do
   8     not know if you can help on that? Is it the case that
   9     you may have opened the letter, looked inside and not
  10     read it, but looked to see what was there? It is
  11     WIT 337/24, to be fair to you, because I think you ought
  12     to see this on the screen.
  13   A. I cannot even remember at this stage whether the
  14     envelope was actually sealed or not.
  15   Q. Just pause for a moment. Can we scroll down, please?
  16     You see the question on the screen:
  17        "Question: The brown envelope which you described
  18     being passed in the taxi contained information about
  19     surgical procedures undertaken at Bristol Royal
  20     Infirmary?
  21        Answer: It did.
  22        Question: Was the information that you were given
  23     surgeon specific or was it just general information?
  24        Answer: The answer is, I do not know because as
  25     I made clear to Dr Bolsin at the time, I am not an

   1     expert statistician and was not expert in audit and
   2     therefore I did not look at the data. I opened it in
   3     order to see what was enclosed, put it back again and
   4     I have never looked at the actual figures, tables and
   5     data that was provided ..."
   6        So your recollection at the GMC was that you had
   7     opened the envelope which you told us on more than one
   8     occasion remained entirely sealed?
   9   A. As I have said, it is difficult to recall exactly what
  10     happened five years ago. This statement I made a lot
  11     nearer the events. I cannot recall. It may be that
  12     this may be entirely correct, that I opened it -- in
  13     fact, I have a feeling now I think about it, I cannot
  14     remember exactly what happened but it was not actually
  15     sealed, it was just a brown envelope with some papers
  16     inside, so I glanced in the flap, put it away in my
  17     briefcase.
  18        Certainly, I did not do anything other than take
  19     the merest glance at the thing and put it away in my
  20     briefcase, and never looked at it again.
  21   Q. The second question which arises from the same answer is
  22     that you told us a moment or two ago that although the
  23     envelope had remained sealed in your files, it was
  24     opened once matters came on top in January 1995 and the
  25     envelope was then opened, and when I asked you whether

   1     you would check to make sure that the letters were the
   2     letters, you said those were the letters that went to
   3     the GMC.
   4        So you have in fact looked at the documents, even
   5     though you may not have scrutinised them?
   6   A. I certainly looked at the letters subsequently. I mean,
   7     this clearly points out exactly what I have been
   8     saying. My transcript confirms everything I have been
   9     saying today. My concern was there was clearly an
  10     interprofessional dispute --
  11   Q. I am focusing just on this.
  12   A. Exactly how -- I have made the point. I cannot exactly
  13     remember every single action my fingers made on that
  14     day. The point at issue is that I took from him an
  15     envelope which he told me contained facts and figures
  16     and may or may not have glanced inside it at the time.
  17     I put it in my briefcase, I went back to the department,
  18     I put that envelope unscrutinised in any further way
  19     whatsoever with the other papers from Bristol in the
  20     folder in my private filing cabinet in the Department.
  21     They remained there until after the events of the 16th,
  22     when I produced all the correspondence in relation to
  23     Bristol, including the brown envelope and those papers,
  24     as I think my colleagues will confirm, were then made
  25     part of the official record, and the official

   1     departmental file.
   2   Q. Did you look at them then?
   3   A. I read the letters subsequently, but I never looked
   4     specifically at the figures, other than to say, there
   5     are tables of figures and this is the audit data.
   6     I would not dream of trying to analyse those. It is not
   7     my area of expertise.
   8   Q. Would it be more accurate then to say you never
   9     scrutinised the actual figures, tables or data, or
  10     examined the actual figures, tables and data?
  11   A. I certainly never examined them. I only ascertained
  12     that there were some papers in the brown envelope.
  13   Q. Which were figures and tables and data?
  14   A. That is what Dr Bolsin had told me. If I looked at them
  15     at all, it was just to glance inside that there were
  16     some papers.
  17   Q. Two other matters only which I need to ask you about.
  18     The attendance at the meeting on 9th March 1995. You
  19     said service was not designated. It was now a Regional
  20     Health Authority responsibility. Can you help why it
  21     was a Regional Health Authority responsibility?
  22   A. That is 1994. That was post 1991.
  23   Q. We are 1995 now.
  24   A. It was de-designated as from 1st April 1994.
  25   Q. Yes.

   1   A. I honestly cannot remember who would then be
   2     commissioning the service. I do not know, is the answer
   3     to that.
   4   Q. Can you help as to why there was no representative of
   5     the purchaser, or purchasers, at the meeting?
   6   A. Because this was a primary question of Trust management,
   7     for which the responsibility lay jointly between the
   8     Department and the Regional Health Authority.
   9   Q. The last matters which I have to raise with you,
  10     something completely different. It concerns evidence
  11     that we had from Catherine Hawkins. She was telling us
  12     that the Department of Health and Social Security
  13     insisted that the Region increased the cases undertaken
  14     in spite of the fact that they had raised concerns on
  15     outcomes with them on a consistent basis.
  16        Those are her words relating to, I think, a period
  17     of time in the 1980s, in particular.
  18        Are you in a position to assist at all with what
  19     the DHSS did in respect of insisting or advising or
  20     encouraging a greater number of cases to be undertaken
  21     in paediatric cardiac surgery, or cardiac surgery, in
  22     Bristol?
  23   A. No, not at all.
  24   Q. Again, she told us -- the reference for those who want
  25     to have it is Day 46, page 85, line 1 -- that if the

   1     Medical Officer of the Department knew from the Royal
   2     College that concerns had been expressed about a very
   3     specific unit in the service, they would have expected
   4     to have been informed, even if it was a supra-regional
   5     service in children's cardiac surgery.
   6        Obviously this was no longer when you were
   7     involved a supra-regional service, but when you had
   8     concerns which you took very seriously, so seriously as
   9     to write to Professor Angelini and you were concerned
  10     that Dr Roylance should know about it, which, because of
  11     his response to you, you found out he did, did you think
  12     that it was something that Region ought also to know of?
  13   A. At the time that I was asked for advice and offered my
  14     advice and a warning shot to Professor Angelini,
  15     following my initial correspondence, my first reaction
  16     to a problem put to me, I got back from first Professor
  17     Angelini and then, entirely unsolicited, a letter from
  18     Dr Roylance, assuring me not only that he was totally
  19     aware of the problem, but that the Trust Board were
  20     fully aware of the problem. It did not appear to me
  21     then, at that time, having got those reassurances, that
  22     I needed to inform anybody else.
  23        Do not forget, this is a background where
  24     I frequently give advice about problems, senior or
  25     minor. If they are solved by the appropriate mechanisms

   1     and do not involve anybody else, what is the point? The
   2     problem is to all intents and purposes solved. The
   3     moment I became aware that the problem had not been
   4     resolved and that it had recurred, I informed not only
   5     senior officials within the Department but senior
   6     officials as well, in fact, all those who needed to
   7     know, immediately.
   8   Q. Dr Doyle, I have asked you a lot of questions. There
   9     may have been something which I have not asked you which
  10     you would like to tell us about. This is now your
  11     chance to do so, or your chance to amplify or clarify
  12     anything where you think your answers may have been less
  13     than clear.
  14   A. I apologise to the Inquiry team particularly that fading
  15     memory and so on has made one or two minor points of
  16     exactly what I did, when, unclear. I hope in my
  17     testimony I have been able to make it clear that I felt
  18     that I had acted in broad terms exactly in the way
  19     I felt was appropriate to resolve the problem and that
  20     when it became apparent that the problem had not been
  21     resolved, I then, if you like, invoked the full
  22     machinery of the department to ensure that the necessary
  23     action was taken.
  24   MR LANGSTAFF: Thank you. There may be some questions from
  25     the Panel.

   1   THE CHAIRMAN: Dr Doyle, Mrs Howard ...
   2            Examined by THE PANEL:
   3   MRS HOWARD: Just one question. If I can take you back to
   4     your initial discussions of the situation prior to the
   5     January operation, at any time did anyone, including
   6     yourself, discuss whether the parents of this child were
   7     aware of the professional dispute which you describe?
   8   A. I did not discuss that with anybody.
   9   MRS HOWARD: Thank you.
  10   THE CHAIRMAN: Professor Jarman?
  11   PROFESSOR JARMAN: Dr Doyle, if it is put to us that the
  12     SRSAG should have been responsible for ensuring that
  13     there was a system in place to monitor the quality of
  14     care of the service at Bristol, and then examine the
  15     results, what would you say to that?
  16   A. I would argue that the system was in place; that this
  17     was an evolving system. Without going into a great deal
  18     of length, as I think others have testified and as
  19     I tried to explain earlier this morning, we are talking
  20     about an evolving situation of accountability, that
  21     contracting was very rudimentary in the early 1990s,
  22     audit was equally rudimentary in the early 1990s.
  23        The initial contracts for the SRSAG required that
  24     people took part in their local quality and audit
  25     mechanisms and required some evidence that they were

   1     participating. That is the earliest contract.
   2        It became, as I said in my testimony -- in the
   3     first year or two it was simply that they were asked to
   4     provide evidence that they were participating in all the
   5     other issues, the mechanisms like HC(91)2 that were part
   6     of the normal NHS proceedings guidance, and these
   7     services were not exempt from any of those requirements
   8     to comply with quality initiatives by their host
   9     purchasers, et cetera, fire regulations and everything
  10     including the audit requirement.
  11        As I said in my testimony, by the time I came to
  12     the post, which was some two or three years into the
  13     contracting process and the development of the quality
  14     initiatives, it became clear that for these highly
  15     specialised services, the sort of ordinary local audit
  16     mechanisms were not going to be totally apparent.
  17        So all the way along, the SRSAG has increasingly,
  18     since its inception, gradually racked up the requirement
  19     of the services to comply with all the agreed
  20     mechanisms. The SRSAG, if it has been notified of
  21     a problem at any stage -- because it is an Advisory
  22     Group, it does not have, apart from a very small
  23     Secretariat of three people, the resources of a normal
  24     Health Authority. It has therefore reverted always, and
  25     still does, to seeking guidance on any problem that

   1     arises in respect of a designated service from the
   2     appropriate professional organisation, and as
   3     I understand it -- I was not there at the time but it
   4     sought advice about this service formally from the
   5     College in 1988, and again in 1992, which is entirely
   6     consistent with its proceedings.
   7        Once I got into post and we became interested in
   8     audit we started to set up a number of inter-unit audits
   9     where it was clear that local audit mechanisms could not
  10     cope with highly specialised data. That process is
  11     still developing and evolving as we speak today. In
  12     fact the last meeting of NSCAG was concerned with how it
  13     meshed in its clinical governance role with that of the
  14     local Trust and the local Medical Director, because
  15     clearly there is some joint coming together and they
  16     have to agree the clinical governance mechanism
  17     appropriate to supra-regional services.
  18        So my experience of SRSAG and subsequently NSCAG
  19     is that there has been a clear but gradually evolving
  20     structure for increasing accountability, and that in the
  21     early 1990s it was very rudimentary.
  22   Q. When you were questioned (it is on page 11 today) about
  23     the system for monitoring the quality of outcome, in
  24     reply as to responsibility, you said, "I think initially
  25     it was the responsibility of the clinicians". You have

   1     just said how difficult it was to get audit data and you
   2     said yourself that it is very difficult to interpret the
   3     statistics; in fact, you yourself would not be able to
   4     do so. I do not think average cardiac surgeons are
   5     known particularly for their ability to interpret
   6     statistical data.
   7        Was it, in your view, possible for a clinician at
   8     that time to check the quality of care, the outcomes,
   9     the death rates?
  10   A. It was not easy, but some certainly were doing it. That
  11     same year, Marc de Leval produced a seminal paper
  12     adapting new techniques to audit methodology to overcome
  13     just some of those problems.
  14   Q. I mean an average cardiac surgeon?
  15   A. But it is a small society, it has the longest record of
  16     audit of any because of its surgical register. It has
  17     been more than concerned than any other profession to
  18     audit its outcomes. The anaesthetists had already set
  19     up ACTA. There was a huge amount of work done,
  20     Parsonnet scores, risk stratification scores had been
  21     developed in the 1980s. There were probably more audit
  22     tools available to the average cardiac surgeon, adult
  23     cardiac surgeons specifically, less so for the
  24     paediatric cardiac surgeon because the definitions are
  25     more complex and the numbers are smaller.

   1        So I would agree it is difficult and it was not
   2     easy for anybody to set up a really good quality valid
   3     audit in those cases.
   4        However, many people were attempting to audit
   5     results and when you attempt audit results and a problem
   6     arises, I think as a clinician you have a duty to
   7     investigate that to the best of your ability, and just
   8     as we take research evidence, if the best of your
   9     ability is simply to get together those experienced
  10     individuals to come to a consensus, then that is what
  11     you do.
  12        If you can analyse the statistics competently to
  13     give a valid result which shows confidence intervals,
  14     then you have a higher level of proof and certainty.
  15     Clearly if you can replicate those results consistently
  16     on some sort of national audit which is properly
  17     risk-stratified, then you have a higher order still of
  18     certainty about the outcomes.
  19   Q. On page 15 of today's evidence you said that the
  20     detailed quality appraisal of any unit was a matter
  21     of -- whenever concerns were raised, the College was
  22     asked, and still is asked, to look into it. I think you
  23     are right, that even with the right people, a first
  24     class service and clinical governance, nice and cheap,
  25     the College still will be asked to look into it. But do

   1     you see the College as being responsible on a day-to-day
   2     basis when looking at the quality, or only when concerns
   3     are raised?
   4   A. I am not saying it works as it should in practice. The
   5     clear implication of the guidance is that clinicians
   6     should be auditing their own performance and that when
   7     problems arise, either through a local or a national
   8     audit system, they have to call on the necessary outside
   9     expertise to resolve the problem.
  10        In our case, the SRSAG might ask the College to go
  11     directly, or might tell the Trust, "We think you have
  12     a problem there, could you please get the College to
  13     come and, visit and advise" and we did that only early
  14     this year.
  15   Q. Just a final small point. There was a question -- this
  16     is actually earlier, on page 13 of today's hearing. You
  17     were asked:
  18        "So far as quality of outcome, who would have the
  19     responsibility there?" and you replied, "I have no
  20     idea". I think possibly you were referring to the
  21     "hotel" service, rather than quality of outcome?
  22   A. I am sorry, but I would not -- there is no way I would
  23     discuss the quality criteria for hotels.
  24   Q. You were actually asked so far as quality of outcome?
  25   A. I would expect every business to have put in place

   1     a quality control mechanism, just as we have tried to do
   2     for the NHS, and that would identify who was
   3     responsible.
   4   PROFESSOR JARMAN: Thank you.
   5   THE CHAIRMAN: I rather think it was a misunderstanding of
   6     the question. The question Mr Langstaff put, as
   7     I understand it, was to separate what he called "hotel"
   8     services, perhaps laundry, food, porterage, as against
   9     outcome, meaning the delivery of treatment. I rather
  10     thought you took the analogy literally, rather than as
  11     an analogy. Am I correct?
  12   A. I apologise, I did!
  13   Q. No apology. It is just that Professor Jarman and I were
  14     anxious to clear up. On its face, your response as
  15     regards who was responsible for outcomes "I have no
  16     idea" might seem a little stark. I think Professor
  17     Jarman was exploring that with you. All you were doing,
  18     as I take it, was absolving yourself from knowledge of
  19     how hotels are run. I am grateful. Mr Pirani?
  20   MR PIRANI: No, thank you sir.
  21   THE CHAIRMAN: I have no questions. That exhausted the
  22     Panel's questions. Dr Doyle, we are very grateful to
  23     you. You have spent a lot of time and we have explored
  24     very important and difficult matters, and we are very
  25     grateful to you for your assistance.

   1        Mr Langstaff may have reminded you, but in the
   2     absence of that, in case he has not, I say if there are
   3     other matters you want to bring to our attention, having
   4     gone away and reflected and read the transcript or
   5     whatever, then we will of course be more than happy to
   6     receive then. We would be anxious to receive them. But
   7     for today, may I thank you very much for coming and
   8     spending time with us.
   9   MR LANGSTAFF: Thank you Dr Doyle. Sir, may we now perhaps
  10     have a 10 minute break before Dr Ashwell?
  11   THE CHAIRMAN: Shall we say 10 minutes? We will reconvene
  12     at 10 to 3.
  13   (2.40 pm)
  14               (A short break)
  15   (2.55 pm)
  16   THE CHAIRMAN: Mr Maclean, good afternoon.
  17   MR MACLEAN: Sir, the next witness this afternoon is Dr Jane
  18     Ashwell. Perhaps Dr Ashwell could come and take the
  19     witness chair, please. Dr Ashwell, I understand you are
  20     going to affirm. Could you please stand and do so?
  21            DR JANE ASHWELL (AFFIRMED):
  22            Examined by MR MACLEAN:
  23   Q. You are Dr Jane Ashwell and you are currently a Senior
  24     Medical Officer for the National Assembly for Wales?
  25   A. I am.

   1   Q. Could I ask you to have a look at the screen in front of
   2     you at WIT 338/1, please? Is that the first page of
   3     a formal written statement that you have made to this
   4     Inquiry?
   5   A. Yes, it is.
   6   Q. If you go to page 5, that is your signature, is it?
   7   A. Yes, it is.
   8   Q. That is the last page of the statement that you made to
   9     the Inquiry?
  10   A. It is.
  11   Q. Have you read that statement through recently?
  12   A. I read it last night.
  13   Q. Are you content that that statement should stand as part
  14     of your evidence to the Inquiry?
  15   A. I am.
  16   Q. I think you also made a statement, did you not, to the
  17     General Medical Council in the context of its inquiry
  18     into Dr Roylance, Mr Wisheart and Mr Dhasmana?
  19   A. Yes.
  20   Q. But you were not in fact called to give evidence before
  21     the GMC?
  22   A. That is correct.
  23   Q. Can we have GMC 14/25? That, I think, is the first
  24     page of your statement to the GMC?
  25   A. Yes, it is.

   1   Q. I understand that the circumstances in which you wrote
   2     that statement were a little different than the
   3     circumstances in which you wrote your statement to the
   4     Inquiry.
   5   A. In that the purposes are somewhat different.
   6   Q. Can you explain to me what the circumstances were and
   7     what materials you had to rely on in writing your
   8     statement to the GMC?
   9   A. I had access to -- no, I did not have access to some of
  10     the documents I have since seen, and I am afraid my
  11     memory was not as good as I would have liked. So that
  12     is one difference.
  13        Also, for this Inquiry I was provided with a list
  14     of questions which I was asked to address, and my
  15     statement that I provided to you is based on the
  16     framework of that questionnaire.
  17   Q. Are you satisfied that the statement you have made to
  18     the Inquiry was one that you made having had the
  19     advantage of seeing what you considered to be all the
  20     relevant documentation?
  21   A. I believe so, yes.
  22   Q. You are an anaesthetist by background; is that right?
  23   A. Yes.
  24   Q. And you practised, I think, for a period at consultant
  25     level?

   1   A. I did.
   2   Q. Where did you do that?
   3   A. In Middlesborough.
   4   Q. How long were you in practice as a consultant?
   5   A. I was appointed in about March 1984, and I resigned in
   6     the early summer of 1987, to go back into full-time
   7     education.
   8   Q. Which was where?
   9   A. Cambridge.
  10   Q. You stayed there, did you, until you went to work for
  11     the Department of Health?
  12   A. I stayed in education there for two years, yes, and
  13     towards the end of the summer of 1989, I applied for
  14     a casual job in the Department of Health, which I got,
  15     and towards the end of the year of the casual
  16     employment, I sat a Civil Service board and was taken on
  17     as a substantive SMO.
  18   Q. Can you tell me when you first had responsibility in any
  19     shape or form, or professional interest in, cardiac
  20     services?
  21   A. When I transferred from my first post in the Department
  22     of Health, which would have been in approximately
  23     October 1991, to a division called HPS working for
  24     Norman Halliday.
  25   Q. If we go to GMC 14/26, which is the second page of your

   1     statement to the GMC, the first new paragraph on that
   2     page, you say:
   3        "I worked from October 1991 until March 1995 in
   4     the health care division within the policy division of
   5     the DOH. The Department of Health was broadly separated
   6     during that time into Management Executive and Policy."
   7        Is that right?
   8   A. Yes.
   9   Q. You mention Dr Halliday. I was going to ask you to whom
  10     did you report from 1991 onwards, in the Department?
  11   A. Dr Halliday was my grade 3, but in the division I moved
  12     to, there was also a grade 4 position, and I believe
  13     that was occupied by Robert Hangartner, and I think,
  14     I believe, that I reported through Robert to Norman
  15     Halliday.
  16   Q. The new grade was what, at this time?
  17   A. Grade 5.
  18   Q. We know that one of Dr Halliday's responsibilities was
  19     as Medical Secretary of the Supra Regional Services
  20     Advisory Group. When you started work in this division
  21     of the Department, in October 1991, neonatal and infant
  22     cardiac surgery was still designated a supra-regional
  23     service. That is right, is it not?
  24   A. As far as I know, yes.
  25   Q. You knew that at the time?

   1   A. Yes, I was aware of it.
   2   Q. What involvement did you have in the Supra Regional
   3     Services Advisory Group?
   4   A. None.
   5   Q. So if we look at the same paragraph on this page, you
   6     say you provided policy advice in a variety of medical
   7     specialties, all surgical specialties save for two which
   8     you identify, anaesthetics and other areas such as
   9     medical audit and clinicians in management?
  10   A. Yes. That is slightly incorrect, if I could just point
  11     it out, in that my distribution of business included
  12     cardiac specialties, so it included cardiology as well
  13     as cardiac surgery and it was the only medical specialty
  14     I covered, but it excluded everything within the
  15     supra-regional services part of work.
  16   Q. So you had responsibility within the Policy Division in
  17     the Department for cardiology and cardiac surgery?
  18   A. Yes.
  19   Q. But you did not directly work for or with the Supra
  20     Regional Services Advisory Group?
  21   A. Not at all.
  22   Q. So just help me with what exactly your responsibilities
  23     were in terms of cardiac services within the
  24     Department? What was your role?
  25   A. It is called "policy development", really, in relation

   1     to the specialties involved. The actual work would
   2     involve a great deal of networking with individual
   3     clinicians, trying to keep up to date with what the
   4     developments in the specialty might be, and particularly
   5     any issues that would have any bearing on development of
   6     government policy.
   7   Q. Can you give me an example of that?
   8   A. I would be taking advice from people in the field on,
   9     say, developments to do with, for example, angioplasty.
  10     There were various new techniques coming on stream.
  11     I would be attending clinical meetings and academic
  12     meetings of the Colleges and learned societies. I would
  13     be liaising usually with academics in the field, but
  14     also with NHS practising clinicians to get advice and
  15     take guidance on what the appropriate literature would
  16     say about the likelihood of particular techniques being
  17     useful to the NHS.
  18   Q. So you would know the leading players in the field in
  19     cardiology and cardiac surgery?
  20   A. I was in the process of trying to improve my networks in
  21     that area, certainly, as I would in all the other
  22     specialties I was involved in. It is quite a large
  23     area.
  24   Q. So people like, for example in 1992 when you had this
  25     responsibility, Sir Terence English, who is the

   1     President of the Royal College of Surgeons --?
   2   A. Yes, I certainly knew Terence.
   3   Q. -- and the cardiac surgeon to boot, would be the sort of
   4     person you would be anxious to have close liaison with?
   5   A. I knew him well and we sat on various committees
   6     together, and I would from time to time consult him,
   7     although at this precise moment I cannot give you an
   8     example.
   9   Q. To what extent did you become familiar with whom the
  10     main players in cardiac services were in Bristol?
  11   A. Not at all.
  12   Q. Why not?
  13   A. I imagine purely a matter of time and opportunity.
  14     I attended the academic meetings of the British Society
  15     of Cardiothoracic Surgery, I believe annually, and at
  16     those meetings, I did my best to meet and be available
  17     for people to talk to about any aspects of
  18     cardiothoracic surgery that they wished to and
  19     fortuitously, I never met any of the surgeons from
  20     Bristol. I can tell you other units where I had met all
  21     the surgeons and had indeed visited them.
  22   Q. What about the cardiologists?
  23   A. No, I did not know the cardiologists.
  24   Q. Your responsibilities would embrace, presumably, adult
  25     and paediatric cardiac services?

   1   A. Yes. I think that is true.
   2   Q. So you would be familiar with recent developments in
   3     paediatric cardiac surgery, the development of new
   4     procedures and so on?
   5   A. I would not be familiar with the technicalities of
   6     procedures. My area of work would be much more to do
   7     with what procedures might be available or coming into
   8     common usage, but not details of technicalities at all.
   9   Q. I am not suggesting you knew how to do the operations,
  10     but you would have known, for example, that a procedure
  11     known as the Sennings procedure had been supplanted by
  12     the arterial switch procedure, for example?
  13   A. I would have been aware of the switch procedure,
  14     certainly.
  15   Q. So you knew that was an important new development
  16     roughly at the beginning of the 1990s in paediatric
  17     cardiac surgery in the UK?
  18   A. I certainly do. It was in use, yes.
  19   Q. In order to keep abreast of these various
  20     responsibilities, I think this is something that
  21     Dr Doyle mentioned earlier. He said that he would try
  22     to keep up with the literature, the journals and so on,
  23     and presumably you would do likewise?
  24   A. I think, to be explanatory, it is reasonable to say that
  25     I would try to keep up, but it was with a variety of

   1     specialties. To put it in context, the cardiothoracic
   2     and cardiological part of my work would amount to about
   3     5 per cent of my time. So the answer is, yes, but in
   4     a very limited way.
   5   Q. When did you cease to have any responsibility for
   6     cardiac services?
   7   A. When Peter Doyle returned to the Department from his
   8     secondment, which was in April 1994.
   9   Q. And you did not finally leave the Department of Health
  10     until 1995?
  11   A. Yes, about a year later.
  12   Q. So there was a period of overlap between yourself and
  13     Dr Doyle?
  14   A. Yes, in the same division.
  15   Q. Were you in physical proximity to one another, in terms
  16     of working in the same building?
  17   A. We were at opposite ends of the same corridor.
  18   Q. So you were close colleagues throughout that period?
  19   A. We were both SMOs in the same division, working to the
  20     same hierarchy.
  21   Q. So members, if you like, of the same team?
  22   A. The same division.
  23   Q. So you would discuss matters across each other's desks,
  24     would you?
  25   A. There would be the opportunity. We certainly would not

   1     discuss every matter, not as a matter of course.
   2   Q. The first thing you deal with in your statement is the
   3     question of audit, and then you go on to deal with our
   4     Issue N. I do not want to dwell long on audit, but can
   5     I ask you to have a look, please, at page 3 of your
   6     statement, WIT 338/3?
   7        Under the heading "Issue M10" in the middle of the
   8     page, you say:
   9        "I think the way the word audit is being used in
  10     Issue M is actually rather different from the Audit
  11     [with a capital A] I am talking about and which the DH
  12     was introducing in the early 1990s. There were no
  13     systems - it was new and developing. Much of the
  14     research information on which to base audit was not
  15     available and much of my work was aimed at helping
  16     doctors to establish research such that robust
  17     guidelines could be produced to do audit against. You
  18     can't look at practice unless you establish a standard
  19     to compare it with."
  20        So you were interested in establishing the
  21     benchmark, if you like?
  22   A. Yes.
  23   Q. Then you say this:
  24        "Audit was not a means of measuring outcomes ..."
  25        Just pausing there, what did you consider the

   1     purpose of audit was?
   2   A. I do not think I mean there that it never would be
   3     a means of comparing outcomes, but at the stage of audit
   4     development we were in, we were very much into process
   5     audit.
   6   Q. What does that mean?
   7   A. It meant that you were trying to establish through
   8     research, and then the production of guidelines, what
   9     the appropriate methods of treatment might be.
  10        The research evidence might not be clear. There
  11     might be clinical choices to be made but we were at
  12     least trying to find adequate research that would
  13     indicate the right course of action and because audit
  14     was in general, as I say, in its early stages, we were
  15     trying to get people within local Trusts and more
  16     nationally to compare what they actually did with what
  17     the research said they should do.
  18   Q. That is what you say in the second part of the
  19     sentence.
  20   A. That is what I mean by "process".
  21   Q. If there is some mechanism --
  22   A. I am sorry, might I add something? It is not that we
  23     thought we would never be able to audit outcomes, it is
  24     just that we were not at that stage yet.
  25   Q. Can I just clarify something, Dr Ashwell, it is not your

   1     fault, I am sure. In your answer there you said the
   2     research evidence might not be clear, there might be
   3     choices to be made; is that right?
   4   A. If the research does not clearly say one drug rather
   5     than another, there are choices.
   6   Q. When you say audit was a way of comparing what doctors
   7     did, as against what the research evidence indicated
   8     they should do --
   9   A. That is fairly simplistic, of course.
  10   Q. If I was a doctor and I am saying "There is research
  11     evidence indicating what I should be doing and I have
  12     evidence of what I am doing", am I not measuring my
  13     quality of my work against what I should be doing,
  14     according to the research?
  15   A. Yes.
  16   Q. So is there not a false antithesis in that sentence:
  17     audit was not a means of measuring outcomes but a way of
  18     comparing what doctors did as against what the research
  19     evidence indicated they should do?
  20   A. Forgive me, I do not think there is, because I think
  21     what doctors would be comparing was their choices of
  22     a particular treatment or drug against established
  23     guidelines based on research of what the best treatment
  24     was, if that was possible. That does not necessarily
  25     deal with outcomes at all.

   1   Q. So the focus as you saw it was on choosing between
   2     treatment A and treatment B, not on, having chosen
   3     treatment A whether treatment A was up to scratch or
   4     not?
   5   A. Whether treatment A was up to scratch or not in the
   6     general sense was a subject for research. Whether
   7     treatment A in this person's hands with this patient is
   8     effective, could be dealt with through audit. I think
   9     I am trying to say that at this stage of the development
  10     of audit, we had not really encompassed that. We
  11     recognised it was something that needed to be done, but
  12     we were not -- I am trying to explain in the context of
  13     the question that seemed to be asked in issue M, that
  14     actually we did have not the robustness -- I am sorry,
  15     the audit methodology to answer the sorts of questions
  16     that the Inquiry might be asking.
  17   Q. So the difficulty with taking audit to that stage, at
  18     that stage, was a technical one?
  19   A. Yes.
  20   Q. Was there any other barrier to taking audit on?
  21   A. There were to a degree professional barriers and people
  22     would make their own judgments about that. Many senior
  23     and very competent clinicians were concerned about the
  24     quality of the data and the uses to which any audit data
  25     might be put.

   1   Q. They were fearful that it would be put as they saw it to
   2     unjustified uses?
   3   A. Yes.
   4   Q. And unjustified conclusions would be drawn from it?
   5   A. Particularly if they felt the data was not sufficiently
   6     robust.
   7   Q. In the context of paediatric cardiac surgery, or cardiac
   8     services more widely, to the extent that you had audit
   9     as one of your responsibilities, as you have said in
  10     your GMC statement --
  11   A. I am sorry, may I explain that? I did not have
  12     responsibility for the implementation of audit. That
  13     lay within the Management Executive.
  14   Q. So what was your responsibility?
  15   A. It was actually listed as policy on audit and in fact my
  16     predecessor had had nothing to do with it, I later found
  17     out, but because I saw that in my job description,
  18     I started to attend the steering group meetings that
  19     were headed up by the division in the Management
  20     Executive that was implementing audit.
  21        So policy had at that point been worked out in
  22     general terms, and the Management Executive was
  23     implementing it. I attended those meetings, really just
  24     to be aware of what was going on within the Department.
  25   Q. In the context of being aware of what was going on in

   1     the Department, did you become aware of the decision to
   2     de-designate neonatal and infant cardiac surgery?
   3   A. I do not know that I was ever informed directly, but
   4     I think I would have heard it probably in divisional
   5     meetings. I was certainly aware that there was talk
   6     about it.
   7   Q. Would you receive the minutes of the Supra Regional
   8     Services Advisory Group meetings?
   9   A. No.
  10   Q. Would you receive copies of any papers from some of the
  11     leading lights in the field that you had known yourself,
  12     for example, Sir Terence English, the working parties of
  13     the Royal Colleges, dealing with the designation of
  14     neonatal and infant cardiac surgery?
  15   A. No, not at all.
  16   Q. Dr Halliday was your boss, and this was one of his
  17     responsibilities?
  18   A. Yes.
  19   Q. But it was not something he would have discussed with
  20     you, because it was not one of yours?
  21   A. He did not discuss it with me.
  22   Q. You would or would not have expected him to?
  23   A. Not at all.
  24   Q. Because it was not one of your responsibilities?
  25   A. Yes.

   1   Q. We heard from Dr Doyle this morning that the
   2     secretariat, if you like, the number of people
   3     physically in the department who were able to deal,
   4     operate, the Supra Regional Services Advisory Group, was
   5     small. Can you help us with the size of the secretariat
   6     for that organisation?
   7   A. I am not sure. I mean, it really was outside my
   8     knowledge. I did not attend the meetings. I think when
   9     I was there, that Alan Angilley was the grade 7, but
  10     I do not know who else would have been involved.
  11   Q. I think it was a Mr Owen who replaced Mr Angilley?
  12   A. You would normally expect a grade 7 to have a number of
  13     people working to him or her, and within his section,
  14     I imagine he had other duties too. They would have been
  15     split up between those duties, so not the whole of the
  16     section would have been dealing with it, but I cannot
  17     give you numbers.
  18   Q. You met Dr Bolsin, did you not, in October 1992, in
  19     connection with an audit project being run by the United
  20     Kingdom Association of Cardiothoracic Anaesthetists?
  21   A. I am not absolutely sure when I met Dr Bolsin, but
  22     I knew him by then.
  23   Q. If we have a look, please, at WIT 65/1398, if we go to
  24     page 1400, this is a letter I think you have seen
  25     recently?

   1   A. Yes, I have.
   2   Q. It is a letter to you from Dr Bolsin. The first
   3     paragraph:
   4        "Thank you very much indeed for attending the
   5     audit meeting.
   6        On page 1400 is Dr Bolsin's signature. If we go
   7     back to 1398, the first paragraph:
   8        "Thank you very much indeed for attending the
   9     audit meeting at the Sir Humphrey Davy Department of
  10     Anaesthesia meeting in Bristol last month. We were all
  11     very pleased that you could attend ..."
  12        So it would appear you attended a meeting in 1992
  13     attended by Dr Bolsin?
  14   A. Dr Bolsin invited me. I had heard him present some of
  15     his data at a meeting, and I do not know where that was,
  16     but I think it was in London. He was presenting some of
  17     his interim findings about the audit that this letter
  18     refers to.
  19   Q. This letter is essentially seeking finance for
  20     a national audit programme being undertaken by the
  21     United Kingdom Association for Cardiothoracic
  22     Anaesthetists?
  23   A. Yes.
  24   Q. If we look at WIT 65/1402, the essence of it is that the
  25     pitch for finance Dr Bolsin had made was successful, was

   1     it not?
   2   A. Shall I explain the process briefly?
   3   Q. Yes.
   4   A. Dr Bolsin was already being funded through the Royal
   5     College of Anaesthetists Audit Committee, which I think
   6     is called the Quality in Practice Committee, to
   7     undertake a project in Bristol, which involved trying to
   8     improve means of assessing risk of surgery for adults,
   9     coronary artery bypass graft patients.
  10        That audit was set up before I took up my post.
  11     I think it was Robert Hangartner and my predecessor who
  12     dealt with it. So I was aware of it through the Quality
  13     of Practice Committee of the Royal College, which I sat
  14     on as an observer for the Department of Health.
  15        I thought it was an excellent project. I then,
  16     attending a meeting on audit -- and I think as I say, it
  17     was in London, I believe it was at the RCP but I am not
  18     sure -- heard Steve Bolsin present the interim findings
  19     of the project we were already funding.
  20        I spoke to him afterwards to say how very
  21     interesting I thought the work was and what potential it
  22     might have for more general audit. He then said he
  23     would be talking about it in more detail at an audit
  24     meeting within his department at Bristol; would I like
  25     to come down and meet his collaborators, including the

   1     statisticians in Bristol University who were helping him
   2     with the work.
   3   Q. That included Dr Black?
   4   A. That included Dr Black, whom I think was the senior
   5     lecturer. That is why I attended the meeting. Steve
   6     invited me to it, and I thought this was a useful means
   7     of improving my acquaintance with anaesthetic colleagues
   8     in Bristol, because that was also one of my subjects,
   9     and hearing a bit more detail about what Steve Bolsin
  10     was doing. Which, as I say, we were already funding and
  11     thought was an excellent piece of work.
  12   Q. So you were impressed by this work?
  13   A. Yes.
  14   Q. And you were anxious to encourage him?
  15   A. I wanted to promote it being taken up by more centres
  16     and that is the thrust of Steve's letter. Because first
  17     I thought that we would strengthen the statistical work,
  18     the more numbers of patients we had in the data
  19     collection. I mean, it would give it more power.
  20   Q. This is December 1992, this letter?
  21   A. Yes.
  22   Q. At that stage, had you had any discussions with anyone
  23     about the quality of paediatric cardiac services in
  24     Bristol?
  25   A. No.

   1   Q. Dr Bolsin had never mentioned it to you?
   2   A. Never.
   3   Q. What was the first occasion on which somebody did
   4     mention that subject to you?
   5   A. Dr Bolsin approached me on a late afternoon in late
   6     1993, as we were both leaving the Royal College of
   7     Anaesthetists, and said could he have a word with me.
   8   Q. What were you both doing at the Royal College of
   9     Anaesthetists that day?
  10   A. I am afraid I do not have my work diaries for the time
  11     so I cannot be absolutely certain. It is possible,
  12     although I am not sure, that we were both attending the
  13     Quality of Practice meeting. It is possible, because he
  14     did not normally attend it but I did. I am not sure.
  15     We may have just been fortuitously both present in the
  16     College.
  17   Q. He approached you outside of the building?
  18   A. We left the lobby together.
  19   Q. And he said and did what, precisely?
  20   A. This is to the best of my recollection: he said
  21     something to the effect of, could he have a private word
  22     with me about something he was worried about. I said
  23     yes.
  24   Q. What was the importance of his suggesting that he wanted
  25     a private word with you? There was no one else present

   1     at this point, was there?
   2   A. I think he probably meant he just wanted it to be the
   3     two of us having a private conversation. He certainly
   4     did not want to have it in the presence of other people,
   5     because it was about very sensitive issues.
   6   Q. You heard Dr Doyle's evidence today, that he explained
   7     that it was his practice when people suggested they
   8     wanted a confidential word with him, to put a "health
   9     warning" out front, if you like, and say "Because of my
  10     position, it may be that confidential matters cannot be
  11     kept confidential"?
  12   A. Yes.
  13   Q. Was there any discussion of that nature with Dr Bolsin
  14     and yourself in December 1993?
  15   A. Not at the beginning of the conversation, I am sure of
  16     that. But I am not sure -- well, I mean I think we
  17     probably discussed the degree of confidentiality.
  18   Q. Why did you think he was having this discussion with
  19     you?
  20   A. I surmised that he thought that with my anaesthetic
  21     experience, I would have some understanding of his
  22     position and he specifically asked me that he wanted
  23     advice from me as a Departmental official because I had
  24     the experience of being a Departmental official, as to
  25     how he could handle a problem that he had.

   1   Q. Do you remember whether he said that he had raised the
   2     same matter he raised with you previously with others?
   3   A. Yes, he said he had.
   4   Q. With whom had he raised it?
   5   A. He said he had raised it with senior members of his own
   6     department in the Trust and he said that he had raised
   7     it -- I am not sure if it was him directly or others --
   8     with at least one of the Medical Royal Colleges. I have
   9     the impression, although I can say no more than that,
  10     that it was the Colleges of Anaesthetists and Surgeons.
  11     As I say, that is my recollection.
  12   Q. So your recollection is that there were three separate
  13     groups or areas that he raised the matter with?
  14   A. Yes.
  15   Q. His own department, that would be the Department of
  16     Anaesthesia?
  17   A. Yes. I do assume he had raised it very much with the
  18     surgeons but I am not sure exactly what he said about
  19     that.
  20   Q. Let us take it slowly. Who did he expressly say to you
  21     he had raised the matter with?
  22   A. He did not mention names.
  23   Q. Did he mention any areas of the Trust, of the Royal
  24     Colleges or the University, or any other organisation,
  25     that he had raised the matter with? Did he say "I have

   1     been to X department or Y department", without naming
   2     names?
   3   A. No. What I remember is what I have told you: that he
   4     raised it with the anaesthetic department in Bristol and
   5     I think he said the Colleges of Anaesthetists and
   6     Surgeons, but I am not absolutely sure. But he
   7     mentioned no individuals' names.
   8   Q. Can we look at GMC 14/28? This is your statement to the
   9     GMC. Just before we go to this paragraph, you said
  10     a moment ago that Dr Bolsin said he wanted to have
  11     a private word with you?
  12   A. Yes.
  13   Q. You did in fact have a discussion when no-one else was
  14     present?
  15   A. Yes.
  16   Q. Is there a distinction between having a private word
  17     with you and discussing a confidential matter with you?
  18   A. Yes.
  19   Q. What is the difference?
  20   A. I took "private" to mean it was not the sort of subject
  21     he would wish bandied about.
  22   Q. What is "confidential"?
  23   A. "Confidential" means you do not tell anyone.
  24   Q. Did he suggest he wanted a private word about something
  25     confidential?

   1   A. No, I do not believe he said it was confidential. And
   2     I did not treat it in that sense. I believe I said that
   3     in my original GMC statement, but it was a misuse of the
   4     word.
   5   Q. I fear you did. If we look at the paragraph beginning:
   6        "I should make it clear ..."
   7   A. It was loose drafting, I do apologise.
   8   Q. So long as we clear it up now, there is no problem.
   9        Four lines down:
  10        "In this case, I understood Dr Bolsin's enquiry to
  11     be confidential to me, and I would not normally have
  12     divulged what he said to others without his explicit
  13     agreement."
  14   A. Yes.
  15   Q. If that is loosely drafted, would you like now to try
  16     and redraft it?
  17   A. I think I would probably put a comma after "agreement"
  18     and say "but that I would reserve the right to judge on
  19     the seriousness of the case whether I should take it
  20     further and if I judge that necessary, I would not
  21     require his consent".
  22   Q. Did Dr Bolsin give you the impression that he was
  23     anxious that you should not disseminate what he was
  24     saying to anyone else?
  25   A. No, it was the impression I had that he wanted to have

   1     a private word. He did not want to talk in front of
   2     other people. That was all.
   3   Q. Might it not be that he was coming to an official of the
   4     Department of Health precisely so that his concerns
   5     could be aired within the Department or taken to
   6     a higher level than he himself had managed to achieve by
   7     discussing the matter with the anaesthetic department or
   8     the Royal College?
   9   A. What he actually said to me, what I recollect him saying
  10     to me, is that he was asking me to advise him on how he
  11     could handle it. He at no time asked me to do anything
  12     about it.
  13   Q. Did you consider whether there were things that you
  14     might, nonetheless, do about it?
  15   A. I did.
  16   Q. Did he show you any pieces of paper?
  17   A. None.
  18   Q. So what was the burden of his story to you?
  19   A. He alleged that he had data that showed that there was
  20     an excess mortality in paediatric cardiac surgery in
  21     Bristol.
  22   Q. Did he go any further, with any other details?
  23   A. No. I mean, he did not say in which cases. He
  24     specifically did not mention any particular surgeon.
  25     I had a vague impression this situation had pertained

   1     for some time, but that would be understandable because
   2     the number of paediatric cases in a year would not be
   3     enormous, so to have a feel for any sort of data you
   4     would have to have data going back a while. But that is
   5     all he said.
   6   Q. Did he specifically say that his concern was about poor
   7     surgery, or simply about poor outcomes of patients who
   8     had had surgery?
   9   A. I really could not be sure.
  10   Q. Because it would not necessarily follow, would it?
  11   A. No, it would not necessarily follow.
  12   Q. If we have a look at WIT 338/5, this is your statement
  13     to the Inquiry. You are talking about there, you say,
  14     the top of the page, you made a judgment. We will come
  15     to what judgment you made in a minute:
  16        "I took specific account of ... (iv) the data he
  17     referred to was unlikely to be sufficient to
  18     substantiate claims of poor surgery."
  19   A. Yes.
  20   Q. So it would seem from that that you did have the notion
  21     that his complaint was about poor surgery as opposed to
  22     poor outcomes of patients who had had surgery?
  23   A. It is difficult to be sure because in fact I have only
  24     written this statement in the last week or so, and
  25     therefore it is coloured by everything that has happened

   1     since the conversation and now. So I am not sure that
   2     that word necessarily indicates what you suggest. But
   3     it is possible.
   4   Q. So this might not be a factor you took specific account
   5     of in reaching the judgment in acting as you did in
   6     1993?
   7   A. I certainly considered what the data he referred to --
   8     what the strength of it might be.
   9   Q. But you had not seen the data?
  10   A. I had not seen it, no.
  11   Q. You did not ask him for it?
  12   A. No.
  13   Q. He did not offer it to you?
  14   A. No. I mean, the basis of my concern about the data was
  15     that because of the nature of the surgery, it was likely
  16     to be very small numbers on rather rare conditions, and
  17     conditions that tend to vary in their detail.
  18     Therefore, it is extremely difficult to establish
  19     reasonable comparisons and that, therefore, data that
  20     showed differing outcomes between units might not, in
  21     itself, be particularly robust. Therefore, if he was
  22     basing an allegation merely on data, the strength of his
  23     case did not seem to me to be very strong.
  24   Q. You say he did not mention the names of any individuals
  25     to you, did he?

   1   A. No.
   2   Q. He did not mention Mr Dhasmana or Mr Wisheart, for
   3     example?
   4   A. No, no names at all.
   5   Q. How worried were you by the information that Dr Bolsin
   6     gave to you, about what he told you in December 1993?
   7   A. I thought it was a very serious allegation and there was
   8     a case to answer.
   9   Q. If it was true, what he was saying, it would be a matter
  10     of some concern, would it?
  11   A. It was a matter of concern that the allegation was made,
  12     I think. It meant that steps needed to be taken to find
  13     out if an appropriate assessment were being made as to
  14     whether the allegation were true or not.
  15   Q. So the very fact that the allegation was made was
  16     a concern?
  17   A. Yes.
  18   Q. If the allegations were on analysis to turn out to be
  19     true, well-founded, that would be a matter of even
  20     greater concern?
  21   A. Yes.
  22   Q. I think you will have seen this morning a letter that
  23     Dr Doyle wrote some months later to Professor Angelini
  24     in July 1994, he having had a discussion with Dr Bolsin
  25     in a taxi on the way to the station?

   1   A. Yes.
   2   Q. I am sure you will agree, Dr Doyle said to Professor
   3     Angelini, "This is a matter for very great concern. If
   4     the position proves to be as reported to me the excess
   5     deaths are in themselves a tragedy. If the problem has
   6     been recognised and adequate remedial steps have not
   7     been taken, it becomes an unacceptable tragedy."
   8        That is what Dr Doyle wrote to Professor Angelini?
   9   A. Yes.
  10   Q. Does that paragraph, written a couple of days after
  11     Dr Doyle had learned of Dr Bolsin's concerns, reflect
  12     your state of mind on hearing Dr Bolsin's concerns some
  13     months earlier?
  14   A. I certainly thought as an allegation it needed to be
  15     looked into.
  16   Q. It was a matter of very great concern?
  17   A. I was concerned.
  18   Q. At this time in December 1993, when you had the
  19     discussion outside the Royal College of Anaesthetists,
  20     neonatal and infant cardiac surgery was still, just
  21     about, a designated service of the Supra Regional
  22     Services Advisory Group; is that right? I think
  23     de-designation took effect from April 1994.
  24   A. Yes. I have heard details of dates today, although
  25     I was not aware of it then, in detail.

   1   Q. But you told us earlier, I think, that you did become
   2     aware that neonatal and infant cardiac surgery was to be
   3     de-designated?
   4   A. Yes, I had heard discussion of it, I was not party to
   5     the papers so I was not absolutely clear as to the dates
   6     and so on.
   7   Q. In December 1993, had you been asked or asked yourself,
   8     "Is neonatal and infant cardiac surgery still
   9     a supra-regional service?" would you have been able to
  10     answer the question?
  11   A. I am not absolutely sure.
  12   Q. Dr Halliday would have been able to answer the question?
  13   A. Indeed he would.
  14   Q. He was by then your boss?
  15   A. I think by then he might have retired. I am not
  16     absolutely sure.
  17   Q. At all events, the Medical Secretary of the Supra
  18     Regional Services Advisory Group would be able to tell
  19     you?
  20   A. Yes.
  21   Q. And you would have known who that person was?
  22   A. Yes.
  23   Q. So you could have, if you had decided to, checked with
  24     the Medical Secretary of the Supra Regional Services
  25     Advisory Group as to whether or not neonatal and infant

   1     cardiac surgery was still a designated service?
   2   A. I could have asked, yes.
   3   Q. Did you in fact discuss Dr Bolsin's concerns with you
   4     with anyone else in the Department?
   5   A. Not at that stage, no.
   6   Q. Why not, if it was a matter of very great concern?
   7   A. The judgment I made, having heard Steve, was that it was
   8     actually a local matter for the Trust. I was not as
   9     well informed as Dr Doyle obviously was about the
  10     procedures, but my definite belief was that the
  11     responsibility for what Steve was talking about lay
  12     primarily with the clinicians concerned, but in
  13     management terms with the Trust. I therefore suggested
  14     to Steve that I would speak to -- actually
  15     a professional member of the Trust, but someone who also
  16     had a management position, who I was actually about to
  17     meet, and Steve was content with that, although I have
  18     to say that had he not been, I would still have done it.
  19   Q. Who was that?
  20   A. That was Professor Farndon.
  21   Q. What did you understand his role to be?
  22   A. I understood that he was the Clinical Director of
  23     Surgery, as well as holding an academic appointment in
  24     the University, and an NHS honorary appointment.
  25   Q. In the discussion that you had had with Dr Bolsin at the

   1     Royal College of Anaesthetists, did either of you
   2     mention the Supra Regional Services Advisory Group at
   3     all?
   4   A. I do not recollect it but it is possible.
   5   Q. When he gave evidence at the GMC, Dr Bolsin, on
   6     23rd October 1997, had said this -- perhaps I will read
   7     this paragraph:
   8        "We [you and he] talked about all sorts of
   9     things. We talked about the reports from supra-regional
  10     paediatric cardiac surgery units. She [you] said 'Is
  11     this not coming out in the report from the
  12     supra-regional paediatric cardiac surgical units?',
  13     because they had to produce annual reports."
  14        Do you remember saying to Dr Bolsin, "Has this not
  15     come out in the supra-regional annual reports?"
  16   A. No, I do not remember saying it, but if he said I said
  17     it, I am quite happy to agree I probably did.
  18   Q. If you had said that, that would have been an indication
  19     that the -- perhaps not the responsibility, at least the
  20     opportunity for spotting any problems that might exist
  21     would lie not simply locally but also with the
  22     Department of Health through the Supra Regional Services
  23     Advisory Group?
  24   A. I wondered if that was the case. I did not know what
  25     the nature of the reports was, that the Supra Regional

   1     Services Advisory Group did, because I never saw them.
   2     You are telling me I put the question. I am agreeing
   3     with you, that would be a reasonable question.
   4   Q. I am telling you that Dr Bolsin told the GMC that you
   5     told him.
   6   A. Then let us assume I said it. I think it would be
   7     a reasonable question, but I did not know, because as
   8     I say, I was not party to the paperwork of that group.
   9   Q. This concern of Dr Bolsin was essentially sprung on you
  10     outside the Royal College of Anaesthetists?
  11   A. Yes.
  12   Q. You had no reason to expect him to tell you this?
  13   A. None at all.
  14   Q. So if it is right that during this conversation -- which
  15     lasted how long?
  16   A. 20 minutes, something like that.
  17   Q. If it is right that during that conversation one of your
  18     first thoughts was, "Has this not come out in the
  19     reports to the Supra Regional Services Advisory Group?"
  20     would you not have gone back to the Department of Health
  21     and yourself dug out those reports to the Supra Regional
  22     Services Advisory Group?
  23   A. I see the thrust of your question, but in fact I did
  24     not.
  25   Q. Why not?

   1   A. I do not know. I cannot tell you that now.
   2   Q. That would have been a reasonably simple thing for you
   3     to have done?
   4   A. It is possible, but I did not.
   5   Q. Do you remember what Dr Bolsin said when you, if you
   6     did, raised the question of the supra-regional services
   7     annual report? Did he say "They are no use because they
   8     only deal with the numbers of operations"?
   9   A. No, I do not remember, because I do not remember the
  10     exchange.
  11   Q. Have you, since then, and before now, become familiar
  12     with what was actually the substance of those annual
  13     reports to the Supra Regional Services Advisory Group?
  14   A. No, I never had anything to do with the group.
  15   Q. Did it cross your mind that in December 1993, the
  16     Department of Health was effectively -- was in fact --
  17     the purchaser of cardiac surgery services for people of
  18     under 1 year of age through the Supra Regional Services
  19     Advisory Group?
  20   A. I was not clear, as I think we have just discussed, as
  21     to what the position was at that time.
  22   Q. Did you have an opportunity to form any impression of
  23     Dr Bolsin's motives or intentions in raising this matter
  24     with you?
  25   A. He seemed to me to be personally involved and very

   1     deeply distressed, because I believe he was
   2     anaesthetising babies and small children, and therefore
   3     the patients he was talking about, some of them were
   4     patients he had become closely involved with. He
   5     certainly gave me the impression that he was affected
   6     himself.
   7   Q. In your GMC statement, GMC 14/20, I do not think we need
   8     to go to it, you say you felt his intentions were
   9     genuine?
  10   A. Yes.
  11   Q. What do you mean by that?
  12   A. They were actuated by care for the patients.
  13   Q. As opposed to what?
  14   A. As opposed to some inter-departmental row. I mean,
  15     I had worked in a couple of cardiothoracic units and
  16     they can be places where very strong characters can have
  17     disagreements and power struggles.
  18   Q. More than other units?
  19   A. On the surgical side, I would say that may well be so,
  20     in the days I was practising. It may be quite different
  21     now.
  22   Q. If we have a look at your statement to the Inquiry at
  23     WIT 338/4. We have already had a look, you will
  24     remember a moment ago, at that passage in your GMC
  25     statement where you referred to Dr Bolsin's enquiry

   1     being confidential, as you understood it. You remember
   2     the passage you said was loosely drafted, or words to
   3     that effect?
   4   A. Yes.
   5   Q. If we have a look at this page, if we scan down
   6     a little, please, to the paragraph beginning "such
   7     approaches ...", just below the middle of the screen,
   8     there is a sentence there, the third sentence in that
   9     paragraph which is very similar to the sentence we
  10     looked at in the GMC statement.
  11   A. Yes.
  12   Q. Is that one also perhaps in need of some correction?
  13   A. I think it is more what I feel is accurate in that
  14     I would not normally divulge something -- if
  15     a professional colleague approached me and said they
  16     wanted to discuss a private matter, I would not normally
  17     divulge that, unless there was, you know, some higher
  18     constraint on me. But I take your point. They are very
  19     similar.
  20   Q. The word "normally": when would you depart from the
  21     normal?
  22   A. One would have to make a judgment in the individual
  23     case. I do not think there are criteria you can apply
  24     in general, perhaps.
  25   Q. Let us unpick that a little. The normal position would

   1     be that if somebody had imparted information to you on
   2     a confidential basis, it would not go any further?
   3   A. Normally. It would depend what the other constraints
   4     were.
   5   Q. There would be some cases where you would take it
   6     further notwithstanding that the person imparting the
   7     information to you had said "This is confidential"?
   8   A. Yes. I think probably the better option is to do what
   9     Peter Doyle suggested earlier, to say to people very
  10     clearly -- and that is more my practice now, I have to
  11     say -- at the start of any such conversation, that "You
  12     must bear in mind that I am actually a civil servant and
  13     not a professional colleague".
  14   Q. I understand that, but even if that "health warning" as
  15     Dr Doyle put it had been given, "There may be
  16     circumstances in which I have to take this further" what
  17     I am trying to explore is what those circumstances would
  18     be in which you would take the matter further,
  19     notwithstanding that the information had been given on
  20     a confidential basis?
  21   A. I think it is easier to comment in the specific case,
  22     because I find it difficult to make a general rule.
  23   Q. Would it be a function of how serious the matter was?
  24   A. I do not think it would.
  25   THE CHAIRMAN: You say you would respond to the particular

   1     case and there are no criteria, but if there were no
   2     criteria, you could readily toss a coin to decide. So
   3     there must be criteria, and I think Mr Maclean is
   4     seeking to explore what they are, that is all.
   5   A. If I may refer to this specific case, it would be,
   6     having taken the action I thought reasonable, if I had
   7     had an indication that that had not succeeded. The
   8     process I went through was the one I thought proper,
   9     which was to consult Professor Farndon. If I had had an
  10     indication that no action had been taken as a result of
  11     that discussion, at that point I would have taken it
  12     further.
  13   MR MACLEAN: Let us look at your statement at WIT 338/5.
  14     We have looked at this already in the context of
  15     sub-paragraph 4, the one about poor surgery. If we look
  16     just below that, you say:
  17        "Having considered these events very carefully, it
  18     is my belief that I would act in the same way under the
  19     same circumstances.
  20        "If Dr Bolsin had indicated that he had continuing
  21     concerns, then I believe I would have taken the matter
  22     further. In fact, he indicated the opposite."
  23        Before we look at that in any more detail, we
  24     should look, perhaps, at what you did, the
  25     correspondence that you had with Dr Bolsin. Can we look

   1     at UBHT 61/265? This is a letter that you wrote to
   2     Dr Bolsin on 13th December, shortly after Dr Bolsin had
   3     spoken to you.
   4        "You spoke to me in confidence last Thursday. By
   5     complete coincidence, John Farndon spoke of the same
   6     matter to me on Friday. I did not mention you."
   7        You say "complete coincidence". Did it not strike
   8     you as a rather remarkable coincidence that two people
   9     from the same department should raise the same concern
  10     on successive days?
  11   A. Yes. That was a terminological inexactitude, I think.
  12     I had spoken to John Farndon. He had not raised it with
  13     me, I raised it with him specifically.
  14   Q. You did not mention Dr Bolsin's name to Professor
  15     Farndon?
  16   A. I did not.
  17   Q. Did Professor Farndon not say, "I know all about this
  18     because Steve has shown me his data already"?
  19   A. I do not recall that Professor Farndon made any response
  20     at all to what I said.
  21   Q. You say:
  22        "This letter includes what I expect you would
  23     receive were you to write to the Chief Medical Officer."
  24   A. Yes.
  25   Q. So is that an indication that the matters that Dr Bolsin

   1     had raised with you might be the sort of matters that
   2     would be fit to be raised with the Chief Medical
   3     Officer?
   4   A. Certainly the Chief Medical Officer might receive
   5     letters about such matters.
   6   Q. But it would not be the sort of matter that the
   7     departments lower down, below the Chief Medical Officer,
   8     would seek to filter up to him?
   9   A. It would be a matter of judgment on the individual case.
  10   Q. Then you say:
  11        "I enclose a copy of the Department of Health
  12     extant guidance which may apply."
  13        Pausing there, do you remember what guidance you
  14     sent?
  15   A. I think what I sent actually was guidance on the "three
  16     wise men" procedure, but --
  17   Q. Do you remember the title of that guidance?
  18   A. It is listed. It is HC(82)13, I think.
  19   Q. If we look at HA(A) 164/426: this is the guidance which
  20     is headed, if we look at the top, HC(82)13. You see
  21     that in the top right-hand corner?
  22   A. Yes.
  23   Q. Is this, so far as you recollect, the guidance you would
  24     have sent to Dr Bolsin?
  25   A. That is the number I have put in the letter, so I assume

   1     it is, although I did not remember doing it.
   2   Q. By the time of your letter, December 1993, there was
   3     other guidance extant, was there not: for example,
   4     HC(90)9?
   5   A. Yes, I believe that is so now. My knowledge of it was
   6     much more limited than Peter Doyle's and I did not send
   7     him the complete guidance because I was not aware of it.
   8   Q. Dr Doyle's evidence as I understood it was that
   9     initially he considered that the appropriate approach
  10     for Dr Bolsin would be to utilise the HC(90)9 procedure
  11     and in particular, the intermediate procedure introduced
  12     by Annex E of that guidance?
  13   A. Dr Doyle was more expert than I.
  14   Q. Do you have a view now as to whether or not the more
  15     appropriate to have sent Dr Bolsin was HC(82)13 or
  16     HC(90)9?
  17   A. I have not read the guidance recently, but I assume that
  18     is probably so, that it would have been the appropriate
  19     guidance.
  20   Q. HC(90)9?
  21   A. Yes.
  22   Q. You say in your letter, if we can go back to
  23     UBHT 261/265, the second paragraph, the second line:
  24        "I can, of course, make no judgment. I merely
  25     wonder if this is a useful mechanism to help an

   1     individual come to terms with a problem."
   2        So the purpose of the guidance you had sent was,
   3     if you like, to deal with cases where, as HC(82)13
   4     says:
   5        "Prevention of harm to patients resulting from
   6     physical or mental disability of hospital or community
   7     medical or dental staff."
   8        So that guidance deals with the position where
   9     there is an individual who has some physical or mental
  10     disability which is leading to harm to patients?
  11   A. Yes.
  12   Q. It is not the kind of guidance that is appropriate for
  13     dealing with systemic failures within an organisation?
  14   A. Yes. I cannot tell you why I thought that now. All
  15     I can say is that I think I must have sent it in
  16     response to something in the conversation with
  17     Dr Bolsin, but I cannot recollect what that might have
  18     been. But I clearly did it in response to something.
  19     I really cannot tell you why I thought that at the time.
  20   Q. You must have thought, must you not, that the problem
  21     was with one or more individuals who could be dealt with
  22     under HC(82)13?
  23   A. Who might be, I think, rather than who could be.
  24   Q. Who might be if Dr Bolsin's concerns were genuine?
  25   A. As I say, it relates to a conversation and I do not

   1     remember the full substance of that conversation and why
   2     I was stimulated to send that particular guidance.
   3   Q. You make a reference in the last paragraph of the letter
   4     to the CMO's committee which was going to address, as
   5     you put it, "these sorts of issues".
   6   A. Yes.
   7   Q. What committee was that? Do you remember?
   8   A. I have had to think quite hard about this. I do not
   9     know for certain but I think it was probably something
  10     to do with the Clinical Outcomes Group. That is the
  11     only thing I have actually managed to work out and that
  12     was a committee I was not on but I knew a little of, to
  13     do with looking at the development of medical audit, the
  14     sorts of issues I am referring to are dealing with
  15     outcome, audits and outcome, I think.
  16        I am not absolutely sure of that. Having seen
  17     this letter in the last week or so, that is all I can
  18     work out that it might have been.
  19   Q. Was there, in December 1993, in the Department,
  20     something called the Performance Management Directorate?
  21   A. Yes, in the Executive.
  22   Q. You will have seen from Professor Angelini the letter
  23     from Dr Doyle to Professor Angelini we looked at
  24     earlier, if I can look at it again. It is
  25     UBHT 52/287, the last paragraph on that page:

   1        "If there is a problem and for any reason you are
   2     not able to reassure me that it has been resolved, the
   3     circumstances are such that I would be obliged to seek
   4     the help of colleagues in the Performance Management
   5     Directorate, who would doubtless raise the matter
   6     formally with the Trust. It is highly likely that some
   7     sort of formal inquiry would follow."
   8        You heard Dr Doyle explain what that directorate
   9     was and why it might have been an appropriate body to
  10     intervene.
  11        Do you agree with the evidence he gave about that?
  12   A. I do not think it was my opinion at the time that the
  13     Performance Management Directorate actually dealt with
  14     clinical practice. It would be much more concerned with
  15     financial management, corporate governance, those kinds
  16     of issues. That was my opinion.
  17   Q. Your idea was that the Supra Regional Services Advisory
  18     Group might be a more obvious organisation to be
  19     concerned, which is why you raised it with Dr Bolsin in
  20     the conversation?
  21   A. Making the assumption I did, I think that is more
  22     logical.
  23   Q. But Dr Bolsin's concerns which he raised with you -- you
  24     remember I asked you about the word "normally" and when
  25     you would depart from the norm and take the matter

   1     further. You said, and I paraphrase, tell me if I put
   2     it unfairly, that if Dr Bolsin had not been satisfied
   3     and had come back again with the same concerns, or
   4     further concerns, then you would have taken it further.
   5     Is that fair?
   6   A. I think if he had come back to me either in writing or
   7     verbally, and said that he was aware I had raised it
   8     with Professor Farndon as a Clinical Director, and that
   9     no management steps had been taken to address the issue,
  10     then I would certainly have taken it further.
  11   Q. Your letter at UBHT 61/265: what was in this letter to
  12     reassure Dr Bolsin that you treated his concerns
  13     seriously and had taken steps to either take action
  14     yourself or make sure that others had taken action?
  15   A. During our conversation at the College, I had told him
  16     that although -- I mean, the sort of areas we discussed
  17     about the guidance were never part of my work in the
  18     Department of Health, so my knowledge of them was very
  19     limited and I told him that during our conversation.
  20     I told him that I thought that an issue of clinical
  21     management or dealing with any indication of outcomes
  22     that might reflect on clinical management, was in my
  23     view a matter for the Trust to resolve.
  24        I then told him that in order to further that,
  25     I proposed to talk to Professor Farndon. I then

   1     confirmed to him that I had done so. I made the
   2     assumption that he would then approach Professor Farndon
   3     and action would be taken.
   4   Q. In fact, Dr Bolsin had probably already spoken to
   5     Professor Farndon?
   6   A. I did not know that. He did not tell me -- when
   7     I mentioned Professor Farndon to him, he did not say to
   8     me at that point that he had already done so.
   9   Q. You see, all this letter does is say, "I have spoken to
  10     Professor Farndon. I enclose some guidance, and there
  11     is a CMO's committee which will report some time, we do
  12     not know when, and it is quite a protracted procedure."
  13   A. Yes. I felt that giving him the information, I had done
  14     what I would told him I would do, would enable him to
  15     take it forward in the Trust, which is where I thought
  16     the responsibility lay.
  17   Q. It is a very different letter, this one, than the one
  18     Dr Doyle wrote to Professor Angelini in July 1994 which
  19     essentially said, "If you do not sort it out, the
  20     Performance Management Directorate will sort it out"?
  21   A. Yes. The letter is different because I was
  22     communicating with Steve Bolsin. I spoke to Professor
  23     Farndon. Again, to the best of one's recollection, I do
  24     not have a transcript of what I said to him, but the
  25     gist of it was that I had heard some allegations about

   1     outcomes in paediatric cardiac surgery in Bristol, that
   2     this was a Trust matter and that I was speaking to him
   3     because he was a senior figure in the Trust and the
   4     Clinical Director, and that my view was that it was the
   5     Trust's responsibility to sort it out.
   6   Q. You did not think that the concerns that Dr Bolsin had
   7     raised with you had anything to do with the Department
   8     of Health, did you?
   9   A. I did not feel they were immediately for us. I felt it
  10     was a Trust matter. I wanted to be assured that the
  11     Trust would act and that is why I spoke to Professor
  12     Farndon.
  13   Q. There is nothing in your letter to Dr Bolsin to suggest,
  14     unlike Dr Doyle's letter, that if the Trust does not
  15     sort its own house out, the Department would step in and
  16     do something about it?
  17   A. No, there is not.
  18   Q. Can we look at your GMC statement, GMC 14/29? If we
  19     scan down the page, the paragraph beginning "I do not
  20     remember ...", you said, in the middle of the paragraph:
  21        "I said to Dr Bolsin I would speak to Professor
  22     Farndon after the meeting he and I were attending to say
  23     that I was aware of some concerns and to suggest that it
  24     was a matter that the Trust needed to sort out.
  25     Dr Bolsin agreed I could do that. I spoke to Professor

   1     Farndon in private about a couple of weeks later ..."
   2        Your letter suggests it was the following day, but
   3     there was only one conversation with Professor Farndon,
   4     was there?
   5   A. Again, I do not have a record of when the particular
   6     meeting was, although I have a recollection of the
   7     meeting. But I know it was very shortly, because when
   8     I spoke to Steve about it I said it was very useful that
   9     this was about to happen.
  10   Q. It does not matter when it was. There was only one
  11     conversation with Professor Farndon?
  12   A. Yes.
  13   Q. "I spoke to Professor Farndon in private about a couple
  14     of weeks later immediately after the Working Party.
  15     I told him it was not a matter for the Department of
  16     Health."
  17   A. At that stage it was not, I felt.
  18   Q. But where do we find any indication in your letter or
  19     your conversation with Professor Farndon, or with
  20     Dr Bolsin, that you thought it was ever a matter that
  21     was going to be a matter for the Department of Health?
  22   A. I agree, what you say.
  23   Q. You did not suggest in the letter to Dr Bolsin that it
  24     was a matter for the Department of Health. You sent him
  25     some guidance dealing with the "three wise men"

   1     procedure. You did not mention it to Dr Halliday. You
   2     did not look for the Supra Regional Services Advisory
   3     Group annual returns. You did not think that it was
   4     a matter for the Department of Health at all?
   5   A. I did not think that an allegation that I was presented
   6     with, when I had no other indications from other sources
   7     of this matter, was something that needed to be taken
   8     into the Department of Health and dealt with there when
   9     the responsibility clearly lay with the Trust. I took
  10     action to ensure that Trust management was aware of it
  11     through a professional meeting that I knew was about to
  12     happen.
  13   Q. Why not contact the Chief Executive of the Trust, if it
  14     is a matter for the Trust? Why not go to the top of the
  15     management and write to Dr Roylance?
  16   A. I think what I thought of at the time was that I was
  17     about to meet someone who was directly concerned with
  18     surgery in the Trust, who also had a management position
  19     and that I could most helpfully put it to him and
  20     discuss it with him. That is what I did.
  21   Q. If a doctor raised a matter with you, a medical matter,
  22     would your instinct be, if you were going to talk to
  23     somebody else about it in the Trust, to talk to a member
  24     of the medical staff as opposed to one of the management
  25     per se?

   1   A. If I had not been going to meet someone in that
   2     position, if one puts that to one side, my practice
   3     would be probably to contact the Medical Director.
   4   Q. When you spoke to Professor Farndon, did you say, "Are
   5     you going to raise this with the Medical Director?" or
   6     "I trust you will raise it with the Medical Director"?
   7   A. No, I say to the best of my recollection, I said that it
   8     was a matter for the Trust to resolve: that there was an
   9     issue that somebody was -- I do not think I said
  10     somebody was making allegations to me.
  11        I think I said that I had heard that there were
  12     concerns about the outcomes of paediatric cardiac
  13     surgery, and it was for the Trust to resolve. I did not
  14     name any names.
  15   Q. Let us look at your statement again, WIT 338/5. You
  16     said you made a judgment based on the information
  17     presented to you by Dr Bolsin, and the context in which
  18     it was presented.
  19        The judgment you are referring to was the judgment
  20     to write the letter of 13th December; is that right?
  21   A. No, the judgment was to contact Professor Farndon.
  22   Q. Yes, okay, which --
  23   A. That was the --
  24   Q. It records that you had spoken to Professor Farndon,
  25     telling Dr Bolsin you had spoken to Professor Farndon?

   1   A. Yes, but the specific relevant action was to speak to
   2     Professor Farndon.
   3   Q. You say you took account of "(i) the fact that he
   4     [Dr Bolsin] had previously flagged up his concerns with
   5     his senior colleagues in the BRI and the Royal College."
   6   A. Yes.
   7   Q. Would not the fact that he had already flagged up his
   8     concerns with his senior colleagues and the Royal
   9     College tend to suggest that he could not see that he
  10     was making any progress on those fronts?
  11   A. What was in my mind, I think in saying that, was that he
  12     had clearly been talking to a lot of senior professional
  13     people with the data he was talking about having to me,
  14     and it appeared that he had not convinced anyone.
  15     I mean, he was saying to me, "I have told them all this
  16     and they have done nothing", words to that effect and
  17     I knew some of the people he was talking about and I had
  18     worked with them --
  19   Q. Which people?
  20   A. Well, people like Terence English, people like Cedric
  21     Prys Roberts, the Professor in Bristol in Anaesthesia.
  22     I knew some of them well. I knew some of them well
  23     professionally. They were very senior and respected
  24     members of my profession and he was telling them -- I do
  25     not know if he told me he had shown them the data but he

   1     had flagged up his concerns with them and they had
   2     decided not to take it further.
   3        If you are trying at that point to make a judgment
   4     about how serious a problem is and what you need to do
   5     about it, the fact that people of repute have already
   6     looked at it and have not made that judgment, must,
   7     I think, weigh with one. It did with me.
   8   Q. Would it not be equally possible to say if somebody
   9     says "I have taken these concerns to my senior
  10     colleagues where I work. I have taken them to the Royal
  11     College. You are a Senior Medical Officer of the
  12     Department of Health", would not one take that as being
  13     a cry for help for the Department of Health to do
  14     something about it, rather than to go back to the same
  15     places where Dr Bolsin had been making no progress?
  16   A. If it were a cry for help, he did not express it to me.
  17     He asked me for advice. He did not say to me, "I have
  18     gone to all these people and got nowhere and you are my
  19     last hope to do something". That is absolutely not what
  20     he said. He asked for my advice and I said to him,
  21     "(a) I do not have a great deal of knowledge of the
  22     areas you are talking about in terms of the government
  23     guidance but I think it is a local matter and in any
  24     event, I think it is worth me talking to Professor
  25     Farndon because I am going to see him very shortly, and

   1     I will raise the issue with him and tell him that
   2     I think it is for the Trust to manage it".
   3   Q. Let us look at the second of these paragraphs. You had
   4     not heard and knew nothing of this issue from any other
   5     source.
   6        To whom did you make any enquiries about whether
   7     or not this matter was raised?
   8   A. That was not a result of enquiry; that was the fact that
   9     I had been two years in the current job and I had spent
  10     a lot of time, within the limits of my time, obviously,
  11     at cardiothoracic meetings. I had been to a lot of
  12     meetings with individual officers of the Association of
  13     Cardiothoracic Surgery and with the British Cardiac
  14     Society, talking about development of audit; and I had
  15     made a lot of effort to actually network with people in
  16     order to enable this kind of communication. I mean,
  17     I am not saying I go around trawling for problems, but
  18     one does make the effort to network with professionals
  19     and give them every opportunity to raise issues should
  20     they so wish, and in all that time, I had not heard one
  21     thing in relation to Bristol.
  22   Q. Were you, like the then Chief Medical Officer for
  23     England, a regular reader of Private Eye?
  24   A. I have not read Private Eye since I was an
  25     undergraduate, and I did not read it much then. I have

   1     seen the article this week for the first time.
   2   Q. There was more than one?
   3   A. Well, I have seen one article, then.
   4   Q. I think the earliest one was 8th May 1992.
   5   A. Yes.
   6   Q. You say at (iii):
   7        "I was not aware of any complaint from patients'
   8     families or more widely in the public domain.
   9        "(iv) the data he [Dr Bolsin] referred to was
  10     unlikely to be sufficient to substantiate claims for
  11     poor surgery."
  12        You had not actually seen the data?
  13   A. No, I made that assessment on what I said to you earlier
  14     about the nature of the data, that by virtue of the
  15     cases they were going to be very small numbers about the
  16     sort of congenital conditions that -- they are not the
  17     same as each other; they do vary from patient to
  18     patient. The statistical power of such data in my view,
  19     would not be sufficient to prove, for example, cause and
  20     effect.
  21   Q. That would apply, would it not, to any centre doing
  22     congenital heart surgery?
  23   A. Yes, it would.
  24   Q. Because the numbers would be small anywhere?
  25   A. Indeed.

   1   Q. If your point is a good one, it would follow that such
   2     data for any centre would never be able on its own to
   3     substantiate claims of poor surgery?
   4   A. Indeed, I think that is correct. At the time we were
   5     speaking, and it may be, I think Peter was referring to
   6     developments in statistical practice in a paper
   7     published by another cardiac surgeon more recently. It
   8     may be that practice has moved on in that field. Nor am
   9     I a medical statistician, so I have no expertise in the
  10     details of this now, but in those days, I think that
  11     would be absolutely true. I cannot comment on the
  12     position now.
  13   Q. Given those four matters that you took account of, why
  14     should it be that if Dr Bolsin had indicated that he had
  15     continuing concerns, then you would have taken the
  16     matter further?
  17   A. If he had indicated that the Trust had taken no action.
  18     I think the point is that the responsibility for dealing
  19     with the problems that Steve raised lay with the Trust.
  20     If Steve had then written in reply to me and said that,
  21     fine, I had spoken to Professor Farndon but there was no
  22     detectable change in the Trust's attitude, that would
  23     have been a trigger to take the matter further. Then it
  24     would have been a matter for the Department of Health.
  25   Q. So it would be a function of the number of times that

   1     Dr Bolsin raised the matter with you? That is what
   2     would determine whether you would take the matter
   3     further?
   4   A. It would have been a function of his response to the
   5     intervention I had made.
   6   Q. You say in fact he indicated the opposite. I should
   7     show you the letter, UBHT 61/270. This is a letter to
   8     you from Dr Bolsin. Can we just have a look at the very
   9     top, please? Can you help me with what "CRM for info"
  10     means?
  11   A. No.
  12   Q. Can we look down at the letter, then, please? I am not
  13     going to read it out, all of it. You see the second
  14     paragraph:
  15        "I am most grateful to you for your intervention
  16     in this matter and I am convinced that you have
  17     significantly helped with the resolution of what was an
  18     unacceptable clinical practice."
  19        This is February 1984.
  20        "I look forward to your meeting next month and
  21     I shall be contacting you before then to report our
  22     progress in national audit."
  23        So your reaction to this letter was what?
  24   A. I felt it indicated that what I had said to Professor
  25     Farndon had had an effect in the Trust dealing with the

   1     matter and that Steve felt that I had done sufficient.
   2   Q. I do not know whether you have had the chance to see the
   3     transcript of the evidence of Sir Alan Langlands earlier
   4     this week?
   5   A. Yes, you showed it to me.
   6   Q. I did -- it was a long time ago: this morning!
   7        Can we have WIT 335/39, please? Halfway down the
   8     page, Sir Alan was asked:
   9        "We have talked about the role of districts and
  10     purchasers in supervising or attempting to begin the
  11     scrutiny of quality. Why is it that whether one is
  12     looking at the specifics of what happened here or the
  13     more general guidance in paragraph 41, those purchasers
  14     have no explicit place in the particular loop?"
  15        Then he says the Inquiry will talk directly to you
  16     and to Dr Doyle. Can I ask you just to read to the
  17     bottom of that page again, please? And over the page
  18     when you have finished. Go over to page 40. Can you
  19     read down to "circumstances".
  20   A. Yes.
  21   Q. Then he says, if we go to the next answer on that page,
  22     scrolling down a little:
  23        "In the case of Dr Ashwell, we are back to this
  24     point about before 1st April 1994, and after 1st April
  25     1994. Dr Ashwell essentially was the purchaser."

   1        That is because, until 1st April 1994, neonatal
   2     and infant cardiac services were the supra-regional
   3     concerns.
   4        "In other words, the purchasing role was
   5     a national one. At the point of de-designation, you
   6     have rightly argued that the purchasing responsibility
   7     was delegated and therefore in theory at least Dr Doyle
   8     did not have the same locus, i.e. he was not the
   9     purchaser."
  10        To what extent did you feel that you the
  11     Department were the purchaser in 1993 and to what extent
  12     did that influence what you did?
  13   A. I do not think I did.
  14   Q. If we go over the page again, please, Sir Alan says that
  15     his assumption is that Dr Doyle behaved as if he was the
  16     purchaser and --
  17        "... my proxy for the Regional Public Health
  18     Director. I think in getting straight to the point of
  19     a potential problem in these circumstances in real life,
  20     notwithstanding the sort of niceties on lines of
  21     accountability, he behaved quite properly."
  22        Can I just ask you, in drawing some threads
  23     together, when you say that the matter was one that you
  24     thought should be dealt with locally was a matter for
  25     the Trust, was there a role for a Health Authority, did

   1     you think, in dealing with Dr Bolsin's concerns and if
   2     so, which?
   3   A. What I felt at the time and what I said to Dr Bolsin was
   4     that it was outside my area of knowledge.
   5   Q. What would the role of the region be, for example? Do
   6     you know?
   7   A. At that time, as I say, I said to him I was not aware.
   8     Obviously Alan Langlands has pointed out that the
   9     Regional Director would have a role and I think it would
  10     be laid down in HC(90)9.
  11   Q. But that was not something that had come into your head?
  12   A. Well, it was not an area of work that I had ever been in
  13     within the Department of Health. I was not expert in
  14     it.
  15   Q. Can you help me with who in the Department of Health,
  16     which part of the Department of Health, would have
  17     received and considered regional clinical audit reviews?
  18   A. It would have been the division in the Management
  19     Executive that implemented medical audit and that was
  20     called PHML at the time, I believe.
  21   Q. Was that the body you mentioned earlier that you
  22     attended some of the meetings at?
  23   A. That was the division that had the steering group that
  24     I did try to attend, yes.
  25   Q. Do you remember who was the head of that department?

   1   A. At the time audit was set up, I think Graham Winyard was
   2     the head, but by this time I think it was Deirdre
   3     Cunningham.
   4   Q. Finally, if we can to WIT 3385, your statement again,
   5     please, the bottom of the page:
   6        "If it had been appropriate to take the matter
   7     further, there would have been several options open to
   8     me, including ..." and we see three set out.
   9        Who was the line manager you are referring to in
  10     early 1994, let us say?
  11   A. It is what I said earlier. I believe Norman had retired
  12     by that point. My recollection is that there was an
  13     acting head of the division at grade 4 level, and
  14     I think it was Robert Hangartner.
  15   Q. Can you help me with what the factors would have been
  16     which would have determined your choice as to which of
  17     those three options you would have opted for?
  18   A. I think I would have discussed with my line manager the
  19     appropriateness of taking it to the Chief Medical
  20     Officer, and I would have discussed also with my line
  21     manager whether we should at that point raise it again
  22     with the Trust, or whether we should do both. So it is
  23     actually not an either/or.
  24   MR MACLEAN: Dr Ashwell, that is all I want to ask you.
  25     Before the Panel ask you any questions they might have,

   1     is there anything unit to add to anything that you have
   2     said already this afternoon?
   3   DR ASHWELL: No, thank you.
   4   MR MACLEAN: There may be some questions from the Panel.
   5   THE CHAIRMAN: Dr Ashwell, Professor Jarman.
   6            Examined by THE PANEL:
   7   PROFESSOR JARMAN: Just one point of clarification. We
   8     were told that Sir Alan Langlands saw the SRSAG as
   9     effectively the purchaser up until April 1994. Did you
  10     say that you did not agree with Sir Alan's point of
  11     view, or you do agree?
  12   A. I think I was reflecting the point that in his statement
  13     he said "I was the purchaser". I did not recognise
  14     that. I see the thrust of what he is saying, but in
  15     fact as I had nothing to do with the Supra Regional
  16     Services Advisory Group, I had not felt it in those
  17     terms.
  18   Q. So you are agreeing that the SRSAG was in effect until
  19     April 1994 the purchaser?
  20   A. Yes, I mean, given the dates, what I have been told.
  21     Yes, it did act as the purchaser.
  22   Q. And the purchaser would therefore have had certain
  23     contractual arrangements with regard to quality of the
  24     service, including mortality rates?
  25   A. I do not know the details of how they contracted with

   1     the service.
   2   PROFESSOR JARMAN: Thank you.
   3   THE CHAIRMAN: Thank you, Dr Ashwell. Mr Maclean maybe did
   4     not point out, but I will, that if there are any other
   5     matters that you would wish to bring to our attention,
   6     we would be very grateful to receive them, but for the
   7     moment, thank you very much indeed for coming.
   8   DR ASHWELL: Thank you.
   9   THE CHAIRMAN: Mr Langstaff, forgive me for disturbing you!
  10   MR LANGSTAFF: Not at all, sir. I shall not detain you or
  11     others much longer. If I can simply remind those that
  12     look at this Inquiry from a distance that we are not
  13     sitting next week; it is a reading and preparatory week.
  14   THE CHAIRMAN: I committed a discourtesy, I did not ask
  15     Mr Pirani, I beg your pardon.
  16   MR PIRANI: I have no questions, thank you.
  17   THE CHAIRMAN: I thought a caught a glance and acted upon
  18     it. I am pleased to see I acted correctly, thank you.
  19          MR LANGSTAFF RE PROPOSED TIMETABLE
  20   MR LANGSTAFF: Sir, we are not sitting next week, which is
  21     a reading week and a week engaged on preparation for our
  22     next hearing week, which begins on Monday November 1st
  23     at 10.30.
  24        During that week, amongst other things, we will
  25     hear evidence on statistics and data sources, and the

   1     results of the Inquiry's clinical case note review.
   2        We are still putting the finishing touches to the
   3     witness programme, but I can tell you and the wider
   4     audience that during the middle and end of November we
   5     expect to hear from a number of clinicians from the
   6     UBHT.
   7        May I indicate again in general terms that the
   8     plea which I made yesterday for witnesses to be more
   9     forthcoming with their witness statements, so that all
  10     who participate in the Inquiry may have the chance to
  11     participate fully, properly and fairly, appears to have
  12     fallen on receptive ears.
  13   THE CHAIRMAN: We are delighted to hear that last remark, as
  14     well as, of course, all the others, but thank you for
  15     that.
  16        We therefore adjourn now until a week on Monday
  17     when we begin at the normal time of 10.30.
  18        May I say good afternoon to everyone and thank,
  19     through you, Mr Langstaff, those behind you who have
  20     been particularly helpful, and thank you also. Good
  21     afternoon.
  22   (16.30 pm)
  23     (Adjourned until Monday 1st November 1999 at 10.30 am)
  24
  25

   1
   2                I N D E X
   3
   4
   5     DR PETER DOYLE (affirmed)
   6        Examined by MR LANGSTAFF ..................... 1
   7        Examined by THE PANEL ........................ 133
   8
   9     DR JANE ASHWELL (affirmed)
  10        Examined by MR MACLEAN ....................... 140
  11        Examined by THE PANEL ........................ 201
  12
  13     MR LANGSTAFF RE PROPOSED TIMETABLE ................. 202
  14
  15
  16
  17
  18
  19
  20
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Published by the Bristol Royal Infirmary Inquiry, July 2001
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