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Daily transcripts
Hearing summary
2nd November 1999
The Inquiry oral hearings focus this week on the results of two major reviews, the
analysis of six data sources relevant to the Inquiry and the clinical case note review, an
independent analysis of 80 sets of clinical case notes, which will complete two important
pieces in the Inquiry’s jigsaw.
The Inquiry will also hear evidence this week from parents and clinicians from United
Bristol Healthcare NHS Trust (UBHT) and University of Bristol. They will describe their
experiences at the Bristol Royal Infirmary (BRI) and comment on the issue of concerns
being raised about paediatric cardiac surgery at the hospital between 1984 and 1995.
Today the Inquiry heard evidence from Professor Gordon Stirrat, former Chairman of the
Division of Obstetrics and Gynaecology, University of Bristol and honorary Consultant
Obstetrician and Gynaecologist, UBHT, Dean of the Faculty of Medicine (1991 – 1993)
and member of the South Western Regional Health Authority (SDWRHA), Bristol and Western HA
and Avon HA. He commented on the financial pressures on UBHT in the context of providing a
unified paediatric cardiac surgery service on one site. He discussed his working
relationships with Dr John Roylance, Chief Executive, UBHT and Mr James Wisheart, Medical
Director and Consultant Cardiothoricic Surgeon, commenting on the pressure of work
associated with a dual clinical and managerial role. He continued by discussing his
correspondence and debates regarding comments made about Bristol’s mortality rates in
Private Eye. Professor Stirrat concluded by commenting on his commitment to clinical
audit.
The Inquiry then heard from Professor John Farndnon, Professor of Surgery, University
of Bristol. He described his role as audit co-ordinator for surgery from 1992 and his
responsibility for collecting audit data from the surgical specialties. He said that Mr
Jonathan Hutter was the nominated surgeon responsible for audit activity in the cardiac
surgical specialty, and explained that Mr Hutter sent audit activity to the UK
Cardiothoracic Surgical Register direct. Professor Farndon went on to discuss how concerns
about paediatric cardiac surgery in Bristol were brought to his attention and how he
responded to them. He went on to describe a meeting with Professor Angelini and Mr
Wisheart in December 1993 called to discuss the appointment of a dedicated paediatric
cardiac surgeon. He also commented on a meeting he had with Mr Wisheart in November 1994,
at which he discussed with Mr Wisheart how to resolve issues relating to paediatric
cardiac surgery at the BRI.
|
FULL TRANSCRIPT
1 Day 69, Tuesday, 2nd November
2 1999
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Mr Langstaff.
5 MR LANGSTAFF: Sir, I just have one apology to make before
6 Miss Grey calls Professor Stirrat to give his evidence;
7 an apology to the wider public for the failure of this
8 Inquiry, the rare failure thankfully, to put on
9 the Internet last night yesterday's proceedings. I am
10 told that this was due to a technical fault and that
11 that description, perhaps sometimes used as a euphemism
12 for other failures, is in fact justified in this case.
13 We hope the technical failure has been rectified
14 and will not happen again, but, for all those who were
15 queueing up to see what was happening yesterday and who
16 did not get it, I am sorry.
17 THE CHAIRMAN: Thank you, Mr Langstaff.
18 MISS GREY: Sir, this morning our first witness is Professor
19 Gordon Stirrat. He is represented by Dr Roger, who sits
20 behind me.
21 Professor Stirrat, would you like to stand to take
22 the oath, please?
23 PROFESSOR GORDON STIRRAT (SWORN):
24 EXAMINED BY MISS GREY:
25 Q. Professor, you have provided a number of documents to
0001
1 the Inquiry, and in particular if I could take you to
2 firstly your two statements to the Inquiry. If we could
3 look please at WIT 245, page 1. This is your first
4 statement to the Inquiry. It is signed, is it not, on
5 page 10? Is that your signature there?
6 A. That is my signature.
7 Q. If we then go on, please, firstly to page 17 we see
8 there the first page of a letter in response from
9 Dr Bolsin to your statement.
10 A. Correct.
11 Q. And you have had an opportunity to read that, have you
12 not?
13 A. I have.
14 Q. And in response to it in fact you prepared
15 a supplementary submission or statement which we can
16 find at page 24. That is the first page of your
17 supplementary submission. You have signed it again at
18 page 31, is that correct?
19 A. That is correct. That is my signature.
20 Q. If I can take you first back to page 11 of your first
21 statement, appended there is a commentary on an article,
22 "The Tragic Series of Events", which was published in
23 the Bristol Evening Post with which you took issue; is
24 that right?
25 A. That is correct.
0002
1 Q. And you have given us in fact the text of your letter to
2 the Post and their response to it. But just for the
3 moment if I can remain on this page, firstly, to
4 identify some of the documents that you refer to.
5 Firstly at reference 1. You refer there to the GMC
6 statistics bundle, table 6. Could we just look please
7 briefly at GMC 16/88? Is that the table that you were
8 referring to at that reference?
9 A. That is correct.
10 Q. And if we go on, please, to the document, DOH 2/116, it
11 is not reference back to the GMC file, but is that
12 the table that you were referring to at reference 2?
13 A. Table 13 is the one I have written down here, have
14 I not? That is table 1 at that point. That is correct,
15 yes.
16 Q. If I take you to GMC 16/50, firstly I think you can
17 perhaps confirm that that is the same table?
18 A. It is, yes.
19 Q. If I tell you that that is the table which appears
20 behind tab 13 of the GMC file, are you happy with
21 that as identifying the --
22 A. Yes, I am happy with that. I just was a little bit
23 disconcerted by the table 1. I am happy with that.
24 Q. There are then I think a couple of amendments that need
25 to be made again to those references. If we go down to
0003
1 reference 6, back please to WIT 245/11. Reference 6
2 I think it says there GMC transcripts for Day 6,
3 page 7. I think you would like to correct that to Day
4 30, page 35, paragraph G, to the evidence of
5 Mr Wisheart; is that correct?
6 A. That is correct, yes.
7 Q. Over the page, please, page 12, there is a change there,
8 an amended change on both 8 and 9. With those
9 corrections then to the original of the statement that
10 was submitted to the Inquiry, are the contents of your
11 statement true to the best of your knowledge and belief?
12 A. They are indeed.
13 Q. Professor Stirrat, I think you understand that we will
14 attempt to confine the evidence today to those matters
15 on which you can give first-hand help and assistance to
16 the Inquiry. For that reason, it perhaps may assist if
17 I explain both to you and also to any members of
18 the wider audience who may have read your statements
19 that I will not be covering therefore what might be
20 called the debate between yourself, Dr Bolsin or any
21 other readers about evidence that was given for instance
22 in the General Medical Council.
23 A. Yes, I understand that and I am perfectly happy with
24 that.
25 Q. If we can go back, please, to page 1 of your statement,
0004
1 you set out there your career as Professor of Obstetrics
2 and Gynaecology in the University of Bristol and also as
3 an honorary consultant obstetrician and gynaecologist in
4 the UBHT, as it now is, since 1982. That is an honorary
5 position. Does that make any difference to the freedom
6 with which you have been able to act for the health
7 authority, for instance?
8 A. Yes, it makes a very significant difference. No-one who
9 is employed by the National Health Service can stand as
10 an executive director of any health authority. But, by
11 dint of having an honorary contract, I was able to do
12 so. It is on that basis that I was able to serve on
13 the regional health authority and then successive
14 Bristol and Weston health authorities until it became
15 Avon Health.
16 THE CHAIRMAN: Miss Grey, forgive me for interrupting. Did
17 you, Professor Stirrat, mean non-executive rather
18 than --
19 A. I am sorry. I do beg your pardon. Non-executive.
20 Thank you very much for correcting me, sir.
21 MISS GREY: If we scroll down to the bottom of the page, we
22 can see that you were Dean of the Faculty of Medicine
23 from 1991 to 1990. Is that date accurate?
24 A. 1991 to 1993.
25 Q. Yes, I am so sorry. That was through the academic
0005
1 years, is that correct?
2 A. That is correct, July 31st, 1993.
3 Q. Can you just tell us a little briefly of your
4 responsibilities as Dean of the Faculty of Medicine?
5 A. The Dean of the Faculty of Medicine is, I suppose, chief
6 executive of the Faculty of Medicine which in Bristol
7 covers medicine, dentistry and veterinary sciences.
8 I think each of us who have carried the responsibilities
9 have found them quite onerous over the years.
10 But obviously, given that medical education was
11 and is the primary function of the Faculty of Medicine,
12 I was very deeply involved in making sure that
13 the clinical training that was obtained by our medical
14 students in our primary teaching trust, which is UBHT
15 and also Southmead and Frenchay, and also in the wider
16 region, was not only safeguarded but was enhanced to
17 the greatest possible extent that I could. So of course
18 it meant that I as Dean liaised very frequently and
19 closely with the Chief Executive and other officers of
20 each of the trusts in Bristol in particular.
21 Q. I ask you that question because you say later in your
22 statement that you consider that as Dean you would have
23 been a natural person to have approached if any member
24 of the University in particular had any concerns about
25 the quality of paediatric cardiac surgery within
0006
1 the UBHT. Why do you say that your function as Dean
2 would have been relevant to those concerns?
3 A. Because any Professor or clinical academic member of
4 staff who had issues which were causing them concern in
5 relation to the health authority, if they were not able
6 to deal with them directly, then in fact the levels of
7 responsibility and accountability would clearly have
8 suggested that I was the one in relation to the faculty
9 to whom they should ultimately come to try to address
10 the problem. Then, if needs be, I could take it
11 further.
12 Q. Why come to the University faculty at all, though?
13 A. I was referring to people who were on the payroll of
14 the University with honorary clinical contracts, and
15 therefore they were actually in a sense members of my
16 staff. So I think in any organisation interfacing with
17 others, if there is a problem -- one individual who in
18 a sense is responsible to me, if he or she has
19 difficulties with another organisation, it would seem to
20 me natural and indeed in the academic world I think they
21 were obliged to inform me.
22 Q. What was the source of that obligation?
23 A. Their status within the University as professors or
24 senior lecturer and my role as Dean of the Faculty.
25 Q. I asked you whether the date 1991 to 1993 was accurate.
0007
1 The reason I asked that was that at the General Medical
2 Council's Inquiry into events at Bristol you were asked
3 a question, "For three years from 1990 to 1993 were you
4 Dean?" So the dates were a little different. Which was
5 correct?
6 A. I do beg your pardon. 1991 to 1993.
7 Q. Thank you. If we turn over the page in your statement
8 you set out firstly a summary of your evidence. If we
9 go over a further page to page 3, you speak about
10 the general background of funding within Bristol over
11 the years with which the Inquiry is concerned. You make
12 the general point that over those years there was
13 a constant need to save money or to make savings because
14 of the formula devised by the resource allocation
15 working party and then its successor.
16 Firstly, you note I think in that discussion that
17 adult cardiac surgery received special funding
18 throughout this period as forming one of
19 the government's priorities, is that correct?
20 A. That is correct.
21 Q. And, secondly, of course funding for the under 1s for
22 paediatric cardiac surgery was funded through a
23 different mechanism, through the supra-regional services
24 advisory mechanism, and therefore was relatively immune
25 from this particular form of financial pressure that you
0008
1 are describing in your statement. Are you therefore
2 able to help us on the pressures on paediatric cardiac
3 surgery that resulted from the general financial
4 background that you have described?
5 A. Yes. The overall effect year on year on Bristol, and
6 I think probably from my experience within the region
7 and the district, on central Bristol and therefore UBHT
8 as it became really was accumulative and affected all of
9 the specialisms. I know that it has been suggested to
10 me that the regional specialism, the regional funding
11 coming to the paediatric cardiac surgery, that mechanism
12 really was not able to deal with the real needs of
13 the service, given that it was in a split site and there
14 were no dedicated paediatric cardiac surgeons et cetera,
15 that that was not able to deal with the resource
16 implications of that particular problem.
17 Q. You mean it was not able to deal with the need for
18 uniting the service on one site?
19 A. That is correct. Every service was constrained over
20 the whole hospital; every single one of them.
21 Q. Is that something that was very much part and parcel of
22 the general background, you say, across this period?
23 A. Yes, it was, very much so.
24 Q. How would it have affected issues such as a
25 consideration of uniting the service, paediatric cardiac
0009
1 surgery, on one site?
2 A. The Trust had no resource free to spend the significant
3 amounts of money required to build the facilities for
4 unified paediatric cardiac surgery. A very significant
5 amount of money was just not available.
6 Q. Why do you say at the bottom of this page that the
7 situation was further exacerbated by the introduction of
8 the internal market in 1989?
9 A. Of course that was a very major upheaval in the whole
10 system and of course that created some destabilisation.
11 But the way that the Health Service then began to be
12 funded, we in our experience found that internal market
13 was a rigged -- no, "rigged" is not the right word; that
14 is a pejorative term; I do not mean that. It was not
15 a free market.
16 There were some calculations made about what
17 individual interventions cost; very poorly done, because
18 the data were not available. They were costed and then
19 work was done with the health authority to work out what
20 price was going to be paid for those. There was some
21 very hard bargaining done at that time, and by then
22 I was a member of the health authority.
23 I think there were some very serious errors made
24 in calculating what the cost of a service was and
25 therefore what price the health authority was going to
0010
1 pay for it. In a sense the tragedy, and I think it is
2 a tragedy, was that having made those decisions, we
3 still have not been able to change significantly
4 the basis of -- the pricing of the service. So it was
5 artificial. The market was an artificial market. It
6 was not really a true market in the economic sense.
7 We suddenly discovered a new bit of history that
8 we were having to fight against, and that was
9 the history of what the costs were perceived to be, in
10 many cases wrongly; and, secondly, therefore the price
11 that was to be paid. The health authority has little
12 resource to be able to alter those, even though they
13 have been significantly underfunding the individual
14 services year on year on year on year.
15 Q. If you have examples to mind of cases in which there was
16 a significant miscalculation of the cost of a service,
17 are you thinking of any examples which have a specific
18 impact upon cardiac surgery, both adult and children?
19 A. No, I do not have enough knowledge, detailed knowledge,
20 to be able to comment on that. But I know that I can
21 comment very specifically in relation to my own
22 experience in my own specialty of obstetrics and
23 gynaecology and in the related specialty of neonatal
24 medicine. These are issues which have really borne on
25 us extremely severely over the years. It is my thesis
0011
1 that actually that is a situation which extends
2 throughout the whole of the service, although as I say
3 I do not have specific examples in relation to adult or
4 paediatric cardiac surgery.
5 Q. But your point is that if it pertained in your specialty
6 it may have done in others as well?
7 A. That is correct.
8 Q. And the clinicians who were as closely concerned with it
9 as you have been would be in a better position to know,
10 presumably?
11 A. That is correct.
12 Q. If we go to UBHT 52/290, this is a letter which was not
13 written to you and you are not copied into it, but it is
14 a letter which I imagine you will now be familiar with.
15 It is the letter from Dr Bolsin to Dr Roylance which was
16 written in August 1990 when the UBHT was putting in an
17 application for Trust status on cardiac surgery. Have
18 you seen this letter before?
19 A. I have not seen this letter before.
20 Q. My apologies. It is a letter written from Dr Bolsin to
21 Dr Roylance. He is commenting there on the appendix to
22 the application for Trust status. If you would like to
23 take a moment to read it through, please. If you say
24 when it needs to scroll up. (Pause).
25 A. Thank you. Scroll up, please.
0012
1 Q. In that letter Dr Bolsin takes issue with a number of
2 statements being made in the application for Trust
3 status and raises the question of mortality rates for
4 open heart surgery under patients under one in
5 the penultimate paragraph. He then concludes:
6 "I look forward to your reply which I hope will
7 help to persuade me of the benefits of trust status for
8 the cardiac unit."
9 Can I take you back to that time in about August
10 1990. What were the sorts of debates that were current
11 in the UBHT amongst the consultant clinicians about an
12 application for Trust status? Firstly, was it
13 a controversial matter?
14 A. I cannot recall it being a controversial matter.
15 I think that was seen to be -- given the political
16 circumstances and the political decisions that had been
17 made, it was seen to be something that really we should
18 pursue.
19 Q. Was there a vote amongst the consultant body as to
20 the benefits of Trust status?
21 A. I really do apologies, I cannot recall whether there was
22 or was not. It is not something I have a recollection
23 of.
24 Q. So are you able to help us then on, as it were,
25 the politics of Trust applications at the time or not?
0013
1 A. The way I can help is that I know very well that
2 the then Chairman of the authority, Mr Peter Durie, was
3 extremely anxious to make sure that the University was
4 on board as far as this was concerned. They worked very
5 hard and worked hard with my predecessor as Dean and
6 then subsequently myself to try to make sure that we
7 were part of the application. So that really was my
8 main direct contact.
9 The issue was of course discussed at the Hospital
10 Medical Committee and I was a regular attendant at
11 the Hospital Medical Committee, but again there were
12 concerns expressed, as I begin to try to dredge it back
13 from my memory. But I think Mr Durie did a very, very
14 good job of putting the case for the Trust, and I think
15 a great deal of credit goes to him for that, both in
16 relation to my health service colleagues but
17 particularly in the University. I can speak directly of
18 that from my own knowledge.
19 Q. I think if that is recollection that you have to dredge
20 up, we will pass on to another matter, if we may, and
21 that is your work and involvement with the other
22 clinicians, some of whom are names that have been
23 brought before the Inquiry on a number of occasions.
24 Firstly, I think it is right that you had no dealings
25 with Mr Dhasmana throughout the years?
0014
1 A. That is correct.
2 Q. But you did however worked with Dr Roylance?
3 A. Yes, I did.
4 Q. Can you tell us what the nature of your work with
5 Dr Roylance was?
6 A. Obviously, holding an honorary clinical contract, we had
7 to work with the management of what then became
8 the Trust. So, in trying to improve the clinical
9 service, I was involved with my NHS colleagues in trying
10 to do that. Indeed, as you can see from the record, for
11 part of the time I was actually chairman of the NHS
12 division of obstetrics and gynaecology in 1989 and
13 1990. So I had the responsibility for making sure that
14 the service was sustained and progressed. So I worked
15 on that professional level as a clinician. I had to
16 work closely with him. That is the first level.
17 Q. What about as Dean of the Medical School?
18 A. That was an extremely important one. This was a time
19 when funding in the University was being constrained as
20 it was in the health service, although funnily enough we
21 now look back on those times as golden times somehow or
22 other; but they did not seem like it at that time, I can
23 assure you. We had recurrent problems of the need for
24 financial reasons to close beds in the BRI, for example.
25 Q. Can I just ask you, firstly, how often you would see
0015
1 Dr Roylance then to work on these sorts of issues?
2 A. I am sure I would see John Roylance probably once a week
3 in some capacity; sometimes more than that. Once
4 a month we had formal meetings. When I say "formal",
5 they were arranged meetings. They were held informally,
6 lunchtime meetings in which we tried to -- the phrase
7 was used "to firefight". So I worked extremely closely
8 with John Roylance and then the Chairman of the Hospital
9 Medical Committee, who then became the Medical Director.
10 Q. That was a lunchtime meeting which was held in order to
11 improve liaison between the University and UBHT; is that
12 right?
13 A. That is correct.
14 Q. Who would attend those meetings?
15 A. The officers of the Trust would attend, the Chief
16 Executive, the Finance Director, the Chairman of
17 the Hospital Medical Committee and the Medical Director,
18 although they were usually the same person, and
19 the Chief Nursing Officer.
20 Q. On whose initiative were those meetings started?
21 A. Mutual between John Roylance and myself.
22 Q. What was Dr Roylance like to work with, in your
23 experience?
24 A. I got on well with John Roylance. I found some of my
25 interactions as a clinician frustrating because when one
0016
1 went to him saying, "The service needs this
2 development. We need this expenditure," he would say,
3 "Fine. Tell me where it is going to come from."
4 He would also be very anxious that you provided
5 solutions, not just problems. I think actually in
6 the context of the financial situation it was good
7 stewardship. Although it was frustrating to me as
8 a clinician, I think it was good stewardship. Having
9 been in the Regional Health Authority, I certainly
10 gained a very strong impression that there were several
11 Trusts within the region, and from talking to colleagues
12 elsewhere in other parts of the country, who actually
13 tried to spend themselves out of trouble, went into
14 deficit. The annoying thing was they seemed to get away
15 with it.
16 On many, many occasions we would say to John
17 Roylance, "Please, why do you not allow us to overspend,
18 because, look, X has been bailed out". He said, "No,
19 that is the spending limit. That is what we are going
20 to stick to". I think that was good stewardship,
21 although it was frustrating.
22 He tended to stand back in management a bit. He
23 did not interfere with the work of clinicians. He was
24 in a sense a bit laid back in that sense also. So
25 sometimes we wished he would do something more. He
0017
1 said, "No, you work that out with X and Y and then come
2 to me with a solution".
3 Q. Why did he stand back from clinicians?
4 A. This is my supposition. I do not know. This is
5 speculation on my part, supposition on my part, and that
6 is that as a clinician himself I think he felt that he
7 had to bend over backwards to make sure that he was not
8 favouring clinicians over any of the other professions
9 in medicine.
10 Q. If that is supposition or speculation, is it actually
11 based on any conversation with John Roylance in which he
12 might have expressed that view or is it observation from
13 how he behaved?
14 A. Observation as to how he behaved.
15 Q. If you say that on occasion you felt that you wished he
16 would intervene rather more but he was saying rather,
17 "You sort it out," can you give us some examples of
18 that sort of attitude?
19 A. Obviously there is one of the letters that is on
20 the record relating to neonatal intensive care and my
21 concerns about the staffing of neonatal intensive care.
22 That was a recurrent issue which, as a clinician,
23 I would say I would give as an example.
24 Q. If we look at UBHT 238/411, that is an example which you
25 gave of problems of restricting admission because of
0018
1 lack of funding.
2 A. Yes.
3 Q. Was that the letter you had in mind a second ago?
4 A. This is the letter that I had in mind about an example
5 of which --
6 Q. How does that relate to Dr Roylance's attitude to
7 clinicians and problems of funding?
8 A. Again, it goes back to, "If we are going to increase
9 that staffing, what staff are you going to do without?
10 You tell me how I am going to balance the books."
11 Q. You spoke about his attitude of wanting to hear
12 solutions rather than problems or encouraging perhaps
13 people to present solutions rather than problems. Which
14 of those two was it?
15 A. Sorry, could you --
16 Q. Was his attitude one of encouraging people to offer
17 solutions rather than problems, or was his attitude one
18 of, "I only want to hear solutions rather than
19 problems"?
20 A. I think it tended to be the latter. He wanted to hear
21 solutions to the problems. He also wanted to hear
22 facts. If we went to him, let us say it was about
23 staffing difficulties in the special care baby unit,
24 quite rightly he wanted to know the facts of this and
25 have details of it. The mere fact that we were
0019
1 experiencing difficulty was not enough for him to say,
2 "Yes, we will do this or that about it". That is
3 something which relates significantly to the issue we
4 have in front of us, because he always wanted people to
5 provide him with evidence to back up their statements.
6 Q. Why do you say that is relevant, at the risk of
7 outlining the obvious?
8 A. You showed me a letter to Dr Roylance from Dr Bolsin
9 which I had not seen before. My feeling when I read
10 what I think was the penultimate paragraph of that was
11 when Dr Bolsin mentioned about mortality in cardiac
12 surgery for children under 1 year of age. John Roylance
13 would not take that as a definitive statement on
14 the matter. He would require that that be backed up by
15 evidence. If that evidence was not forthcoming, then in
16 my own experience and issues in which I was involved
17 then nothing would happen because we had not given him
18 the evidence which he needed.
19 Q. What would he do, if anything, to facilitate
20 the gathering of any evidence?
21 A. Obviously as Chief Executive he was very much behind the
22 move to medical and, as it developed, into clinical
23 audit. There were resources provided for that. They
24 were not a King's ransom. They were relatively meagre.
25 He actually gave us back the responsibility of doing
0020
1 it. He told us exactly where our responsibilities were
2 and told us to get on with it.
3 Q. So, if you were a clinician presenting a problem but had
4 no data to support it, it would be his attitude that it
5 was up to you to gather the supporting data and then
6 present your case?
7 A. Absolutely.
8 Q. If we go on, please, to page 5 of your statement -- this
9 is back at WIT 245, please -- you speak there about your
10 knowledge of Mr Wisheart and your experience of working
11 with him. Firstly, on what was that experience based?
12 A. A close personal contact, given his position as Chairman
13 of the Hospital Medical Committee and then as Medical
14 Director. Obviously the relationship with the Chief
15 Executive, with John Roylance, was slightly complicated
16 because we were interfacing in a whole variety of
17 different ways. So it meant my relationship with James
18 Wisheart was actually much less complex and more
19 direct. We really were facing serious problems: closure
20 of beds; medical students, particularly surgical
21 students, due to start their course on the Monday;
22 several wards being closed on the Sunday. So we just
23 could not cope. This recurred time and time again.
24 We also had issues about new Chairs in a variety
25 of different specialties as people retired or they were
0021
1 newly established Chairs. This tension between what
2 the requirements for the professor or senior lecturer
3 clinically versus those that we laid on them as
4 University staff; this tension between giving service,
5 doing research, doing the teaching and all the other
6 things as well; these were tensions that had to be
7 worked out at a personal level.
8 I really did not know James Wisheart until I had
9 been Dean for a while and then he became Chairman of
10 the Medical Committee and then Medical Director. But it
11 clearly became apparent to me that he was a man with
12 whom I could work. Maybe it had to do with our
13 backgrounds, myself being a Scot, James being an Ulster
14 Scot, I think perhaps we talked the same sort of
15 language.
16 The thing that really made the relationship
17 between James and myself so useful I think to the health
18 authority and to the University was that if James said,
19 "Yes", I could bank that. If he said, "No", I knew
20 where I was.
21 Q. If we could scroll down to the bottom of the page to
22 pick up two references. You have referred there to
23 Inquiry document JDW 219. If we go to JDW 219, is that
24 the letter you had in mind?
25 A. It is one of the examples. It is not the only example
0022
1 by any manner of means. It is a very pertinent example
2 to this Inquiry, but it applied to many other things as
3 well.
4 Q. If we go on to page 220 we see there a memo from
5 yourself to the Vice Chancellor setting out I think
6 a response to the letter we have just seen, a strategy
7 to take this matter forward. Again, just going back to
8 your statement, please, at WIT 245, page 5, if we can
9 just go down to those references again, were those
10 actually the documents that you had in mind when you
11 gave those references?
12 A. Those are the documents I had in mind. But that was not
13 the sole relevant information. I did, as it says in my
14 statement, visit the British Heart Foundation with James
15 Wisheart. I was also involved towards the end of
16 the attempt to bring Martin Elliott here as Professor of
17 Paediatric Cardiac Surgery. That was at the end of that
18 process.
19 Q. Yes. On that, are you able to help us as to whether
20 Mr Wisheart's desire was to see a paediatric cardiac
21 surgeon in Bristol or a further cardiac surgeon?
22 A. My clear understanding was that he wished to recruit
23 a paediatric cardiac surgeon, if at all possible.
24 Q. So that the chronology of event is the attempt to
25 recruit Mr Elliott first, and when that was unsuccessful
0023
1 the support for Mr Angelini, although not a paediatric
2 cardiac surgeon?
3 A. That is my understanding of the matter.
4 Q. You have discussed your confidence in Mr Wisheart and
5 the trust between the two of you. You have also
6 mentioned his many roles: Chairman of the Medical
7 Committee, Medical Director, carrying on a role in
8 managing an acute surgical service and as a cardiac
9 surgeon himself. Did you ever get an impression of
10 the pressure that might be put on Mr Wisheart by those
11 roles?
12 A. Yes, I did. Indeed I spoke to him about it on several
13 occasions as a friend, because our friendship was
14 developing at that stage. I knew from my own personal
15 experience how physically and emotionally costly I was
16 finding my job as Dean. I had to carry on my clinical
17 work for 6 months because there was no-one else in post
18 to do it. But at the end of six months I was able to
19 get people to come on sabbatical from abroad to relieve
20 me of most of my clinical work. For me, that was
21 absolutely life saving.
22 I felt that just from looking at what James was
23 doing and then observing him as I met him not
24 necessarily day by day but very frequently, I felt he
25 was under a great deal of pressure. I knew that he had
0024
1 been in the hospital in theatre until half past 2 in
2 the morning, was up again at half past 6 and then came
3 to a meeting with myself and my University colleagues at
4 8 o'clock in the morning.
5 Q. So, if you were speaking to him about it, what were you
6 saying?
7 A. I was saying, "James, I think you are working far too
8 hard. I do not see how you can actually cope with all
9 these responsibilities. I know that I could not and I am
10 fearful that you are actually working too hard."
11 Q. Do you think that working too hard might carry a danger
12 of affecting either performance as a surgeon or
13 alternatively affecting the insight to scrutinise one's
14 own performance?
15 A. There is a hypothetical -- that could be so. I have no
16 evidence that it was. But my concern in expressing that
17 to James was that one of those might occur if we were
18 not careful. I have no evidence that it did, but I was
19 concerned about it.
20 Q. When you say that you had no evidence that it did, is
21 that because you are not in a position to comment on
22 whether that evidence existed or is that a positive
23 statement that you have received no evidence?
24 A. I have received -- to begin with, it would be the first
25 of those. But even through all this Inquiry I do not
0025
1 think I have received evidence that that actually
2 happened. I do not think that the GMC determination,
3 for example, would be in line with that happening.
4 Q. In discussing Dr Roylance you discussed whether he would
5 have certain accustomed responses to particular dilemmas
6 and worked in a set way or not. What about
7 Mr Wisheart? Was he a flexible character or a rigid
8 character?
9 A. I always found him to be flexible, within the ethnic
10 constraints of underlying Scottishness, with which
11 I share some rigour. So I could understand that.
12 I hope that comes across as I mean it to do.
13 Q. Given that you are not being asked questions by my
14 colleague Mr Maclean, who would instantly understand,
15 perhaps you can just discuss a little bit more what you
16 mean by that rigour?
17 A. The Scots, and James in a sense being an Ulster Scot,
18 have a reputation for directness and wishing people to
19 be direct and not beating about the bush. I always find
20 James wanting people to be direct and being direct back
21 to them. Sometimes there may be individuals who may
22 misunderstand that and take it wrongly. In all my
23 dealings with him, that was what it was.
24 I suppose again that was one of the strengths of
25 my relationship with James, because I knew if I asked
0026
1 him a question I would get a direct answer. I would not
2 get a definite maybe. He would not beat around
3 the bush. He would say exactly how he found it. So
4 I cannot say I found him to be inflexible. But
5 the flexibility needed a little bit more force than
6 average, perhaps. You had to convince him. If you
7 convinced him, then that flexibility was there. I found
8 that on several occasions.
9 Q. You were obviously peers working together on matters of
10 concern. What about junior colleagues? Did you ever
11 see him working with junior colleagues, if they had
12 brought problems to him or were challenging him?
13 A. I did not see him in the clinical context. Where I did
14 see it was of course in the Hospital Medical Committee
15 when more junior colleagues would challenge. I found
16 him perfectly open and amenable to those challenges.
17 Q. You have experience of running or being part of a large
18 division, division of obstetrics. In that context you
19 have been heavily involved I think with the audit
20 programme, is that right?
21 A. That is correct.
22 Q. That is an audit programme which involves liaison with
23 other specialties including anaesthesia, is that right?
24 A. That is correct.
25 Q. Have you at any time had experience of colleagues,
0027
1 particularly from other departments, coming to you with
2 criticisms or concerns of what might be happening in
3 your department?
4 A. No, I have not.
5 Q. So are you in a position to comment on the evidence of
6 Mr de Leval when he was asked of how his department
7 might react if a more junior colleague from another
8 department came with concerns? If I might read it out
9 to you and then see whether you have any observations to
10 offer. He said:
11 "If I try to take a situation which is current,
12 for example, and try to see what would happen today, let
13 us say, at Great Ormond Street, if a young anaesthetist
14 who had been [appointed, to paraphrase] in 1988, if
15 a junior anaesthetist coming to Great Ormond Street
16 today who, for example, spent a year with Dr Bovey, who
17 has the best results or one of the best results, with a
18 particular heart syndrome, and assuming that a young
19 anaesthetist spent a year there, comes to Great Ormond
20 Street and the mortality is twice as high, it is
21 100 per cent higher, let us suppose, and that
22 anaesthetist, without telling us, starts taking notes
23 about our performance and goes to see the Chief of
24 Anaesthesia to tell him or her that the results are
25 appalling, I am not sure that more reaction would take
0028
1 place because we know the results. We are aware of
2 the fact that our results are not as good, and I do not
3 think that more action would take place today. So
4 retrospectively [he added] I am not sure that I expected
5 more reaction, I must say."
6 Do you have any comments to offer on that as
7 a likely response to a challenge, as it were, from
8 a younger member of another department to a set of
9 results?
10 A. If the challenge took the form which Martin de Leval
11 describes in which the young anaesthetist did not deal
12 with it directly with the surgeons themselves, then
13 I think that would be seen as not acceptable and -- not
14 appropriate, is the better word, not appropriate.
15 The reaction would be as he described.
16 However, my experience with James would be that,
17 if someone came to him with figures and put them in
18 front of him openly and was direct and open and honest
19 with him, then he would deal with it. But what he could
20 not stand was a sense that people were actually not
21 being direct and not being open.
22 Q. When you say he could not stand it, what do you mean by
23 that? On what is that observation based?
24 A. Again, based on my personal observations of him in
25 a variety of situations over the years. I think that,
0029
1 for example, he was upset by the way that the British
2 Heart Foundation dealt with Gianni Angelini, because it
3 was Mr Wisheart's initiative that got all of that
4 going. The letter, for example, that came from the
5 British Heart Foundation was opaque but not all that
6 very helpful. I remember him being very frustrated by
7 that, because he felt that he got a reassurance from
8 them, and now this letter was coming and was obscuring
9 it. That was something he found difficult.
10 Q. Does it follows that he would be frustrated if he had
11 a sense that things were happening behind his back but
12 not being discussed with him openly?
13 A. Yes.
14 Q. We talked briefly about the role of Mr Wisheart in
15 obtaining funding and support for a chair of cardiac
16 surgery, and you mention also in your statement the fact
17 that the paediatric cardiac surgeons were involved from
18 1989 onwards in attempting to unify the service on one
19 site. Did you have any direct recollection of the moves
20 or the manoeuvres that took place in order to achieve
21 that finally in 1985?
22 A. Yes, I was fully aware of the various stages of that
23 discussion, yes.
24 Q. Professor Angelini's comment was, and I am paraphrasing
25 roughly here, that although he knew that proposals to
0030
1 end the split site had been around for a while, there
2 had been a severe lack of trust commitment to that
3 proposal until late in the day, even as late as 1994
4 onwards. Are you able to help us on the question of
5 trust commitment or enthusiasm for this proposal?
6 A. The problem in my understanding was purely a financial
7 one, of being able to afford it. That is why I think
8 the earlier statements of my submission are highly
9 relevant to that. It was going to be a very costly
10 solution and I think, given the financial situation,
11 the trust did not see how it could possibly afford it.
12 To me that was the top and bottom of it. I have never
13 doubted that there was a commitment to try to achieve it
14 in the end. It was the means by which it should be
15 achieved. The end was accepted. The means were
16 the problem.
17 Q. And hence your comments on funding at the beginning of
18 your statement.
19 A. Yes.
20 Q. Going on then back to your statement, page 8, please,
21 you deal firstly on that page with Private Eye matters,
22 and I will come back to those, if I may. But if we
23 scroll down to paragraph 6, you talk there about
24 the failure of Dr Black and Professor Angelini and
25 Professor Prys-Roberts to raise these matters with you
0031
1 as Dean of the Faculty of Medicine. Firstly, is there
2 any further comment that you would wish to make about
3 Professor Angelini's failure to raise these matters with
4 you?
5 A. Yes, thank you for giving me this opportunity. I have
6 read Professor Angelini -- the transcripts of his
7 evidence here and also his statement in response to my
8 comment. It is perfectly clear that, given that I ended
9 my deanship in mid-1993, he would not have had
10 the opportunity to approach me as Dean about these
11 matters. So that is quite clear.
12 Q. And I think he further makes the point that he did go
13 up, as it were, the University line of command -- it is
14 not meant to imply that orders are given -- to Professor
15 Prys-Roberts as well as to Professor Vann Jones, who
16 held I think a personal chair in cardiology.
17 A. Yes, I understand that.
18 Q. But your statement makes the point that you would
19 nevertheless have expected Dr Black and Professor
20 Prys-Roberts to raise these matters with you?
21 A. I would have most certainly expected Prys-Roberts to
22 have done so. From his evidence to the General Medical
23 Council and trying to fit them in with timetables, there
24 were opportunities I think in which he could have done
25 so.
0032
1 Dr Andrew Black's first responsibility was to
2 Professor Prys-Roberts. But Andrew Black I have worked
3 closely with for a long time. He was and is a friend.
4 We worked very closely together. He was my anaesthetist
5 at one time in the past, but also because of our
6 interest in medical education. I would have hoped he
7 might have felt able to tell me. But his direct line of
8 responsibility was through Prys-Roberts.
9 Q. You then set out what you would have done if anyone had
10 brought these matters to your attention. It follows
11 that that, in your judgment, was what the proper
12 response was to such allegations.
13 A. Yes, absolutely.
14 Q. If we can turn back then, please, to the part of your
15 statement which starts at page 7. You discuss there at
16 the bottom of the page, or start the discussion, of
17 the series of articles in Private Eye. It is right
18 I think that you did not meet Dr Hammond or know of his
19 involvement in Private Eye articles until fairly
20 recently?
21 A. Until November 1998 was the first I knew of it.
22 Q. How did that come about?
23 A. I was asked by the medical students through the Medical
24 Society of the Galenicals to appear in a debate, I think
25 it was 28th November, with Dr Hammond; the motion
0033
1 being: this house believes that patients should be told
2 as little as possible. Dr Hammond was proposing it and
3 I was opposing it.
4 During the debate in which he was proposing it, in
5 his, in a sense, satirical and polemical manner which
6 I was aware of from his television appearances, he made
7 some I thought they were derogatory comments about
8 Mr Wisheart and Mr Dhasmana and categorised them as
9 the same sort of failing doctors and unacceptable face
10 of the medical profession, as a gynecologist who had not
11 all that long before been struck off in London, who had
12 been my senior house officer when I was a senior
13 registrar in London. So I knew each one of the people
14 he had named.
15 I have already given you my view as to James
16 Wisheart as a man of high integrity. I had not worked
17 with Janardan Dhasmana, but his reputation was one of
18 a caring and concerned doctor.
19 My problem was that the gynecologist who had been
20 struck off, when he was my HSO, exhibited exactly
21 the same sort of qualities that I think ultimately led
22 to him being struck off. I actually became rather
23 annoyed, in fact I became very angry to be perfectly
24 honest, that Phil Hammond in front of the whole body of
25 medical students had actually made this connection,
0034
1 which I thought was totally, utterly and absolutely
2 inappropriate.
3 Q. And from that arose your further discussions with
4 Dr Hammond?
5 A. I then, both in the debate and then subsequently in
6 the bar, remonstrated with him and gave him the
7 information that James and Janardan had been the people
8 who had pushed to have the paediatric cardiac surgery
9 service sorted out in 1989, 1990. He then told me that
10 he was MD in Private Eye, which I had not known.
11 Q. It follows from what you say then that certainly back in
12 1992 it was not known to you that Phil Hammond was MD,
13 and you were working in Bristol at the time clearly?
14 A. Yes.
15 Q. What about public knowledge of the duo he was in,
16 "Struck Off and Die", in Bristol at that time, late
17 1991 early 1992? Was that a matter of public record,
18 comment?
19 A. I cannot recall it ever being commented on. It was
20 public knowledge that he was involved.
21 Q. By "public knowledge", what do you mean by that?
22 A. People were aware that he was on television. I am not
23 aware that he was working in Bristol at that time. I do
24 not know the timetable. I do not know he was working in
25 Bristol at that time.
0035
1 Q. I think he was in the Bristol area certainly because he
2 stood against Mr Waldegrave in the 1992 general election
3 in the Bristol constituency. Was that again something
4 that was of public profile at the time?
5 A. Yes, but it was not -- there was nothing particularly
6 significant about it. It was no big deal. It was and
7 therefore it was. There was no discussion about it; no
8 comment on it.
9 Q. What I am trying to do -- it may be a difficult
10 exercise, and one that you cannot help us on -- but if
11 you met Dr Hammond in early 1992 what would you have
12 known about him? Anything at all, other than his name?
13 A. And that he had a part-time job as lecturer in
14 communication skills, which I thought was a good idea
15 because he has great ability to communicate, and that he
16 had appeared on television. He had actually also
17 appeared with his partner, Dr Gardener, in our hospital
18 review. Actually it was very funny. It was very
19 polemical, very satirical; actually exceedingly funny.
20 That is the basis --
21 Q. Can you remember when that hospital review took place?
22 A. I am sorry, I cannot.
23 Q. Equally well, can you remember when the television
24 performances took place?
25 A. No, I never watched any of them, so I do not know.
0036
1 Q. If we are looking at what you might have known in early
2 1992 about Dr Hammond, is your recollection ultimately
3 very vague indeed?
4 A. Very little, yes.
5 Q. If we look forward to page 26 of your statement, this is
6 in the further commentary in response to Dr Bolsin's
7 evidence. You are discussing, if we carry down please
8 through to the comment there, whether Dr Bolsin in fact
9 knew of Dr Hammond's identity back in 1992. Clearly
10 this is primarily a matter for Dr Bolsin to answer. But
11 I want merely to confirm a reference with you.
12 If we look at paragraph 6.3 we can see
13 a discussion of whether or not Dr Bolsin, a reference to
14 the fact that he claimed to see Private Eye for
15 the first time in the GMC hearings. Then over the page,
16 please, you give a reference to further evidence at
17 the GMC. Then you give a reference to the Inquiry
18 transcript for Day 46. Can I read you back a part of
19 the evidence of Helen Stratton where the question was
20 put to her:
21 "Despite the fact that concerns had already been
22 raised in Private Eye in the middle of 1992, you knew
23 about that, I take it," said the questioner. She
24 answered:
25 "I only knew about it because Dr Bolsin mentioned
0037
1 it to me and people obviously talked about it on
2 the unit."
3 Was that the reference you had in mind?
4 A. It is indeed.
5 Q. Going back then to mid-1992 and to the Private Eye
6 articles, were you yourself aware of them at the time
7 they came out?
8 A. Not from reading Private Eye but from the fact that they
9 were part of the buzz within the hospital, and also we
10 did discuss them at one of these firefighting meetings
11 with John Roylance and James Wisheart and myself.
12 Q. Can you remember, firstly, which articles were being
13 discussed? Did you actually see them physically at that
14 time?
15 A. There was a photocopy of the 1992 article, I think.
16 Q. 1992 article, is that singular or plural?
17 A. 1992 article I think was the first one.
18 Q. So if I brought up SLD 2/3, which should I hope be
19 the May 1992 article. There is a date, as you see,
20 handwritten across the top; 8/5/92. If you scroll down
21 the first by eye, not on screen, the first column you
22 can see the reference firstly to the unit being dubbed
23 the "killing fields" and then further discussion of
24 Fallot's tetralogy figures at the top of the second
25 column. Is that the article you can remember being
0038
1 discussed?
2 A. Yes, I believe it is.
3 Q. What was the nature of the discussion that took place
4 then?
5 A. Obviously wondering who MD was. We certainly had no
6 idea about that. Then I of course wanted to know what
7 was thought to be the veracity of these particular
8 comments. We did discuss that. I felt that I was
9 reassured at that time that audit was being carried out
10 within the unit and that, although there were problems
11 that were recognised and that was why they were trying
12 to get the unit unified, the problems had been
13 identified and attempts were being made to resolve them.
14 Q. You were reassured by whom?
15 A. By John Roylance and James Wisheart.
16 Q. What did each of them say?
17 A. I am sorry, I cannot remember specifically what they
18 said. I know that I was reassured. I was concerned
19 that such information could get into Private Eye, of
20 course. But I cannot remember what they said, I am
21 sorry.
22 Q. So if I asked you whether you had any recollection of
23 the problems that had apparently been identified but
24 were also being solved, can you help us on that?
25 A. This article was the first time I had any knowledge of
0039
1 any specifics at all. No-one else had mentioned it to
2 me in any other context, so I did not know of this.
3 Q. Can you help us at all on the detail of the conversation
4 in terms in particular of any problems that might have
5 been identified but were on their way to being solved?
6 A. I am sorry. After the time lapse I cannot give you any
7 more details.
8 Q. You have told us in very general terms that it was
9 raised, you were reassured, audit was being carried out
10 and steps were in hand. Can you add anything further to
11 the detail of that conversation?
12 A. No, I am afraid I cannot.
13 Q. Again you may not be able to help us on this, but if we
14 show you JDW 3/157, this is a letter to Ms Binding at
15 the NHSME. If we scroll down the page and then over,
16 please, you will see that it is a letter from
17 Dr Roylance. Turning back, please, to the first
18 paragraph you see that it is a letter in response to
19 concerns in Private Eye and a person raising that with
20 Ms Binding. Did you have any knowledge at the time of
21 this correspondence?
22 A. No, I did not. I had not seen this letter before.
23 Q. Thank you. You have spoken in your statement about your
24 involvement in audit both at the level of your own
25 involvement in your department and also through your
0040
1 involvement with the health authority. On that point,
2 you have given us the reference HA(A) 34/96. If we
3 could have that, please. This is a letter from you,
4 August 1989. You are setting up, if we can scroll down,
5 please, arrangements for -- formalising, perhaps
6 I should say, arrangements for medical audit within
7 the division of obstetrics and gynaecology; is that
8 correct?
9 A. That is correct, yes.
10 Q. I think audit had already taken place before August
11 1989?
12 A. I am glad to say that the specialty of obstetrics and
13 gynaecology has been involved in audit before the word
14 was ever invented I think, to be honest with you,
15 forever. My training, we always looked at parental
16 mortality and then parental morbidity, you know, the
17 near-miss cases. Of course the maternal mortality
18 inquiry as a national thing has been an extremely
19 valuable clinical tool. So we have always been
20 involved. This, as you say, was formalising it and
21 bringing gynaecological audit more on line. That,
22 I think, is important to note. That is something which
23 had not been so strong.
24 Q. Was the date in which you set out to formalise audit in
25 that fashion fairly typical of movements across the
0041
1 trust in other divisions to do the same?
2 A. Yes, it was.
3 Q. So, if we looked at UBHT 61/107, this is a letter now
4 talking about departmental audit meetings in paediatric
5 cardiology and cardiac surgery. If we scroll down
6 the page, we will see I think that it is from
7 Dr Martin. If we scroll back up, the date there,
8 December 1989, that would be roughly consistent then
9 with moves across the trust in mid-to late 1989 to
10 formalise audit under the initiative perhaps of both
11 regional and national moves on this front, is that
12 correct?
13 A. That is correct.
14 Q. You go on in your statement, perhaps we should go back
15 to it, to describe your role in the health authority
16 within audit. The reference to your involvement is in
17 the first page where at page 1 of your witness statement
18 245 you set out your involvement -- scroll down
19 the page, please -- with the health authority. Can
20 I ask you to describe your involvement with the health
21 authority in the matter of audit?
22 A. Yes, I was a non-executive director -- I got it right
23 this time -- of the trust. It has always been a key
24 part of my practice and my teaching and training of my
25 junior staff that we have to make sure that we are
0042
1 practicing to the highest possible standards and we need
2 to audit that. So, as a non-executive director and
3 having clinical understanding, I felt and proposed to
4 the then chairman that I would like to be involved with
5 the Director of Public Health Medicine in the authority
6 and other staff in trying to have a district-wide
7 initiative in clinical audit. Medical audits in which
8 doctors looked at their own results had been going on
9 for some time, but we wanted to widen it so there were
10 other health care professionals involved within the
11 trust as well.
12 Q. You said non-executive director of the trust.
13 A. Of the authority.
14 Q. Of the health authority, not the UBHT.
15 A. Of the health authority.
16 Q. So you were involved in trying to widen medical audit to
17 clinical audit?
18 A. Yes.
19 Q. From the perspective of the health authority, how did
20 the UBHT fit in to that initiative?
21 A. I think there were two things. Firstly, again medical
22 audit, given it was a teaching hospital and of course
23 the presence of clinical academics does mean that
24 questions are always being asked, so medical audit was
25 really quite well established. I think we perceived
0043
1 there was some resistance to go from medical towards
2 clinical audit. So there was some resistance.
3 Yet I do recall there were occasions where we set
4 out some issues that we felt needed to be audited
5 throughout the whole of the district. I cannot recall
6 what they were at the time. But we required that that
7 be done. UBHT provided the data, but perhaps the other
8 trusts did not. So they had to provide that.
9 However, I do recall in Southmead Trust they moved
10 very nicely and very smoothly, seamlessly, into clinical
11 audit. I think that was a very good example of it. We
12 tried to use Southmead as a good example to UBHT for
13 clinical audit.
14 Q. If there was resistance at the UBHT to moving from
15 a strongly developed medical audit position to clinical
16 audit, was that more or less than you were seeing in
17 other trusts across the district?
18 A. I think it was a bit more because the system had been --
19 the informal system had been established, and of course
20 clinicians were rather reluctant to think of dismantling
21 that and putting something else in place which they were
22 unsure of. Again we entered the phase of uncertainty
23 when I think actually audit probably did not achieve all
24 that very much and some of the benefits that have been
25 achieved from the more confined medical audit may have
0044
1 been lost. I think that was a concern that colleagues
2 in UBHT had.
3 Q. If we go back to your role in audit within your own
4 division, were there any particular problems or
5 obstacles to the development of audit across this
6 period?
7 A. In 1999 it may seem rather bizarre to say so, but
8 computerisation was the biggest block we faced. We had
9 a system of manual audit over many years in which books
10 were filled in. Indeed that is how the name "registrar"
11 for the staff came about. The registrar was the one who
12 filled the books in. So we had a very good system of
13 audit within my specialty.
14 We then through our anaesthetic colleagues,
15 Dr David Jenkins in particular, and Dr Trevor Thomas was
16 also involved in this, began to develop a computer
17 system. A colleague, Dr Michael Halton, who has now
18 died unfortunately, produced a computer programme which
19 worked well for us, but it was not compatible with
20 others within the hospital.
21 There was a Regional Health Authority directive
22 that we had to conform to their system, which was
23 patient administration system based and then
24 subsequently MDI and all sorts of other acronyms have
25 come along. We resisted that because we argued that
0045
1 the system was for patient administration and would not
2 provide the clinical data that we required.
3 Q. Did it?
4 A. No.
5 Q. Did you have experience in attempting to set up audit
6 across different divisions, in particular involving
7 other disciplines such as anaesthetics?
8 A. Yes. Indeed that, I think, ultimately did work. They
9 were very anxious to try to make sure that they did
10 their audit properly, and so they were compartmentalised
11 a begin with. So we had to work a little bit to make
12 sure that was spread across. But we did achieve that.
13 Q. By when?
14 A. It took a couple of years, I would think.
15 Q. A couple of years from?
16 A. From 1989.
17 Q. If we go on to your statement to the supplementary one
18 at WIT 245/25, you discuss there the format of
19 Dr Bolsin's audit. You are stepping back, of course,
20 from a debate as to whether or not it should be properly
21 called secret or not. But you do nevertheless say at
22 the end that you consider that it was unprofessional to
23 deal with colleagues in this way, that is not to inform
24 a variety of individuals of the fact of this audit.
25 What information or what knowledge do you have of
0046
1 how an audit which was commenced within the department
2 or by an individual within the department of
3 anaesthetics should be integrated or brought to
4 the attention of colleagues in other departments?
5 A. If the anaesthetic audit is looking at the activities of
6 the anaesthetists, then that is fine. That is something
7 for that division. But when a colleague, be he an
8 anaesthetist or a paediatrician or an obstetrician, is
9 actually looking at the clinical work of other
10 colleagues, let us say I as an obstetrician wanted to
11 look at my neonatal paediatric colleagues, then I think
12 it is an absolute condition that those other colleagues
13 must be involved in the design of the audit and in
14 collecting the data and the analysis and then ultimately
15 the delivery of those data.
16 Q. Is that purely a matter of courtesy or is that a point
17 about effectiveness of audit?
18 A. It is a point of professional conduct to me. It is
19 a matter of relationships. It is far beyond courtesy.
20 Q. So if I use the word "courtesy", you would substitute
21 "professional conduct"?
22 A. Yes.
23 Q. What about effectiveness? Is that affected?
24 A. It is much less likely to be effective if it is done in
25 that particular manner, because it will raise very major
0047
1 issues, and of course any errors are less likely to be
2 picked up. I think Dr Bolsin's audit is a very clear
3 example that these errors were not picked up.
4 Q. If we talk of professional conduct, we go to the Royal
5 College of Surgeons guidelines, these are the 1989
6 guidelines. Looking at witness 48, please, firstly
7 page 116. That just gives us the title page to see what
8 we are looking at. If we turn on, please, to page 118
9 and look at the paragraph on confidentiality. I think
10 it is really this paragraph that you have had in mind in
11 making some of your submissions or comments on
12 the nature of this particular audit. Is that correct?
13 A. Yes. I did refer to exactly this document in a letter
14 to the BMJ, which I think --
15 Q. Indeed, yes; we have that, I think. It is apparent if
16 we look at this that the document does stress
17 the importance of confidentiality. Is there any
18 particular reason why confidentiality might in
19 the Bristol setting have been more or less sensitive
20 than it was regarded as being nationally?
21 A. I can see no reason for it to be so.
22 Q. When Dr Thomas gave evidence he talked about a past
23 history involving the performance assessment committee
24 and its involvement with medical information in
25 Bristol. Is that anything that you can recollect as
0048
1 being an issue?
2 A. I was unaware of such a problem.
3 Q. Just two small matters if I might clear them up with
4 you, Professor Stirrat. The first was a previous
5 reference to you in the evidence of Mr Nix, where if we
6 look at UBHT 249/1, we will see there the first page to
7 give us the reference and minutes of a meeting of
8 the Health Authority in February 1991. If we go on,
9 please, to page 3 -- scroll to the bottom of the page --
10 we can see there that you are reported as having written
11 back being reassured on the quality of the surgery
12 involved in waiting list initiatives. Mr Nix was asked
13 if there was any light to be shed on that. I wonder if
14 you can help?
15 A. My recollection of my concern, and I cannot be absolute
16 about this, was in relation to hip replacements --
17 waiting list initiative and hip replacements.
18 Q. So that it had nothing to do with either adult or
19 paediatric cardiac surgery as far as you can recollect?
20 A. Absolutely not.
21 Q. One further matter, if I can put to you a part of
22 a statement that has been put in by a Mrs Shortis.
23 I appreciate that you have not had a chance to look into
24 your records in any of this matter and it is coming to
25 you for the first time today. So if there is anything
0049
1 further you want to add, please do. But if I could read
2 it out. She says, in October 1995:
3 "I wrote to Gordon Stirrat in late September 1995
4 to make my concerns known about paediatric cardiac
5 surgery at the BRI and to ask him for his view. I had
6 met him at a lecture he gave in December 1994 at Reading
7 parish hall. The lecture was entitled `A baby is not
8 just for Christmas'."
9 Then she talks about speaking to you afterwards.
10 Are you able to recollect any meeting with Mrs Shortis?
11 A. I have no recollection of ever meeting Mrs Shortis
12 before. No, I cannot recall this at all.
13 Q. Equally well, she says she is still waiting a reply from
14 you. Do you have any recollection of a letter being
15 sent to you?
16 A. No, I cannot recall receiving any letter. I saw this
17 for the first time this morning, but I do not have that
18 on record at all. If I had a letter of that importance,
19 I hope I would have replied to it. I have no
20 recollection or record of that letter.
21 Q. Would you have replied to it even if it had been
22 critical of Mr Wisheart or the other surgeons involved
23 in this matter?
24 A. Absolutely, yes.
25 Q. Finally, she suggests that she had a conversation with
0050
1 a Mr James Garrett. He told her that you were a leading
2 Freemason. Do you have any comment to offer on that?
3 A. Firstly, am I correct in saying that James Garrett is
4 a journalist working with HDV or one of the television
5 companies?
6 Q. I would have to check that.
7 A. Was he the producer of the Dispatches programme?
8 Q. We would need to come back to you on that, I am afraid.
9 A. I will say that how on earth he got any information that
10 I was a Freemason, let alone a leading Freemason, I have
11 no idea whatsoever. I have never been nor will be
12 a Freemason and indeed I must confess to having some
13 antipathy towards Freemasonry. So it is absolutely
14 a categorical denial.
15 Q. Thank you, Professor Stirrat. I have asked you a number
16 of questions in an attempt to cover the ground in your
17 statement and also to deal with those matters that you
18 can give direct evidence to the Inquiry about. Is there
19 anything else that you would like to add or to tell
20 the Inquiry either by way of addition or things that you
21 feel have not been properly covered this morning?
22 A. May I have a minute to think about that? I cannot think
23 of anything at the moment that comes into that
24 category. Mr Whitehurst did send to me a comment from
25 Phil Hammond that is on the record with my name
0051
1 attached, and it may very well be that it would be worth
2 dealing with that because we have not dealt with it. Do
3 you think it would be of any value to come to that?
4 Q. If you want me to draw up Phil Hammond's comments on
5 your statement, I am very happy to do that. It is at
6 WIT 283/1. The alternative would be if we now,
7 particularly since you asked, if you wanted a minute,
8 took a break for ten minutes and came back and gave you
9 the opportunity to say anything further that you wanted
10 at that stage. But perhaps we might possibly also take
11 questions from the panel first in a slight diversion
12 from normal procedure, because if Professor Stirrat does
13 not want to raise anything further we can move directly
14 onwards to re-examination.
15 EXAMINED BY THE PANEL:
16 THE CHAIRMAN: There are no questions from the panel, save
17 one from me if I may put it to Professor Stirrat. It
18 involves going to your statement, if that can be called
19 up. I just wanted to take you to page 4 of WIT 245.
20 Could I take you down towards the bottom of that
21 and the observation of Mr Martin Elliott, which you draw
22 attention to, where he is commenting, as I understand
23 it, on the split site. You expressed views about
24 the need to remedy that over time.
25 He states, and I am looking at your statement,
0052
1 that "the separation must be inefficient and is
2 potentially dangerous".
3 Do you know whether it was ever a matter of
4 discussion in the light of observations such as that,
5 which I am sure other people will have made, though
6 perhaps not in as strong terms, whether paediatric
7 cardiac surgery should in fact take place at the BRI,
8 given the circumstances of a split site and the fact
9 that to resolve it would be long-term because money had
10 to be raised?
11 A. Yes, I am not aware that -- that was certainly not
12 a discussion in which I was involved at the time. It is
13 certainly something that I know has been raised. How
14 one takes a service, a routine service, and then
15 develops it into a supra-regional service and
16 a supra-regional service of high quality, in other words
17 how one innovates in health services, is an extremely
18 difficult problem.
19 I know for a fact that within my own area of
20 interest and specialty, I think for example although
21 I am not a neonatal paediatrician I think neonatal
22 paediatrics must come into this. As a doctor you are
23 faced with a clinical situation in which you are working
24 and you are actually trying to do the very best you can
25 under the circumstances. That is the ethos that we have
0053
1 had and probably still have in the health service.
2 I think that was the ethos at the time.
3 If, however, there had been information which had
4 come to show that the surgery was inappropriate, it
5 should have been stopped. But I must say that of course
6 the concerns about paediatric cardiac surgery related to
7 only about 3 or 4 per cent of the paediatric cardiac
8 surgery done by these surgeons. So, that being so, to
9 think of stopping all of it is actually in a sense a bit
10 of overkill. I think for me and the reassurance I got,
11 I was being given reassurance about paediatric cardiac
12 surgery in the round and able to show that that was
13 actually appropriate. Focusing on the 3 to 4 per cent
14 can distort things.
15 THE CHAIRMAN: If I may follow up with just one further
16 question. Albeit that it was a small proportion and it
17 is really about the open surgery being done elsewhere
18 which creates that problem, are not the words
19 "potentially dangerous" such as to cause that debate to
20 take place? After all, there were other centres able to
21 do that surgery.
22 A. Yes, you are absolutely right, and it did. Of course my
23 understanding is that the surgeons themselves were
24 trying to make sure that the changes took place. They
25 were the ones who were pushing from very early on to get
0054
1 a paediatric cardiac surgeon in, hoping next month, next
2 month, next month the situation is actually going to
3 improve. In retrospect of course, and this is
4 the benefit of retrospective scope, it has 20/20 vision,
5 all of us know what we should have done in retrospect.
6 THE CHAIRMAN: Professor Stirrat, I am not taking a view as
7 to what should have been done. That would be
8 inappropriate at the present moment. I am merely asking
9 what might have been a response to words like that from
10 a man who the Trust was seeking to recruit. It is one
11 thing to say, "Perhaps next month someone will be
12 appointed; someone will be appointed which will solve
13 the problem as pointed out by Mr Elliott." It is another
14 thing to say, "We ought not to do it until we have
15 solved the problem." I just want to know whether that
16 debate ever took place.
17 A. I was never directly involved in the debate, as
18 a participant in the debate. But I know from what James
19 Wisheart has told me that these discussions did take
20 place. Ultimately of course the operations were
21 stopped. I cannot recall when it was, but it was
22 some time later.
23 THE CHAIRMAN: I will be corrected if I am wrong, but my
24 recollection is Mr Wisheart said in evidence that that
25 was never contemplated, stopping.
0055
1 MISS GREY: Could I just pick that up by asking you to help
2 us a bit further on when you say it was made plain to
3 you by Mr Wisheart that that debate had taken place.
4 Can you help us a little further on what he has said to
5 you and when that leads you to believe that to be
6 the case?
7 A. I need to reflect on that because I cannot bring
8 specific instances back to mind immediately. Would it
9 be appropriate for me to come back to that once
10 the break is over? Would you allow me to do that?
11 THE CHAIRMAN: Of course. I think it would be proper now to
12 take a break for let us say 15 minutes. The young man
13 on your right deserves a rest. His fingers will begin
14 to bleed. We will take therefore 15 minutes and
15 reconvene at 11.30.
16 MISS GREY: Thank you.
17 (11.15 am)
18 (A short break)
19 (11.30 am)
20 MISS GREY: Just a few further matters, then, Professor
21 Stirrat. Firstly we were discussing the response to
22 Mr Elliott's paper. I think so that any wider audience
23 can follow that, we should perhaps bring it up on the
24 screen and therefore make it available. It is
25 JDW 3/104.
0056
1 That I think is the paper you were referring to
2 but were not able to reference in your statement;
3 is that right?
4 A. That is correct, yes.
5 Q. When this paper was circulated, firstly are you aware of
6 any discussions from your own involvement about the
7 statement in it that a split site was potentially
8 dangerous?
9 A. No. I am not aware of that, sir.
10 Q. What about from discussions from other people? Are you
11 aware of any discussions about the paper from talking to
12 any others?
13 A. No, I am not.
14 Q. So when you said earlier that you thought there had been
15 discussions, on what was that based?
16 A. It was based on the fact that the two surgeons
17 themselves, in 1989, had proposed the unified service
18 and therefore that was based on some sort of risk
19 analysis, but it is nothing more than that.
20 Q. If we are looking more specifically at the question of
21 whether there was any discussion of whether particular
22 procedures or indeed surgery more generally should be
23 stopped pending the unification of the service, are you
24 able to help us on whether those sorts of discussions
25 were taking place?
0057
1 A. No. I do not have any direct evidence that such
2 discussions did or did not take place.
3 Q. So that when again you thought some such discussions
4 might have taken place, was this partly a matter of
5 inference based on the fact that you understand that
6 reviews of the cardiac surgical results were taking
7 place?
8 A. That is exactly the situation.
9 Q. And in particular, that some procedures -- I am thinking
10 of Mr Wisheart's performance of the AVSD procedures --
11 did stop at some point in time?
12 A. That is exactly right.
13 Q. When you say that the two surgeons proposed that the
14 service be unified and that therefore that was based on
15 some sort of risk analysis, again, is that a firsthand
16 knowledge of what analysis took place?
17 A. No, it is not, I am afraid.
18 Q. So it is an assumption that there was some sort of risk
19 analysis?
20 A. It is.
21 Q. And equally well, again before the break, you referred
22 to the fact that the concerns related to some 3 to 4 per
23 cent of the surgical work that was being carried out in
24 paediatric cardiac surgery. What was that statistic
25 based on?
0058
1 A. Evidence given to the General Medical Council, as
2 I understand, and discussion with Mr Wisheart.
3 Q. So, in other words, your 3 to 4 per cent is a commentary
4 on the nature of the proceedings in front of the General
5 Medical Council, is it?
6 A. It is, yes.
7 Q. Can I take you back then just to a couple of matters
8 which I understand should be further explored, firstly,
9 the point in your statement in which you discuss
10 whistle-blowing and the involvement of Dr Bolsin.
11 Can I take you, please, to page 10 of your
12 statement [WIT 245/10] where there you discuss
13 whistle-blowing generally, and I think at another point
14 in your statement, you refer to the fact that
15 Dr Roylance discussed Dr Bolsin's position.
16 If we could look, please, at page 9, and scroll
17 down a little, please, where at one of the meetings in
18 1995, Dr Roylance made it clear that so-called
19 whistle-blowers must not be pursued.
20 Can you help us a little further on the nature of
21 that conversation?
22 A. This took place in the context of the fire-fighting
23 meetings I talked about, and although this was not
24 a matter specifically between the University and the
25 UBHT, it certainly was a very major issue facing all of
0059
1 us when it arose in 1995.
2 Because in a sense it was outside our usual kind
3 of agenda, and because John Roylance made the statement
4 so clearly, I have a vivid recollection of where it
5 happened. I cannot give you the date, but I can see him
6 sitting in the boardroom of the Trust headquarters
7 making this statement, that whistle-blowing must not be
8 pursued. I think his words were, "We must not make
9 a martyr of a whistle-blower and we must deal with it
10 and he must not be --
11 Q. Those are in general terms. What about the position of
12 Dr Bolsin in particular? Was that referred to?
13 A. No, I am talking about specifically in relation to
14 Dr Bolsin. This was raised specifically subsequently to
15 Dr Bolsin's so-called whistle-blowing and his comments
16 were specifically in the context of Dr Bolsin.
17 Q. So Dr Bolsin should not be made a martyr of; is that
18 correct?
19 A. As I recall, I think that was the sense of the words.
20 Q. Are you able to help us on any concrete steps made by
21 Dr Roylance to support or defend Dr Bolsin's position?
22 A. No. I cannot comment on that. I do not know.
23 Q. Did you yourself have any firsthand involvement in the
24 discussions over Dr Bolsin's anaesthetic sessions and
25 whether or not he could work with the cardiac surgeons?
0060
1 A. None whatsoever.
2 Q. Is there anything further that you wanted to add to that
3 part of your evidence, Professor Stirrat, because you --
4 A. No, I am content, thank you.
5 Q. Then more generally, we had reached the stage where we
6 were inviting you to add anything further to your
7 evidence if you wished to. Is there any matter you
8 would like to raise?
9 A. I do not believe there is. Thank you very much,
10 Chairman. I believe the issues have been dealt with.
11 THE CHAIRMAN: Thank you, Professor Stirrat. Dr Roger?
12 DR ROGER: No, thank you, sir.
13 THE CHAIRMAN: Professor Stirrat, thank you very much for
14 coming to talk to us this morning. As we say to all
15 witnesses, if there are other matters you would wish to
16 bring to our attention subsequently, then of course we
17 are here for a while and we would be happy to hear from
18 you, but for today at least, thank you very much
19 indeed.
20 PROFESSOR STIRRAT: Thank you very much indeed, sir.
21 (The witness withdrew)
22 MISS GREY: Sir, we should be hearing shortly from Professor
23 Farndon. I wonder if it might be appropriate to invite
24 you to rise for just five minutes?
25 THE CHAIRMAN: That would be to my advantage because I have
0061
1 just made sure I cannot see through my glasses, so it
2 will help. Thank you.
3 (11.45 am)
4 (A short break)
5 (11.50 am)
6 MR MACLEAN: Sir, the next witness is Professor John
7 Farndon. Professor Farndon, could I ask you to stand,
8 please, to take the oath?
9 PROFESSOR JOHN FARNDON (AFFIRMED):
10 Examined by MR MACLEAN:
11 Q. Professor, could I ask you to have a look at the screen
12 in front of you, at WIT 87/1, please? That is the first
13 page, is it, of the formal written statement that you
14 made to the Inquiry?
15 A. It is.
16 Q. If we go to page 12, can you identify that signature?
17 A. I do.
18 Q. That is yours, is it?
19 A. It is.
20 Q. That is the last page of a statement you made to the
21 Inquiry?
22 A. I would imagine so. There were various appendices.
23 Q. Have you had a chance to read through that statement
24 recently?
25 A. I have.
0062
1 Q. Is there anything in it you want to change?
2 A. Not particularly, no.
3 Q. You rightly point out that there were a number of
4 annexes to the statement and we will see some of those
5 in due course, but I think there were a total of 6
6 annexes, were there not, the last of those being
7 a letter from you to Dr Black of 24th July 1996?
8 A. That is the last annex.
9 Q. I think you have had the chance, have you not,
10 Professor, over the last day or so, to see the comments
11 that have been made on your statement from Dr Bolsin.
12 Perhaps we can just see those briefly, WIT 87/32. That
13 is the first page of a two-page e-mail sent by Dr Bolsin
14 to the Inquiry commenting on your statement.
15 A. It is. I saw it last night.
16 Q. You have had a chance to see that?
17 A. Yes, I have.
18 Q. I think it is right to say that you yourself have
19 commented once before on the witness statement of
20 a witness, that was Mr Bryan at WIT 81/34.
21 A. Yes.
22 Q. That is your comment, is it not, on Mr Bryan's
23 statement? He gave evidence a couple of weeks ago.
24 A. Yes. And the full page you will see is one of my prompt
25 replies.
0063
1 Q. If we scan down the page, this is essentially dealing
2 with the meeting on 23rd December 1993 involving
3 yourself, Professor Angelini and Mr Wisheart, which we
4 will come to in due course.
5 A. Fine.
6 Q. I should have said at the outset, you are represented
7 today by Mr Hoyte, who sits behind me?
8 A. Yes, I am grateful for that.
9 Q. You are the Professor of Surgery and have been Professor
10 of Surgery, head of the Division of Surgery at Bristol,
11 since 1988?
12 A. That is correct.
13 Q. And you are employed, are you, by the University of
14 Bristol?
15 A. I am.
16 Q. You hold and have held, since 1988, an honorary
17 consultant contract with, as it now is, the UBHT?
18 A. That is correct.
19 Q. You tell us in your witness statement that you were or
20 are a member of the Royal College of Surgeons Committee
21 on Audit and Quality Assurance?
22 A. I have been, yes.
23 Q. When were you a member of that committee?
24 A. It would be -- I cannot remember accurately, but several
25 years ago. I do not hold any position in that capacity
0064
1 now. I have just been asked to join NCEPOD, the
2 committee which looks at peri-operative deaths.
3 Q. The source of my remark was WIT 87/16, which is part of
4 your CV you submitted as annex 1 to your statement. We
5 see in the top half of that page the numerous committees
6 of which you have been Chairman, or a member, and under
7 the heading "Committee member", about five lines down,
8 "Audit and Quality Assurance Committee".
9 A. Yes.
10 Q. What did that committee do?
11 A. It is looking at the process of audit generally and its
12 implementation in general surgical matters.
13 Q. It was concerned with general surgery?
14 A. General surgery.
15 Q. And you yourself are a general surgeon by background?
16 A. I am.
17 Q. You have developed, I think, a specific specialism?
18 A. The trend is certainly in the bigger teaching institutes
19 to develop specialists interests, and I hardly look
20 after anybody else now, other than patients with breast
21 disease or endocrine disease.
22 Q. I think you mention this in your statement: your own
23 involvement, professionally with cardiac surgery, has
24 been what?
25 A. It was a period of rotation as a Registrar in the
0065
1 Northern Regional Training Programme, when cardiac
2 surgery was based in a small hospital in Shotley Bridge,
3 which coped with the whole of the northern region at
4 that time.
5 The cardiac surgery subsequently moved to Freeman
6 Hospital in Newcastle, but I was attached to the unit at
7 Shotley Bridge.
8 Q. And that was some time ago?
9 A. It is many years ago, in my training.
10 Q. Can we look at WIT 87/2? This is your statement to the
11 Inquiry. Paragraph 6. You say that you became the
12 "audit co-ordinator for surgery" in January 1992?
13 A. That is correct.
14 Q. Your role as audit co-ordinator was to collect data from
15 audit meetings that had been carried out throughout the
16 division; is that right?
17 A. Yes. The responsibility was two-fold; it was to
18 organise and direct audit activity within the general
19 surgical directorate, and to receive reports from the
20 other divisions or specialty areas within the surgical
21 umbrella, and then pass those reports on to the hospital
22 Audit Committee.
23 Q. When you received audit reports from elsewhere in the
24 Division of Surgery, other than your own particular
25 area, to what extent did you look at those returns and
0066
1 evaluate them before passing them on to Dr Thomas for
2 inclusion in the annual audit report?
3 A. I felt I had a responsibility to ensure that the format
4 and content was appropriate for further processing by
5 the Audit Committee, so there was a specific style of
6 return requested. In fact, a form.
7 Q. So you would be looking at the style, the layout, if you
8 like, of the information?
9 A. Yes, to ensure that its content and style followed the
10 requirements of the Audit Committee of the Trust.
11 Q. So you would read these returns when you got them?
12 A. Yes.
13 Q. So you would be aware, in broad terms, of what the
14 report was saying?
15 A. Yes.
16 Q. And so if there were, in any of the reports that you
17 received, something which stood out, which leapt from
18 the page as being strange or curious, you would be in
19 a position to pick that up?
20 A. Yes, to some extent. I think sometimes the degree of
21 specialisation of surgery and the specialty subgroups
22 might provide detail that it would be unfair of me as
23 a general surgeon to have a depth of knowledge about,
24 but if there was something that was glaringly outlying
25 or a difficult statement, I hope it would impact.
0067
1 Q. You referred in your answer a moment ago to the
2 processing of these reports by the Audit Committee.
3 That would be the Trust's Audit Committee, would it?
4 A. Yes, it would, and it produced an annual report.
5 Q. The committee chaired at least at some stage by
6 Dr Thomas?
7 A. Yes.
8 Q. What was the nature of the further processing that that
9 committee subjected the audit returns to?
10 A. Well, it would be looking for, as any good audit process
11 would, the closure of loops. I can only speak for how
12 we did it in general surgery, and how I tried, where
13 possible, and where appropriate, to guide the other
14 groups, that the objectives of audit activity should
15 have clearly defined questions, then go through the
16 process of data gathering and analysis, and
17 recommendations, if any were required, on the results so
18 obtained.
19 Q. What were the objectives as you understood it of the
20 audit process and the gathering of data?
21 A. It is part of today's jargon of clinical governance that
22 we have had in place in surgery, certainly in my own
23 practice, for more years than I care to remember, but
24 the process of looking at performance and outcomes,
25 whether those are hard outcomes such as a wound
0068
1 infection or softer outcomes like patient information.
2 I do not mean to demean the patient information as any
3 less important than a hard outcome like a wound
4 infection, but you pose the question what is the rate of
5 a wound infection in general surgical practice, how does
6 it vary, is it higher in one unit on one ward than
7 another? If so, why? Then you try and identify the
8 reasons and correct them.
9 That is the so-called loop.
10 Q. So the idea ultimately is to try to identify any
11 problems and then deal with them in order to raise the
12 standard of care?
13 A. There is no point in audit if you do not have a loop and
14 close it, so that you see if there is a problem, what is
15 the problem, how is that problem accounted for and is
16 there any understanding of why there is a problem? What
17 can we do to correct it?
18 Q. You have used the expression "loop" several times
19 already. You use it in your statement at paragraph 9 on
20 page 3, the bottom of the page. We will come back to
21 cardiac surgery in just a moment, but just focus on the
22 last complete sentence on that page:
23 "The process should have identified problems and
24 corrections to allow closure of the audit loop".
25 A. Yes.
0069
1 Q. So you are referring there to the process you have just
2 described of gathering data, identifying problems,
3 addressing problems and thereby addressing and improving
4 the standard of care?
5 A. Yes. There was one, I think, I believe it was in the
6 anaesthetic audit report, which actually highlighted one
7 of the proposed projects which was to look in fact at
8 paediatric cardiac surgery. I cannot remember the page
9 reference immediately, but it is there in the bundle
10 which I have got headed 1846, but somewhere in there,
11 for example, is the joint audit project, I think it was
12 somewhere in 1992, to look at paediatric cardiac surgery
13 outcome, identifying high risk patients, and there would
14 be an example.
15 Q. You were the audit co-ordinator for surgery?
16 A. Yes.
17 Q. To what extent did you have an input into selecting
18 topics to be audited, something that follows on from the
19 point you have just made?
20 A. None whatever, in that I was the co-ordinator so we
21 could meet as a group of general surgeons and we would
22 look at important areas together that we felt needed
23 addressing, very important areas I think of clinical
24 relevance and feeding back into quality of patient care.
25 Q. So you as co-ordinator did not choose topics to be
0070
1 audited?
2 A. No. I think for the other disciplines, again in the
3 bundles there is mention in A & E of difficulty in
4 getting the process started because of low numbers of
5 members of staff and so on, and with orthopaedics, some
6 guidance on the sorts of questions that ought to be
7 addressed in the audit process. I do not mean it
8 unkindly, but some disciplines were behind general
9 surgery in the Infirmary, in getting that process up and
10 running effectively.
11 Q. What about the Trust Audit Committee, the committee to
12 which you submitted the reports when you got them for
13 further processing and turning into the annual report?
14 To what extent did that central committee, if you
15 like -- I do not mean that in the old Soviet Union sense
16 of the word -- have the ability or the responsibility
17 for choosing topics to be audited?
18 A. I do not believe it did.
19 Q. So it was a bottom-up process, was it, in terms of it
20 would be the division or the group of clinicians
21 themselves would essentially get together and decide on
22 which topics would be picked for audit in the up-coming
23 period?
24 A. Yes -- well, all I can say is I never had any
25 instruction or conversation that said "general surgery
0071
1 should not look at this or that" from that committee.
2 Q. Or from anyone else?
3 A. Or from anyone else, but as a group of general surgeons,
4 the topics were chosen as those most relevant to our
5 practice.
6 Q. When you began work in Bristol there was no Trust and
7 there was no Clinical Directorate structure because that
8 was instituted with the institution of the UBHT in 1991?
9 A. Yes.
10 Q. To what extent did the coming about of the directorate
11 system impact upon the audit work that was carried out?
12 Did the Clinical Directors, for example, have a role to
13 play in choosing audit topics, or ensuring that audit
14 was carried out?
15 A. I think it was done mainly by the audit co-ordinators.
16 Q. Of which you were --
17 A. Of which I was one, but that position was chosen by the
18 Division of Surgery, for example, and it is
19 a responsibility that we each take at some time or
20 other. Not everyone takes it, but everyone is asked to
21 lead at some stage in that process.
22 Q. It is done on a rotational basis?
23 A. Sort of a rotational basis, yes. We look to the
24 workload of everybody helping support the administration
25 and directorate, and hopefully, share the burden and the
0072
1 load of these other sorts of responsibility.
2 Q. If we go back to paragraph 6 of your statement which we
3 looked at earlier, page 2, you refer there to monthly
4 audit meetings in general surgery. There is no mention
5 in paragraph 6 of cardiac surgery, adult or paediatric?
6 A. No.
7 Q. If we go to page 3, paragraph 8, there is a mention of
8 cardiac audit?
9 A. That is right.
10 Q. Can you just summarise for me the position, the
11 relationship between cardiac surgery on the one hand and
12 your role as co-ordinator of audit for the Division of
13 Surgery on the other?
14 A. The Cardiac Directorate would be one group, like trauma
15 and orthopaedics, or the emergency room would be other
16 examples, of subdirectorates who would be expected to
17 provide their own report of their audit activity, which
18 I would collate and submit to the Audit Committee of the
19 Trust.
20 Q. So you would have, passing through your hands, audit
21 results for cardiac surgery?
22 A. I did not. I remember writing to Mr John Hutter who
23 I think was responsible for audit activity during the
24 time of my responsibility in the overall surgical
25 directorate, and being told by John that their
0073
1 submission was to a national audit, and I think that
2 there is correspondence where I relay that advice or
3 information to Dr Trevor Thomas.
4 Q. So your understanding was that Mr Hutter, himself an
5 adult cardiac surgeon, was responsible for the
6 co-ordination of the cardiac surgical audit which was
7 submitted to a national audit register of some sort?
8 A. That is correct.
9 Q. Did you know any more detail about it? Had you heard
10 of the Cardiothoracic Register, for example?
11 A. I had heard of it but I did not know any detail of it.
12 I did not know the machinery of its workings.
13 Q. Did you know the nature and scope of the returns that
14 were made to the register?
15 A. I did not know that detail.
16 Q. Did you ever see the returns made to the Cardiothoracic
17 Register?
18 A. Not that I can remember, no.
19 Q. So if to the extent of the committee Dr Thomas himself
20 received audit data on cardiac surgery, he would not
21 have got it from you?
22 A. It was not included in any of the reports that
23 I submitted.
24 Q. So he would not have got it from you?
25 A. No.
0074
1 Q. Do you happen to know whether or not Dr Thomas did or
2 did not get such audit data from elsewhere?
3 A. I do not know.
4 Q. You make the point at paragraph 13 of your statement
5 that no joint audit was carried out between the general
6 and the cardiac surgery departments?
7 A. That is correct.
8 Q. Do you know whether or not the cardiac surgery
9 department carried out audits jointly with any other
10 department?
11 A. I believe the audit that I hinted at earlier on, where
12 I could not remember the exact page number, was
13 a proposed audit with anaesthesia, and we had, because
14 of our close working relationship with anaesthesia,
15 perhaps had more joint audit activity with anaesthesia
16 than any other directorate.
17 Q. Can we have a look at UBHT 66/107? This is the annual
18 Medical Audit Committee report for 1992.
19 A. Yes.
20 Q. If we go to page 108, you see the list of reports there,
21 if we scan down. I think the Inquiry has heard evidence
22 already to the effect that there was nothing in that
23 report dealing with cardiac surgery or paediatric
24 cardiology.
25 A. I remember that report, and that I think is correct.
0075
1 I do remember that under "Anaesthesia" on page 22 of
2 that report, there is some mention of I think proposed
3 audit activity between paediatric cardiac surgery and
4 anaesthesia.
5 Q. Shall we have a look at that? If we go to page 129
6 [UBHT 66/129] that is the anaesthesia audit. We see the
7 audit topics discussed.
8 A. I think there is a section on the reports, if I remember
9 those forms correctly, where there are proposed topics
10 or future topics, or some such heading. But I do not
11 remember that there was any cardiac data presented
12 through the anaesthetic audit group.
13 Q. Perhaps we can come back to that later, if it matters.
14 Dr Thomas has given evidence to the Inquiry, as you may
15 know. He did so on Day 62. At page 125 of the
16 transcript, he said this:
17 "The route to cardiac surgery from the committee",
18 he means his Audit Committee, "would have been via the
19 co-ordinator for surgery. That was Professor Farndon."
20 A little later on, he said:
21 "Professor Farndon was our contact point with
22 surgery."
23 To what extent do you agree with those statements,
24 that the route to cardiac surgery from Dr Thomas's
25 committee was via you?
0076
1 A. I do not disagree with him.
2 Q. You do not disagree?
3 A. I do not.
4 Q. But you were not responsible for sending any cardiac
5 audit reports to Dr Thomas?
6 A. Well, there were no prospectively given ground rules on
7 this. No-one told me what my direction was or what
8 I had to do and I assumed that I needed to gather audit
9 data from each of the surgical specialty groupings, and
10 to that end, would write to the head of the audit
11 activity within the specialty groupings. For cardiac
12 surgery that would be John Hutter. I did not receive
13 returns from John Hutter and told Dr Thomas exactly
14 that. I also said that I understood that the
15 submissions were going nationally.
16 Q. So having given that explanation, you essentially left
17 it then up to Dr Thomas if he wished to take the matter
18 up with Mr Hutter?
19 A. I had tried my best to retrieve information that could
20 easily have been enclosed within the hospital report and
21 had done my best to try and obtain that. I did not get
22 anything in that regard, and reported that fact to the
23 Audit Committee.
24 Q. Mr Hutter was an adult cardiac surgeon -- still is?
25 A. Still is, yes.
0077
1 Q. To what extent did you understand Mr Hutter was
2 responsible for collecting the audit data on paediatric
3 cardiac surgery as well as adult cardiac surgery?
4 A. I would have imagined that he had total responsibility
5 for that. It is a similar question to asking me to
6 comment, as a breast and endocrine surgical specialist,
7 about having any knowledge about upper GI surgery that
8 my colleagues do. We gather it together within that
9 fold and I would have imagined that paediatric cardiac
10 surgery should have been within that same fold of
11 cardiac surgery.
12 Q. So you were not aware of anybody else being responsible
13 for collecting audit data on paediatric cardiac surgery?
14 A. Not that I was aware of, and indeed, the two surgeons
15 who looked after children also looked after adults with
16 cardiac problems.
17 Q. That is an important point; we will come back to that
18 point. Somebody in your position, you would have known
19 that there were two cardiac surgeons who did paediatric
20 work?
21 A. Yes.
22 Q. And you would have known that those were Mr Wisheart and
23 Mr Dhasmana?
24 A. Yes.
25 Q. And that is something you would have known from very
0078
1 early on in your period at Bristol?
2 A. Yes.
3 Q. Did you know that Mr Bryan, when he became an adult
4 cardiac surgeon in Bristol, as I recall towards the end
5 of 1993, took on responsibility as being the cardiac
6 surgery audit co-ordinator?
7 A. I think I recall that, yes.
8 Q. Did you ever receive cardiac audit material from him for
9 onward transmission to Dr Thomas's committee?
10 A. I did not.
11 Q. Did you ever ask him for such?
12 A. I do not recall doing so.
13 Q. Was that because, by that time the established system,
14 if that is what it was, was for Mr Hutter to send the
15 material, later Mr Bryan or whoever, to the Cardiac
16 Register, and not to send material to you for you to
17 send on to Dr Thomas's committee?
18 A. Exactly so, and I think I would have taken some comfort
19 in the fact that if data were being submitted
20 nationally, there would be good national comparative
21 data that would allow comparison and feedback.
22 Q. Did you know, for example, whether the national
23 register, or the national repository of this data,
24 allowed comparison of one centre with another named
25 centre, for example?
0079
1 A. I assumed that it did, but did not know so.
2 Q. You now know perhaps that it did not do so: that the
3 register was anonymised?
4 A. I do know now.
5 Q. Would knowing that information, knowing that the
6 register was anonymised, have made you any more or less
7 happy about, if you like, relying on the fact that
8 cardiac audit data was submitted to a national register?
9 A. It may be that there was another step, because NCEPOD
10 data can be anonymised, and many other audit activities,
11 such as I helped with the College, that although the
12 data is anonymised, your own individual performance can
13 be identified and be given to you to allow you to
14 benchmark across the spectrum of performance.
15 Q. So you would still know how you stood against the
16 national benchmark?
17 A. That is right.
18 Q. Albeit, you would not know whether you were better or
19 worse than the centre next-door?
20 A. No, if it were plotted out as it often is as a spectrum
21 of performance, that if you were number 36 centre and
22 you were well up here, you would not know who number 2
23 was or who number 38 was, but you would know you were
24 number 36.
25 Q. Did you ever receive any reminders and so on, any
0080
1 chasers, if you like, from Dr Thomas, about producing
2 audit data to him for cardiac surgery?
3 A. Not that I remember.
4 Q. When he gave evidence to the Inquiry on Day 62,
5 page 141, he was asked:
6 "When you received an account of what audit was
7 taking place within the cardiac surgery department,
8 notwithstanding the absence of annual reports for 1992
9 and 1993, would that information also have reached you
10 from Mr Wisheart?"
11 He said:
12 "Not necessarily, because Professor Farndon,
13 I think, would probably have been in a position to
14 reassure me as well. Certainly, I spoke to him about
15 surgical audit on a substantial number of occasions."
16 To what extent were you in a position to reassure
17 Dr Thomas about audit going on in the cardiac surgery
18 department?
19 A. Not really at all.
20 Q. Did he ever seek such reassurance from you?
21 A. Not that I remember.
22 Q. Mr Wisheart was a member of the committee that Dr Thomas
23 chaired, was he not?
24 A. So I see in the report, yes.
25 Q. Did you know that at the time?
0081
1 A. I did not know at the time.
2 Q. If Dr Thomas had come to you and said, "Can you tell me,
3 John, what the state of play is about cardiac surgery
4 audit?", what would you have said?
5 A. I would have said that I had been assured that audit
6 activity was being carried out within the Directorate of
7 Cardiac Surgery and that the returns were made to
8 a comparative audit system held nationally.
9 Q. Would you have identified your source of that
10 information?
11 A. I could have. It was only one source and it was John
12 Hutter, and then an assumption that the process
13 continued.
14 Q. To what extent were you familiar with the details of the
15 audit process that Mr Hutter had established?
16 A. None.
17 Q. To what extent were you familiar with the audit that
18 Mr Hutter carried out of paediatric cardiac surgery?
19 A. None. But equally, I was not aware of the exact
20 process, from orthopaedic surgery. I would receive
21 their reports, but how good that process was, it is
22 difficult to judge.
23 Q. Can we have a look at WIT 96/39? This is an extract
24 from a statement that has been made by Mr Hutter.
25 I just want to show you one paragraph. The bottom of
0082
1 the page. Just have a look at those three lines and
2 tell me when you want to go over the page, please.
3 (Pause).
4 A. Thank you.
5 Q. Can we go to page 40? Read down, if you will,
6 Professor, to the bottom of the screen as we see it now,
7 and then just a little below, and again, ask when you
8 want to scan down. (Pause).
9 A. Right.
10 Q. If we just scan down a little more, read as far as
11 "computerised audit system". (Pause).
12 A. Okay.
13 Q. That would appear to be saying that Mr Hutter's initial
14 focus was on audit of adult surgery. That, as he says,
15 took longer than anticipated, and he did not attempt to
16 develop a system for paediatrics.
17 So assuming that statement is correct, it would
18 follow, would it not, that there was no system of audit
19 in Mr Hutter's time as audit co-ordinator for cardiac
20 surgery, dealing with paediatrics specifically?
21 A. That is the first I knew of that situation. But it
22 could equally be said for any other discipline, that
23 there might be important things that should be checked
24 and audited that I would not know were occurring in
25 orthopaedics, or in trauma, that I would not know about,
0083
1 because the topics would be chosen by a specialty group.
2 Q. That is why I asked you earlier about the role of the
3 co-ordinator. I do not want to be rude about the role
4 of the co-ordinator, but at its most basic, it was
5 a postbox?
6 A. I do not think you are being rude; I think that is
7 correct. Except that I also had responsibility for
8 generating the quality audit in general surgery.
9 Q. But that was your own view?
10 A. That was my own, yes, field.
11 Q. But outside of your own field, you were essentially
12 a postbox for Dr Thomas's committee?
13 A. That is correct.
14 Q. And Dr Thomas's committee itself did not have any role
15 in choosing the audit topics either?
16 A. It did not; it received the reports.
17 Q. So it received such mail via you as people further down
18 the line chose to send?
19 A. That is correct.
20 Q. We have dealt with cardiac surgery and the system that
21 they had. If there was somebody who commonly sent
22 returns to you for onward transmission to Dr Thomas's
23 committee and they did not, what was the sanction?
24 A. I mean, I had to chase some groups more vigorously than
25 others to get returns, and others found it difficult or
0084
1 impossible. The accident room, I think, found it
2 particularly difficult because of staff shortages to
3 initiate the process. Orthopedics was gradually getting
4 up to speed. And I would chase and encourage as much as
5 I could, but it was as much as I could do to have
6 responsibility for general surgery.
7 Q. So you could exhort for the return of audit material?
8 A. There would be an embarrassment that there was no return
9 from orthopaedic surgery, if that were the case, and it
10 would appear in the report.
11 Q. Having discussed this system of audit that was there at
12 the time, to what extent do you think the Trust Audit
13 Committee had its finger on the pulse of what was
14 happening in terms of audit across the Trust?
15 A. I think that question has to be put in the context of
16 the evolution of the process of audit, and its
17 development as a more robust tool for looking at
18 performance, and I have no idea, I have no comparative
19 understanding or knowledge of how we, as a Trust, fared
20 compared to other Trusts, for example, whether we were
21 particularly bad in that committee or particularly good;
22 I have no idea of benchmarking, other than simple
23 hearsay things in general conversation on visiting
24 another hospital, and perhaps seeing how small aspects
25 of audit were being carried out.
0085
1 Q. Is that an explanation -- perhaps a justification -- for
2 the answer to the question being that the Trust Audit
3 Committee did not have its finger on the pulse of audit
4 across the Trust?
5 A. I am trying to describe the situation as it was at that
6 time, and it is very easy, as we look back on it now, to
7 see it as something that perhaps did not have its finger
8 on the pulse, but some directorates were very vigorous
9 and have very good and active audit with closed loops
10 feeding back into patient care.
11 Q. I do not know if you have had the chance to see the
12 statement of Jill Bullimore at all, have you?
13 A. No, I have not.
14 Q. Can I show you a little extract from it, WIT 342/2? If
15 we go to paragraph 3, first of all, in 1994, towards the
16 end of 1994, we see she refers to a discussion with
17 Mr Wisheart. At paragraph 4, on 9th November 1994,
18 Mr Wisheart proposed that Dr Bullimore should be become
19 Chairman of the Clinical Audit Committee of the UBHT.
20 Could I ask you to read, please, paragraphs 5,
21 6 and then over the page, 7, 8 and 9? (Pause).
22 A. Thank you.
23 Q. If we go over the page, please, to page 3 ... (Pause).
24 A. Thank you.
25 Q. First of all, did you notice any difference in the
0086
1 approach of the Clinical Audit Committee between the end
2 of 1994 and the completion of Dr Bullimore's term of
3 office as Chairman in 1996, that she refers to in
4 paragraph 9?
5 A. I cannot recall a major change. There was a question of
6 looking at the resource and to be sure that it was being
7 used appropriately within directorates.
8 Q. To what extent do you agree or take issue with the
9 comments that Dr Bullimore makes in paragraphs 5 to 9?
10 A. I can see what Jill is saying, and I think it is similar
11 to my comments when the audit process for starters --
12 and we are looking at the evolution in the strengthening
13 and development of an audit programme, and Jill was part
14 of that process. So I can see that she would see a need
15 for change to make the process more robust.
16 Q. Is there any comment she makes in those five paragraphs
17 that you disagree with?
18 A. Would it be possible to go back, just for me to --
19 Q. Yes, of course. 5 and 6.
20 A. Well, the funds were certainly dispersed and there was
21 very little support centrally. I am a little surprised
22 at 6, because certainly we tried to produce as
23 comprehensive a report as we could, when I was surgical
24 co-ordinator, and I think we had one of the fuller
25 reports in surgery.
0087
1 The next paragraphs, please?
2 Q. Can we go over the page, please, to page 3? (Pause).
3 A. I am not too sure about the small audits. We tried to
4 pick topics of varying size. The topics can sometimes
5 be very easily accomplished because of volume of
6 patients and sometimes it is very difficult and you need
7 perhaps to scan patient outcomes for a year or more.
8 I cannot remember the paper that she produced for
9 clinical directors in 1995.
10 Q. She is suggesting that it was not necessarily, if even
11 at all, because of the lack of effort that the system
12 needed, as she puts it, some restructuring, but that
13 there was really a lack of focus or control or direction
14 to the audit process from the Clinical Audit Committee
15 of the Trust which was at the top of the "audit tree",
16 if you like.
17 A. That is right. Then we have the distinction between
18 clinical and medical audit that is beginning to emerge
19 and the coming together across disciplines to look at
20 outcomes, rather than this is just a surgical output.
21 I mean, we had been doing that in surgery and
22 I think all branches of surgery, where there had been
23 very good joint audits with our closest working
24 colleagues, anaesthetists.
25 Q. Let us turn, Professor, to something else.
0088
1 In the early part of 1993, what was your view of
2 the quality of paediatric cardiac surgery carried out at
3 Bristol?
4 A. I am not really sure, to know how to answer that.
5 I know it is a very bald and direct question. I think
6 at the beginning of 1993 I was aware of -- I use it in
7 statements "of noise and disquiet" in some quarters,
8 about the performance of paediatric cardiac surgery.
9 Q. Which quarters were those?
10 A. Again, it is difficult for me to be sure on timing, but
11 it probably was in 1993, but I cannot be sure, that
12 perhaps Professor Angelini had first voiced disquiet
13 about performance in paediatric cardiac surgery?
14 Q. Was, as you put it, "noise" coming from anywhere else?
15 A. Again, I have to be careful of trying to remember when
16 and where. I think that was more in 1994, that others
17 approached me. You may have to help by prompting with
18 specific examples of what I do not, I am afraid, recall
19 easily off the top of my head.
20 Q. Did you have any reason to think that Bristol's
21 performance in paediatric cardiac surgery or services
22 more widely was good?
23 A. It is a very difficult question to answer, because
24 I suppose in hospital settings, one gets a buzz or
25 a ring and some departments are totally quiet and one
0089
1 hears of no reputation or repute, and in others one
2 hears of some anxieties, general anxieties. I cannot
3 honestly recall when I first became aware of others'
4 concern in that area.
5 Q. The focus of the question was really the other side of
6 the equation: whether you had any reason to believe that
7 Bristol's performance in paediatric cardiac services was
8 good in 1993?
9 A. No reputation came out of Bristol as I looked at
10 Bristol, coming here as the Professor of Surgery, that
11 this was a centre of excellence for cardiac surgery or
12 was good for cardiac surgery. We know of various other
13 hospitals where that repute is good.
14 Q. So by 1993, you had heard, as you put it, "noise", which
15 you mean the expression of concerns, about the quality
16 of certainly paediatric cardiac services in Bristol?
17 A. Yes.
18 Q. From Professor Angelini, at least?
19 A. At least.
20 Q. You also, I think, in the early part of 1993, had
21 a conversation with Dr Bolsin?
22 A. That is also true.
23 Q. How well did you know Dr Bolsin at that time?
24 A. Hardly at all.
25 Q. Did you know who he was, what his job was?
0090
1 A. Yes. I knew he was a paediatric -- or tended to do most
2 of the anaesthetics for children with heart disease.
3 Q. So you would have known that he would frequently have
4 anaesthetised for Mr Wisheart and Mr Dhasmana?
5 A. I would not know that at all.
6 Q. If he did paediatric cardiac --
7 A. I do not know how often -- whether he worked with one or
8 both or -- I had no idea of knowing that. I still do
9 not know.
10 Q. But to the extent that he anaesthetised paediatric
11 cardiac work, it must be one or other of those two
12 surgeons?
13 A. Yes, presumably.
14 Q. Do you remember when Dr Bolsin had this conversation
15 with you? You say in your witness statement, if this
16 helps -- WIT 87/6, paragraph 21 -- that it was the
17 "early part of 1993."
18 At the GMC when you gave evidence, page 2 of my
19 version of your transcript, there was a suggestion that
20 it was no more than 4 to 5 months before September 1993
21 when you had another conversation with Dr Ashwell?
22 A. Yes.
23 Q. Is that still the best you can do?
24 A. That is the best I can do.
25 Q. So that would be the spring or very early summer of
0091
1 1993?
2 A. Yes.
3 Q. What was the circumstance of the meeting with
4 Dr Bolsin? Where did it take place?
5 A. I think he came to see me.
6 Q. In your office?
7 A. I think so, yes.
8 Q. What did he say?
9 A. That he had a concern about the performance of
10 paediatric cardiac surgery.
11 Q. So you knew that his concern was about surgical
12 outcomes?
13 A. Yes.
14 Q. Did you get the impression that he thought there was or
15 might be a problem with the quality of the surgery?
16 A. He talked about outcomes, and -- it is difficult to
17 remember, but I think he did either imply or talk
18 directly that he had a concern about the quality of
19 surgery.
20 Q. So to that extent, his concern must have been about the
21 quality of the work of Mr Wisheart or Mr Dhasmana, or
22 both?
23 A. Since they were the practitioners looking after children
24 with heart disease, yes.
25 Q. Do you remember whether the focus of his concern as
0092
1 expressed to you was about one or other, or mostly one
2 or mostly the other, of the surgeons?
3 A. I do not recall.
4 Q. Did you get the impression that his concern encapsulated
5 the work of both surgeons?
6 A. It would be more the latter.
7 Q. Both?
8 A. What you have just said, yes.
9 Q. Why should Dr Bolsin, do you think, come and share this
10 information with you?
11 A. I do not know.
12 Q. What did you think at the time?
13 A. I thought it strange.
14 Q. If you had been Dr Bolsin, with that information, would
15 you have gone to the Professor of Surgery?
16 A. No.
17 Q. Where would you have gone?
18 A. Well, it depends what other stages had been gone
19 through, but I would hope that the data, if data there
20 was, that purported to show a problem or possible
21 problem, that the data would have been shared and owned
22 by surgeons and anaesthetists, cardiologists, taking
23 care of the children with heart disease, and that such
24 data would have been discussed in audit meetings and
25 presented in audit meetings, and owned by the group.
0093
1 Q. We will come back to that concept later. What was your
2 impression of what Dr Bolsin wanted you to do as
3 a result of this conversation?
4 A. I think he was looking for advice about what to do with
5 the data that he had.
6 Q. Did he show you any data?
7 A. I believe he did, but I find it very difficult to
8 remember exactly what the nature is, and contrary to his
9 statement with regard to my own, I do not have and do
10 not ever remember receiving a folder of data. If such
11 data were in my possession, I would have released that
12 to the GMC, along with all my other papers relating to
13 the situation.
14 Q. We will come to what Dr Bolsin says. Do you remember
15 whether the data that he showed you referred to specific
16 procedures?
17 A. I think I remember correctly that it did.
18 Q. Do you remember which those were?
19 A. I am not sure whether it was switch or AV canal, or
20 VSD.
21 Q. You did I think at some stage receive data from
22 Dr Bolsin about each of those three procedures; is that
23 right?
24 A. Yes.
25 Q. Did the data that Dr Bolsin showed you discriminate
0094
1 between the results of one surgeon and the other?
2 A. I cannot remember such a discrimination, no.
3 Q. Did he show you any data which gave indications of
4 outcomes, of factors, other than simply whether the
5 patient was alive or dead, for example, time on bypass
6 or time in intensive care unit, or length of stay in
7 hospital?
8 A. No, I think it was pure mortality data.
9 Q. And what impact did this data have on you? What
10 conclusions or thoughts did you have, having seen it?
11 A. Two things, really. One was that from my perspective,
12 I had nothing with which to benchmark. The concept of
13 some of the operations, the complexity, the outcome
14 measures, are totally unknown to me in my own practice.
15 It does not come across to me in any professional
16 reading or continued education. I have no idea where to
17 benchmark any such data.
18 Then the second thought was, why is this data
19 being presented to me in the form that it is, and if
20 there is a concern about it, why is it not shared?
21 Q. Was the data that you saw on the face of it indicative
22 of high mortality?
23 A. As I recall it, the figures showed mortality rates
24 which -- again, I have to say again and repeat, I have
25 no idea of benchmarking, but the figures did show
0095
1 mortality that I would wonder about. If, for example,
2 that had crossed my desk as the audit co-ordinator
3 presenting to a report, I would have thought, "What is
4 the benchmark? What is the national average? Are these
5 patients high risk patients? Is there some explanation
6 for this?"
7 Q. Did you ask Dr Bolsin, for example, "This data, on the
8 face of it, looks surprising: how does it compare to the
9 national data?"
10 A. I cannot remember doing that. The thrust of my reply
11 would be that this data has to be owned and shared and
12 you need to look at what is the mechanism of any
13 problem, if there is a problem, if you are able to
14 benchmark, is there a problem? What are the likely
15 contributory factors?
16 More than any other surgery, the interaction
17 between anaesthetist and surgeon is in this particular
18 form of surgery -- more than any other, the patient
19 basically on bypass, and so on.
20 Q. Just before we come to what happened then, let us just
21 deal with what Dr Bolsin says, WIT 87/32. It is
22 a passage under the heading "Paragraph 21:
23 "I did contact Professor Farndon about my concerns
24 relating to paediatric cardiac surgical mortality in
25 1993."
0096
1 You agree with that comment so far?
2 A. That I met with him, yes.
3 Q. And you discussed paediatric cardiac surgical mortality?
4 A. Yes, we did.
5 Q. He says he provided you with "summarised data from the
6 Bolsin/Black audit and also summarised data on the
7 arterial switch mortality and the current data on the
8 AV canal mortality."
9 Pausing there, you do remember seeing data on the
10 arterial switch and the AV canal, although you cannot,
11 I think, be sure whether you saw that at the first
12 meeting with Dr Bolsin?
13 A. That is correct.
14 Q. Is that an accurate summary?
15 A. Yes.
16 Q. So he might have shown you data relating to those
17 procedures at the first meeting?
18 A. He may have.
19 Q. Then he says:
20 "I left hard copies of this data with Professor
21 Farndon in a clear plastic folder."
22 Do you remember him not doing that, or do you
23 simply not remember whether he did or did not leave you
24 data?
25 A. Well, I am a great hoarder of paper. You just need to
0097
1 look round my office and my secretary's office. If it
2 were there, I would have it and would have submitted
3 it. I have no recollection of receiving and keeping
4 a folder of data from Dr Bolsin.
5 Q. So you do not remember delivering up the plastic folder
6 to the GMC?
7 A. I do not remember doing that.
8 Q. And it is because you do not remember doing that, that
9 you suspect you might not have had it in the first
10 place; is that right?
11 A. That is right, yes.
12 Q. When we were discussing earlier why Dr Bolsin should
13 have come to you with this concern, and I asked you
14 where you would have gone if you had been him, you said
15 that it was important that the data should be shared and
16 owned by those who were directly concerned with the care
17 of the patient -- words to that effect?
18 A. Yes.
19 Q. If we shift the focus from the people who were directly
20 concerned with the patients and look at the hierarchy,
21 if you like, of where this type of concern might be
22 taken, we have various different options, have we not?
23 We have the various divisions. There is the division of
24 anaesthesia. There is the Professor of Anaesthesia,
25 Professor Prys-Roberts. There are clinical directors in
0098
1 the directorate structure. There is the Medical
2 Director of the hospital, and there is the Chief
3 Executive of the hospital.
4 To what extent would those be appropriate places
5 to go with concerns of this nature, if one was
6 a consultant such as Dr Bolsin?
7 A. You think about those higher levels if a mechanism
8 within the directorate had failed to address the issues.
9 Q. Let us assume for the moment that it had.
10 A. Then the next port of call for me would be the Audit
11 Committee.
12 Q. Dr Thomas's committee -- Dr Bullimore's committee?
13 A. Dr Bullimore's committee.
14 Q. Why?
15 A. Presumably it would spill higher because people were
16 unwilling or finding it difficult to address a problem
17 of performance. I have no idea of whether that was the
18 case which obtained or not. But if there was some
19 mechanical or philosophical problem of getting the
20 question posed and addressed in an audit fashion within
21 a cardiac directorate, then presumably this was exactly
22 what Dr Bullimore was looking for: proposals to examine
23 this particular issue.
24 Q. There is an assumption in that question that those
25 directly concerned had not managed to sort out among
0099
1 themselves what the data said and what the implications
2 were.
3 What was your response to Dr Bolsin?
4 A. My response was that this was the route to go: that any
5 audit has to be carried out with the knowledge of all
6 participants looking after the care of those particular
7 patients, with clearly defined objectives and with
8 a mechanism for closing a loop, so that he would have to
9 go to the Directorate of Cardiac Surgery and report
10 those findings and say, "Is there a problem? How do
11 these results benchmark? Have you got any data on the
12 risk of each particular child? Were these all high risk
13 patients? Average risk? Low risk? Were there other
14 contributory factors, anaesthesia, cardiology, that led
15 to these outcomes?"
16 Q. You say in your statement at page 7, the top of the
17 page, paragraph 21:
18 "I would encourage its [the data's] discussion by
19 all colleagues in the Cardiac Directorate."
20 A. Yes.
21 Q. How did you do that when Dr Bolsin came to see you in
22 1993?
23 A. I would tell him to do that.
24 Q. So you would tell him, Dr Bolsin, "Go away and discuss
25 this with your colleagues in the cardiac field"?
0100
1 A. "This has to be shared and owned by everyone concerned
2 in the care of those infants."
3 Q. So it was important that all those directly concerned in
4 the care of these patients should have been aware that
5 Dr Bolsin had this data, so they could all sit down and
6 work out what it really meant?
7 A. Not only that; that everyone, before the data gathering
8 had begun, was aware that this was a process of audit
9 and knew that they were contributing to the data and its
10 analysis, so that the data is gathered with everyone
11 knowing, looking at the risk management of patients so
12 that the data can be meaningful.
13 Q. So as part of that process, the audit data would have to
14 be shared with the surgeons?
15 A. It would have to be shared with the surgeons, with every
16 anaesthetist who put those children to sleep for their
17 surgery, with the cardiologists, if they had to do with
18 their care perioperatively, perhaps with nursing staff,
19 to ensure that if there were a nursing contribution to
20 outcome, that was documented.
21 Q. Have a look at paragraph 22. You say you would not have
22 been able to come to any significant and meaningful
23 conclusions from that data unless there had been gross
24 anomalies.
25 Was it your opinion that the data from Dr Bolsin
0101
1 did not show gross anomalies?
2 A. I have to say I hardly know what a switch operation is,
3 let alone what the outcome should be. I have no idea
4 whatever. Even now, I do not know what would be
5 a benchmark, what would be the 50 per cent performance
6 of all the units of paediatric cardiac surgery. It is
7 not within my domain to know.
8 Q. So does that mean, no, you did not detect any gross
9 anomalies?
10 A. I do not know what gross anomalies are. If all of them
11 had died, then I think I would be asking the question,
12 but there could be conditions that I did not know about
13 where that sort of outcome might occur. It would
14 certainly pose the question, "What are we operating on
15 these children for?", if the outcome is so bad from
16 a surgical intervention, unless there is no other
17 intervention that could be given.
18 Q. You said you were only able to give general advice about
19 how to go about audit and so on. Dr Bolsin was, at that
20 time, a recognised expert in the field of audit, was he
21 not?
22 A. You say so.
23 Q. Did you know that?
24 A. I did not know that.
25 Q. Do you know that now? That he had some reputation in
0102
1 the audit field?
2 A. I hear that he is.
3 Q. But at the time, you had no particular view?
4 A. No. And if that were the case, I am disappointed that
5 the audit was not carried out in a more standard fashion
6 with the involvement of all concerned.
7 Q. Did you think that Dr Bolsin was coming to you for
8 general advice about how to go about audit, or was he
9 bringing you particular concerns about particular
10 surgeon or surgeons in particular operations?
11 A. I presume he was coming perhaps for two reasons:
12 (1) that I had been the audit co-ordinator for surgery;
13 and (2) that he had some idea that my stance might be
14 one of equity and be one of providing some help in
15 a situation that he found difficult.
16 Q. You said you did not particularly expect Dr Bolsin to
17 come back to you. You did have further conversations
18 with Dr Bolsin about the surgery, I think; is that
19 right?
20 A. I believe so.
21 Q. Do you remember how long it was before he came back to
22 you?
23 A. I cannot remember off the top of my head.
24 Q. Did you discuss the nature of the conversation you had
25 had with Dr Bolsin with anyone else?
0103
1 A. Probably with Professor Angelini.
2 Q. Why him?
3 A. Or he with me, rather than my initiating it.
4 Q. Because he may have known from Dr Bolsin that Dr Bolsin
5 had been to see you?
6 A. Yes.
7 Q. Anyone else?
8 A. Other people certainly knew about Dr Bolsin's data, and
9 it might have also been Sheila Willatts, or ...
10 Q. You did not discuss it with Mr Wisheart, for example?
11 A. I did not.
12 Q. Mr Dhasmana?
13 A. At that time, no, I did not.
14 Q. Dr Roylance?
15 A. No, I did not.
16 Q. Discussing it with at least the first two of those,
17 Mr Wisheart and Mr Dhasmana, would have been an obvious
18 way, would it not, to have encouraged the discussion of
19 the data by all the colleagues in the Cardiac
20 Directorate?
21 A. I would throw the question back and say, why is that the
22 responsibility of the Professor of Surgery to be
23 speaking to colleagues with whom you are working day in,
24 day out, week after week?
25 Q. Mr Langstaff very fairly reminds me I used the
0104
1 expression "Cardiac Directorate" which I actually took
2 from paragraph 21 of your statement. I think it is
3 right that cardiac services as a directorate was not
4 fully fledged until April 1994, but there were various
5 subdirectorates of cardiac surgery and so on.
6 I think what we are talking about are the
7 clinicians involved in the case with cardiac patients.
8 A. Exactly.
9 Q. So when you say you would throw the question back,
10 essentially you saw it as Dr Bolsin's responsibility to
11 take his data to, for example, the surgeons and the
12 other anaesthetists and the cardiologists and make sure
13 that it was discussed?
14 A. Absolutely.
15 Q. Are you aware of whether Dr Bolsin ever did initiate
16 that type of discussion with all of those involved in
17 the care of the patient?
18 A. No.
19 Q. Did you ever ask him if he had?
20 A. I think I must have, because the thrust has always been
21 from me that the data has to be shared and owned by all
22 concerned in the care of those children.
23 Q. When I asked you why Dr Bolsin came to you, whether you
24 thought he was coming for general advice or whether he
25 was bringing you particular problems with particular
0105
1 surgeons in particular operations, you said you presumed
2 he was coming for two reasons: (1) that you would be the
3 audit co-ordinator for surgery, and hence I assume would
4 be in a position to give some general advice about the
5 carrying out of audit; and (2) that he had some idea
6 that your stance might be one of equity, and might be
7 one of providing some help in a situation that he found
8 difficult.
9 What "help" were you referring to?
10 A. The advice that he needed to be sure that everyone could
11 agree his data, and then to benchmark and see whether
12 there was a problem.
13 Q. So the help you provided was to tell him, give him
14 general advice about benchmarking his audit?
15 A. About the process -- advice about audit in general.
16 Q. And then telling him to discuss it with the other people
17 involved in the care of children?
18 A. Absolutely.
19 Q. Which bit of that was the situation, as you put it, that
20 Dr Bolsin found difficult?
21 A. I do not know.
22 Q. He was obviously having some difficulty or other, was
23 he?
24 A. I do not know.
25 Q. Was he having some difficulty in getting his concerns
0106
1 listened to by people with influential positions at the
2 hospital or University?
3 A. I would hope not. I can understand how, to use your
4 words, people in positions of responsibility might be
5 off-putting or rejecting of such information, but it was
6 not a problem or a style that I was used to in any other
7 audit domain that I had worked with.
8 MR MACLEAN: Sir, I think it may be a moment or two longer
9 before I can move on to the next topic. I am conscious
10 that it is now 1 o'clock. I wonder if this is
11 a convenient moment to take a break?
12 THE CHAIRMAN: Yes, why do we not do that, until 1.45,
13 then? We will take a break now and reconvene at 1.45.
14 (1.05 pm)
15 (Adjourned until 1.45 pm)
16 (1.45 pm)
17 MR MACLEAN: Professor Farndon, do you remember, just before
18 lunch, we were discussing one of your answers when I had
19 asked you whether or not Dr Bolsin came to you to seek
20 general advice, or whether he came with particular
21 concerns about particular surgeons and particular
22 operations, and you gave a two-fold answer, that first
23 of all you were the audit co-ordinator for surgery, and
24 secondly, your stance might be one of equity, and you
25 might provide some help to the situation he found
0107
1 difficult.
2 Can we be clear by looking at the first of those
3 two answers that when you refer to your position as
4 audit co-ordinator for surgery, the particular
5 assistance you could give to Dr Bolsin would have been
6 from your experience of being audit co-ordinator, your
7 knowledge of essentially how to conduct an audit?
8 A. Having been audit co-ordinator, I would have perhaps
9 known how best to deal with information that he had.
10 Q. In the second part of your answer, it has three concepts
11 in it: that your stance might be one of equity?
12 A. Yes.
13 Q. What do you mean by that?
14 A. I would hope that if there were a difference of opinion
15 on performance from different areas, I might be able to
16 help to mediate in that situation.
17 Q. So you would have some active role in an even-handed way
18 in trying to reconcile differing positions?
19 A. If such obtained.
20 Q. If, on analysis, there were a difference to be mediated?
21 A. Yes.
22 Q. You also suggested that you might provide some help to,
23 in this case, Dr Bolsin. The nature of that help would
24 be, would it, this mediating type of role?
25 A. Mediating and advice on how to take forward the data.
0108
1 You say Dr Bolsin was an acknowledged expert in audit.
2 He eventually became a member of the Audit Committee.
3 He could have presented the audit data there, for
4 example.
5 Q. You also mentioned that you think that Dr Bolsin might
6 have come to you because you could provide some help in
7 the situation that he found difficult. What was the
8 difficulty?
9 A. I do not know.
10 Q. What Dr Bolsin would have to do, as you saw it, would be
11 first of all to conduct the audit appropriately? That
12 would be the first thing?
13 A. There might be something before that. That if an audit
14 had been carried out without prospective knowledge and
15 without questions and clear objectives set out by all
16 who had concerns with the care of infants with heart
17 disease, if that first condition had not been achieved,
18 that that is really not a way to conduct audit.
19 Q. The fact was that Dr Bolsin had got himself to the stage
20 of having produced some data?
21 A. Yes.
22 Q. Which he shared with, amongst others, you?
23 A. Yes.
24 Q. Having got to that stage, the appropriate thing for him
25 to do, as far as you saw it, was first of all to ensure
0109
1 that the audit data was validated and so on, properly
2 conducted audit, and secondly, to share it with the
3 other clinicians involved in the care of those patients?
4 A. Absolutely essential.
5 Q. And so to the extent that Dr Bolsin was having some
6 difficulty with this two-stage process, his difficulty
7 must have been either in the technical business of
8 concluding the audit, and/or sharing it with the other
9 clinicians?
10 A. I am not sure that I was aware of that difficulty at
11 that time.
12 Q. Was not the difficulty that Dr Bolsin was having the
13 difficulty of having his concerns listened to, either by
14 those who were involved in the care of the patients
15 themselves, or indeed by others in positions of power
16 and influence in the Trust?
17 A. You use the words "power and influence in the Trust"
18 again. I know what you are suggesting. I come back to
19 the point that the data needed to be shared. If you
20 have especially sensitive data, that needs to be owned.
21 You cannot broadcast that abroad without it having been
22 validated and endorsed.
23 Q. You say "broadcast abroad". To whom had Dr Bolsin
24 broadcast the information, the data, abroad?
25 A. I am sorry, perhaps that was too broad a statement, but
0110
1 there were obviously others that had seen that data.
2 Q. Was it your opinion that it was inappropriate for
3 Dr Bolsin to bring this data to you before it had been
4 discussed openly among all the clinicians involved in
5 the care of the patients?
6 A. If he was coming to me with a clear message that he had
7 openly discussed both prospectively before the audit was
8 commenced and subsequently when the results were
9 obtained, that there was then difficulty, I would be
10 very happy to represent his view and help present that
11 data, for example, to the Audit Committee.
12 Q. If the key notion was that the data should be shared
13 among those who were responsible for the care of the
14 patients, did it particularly matter whether the
15 sharing, if you like, was initiated by Dr Bolsin with
16 the other people involved, or by somebody else?
17 A. I think it particularly is important that it is shared
18 by those concerned in the care of those patients to
19 which that data pertained.
20 Q. If it was your overriding concern that the data should
21 have been shared among all those who had care of the
22 patients involved, why could you not have taken the
23 data, taken the information you had got from Dr Bolsin,
24 to Mr Wisheart or Mr Dhasmana, or both, and said, "You
25 need to know about this. For some reason, Dr Bolsin has
0111
1 not shared it with you, but it is very important for
2 this unit that you all know about this, and if he will
3 not share it with you, then you share it with him"?
4 A. It is very easy now with hindsight looking at it and
5 answering that question. The first step needs to be the
6 sharing and validation of the data.
7 Q. Did you ask Dr Bolsin whether he had made any attempt to
8 share his data with people more directly concerned with
9 the care of patients than you?
10 A. I cannot recall with certainty, but I do believe that
11 I did ask.
12 Q. If you believe that you asked, do you remember what the
13 response was?
14 A. Again, it is very difficult because it is so long ago,
15 but I do not think he had made an attempt to share that
16 data.
17 Q. And you suggested he should?
18 A. Yes. I had never ever been in a situation before of
19 a surgical co-ordinator receiving or hearing in this way
20 of data presentation regarding audit.
21 Q. You refer there to the "surgical co-ordinator". Was it
22 your impression that Dr Bolsin was coming to you with
23 you wearing your hat as surgical co-ordinator for the
24 Division of Surgery?
25 A. I cannot remember whether I was still wearing that hat
0112
1 at that time. Perhaps you have a statement which says
2 that I was. I cannot remember. But I do not believe
3 I was wearing that hat anyway.
4 Q. Which hat do you believe Dr Bolsin saw you as wearing?
5 A. I really am not sure. Perhaps one of the more
6 influential people in the Trust.
7 Q. One of the more influential people among the surgeons in
8 particular?
9 A. In particular, perhaps. I have no idea.
10 Q. Did you believe it to be true, the data that Dr Bolsin
11 showed you?
12 A. I have no idea. I had no idea then.
13 Q. If it were true, would it be important that it was
14 shared urgently with the surgeons?
15 A. The whole thing was crying out for him to share that
16 data with the surgeons.
17 Q. Did it matter whether the data was true or not true?
18 The very fact that this data had been produced at all
19 had to be shared with the surgeons, did it not?
20 A. That is what I was persuading him to do.
21 Q. If we go to page 9 of your witness statement, WIT 87/9,
22 paragraph 31, you say:
23 "My colleagues did not provide me with any
24 tangible objective evidence that had been uniformly
25 agreed in respect of their concerns in cardiac surgery."
0113
1 There are three concepts there: tangibility,
2 objective and uniform agreement.
3 As a matter of principle, is it the case that
4 tangible and objective evidence is capable in principle
5 of indicating poor results and raising a question over
6 the quality of care as a result, without the agreement
7 of the surgeon whose results are called into question?
8 A. You are asking me to split off those three qualifying
9 terms that I would prefer not to be forced to do,
10 because I think the pivotal thing is that there is
11 agreement that the data is tangible or obvious, and
12 objective.
13 Q. Those are the first two. The one I was seeking to split
14 off is the third one. If you have tangible objective
15 evidence that, let us say, a particular surgeon in
16 a particular procedure has results which are
17 concerningly bad --
18 A. Concerningly --
19 Q. Which appear to be poor, and sufficiently poor to be
20 worrying, you do not need, do you, the uniform agreement
21 of everybody before action ought to flow?
22 A. If you have one specialist colleague in anaesthesia
23 providing evidence about an outcome from another
24 specialty group, there could be all sorts of reasons how
25 and why that evidence might be provided. My best belief
0114
1 of its certainty is if it came with the endorsement of
2 the group.
3 Our audit data submissions were endorsed by all
4 members of the group.
5 I have also said to you that I had no idea where
6 to begin to benchmark any data that might be put before
7 me.
8 Q. But it takes us back to what Dr Bolsin was trying to
9 achieve by showing you the data. You would not have
10 expected him to bring you the data and ask you as
11 a general surgeon, without a specialism, removed from
12 cardiac surgery, to validate the data that he was
13 presenting you with? That would have been a strange
14 request?
15 A. Very strange, and I would not have been able to do it.
16 Q. And you did not understand that that is what he was
17 doing?
18 A. No. But I also know that in the audit process there are
19 other things which feed on outcome measures, whether
20 these are mortality or morbidity, and I know, and knew,
21 that there were other things that could feed on those
22 data, whether they were right or wrong.
23 Q. Are you suggesting that it is a necessary condition for
24 taking audit data seriously, if you like, that it is
25 tangible, objective and uniformly agreed by all the
0115
1 clinicians involved?
2 A. That is the best quality data. There is no argument
3 then, because --
4 Q. I mean the best quality data, but is it necessary that
5 all the conditions are satisfied before you would be
6 prepared to take audit data seriously?
7 A. In my own domain, and outside it, I would prefer it that
8 way, yes.
9 Q. That is a different point. Is it necessary to have all
10 three conditions satisfied before one ought to look
11 seriously at this type of audit data? Unless it is
12 owned by all the clinicians involved in it, it is not to
13 be treated seriously?
14 A. I am not saying it is not supposed to be treated
15 seriously. I am saying that the quality of the data, if
16 endorsed by all parties, must be of the highest level.
17 If it is less, then we still go back to the process that
18 you have to go back and say, "This is some data that
19 I have. What are your opinions on this?", from the
20 surgical point of view, from the cardiological point of
21 view.
22 Q. So it is not necessary that all three conditions would
23 be satisfied, but the satisfaction of those three
24 conditions would provide, if you like, the gold
25 standard?
0116
1 A. That is right.
2 Q. So in this case, Dr Bolsin brought you data which, on
3 the face of it, showed results which, without you having
4 any benchmark available readily to refer to, showed
5 mortality which, on the face of it, was high for these
6 particular procedures, and it was important, as you saw
7 it, that that data should be shared by the clinicians
8 involved in the care?
9 A. Yes.
10 Q. And you left it to Dr Bolsin to initiate that process?
11 A. Yes.
12 Q. Did you ask Dr Bolsin to follow up whether or not he had
13 made any progress in sharing this data with the other
14 clinicians?
15 A. I cannot remember.
16 Q. This is the early summer or late spring of 1993, is it
17 not, this contact with Dr Bolsin?
18 A. Yes, the initial contact.
19 Q. You yourself, leaving aside for a moment the meeting of
20 23rd December 1993, to which we will come, leaving that
21 that aside for the moment, you yourself had
22 a face-to-face discussion with Mr Wisheart about these
23 matters in November 1994?
24 A. I did.
25 Q. But not in-between times; not in-between Dr Bolsin
0117
1 seeing you in the late spring or early summer of 1993
2 and November 1994?
3 A. I do not believe I did, no.
4 Q. And you will correct me, I am sure, if I am wrong. You
5 did not, I think, certainly before the operation on
6 Joshua Loveday, have a face-to-face discussion with
7 Mr Dhasmana?
8 A. No, I did not.
9 Q. There was never any debilitating factor preventing such
10 a discussion once you were in position or had knowledge
11 of the data that Dr Bolsin presented to you in 1993?
12 A. Except that our paths and the directorate's rarely
13 interacted.
14 Q. There is an internal telephone system?
15 A. There is, yes.
16 Q. Do you accept that the data that Dr Bolsin showed you
17 was tangible?
18 A. There were figures there.
19 Q. Was it objective?
20 A. I have no way of knowing.
21 Q. How would its objectivity or lack of objectivity be
22 ascertained?
23 A. By cross-reference to be sure that all the children so
24 listed had been so listed and that the results so
25 collated had been cross-referenced and cross-checked.
0118
1 Q. So that would be a matter of the technical carrying out
2 of the audit process?
3 A. But vitally important. I think the group may have seen
4 discussion over the VSD results, for example, where the
5 objectivity of those results was not spotted by the
6 Professor of Cardiac Surgery, or cross-checked.
7 Q. A little earlier on we had a discussion about what the
8 appropriate response to this type of data was, and you
9 said it is important for all those involved in the case
10 to share and own the data.
11 In a situation where either that does not take
12 place, for whatever reason, or there is an attempt to do
13 it and the parties simply cannot agree, I asked you what
14 would be the next port of call. I think you mentioned
15 Dr Bullimore's Audit Committee.
16 If a consultant has a concern about the
17 performance of, let us say, a surgeon in the hospital in
18 which he or she works, without having carried out an
19 audit -- a formal, tangible, objective audit -- has
20 a concern, would it be appropriate in principle to take
21 such a concern to the Medical Director of the hospital?
22 A. I think it would, yes.
23 Q. Would that be the most appropriate place to take such
24 a concern, in general?
25 A. Where this is a subjective impression about
0119
1 a consultant's performance?
2 Q. Where no formal audit has been carried out, but the
3 consultant reasonably or honestly believes that he or
4 she has reason to question the competence of a surgeon.
5 A. The initial concern could be carried out at directorate
6 level, so the director of that specialty area might be
7 approached initially.
8 Q. What about the situation when a concern such as that was
9 actually about the person who, at that time, was himself
10 a Medical Director, so that that avenue of taking
11 a concern forward would not be available?
12 A. Then another avenue, presumably, might need to be
13 found.
14 Q. What would that be?
15 A. It might be the Chief Executive of the Trust or the
16 Chairman of the Trust Board.
17 Q. Those would be the obvious two, because they would be
18 higher up the tree?
19 A. Yes. It could still be to colleagues lower down the
20 tree, to use your words, that one might entrust such
21 a concern.
22 Q. You yourself did not have any discussions about
23 Dr Bolsin's concerns, or the concerns Professor Angelini
24 had expressed to you with Dr Roylance?
25 A. Not that I remember, no.
0120
1 Q. Who else did you understand Dr Bolsin to have shown his
2 data to, or discussed his concerns with?
3 A. I cannot remember.
4 Q. You have mentioned Professor Angelini?
5 A. Professor Angelini talked to me about the data, so
6 I know that he is definitely someone who had seen it.
7 Q. Anyone else?
8 A. Dr Black had been party to the data. I do not know how
9 widely it was shown or declared within anaesthesia.
10 Q. What about Professor Prys-Roberts in anaesthesia?
11 A. He certainly knew about it at some stage. At what
12 stage, I am not sure.
13 Q. What about Professor Vann Jones?
14 A. I do not know.
15 Q. You had a discussion with Dr Ashwell, did you not?
16 A. I did.
17 Q. Who did you understand Dr Ashwell to be? What was her
18 post?
19 A. She worked in the Department of Health.
20 Q. As a Senior Medical Officer?
21 A. I believe so.
22 Q. If we go in your witness statement to WIT 87/8, please,
23 in paragraph 25 at the top of the page -- I will read
24 you the sentence that goes before on the previous day:
25 "During September 1993, I was at a meeting at the
0121
1 Department of Health of the Acute Sector Panel of which
2 I was Chair. Dr Ashwell from the Department of Health
3 was an observer. She approached me after the meeting to
4 see if I could spare some time to talk to her."
5 Then you see what is said in that paragraph. How
6 many discussions did you have with Dr Ashwell about
7 Dr Bolsin's concerns?
8 A. The one at that particular meeting.
9 Q. You had one discussion with her?
10 A. As far as I remember, yes.
11 Q. You say in your statement that this discussion took
12 place during September 1993. Are you sure that that is
13 the correct time-scale?
14 A. I think we got the date for that meeting from a diary
15 which logged my attending a meeting in London at the
16 Elephant & Castle.
17 Q. So you have no direct recollection that it was
18 September?
19 A. None whatever. I am afraid my memory does not work so
20 well.
21 Q. If we have a look at UBHT 61/265 -- maybe you have never
22 seen this letter before. There is no reason why you
23 should have done. It is from Dr Ashwell to Dr Bolsin,
24 dated 13th December 1993. Do you see in the first
25 paragraph:
0122
1 "You [that is Dr Bolsin] spoke to me in conference
2 last Thursday. By complete coincidence, John Farndon
3 spoke of the same matter to me on Friday."
4 That would suggest that the discussion took place
5 in the few days leading up to 13th December?
6 A. Yes. That almost implies that I initiated that.
7 Q. We will come to that. Just looking at the date, might
8 it not be that the discussion with Dr Ashwell was in
9 fact in the first couple of weeks of December 1993,
10 rather than September?
11 A. That is a good memory prompt, but I have no idea of
12 being shown that is the case. I am willing to accept
13 that it is.
14 Q. If we go back to your witness statement -- we will come
15 back to that letter for that point you have rightly
16 picked up. WIT 87/8, the top of the page, the end of
17 the paragraph. You say you were both aware of
18 statistics being prepared by Dr Bolsin.
19 Are those different statistics from the ones you
20 had already been shown by Dr Bolsin?
21 A. I presume they were the statistics already prepared.
22 So "were being" is ...
23 Q. That suggests work in progress.
24 A. Yes, it does, I am sorry.
25 Q. Is that not the impression --
0123
1 A. I am sure that I must have been aware that statistics
2 had been prepared by Dr Bolsin.
3 Q. Then the penultimate sentence:
4 "In general terms, we discussed the concerns that
5 some people had about paediatric cardiac surgery."
6 Who were the people who had concerns and what were
7 the general terms of your conversation?
8 A. These would be mainly people such as Professor
9 Angelini. I am not sure, again, at what stage others
10 spoke to me, whether people like Sheila Willatts or
11 Cedric Prys-Roberts spoke to me around that time.
12 Q. So the people you are specifically referring to, would
13 be Dr Bolsin and Professor Angelini?
14 A. Yes.
15 Q. And perhaps Professor Prys-Roberts and Dr Willatts?
16 A. Perhaps, I cannot be sure.
17 Q. Then you say:
18 "Something was discussed about the mechanisms by
19 which those concerns had arisen" so that is a historical
20 discussion, "and about the ways forward, to either
21 substantiate or refute the concerns."
22 What were "the ways forward"?
23 A. The ways forward were again an endorsement of the data.
24 Q. You mean the --
25 A. The Bolsin data.
0124
1 Q. The tangibility, objectivity and agreement of the data?
2 A. Yes.
3 Q. So what would your involvement be in those ways forward?
4 A. I had no formal responsibility in that regard. I mean,
5 I felt that this was almost like "gossip in corridor"
6 conversation to someone that had no direct
7 responsibility in these areas.
8 Q. Wait a minute. This is a Senior Medical Officer of the
9 Department of Health taking you aside, after a meeting
10 about something else completely different, and raising
11 with you a concern, as you put it, about performance in
12 the paediatric cardiac unit in Bristol. It is not
13 a corridor discussion in that sense, is it?
14 A. But in some ways it is. I am sorry, I do not mean to
15 challenge what you have said, but put another way, here
16 is a Senior Medical Officer in the Department of Health,
17 if she does believe the data, is in possession of data,
18 why does she have to have a meeting with me that was by
19 chance? Why does she not, if she is in possession of
20 information -- I have to say, I found it strange and
21 slightly disconcerting that she pulls me out of
22 a meeting to talk about something that I was not at the
23 Elephant & Castle to deal with.
24 Q. Your statement says she approached you after the
25 meeting.
0125
1 A. Yes.
2 Q. As opposed to extracting you from the meeting?
3 A. Well, it was after the meeting had finished, yes.
4 Q. Did you think it was inappropriate for Dr Ashwell to
5 have this conversation with you?
6 A. I found it strange, and as I say, disconcerting, and
7 I honestly at that time did not know what to make of it,
8 because was she aware in a formal sense that she had
9 been advised of data from Dr Bolsin? I did not know
10 where it came from.
11 Q. What did she say?
12 A. I cannot remember.
13 Q. You could have asked her whether she was aware?
14 A. I am sure perhaps I did, but I honestly cannot remember
15 with that degree of detail.
16 Q. When you say the meeting was disconcerting, was it
17 disconcerting because of the content of the discussion,
18 or was it disconcerting because it took place at all?
19 A. I just found it strange and almost unreal that here was
20 someone from the Department of Health, knowing about
21 issues and talking to me after a meeting was complete
22 when other business was being done, and I suppose one
23 had to think, "Is the Department of Health knowing about
24 this formally, informally? Is this a formal approach to
25 me to do something about this? Am I still part of
0126
1 a process of trying to help this situation?"
2 Q. So would it be fair to say that if the Department of
3 Health was, as you put it, formally aware and wanted you
4 formally to do something about it, this would be an
5 inappropriate forum to raise it with you, in your
6 opinion?
7 A. Yes. I mean, the conversation was mixed with some
8 social chitchat about some people we both knew in
9 anaesthetics and so on and so forth. I did not know
10 exactly what its purpose or position was.
11 Q. So you thought it was a strange thing for Dr Ashwell to
12 do?
13 A. Not really, because doctors often chitchat in sort of
14 corridors or when they meet, but this sort of came out
15 of the blue.
16 Q. We looked at that last paragraph about "the ways
17 forward". I asked you what your role would be in taking
18 the matter forward.
19 As a matter of substance, you did not see yourself
20 as having any role in taking the matter forward?
21 A. Well, I think, when we had our informal talk last night,
22 that every one of us is so burdened with our own
23 responsibilities in our own domain, one hopes that one
24 does not have to assume responsibilities from areas
25 where there may be no area of expertise, no professional
0127
1 interaction whatsoever. And I felt up to that point
2 that I had given advice as well as I could.
3 Q. To Dr Bolsin?
4 A. To Dr Bolsin and to Professor Angelini and to others who
5 have said to me about the situation: "Talk together. Is
6 there a problem? Is there not a problem?"
7 Q. Had a Senior Medical Officer at the Department of Health
8 ever raised this type of matter with you before, in your
9 career?
10 A. I had not really had the privilege of meeting so many
11 senior medical officers in my career before, I do not
12 think. The only other one I have ever remembered
13 meeting was Jeremy Metters, and that was again in
14 a committee situation.
15 Q. So you never had this type of experience before?
16 A. No.
17 Q. What did you understand Dr Ashwell's role to be in
18 taking the thing forward, the ways forward you refer to
19 in that paragraph?
20 A. I have no idea. I did not know what her position was,
21 whether she had responsibility for audit activity, for
22 professional conduct, for -- I do not know. We had been
23 at a meeting which was looking at Acute Sector Panel
24 health prioritisation, so this was in a completely
25 different context.
0128
1 Q. So you cannot help us with what the substance of her
2 role was going to be in taking the thing forward, and
3 you did not see yourself as having any role either, as
4 a matter of substance, in taking it forward?
5 A. If a Senior Medical Officer had said to me, "Look,
6 Professor Farndon, there is a problem here and we want
7 you to particularly do it" and that was flagged as
8 a very objective or clear statement to me, I would take
9 that very seriously. But I do not know what to make of
10 a medical officer -- I was not sure I was really fully
11 aware of her status at that time -- speaking apparently
12 informally to me in a separate office about these
13 matters.
14 Q. What difference does it make whether she speaks to you
15 formally or informally?
16 A. I am trying to hint that if there were a clear
17 instruction that she had a concern, it was in her domain
18 to have responsibility for clinical performance and that
19 she knew, for example, that there was a problem in
20 Bristol, if she wanted me to be part of that, and
21 a clear signal had come to me from her that this was
22 a responsibility she wanted me to take, I would take it
23 very seriously.
24 But as I say, this was admixed with a chat about
25 other anaesthetic colleagues that she knew and I knew.
0129
1 I remember talking about motor racing and things.
2 Q. Let us look at her letter again, UBHT 61/265, a letter
3 to Dr Bolsin of 13th December.
4 You picked up straight way in the first paragraph
5 of her letter:
6 "By complete coincidence, John Farndon spoke of
7 the same matter to me on Friday. I did not mention
8 you. This letter includes what I expect you would
9 receive, were you to write ..."
10 Is it your recollection that you raised the matter
11 first with her, or she raised it with you?
12 A. My recollection was that she raised it with me and
13 invited me to walk around to another office block of the
14 Elephant & Castle, to talk to me. I was ready to get
15 the train back to Bristol after the meeting.
16 Q. In your statement in the paragraph we have looked at,
17 25, you say:
18 "At this stage both Dr Ashwell and I were aware
19 that statistics were being prepared" and we dealt with
20 the "were being" by Dr Bolsin.
21 She says "I did not mention you to Dr Bolsin", but
22 your evidence is that Dr Bolsin, being one of the
23 sources of concerns, was discussed between you and
24 Dr Ashwell?
25 A. I presume so.
0130
1 Q. The meeting that you were at to discuss the Acute Sector
2 Panel: where did that meeting take place?
3 A. In one of the office complexes of the Elephant & Castle.
4 Q. So in that big tower block at the Elephant & Castle?
5 A. Yes. If you stand with your back to the tube station,
6 it is the one behind you on the right, and I remember
7 walking around the apex of the block to another block in
8 which her office was.
9 Q. So it was a separate building?
10 A. Yes.
11 Q. How long did it take to get there?
12 A. It would only take five or ten minutes.
13 Q. And you discussed the matter as you went along?
14 A. I honestly cannot remember.
15 Q. Did you yourself ever receive any correspondence with
16 the Department of Health about paediatric cardiac
17 surgery in Bristol?
18 A. Not that I remember.
19 Q. Or see any?
20 A. Not that I remember.
21 Q. This is the very last part of 1993. This letter of
22 13th December 1993 is 10 days before a meeting that took
23 place involving you and Professor Angelini, and
24 Mr Wisheart; is that right?
25 A. Yes.
0131
1 Q. At that time, late 1993, how would you describe
2 Mr Wisheart's position in the UBHT?
3 A. I really find that question very difficult. Just
4 because of an inability to know in fact whether James
5 was still Chairman of the HMC or whatever at that time.
6 I find it very difficult to remember.
7 Q. He was one of the most important, if you like, doctors
8 in the Trust?
9 A. He was one of the older-established consultants in the
10 Trust.
11 Q. One of the most influential surgeons?
12 A. One who was respected and therefore chosen for his
13 position as Chairman of HMC, and you do not get chosen
14 as Chairman of HMC unless people believe in your
15 abilities and character.
16 Q. Because you are chosen by your peers?
17 A. You are chosen by your peers, by the whole -- everyone
18 and anyone in the consultant body can have a view on who
19 is to chair HMC, the Hospital Medical Committee.
20 Q. He was also the Medical Director of the Trust?
21 A. I believe he was, at some stage during this.
22 Q. He had always been the Medical Director of the Trust
23 since it was instituted in 1991.
24 A. Thank you.
25 Q. And was, for a time, two years I think it is, both
0132
1 Medical Director of the Trust and Chairman of the
2 Hospital Medical Committee?
3 A. Yes.
4 Q. So those were two, for a clinician, of the most powerful
5 positions open in the whole structure of the hospital
6 and the Trust, and so on?
7 A. Two very important positions.
8 Q. What were James Wisheart's strengths as a clinician and
9 as a manager?
10 A. As a clinician, I saw nothing but total dedication from
11 James for his patients, both in terms of his hours at
12 work and commitment to his patients, pre-operatively and
13 post-operatively. I have never seen him operate at all,
14 just because I never had occasion to do that. On
15 a couple of occasions when I have had to speak to him
16 about administrative matters and have had to wait to
17 catch him in outpatients, I remember waiting many, many
18 minutes while he was talking to a patient about
19 a procedure; indirect evidence of the amount of
20 commitment that there is in patient care; knowing him
21 a little bit socially and seeing him around the Trust,
22 nothing but total dedication to the Trust and its
23 patients, and to the welfare of many members of staff,
24 as well.
25 Q. What were his weaknesses?
0133
1 A. Like many of us, I think we take on enormous burdens,
2 and I suppose I had a concern that -- it is very easy to
3 say, when you look at yourself you have to be careful,
4 but just the sheer burden, the workload of a very
5 demanding clinical specialty with also a very big
6 administrative workload. So I do not know whether that
7 is a weakness that we do not see that as a potential
8 problem, but certainly one that those of us who see
9 characters who take on these enormous loads are
10 concerned, can they do it and will the stress be too
11 much or too great?
12 If there is another one, it is just a slight
13 concern that if there were a question posed, it might
14 not be seriously received.
15 Q. A question about what?
16 A. I can only speak for any data that were to be shared.
17 Q. So you mean you would have a slight concern, I think is
18 how you put it, that if some data were presented to
19 Mr Wisheart which might tend to show that his results
20 were poor, for example --
21 A. No, it is not quite as hard and fast as that. In the
22 notes of my meeting with him -- I know that is further
23 along, but I do make a notation there -- I do not know
24 whether you can call that up -- which is relevant to
25 that point?
0134
1 Q. Of course. WIT 87/25. This is a typed version.
2 A. Thank you.
3 Q. I should say, you and I have agreed, Professor Farndon,
4 that this is your own typed-up version of your own
5 handwritten note.
6 A. Yes.
7 Q. And this is, as it were, the best you can do in
8 transcribing your own note, complete with question marks
9 around the words we can see for example in the second
10 paragraph; is that right?
11 A. Thank you.
12 Q. You take me to the passage here that you want to go to.
13 A. So scroll, please. (Screen scrolled).
14 Q. Can we go over the page?
15 A. I am sorry, I thought I made a ...
16 Q. We will come back to this in some detail.
17 A. I just thought I had some words which captured what
18 I was trying to say slightly better than I was providing
19 for you.
20 Q. Maybe I can help you a little. Can we go to
21 UBHT 150/19? This is a letter to you from Dr Black of
22 18th July 1996 -- that is not the one I am looking at
23 which has exactly the same notation on it.
24 A. I have Dr Black's letter, if that will help.
25 Q. Can we try page 21? No. I think that is the first time
0135
1 we have ever had one document with apparently the same
2 references.
3 If you have Dr Black's letter there, Professor
4 Farndon --
5 A. Is it not in the annex to my statement? That might be
6 the best route.
7 Q. Let us try WIT 87/30. That is your letter back.
8 A. I may have remembered incorrectly that the reference is
9 in here, then.
10 Q. Can I just read you a passage from Dr Black's letter to
11 you, first of all? It is the document I was trying to
12 get. Dr Black says to you that those conversations
13 were -- he has talked about Professor Pickering and
14 Steve Bolsin talking to you, and so on. Then he refers
15 to a letter from Dr Joffe to the British Medical
16 Journal, do you remember that?
17 A. Yes, I do.
18 Q. He says, to you:
19 "You appear to agree and recited the litany of the
20 shortcomings in the Trust's performance in paediatric
21 cardiac surgery and your strenuous but unsuccessful
22 effort to make James Wisheart see the error of his ways,
23 efforts frustrated by James's total lack of insight into
24 deficiencies in his own performance."
25 That is what Dr Black said to you.
0136
1 Then here we have your response to Dr Black if we
2 go over the page to page 31, the first new
3 paragraph beginning "The other major thread ..."
4 Towards the end of the paragraph, you say:
5 "Mingled into that difficult area are the things
6 that you comment upon which are the structure of each
7 person's makeup and personality. One example of which
8 might be some inability of James to always see the
9 problem being directed at him."
10 A. Yes. That is where the reference was. That is what
11 I was trying to search for.
12 Q. Dr Black, in his letter to you, reports you putting it
13 perhaps a little more strongly than you put in the
14 letter to Dr Black. He said that you had mentioned to
15 him your strenuous but unsuccessful efforts to make
16 Mr Wisheart see the error of his ways, but those efforts
17 were frustrated by his total lack of insight into
18 deficiencies in his own performance?
19 A. That is Dr Black's interpretation.
20 Q. Are you both there, in your different ways, making the
21 point that Mr Wisheart did have a lack of insight into
22 deficiencies in his own performance?
23 A. I am saying what I am saying. I do not know to what
24 depth Dr Black means what he says.
25 Q. I am very grateful to Miss Grey, who has not solved the
0137
1 mystery as to why my copy still has the wrong number on
2 it, but if we go to UBHT 150/11, there is the letter to
3 you from Dr Black.
4 If we go over the page, I hope you will have the
5 second page of the letter. The paragraph I have been
6 referring you to is the top paragraph on that page.
7 A. Yes. I have the hard copy here.
8 Q. So you prefer your way of putting it to Dr Black's?
9 A. It is a "degree" of deficit, if that is not too strong
10 a word. I think Andy's letter implies a major problem.
11 I think my working with James over the years
12 characterises it more accurately, as I do in my
13 "degree". But I am not sure exactly what the nature of
14 that is, whether it is a true denial or in fact there
15 may be an intrinsic belief that he is right. I find
16 that difference sometimes difficult to determine.
17 Q. You yourself had never had the experience of taking data
18 to Mr Wisheart and meeting such a response, had you?
19 A. Well, the only time when we discussed that was at the
20 meeting which is -- you probably will come to -- the
21 November 1994 meeting, when we did talk about
22 performance.
23 Q. This aspect of Mr Wisheart's personality, if you like:
24 was that something that you had this view on when
25 Dr Bolsin spoke to you in November 1993, that
0138
1 Mr Wisheart did have this "some inability" as you put
2 it, to see a problem directed at him?
3 A. No, not at all. I think my workings and knowledge of
4 James and his workings and all his positive attributes
5 have grown as this episode has unfolded. So really, my
6 closest working with James was really to establish
7 academic presence in cardiac surgery, to work with James
8 to try and appoint a paediatric cardiac surgeon, and
9 those were all obviously growth development areas,
10 positive for cardiac surgery in general and paediatric
11 cardiac surgery in particular. Those working
12 relationships had always been very positive. This was,
13 if you like, the first episode that would represent any
14 form of, inverted commas, "challenge".
15 Q. When I asked you about whether or not the lack of
16 insight or the inability to see things as being critical
17 of himself was something you were aware of when
18 Dr Bolsin spoke to you, you replied by saying that "his
19 positive attitudes have grown" since then, as this
20 episode has unfolded?
21 A. For me, in my understanding of James and how he works.
22 Q. But this letter you wrote in 1996 to Dr Black, referring
23 to this part of Mr Wisheart's makeup: was that something
24 that you were aware of in 1993?
25 A. I am sorry, I had answered you no to that, quite
0139
1 definitely. I was not aware of it to that degree at
2 all.
3 Q. When did you become aware of it to the degree that is
4 set out in the letter to Dr Black?
5 A. I suppose slightly after the November 1994 meeting. And
6 then the same attribute as more and more, for want of
7 a better word, momentum gathered about paediatric
8 cardiac surgery and James's ability to continue as
9 Chairman of HMC and Medical Director. I really then, at
10 that time, had concern that the Trust and colleagues
11 were asking too much of him, with everything else going
12 on around, and yet -- and I would not want to put in it
13 a totally negative way, but the commitment of the man
14 was such that he would want to keep going.
15 In a way, I do not mean to paint that as
16 a detractor, but the insight sometimes of the burden of
17 things we have to bear is not easy, and acknowledging
18 that we should give something up.
19 Q. Let us move to something else. We were coming on to
20 this meeting of December 1993. You were present,
21 Mr Wisheart was present, Professor Angelini was present?
22 A. That is right.
23 Q. Did you know that Professor Angelini had been to see
24 Mr Stark at Great Ormond Street, I think in about
25 November 1993?
0140
1 A. I did not. The first time I knew of it I think was in
2 reading Professor Angelini's statement or transcript of
3 the Inquiry.
4 Q. You will have seen from reading Professor Angelini's
5 transcript, he was asked:
6 "Did you tell Dr Bolsin you were going to see
7 Mr Stark?
8 Answer: I do not think I did until I came back."
9 This is page 75 of the transcript, Day 61.
10 "When I came back, I told Dr Bolsin and I told
11 Professor Farndon and my senior lecturer, Mr Bryan."
12 You disagree with that?
13 A. I do not recall it.
14 Q. Might he have told you he had been to see Mr Stark?
15 A. I suppose he could have, but I have no way of confirming
16 one way or another. It does not stick in my mind as
17 something that he did.
18 Q. Does it follow that it does not stick in your mind what
19 Professor Angelini had told you Mr Stark had said to
20 him?
21 A. That is right.
22 Q. Do you remember Professor Angelini telling you that
23 Mr Stark had said that patients could be sent to Great
24 Ormond Street and the surgeons from Bristol could go to
25 Great Ormond Street and observe the operations being
0141
1 carried out there?
2 A. I do not recall that.
3 Q. You will have seen from the transcript at page 82 that,
4 before the meeting with Mr Wisheart and yourself in
5 December 1993, Professor Angelini said that there had
6 been several meetings with you in your office, "several,
7 four or five", he said. It is page 82, line 18.
8 A. Will that come up on the screen?
9 Q. It is not going to come up on the screen, I am sorry,
10 no. He said:
11 "We had several meetings with Professor Farndon in
12 his office -- several, four or five, I do not know how
13 many -- where we discussed the whole situation of the
14 paediatric. He was aware that there had been problems
15 even prior to my arrival. It was nothing new to him and
16 we decided to have a meeting with Mr Wisheart, who,
17 after all, was the more senior person, not only as
18 a surgeon but also as the Chairman of the Hospital
19 Medical Committee ..."
20 Do you remember discussions between yourself and
21 Professor Angelini before the meetings with Mr Wisheart
22 in December 1993?
23 A. Only along similar lines vis-a-vis the Bolsin data.
24 Q. So there had been a number of discussions?
25 A. I do not believe it was four or five. It might have
0142
1 been two or three and even then, they were, I think,
2 apart from one, corridor conversations.
3 Q. You had been keen on the appointment of Professor
4 Angelini to his Chair?
5 A. Been keen on the appointment of an academic surgeon to
6 the Chair in Bristol University.
7 Q. Can we have a look at JDW 2/220? It is a letter I think
8 from Professor Stirrat, copy to you, and also to
9 Mr Wisheart. Have you seen this letter before,
10 Professor? This is the time when Professor Angelini, as
11 he then was, had been offered a chair by the University
12 but the British Heart Foundation had not concluded
13 whether or not to make the money available for the
14 Chair. Do you remember?
15 A. I cannot remember the bit of paper.
16 Q. If we scan down the page, please, we see the last
17 paragraph: "JW", I assume Mr Wisheart, and "JF", that is
18 you?
19 A. Yes. I do remember the consequence of the paper and the
20 consequence was, spending the whole of a Saturday, well
21 into the afternoon, writing a package to BHF.
22 Q. And in the end, as we know, Professor Angelini was
23 appointed with the support of the BHF?
24 A. Yes.
25 Q. How would you characterise your relationship with
0143
1 Professor Angelini by the end of 1993?
2 A. Again, this is always difficult to put in time post, to
3 know how long he had been there. That would be about
4 a year, would it?
5 Q. That is right, just over.
6 A. Just over?
7 Q. Yes.
8 A. Reasonably cordial, but very infrequent meetings. He
9 would come if there was something that he wanted to talk
10 about or discuss.
11 Q. If we go to your statement, please, WIT 87/6,
12 paragraph 17, you have been talking about Mr Elliott and
13 we know that there have been suggestions that Mr Elliott
14 might take up the chair as a paediatric cardiac surgeon,
15 which had not come to pass.
16 You say, in the last two sentences:
17 "We decided, as there would clearly be problems in
18 obtaining candidates for the Chair in Paediatric Cardiac
19 Surgery, we would have to obtain any good academic
20 cardiac surgeon. Professor Angelini, an adult cardiac
21 surgeon, emerged as the only [underlined] candidate."
22 Why emphasise the fact that he was the only
23 candidate?
24 A. I was just saying he was the only candidate.
25 Q. You mention in paragraph 19 that you assisted Professor
0144
1 Angelini in the writing of the application for the
2 British Heart Foundation's sponsorship of the
3 chair, "both in the structure and grammar of the
4 application and its content."
5 Why tell us that you helped him with the structure
6 and grammar of his application?
7 A. Because there was a considerable amount of work involved
8 in getting the application ready for a successful appeal
9 to the British Heart Foundation.
10 Q. If we go over a couple of pages to page 8 --
11 A. It reflects my commitment, if you like, to attempting to
12 obtain an academic presence in cardiac surgery.
13 Q. And your efforts, given that Professor Angelini was the
14 only candidate, to make sure that the BHF supported the
15 post and put Professor Angelini into the post?
16 A. His credentials were excellent and both James and I felt
17 he would be an ideal candidate if the BHF supported such
18 an application.
19 Q. In paragraph 29 you are beginning to discuss the meeting
20 of December 1993 which I keep threatening to come to.
21 You say there:
22 "I was present at that meeting because of my
23 academic role. I had a responsibility to work with
24 Professor Angelini on matters of academic import."
25 That perhaps sounds as though you were a little
0145
1 reluctant in working with Professor Angelini. Is that
2 a fair inference?
3 A. No.
4 Q. You and he were not, perhaps, the closest of
5 professional colleagues?
6 A. In 1993 there were no problems.
7 Q. Well, is it not the case that you were a little
8 underwhelmed with Gianni Angelini as the candidate for
9 the post, but given that he was the only candidate for
10 the post, you thought the right thing to do was throw
11 your weight behind him, albeit a little reluctantly?
12 A. No, he was appointed by a full University committee who
13 looked at his ability as an academic surgeon with an
14 interest in cardiac surgery and he came with the
15 endorsement of a full committee chaired by the VC and
16 nobody could want for more. If he was not a credible
17 candidate, the committee would have advised that there
18 was only one candidate but "we will not appoint" if he
19 is not of the appropriate stature.
20 Q. I asked you about Mr Wisheart's strengths and
21 weaknesses. What about Professor Angelini's?
22 A. He is committed to his subject totally. I think others
23 have said he is not a team player. He does not
24 contribute more widely in the Trust. This is
25 a weakness. I do not think I have ever seen him at an
0146
1 HMC meeting, for example.
2 Q. I can help you. I think he said he attended one which
3 was the one when he was first introduced to the HMC and
4 he never went back.
5 A. Thank you. Very little other contribution to
6 departmental matters in surgery but total commitment to
7 his own subject, almost to the exclusion of anyone else
8 and their requirements or concerns.
9 Q. So almost a selfish attitude?
10 A. That might be one interpretation.
11 Q. A narrow focus?
12 A. It may be one interpretation, yes. In his own
13 admission, I think I have heard him say, and I think in
14 his statement, there is a certain emotional element as
15 well, which sometimes is difficult to work with.
16 Q. Does that last point you mention mean that you yourself
17 might have a tendency to discount a little what
18 Professor Angelini might say?
19 A. I really do try and take note of anyone and everyone's
20 structure, function, personality and do my best to
21 accommodate, within an acknowledgment that everyone is
22 different.
23 Q. The meeting with Professor Angelini and Mr Wisheart took
24 place in Professor Angelini's room?
25 A. It did.
0147
1 Q. How long did it last?
2 A. Less than an hour, I think. I cannot be sure, but
3 I seem to remember about an hour. I think it was around
4 lunchtime.
5 Q. Professor Angelini, if it helps, said (Day 61 page 91)
6 that it lasted between three-quarters of an hour and an
7 hour. Do you quarrel with that?
8 A. That seems about right, from what I can remember.
9 Q. What was it about?
10 A. It was about the appointment of a paediatric cardiac
11 surgeon.
12 Q. Did all the three of you present think that was a good
13 thing?
14 A. My recall was that that was thought by all three present
15 to be a good thing.
16 Q. Why?
17 A. I think there was a recognition from James and Janardan
18 that the burdens of their practice and attempts at
19 attempting to look after both adults and children was
20 a task far too onerous for anyone and that as the
21 specialty grew and developed, we needed, as in many
22 other branches of surgery, to obtain and appoint
23 specific experts.
24 Q. Was this, the onerous nature of the task of caring for
25 adults and children, something which was begin to
0148
1 manifest itself in the quality of the paediatric work
2 that was done?
3 A. I suppose clearly, going to a meeting at that time, then
4 there would be an undercurrent of that in certainly in
5 my mind and perhaps in Gianni's mind as well.
6 Q. What about Mr Wisheart's mind?
7 A. I cannot say. I do not know. I had not broached it
8 personally with him at that time.
9 Q. By that time, was it your impression that the fact that
10 what became known as the Bolsin/Black audit existed was
11 generally known throughout the Bristol Royal Infirmary?
12 A. I have no idea.
13 Q. Professor Angelini's suggestion, as you will have seen
14 from the transcript, was that, yes, the meeting was
15 about the appointment of a paediatric cardiac surgeon,
16 but that that appointment was seen as being the
17 resolution of the concern or the problem about the
18 paediatric cardiac results.
19 So from what you have just said, is there an
20 element of truth in that, that the appointment of the
21 paediatric cardiac surgeon was seen as being a necessary
22 answer to an existing problem?
23 A. The desire for a paediatric cardiac surgeon was there
24 well before that, when James Wisheart and I were trying
25 to appoint an academic, when our desire was to look for
0149
1 someone with an interest in paediatric cardiac surgery
2 to fill the chair.
3 So it was well before then.
4 Q. Was there any data from Dr Bolsin, or anyone else, about
5 the outcomes of paediatric cardiac surgery at that
6 meeting?
7 A. Not that I remember.
8 Q. Do you remember any discussion of any data?
9 A. I do not. I remember that our meeting was amicable and
10 proceeded well and it concerned the appointment of
11 a paediatric cardiac surgeon.
12 Q. Do you remember Mr Wisheart suggesting at that meeting
13 that a young Senior Registrar might be trained up
14 elsewhere, possibly abroad, in order to come back and
15 perform paediatric cardiac surgery in Bristol?
16 A. That rings a bell now, yes. I do.
17 Q. Professor Angelini said at page 93 of his transcript
18 that that was a suggestion that was made. That rings
19 a bell with you.
20 Professor Angelini was asked about this meeting.
21 He said, at page 73, and at page 85, perhaps in
22 particular, he was asked:
23 "Was the data that you had seen from Dr Bolsin
24 actually presented and discussed at that meeting?"
25 He said this, at page 85, line 3:
0150
1 "The data was sitting on the table between myself
2 and Professor Farndon, who were on one side facing
3 Mr Wisheart. We did not go through in detail with the
4 data, because my and Professor Farndon's impression --
5 incidentally, I hardly ever spoke at the meeting because
6 Professor Farndon did most of the talking. I did not
7 think there was any question we were discussing the fact
8 that we were aware of the data of Dr Bolsin, we had
9 looked at the data of Dr Bolsin and we wanted to find
10 a way forward in this, and again, the way forward which
11 was put forward by Professor Farndon, which in a way had
12 been discussed with me before, was the appointment of
13 a new paediatric cardiac surgeon."
14 To what extent does that accord with your
15 recollection of that meeting?
16 A. I do not remember the data sitting there. It may have
17 been. If Gianni had a bundle of papers -- I think
18 I went paperless to that meeting. I did not call the
19 meeting. If he had papers there which had the Bolsin
20 data, then he did, if that is what he says. I am not
21 sure I did all the talking.
22 Q. I was going to ask you about that.
23 A. That is not my style. I was there as a facilitator, to
24 help. This was something we wanted to see developed, to
25 enhance the care of children in Bristol and the academic
0151
1 output of the department.
2 Q. In his witness statement, and also I think orally,
3 Professor Angelini said that the meeting was conducted
4 most diplomatically, and I think he was essentially
5 saying that it was conducted most diplomatically by you,
6 because you were the one, he said, who did most of the
7 talking.
8 Was it a diplomatic and non-confrontational
9 meeting?
10 A. I try not to have confrontational meetings.
11 Q. I understand that. So this meeting was --
12 A. I did not recall having to put any particular style on
13 that meeting. I was, myself, talking about the
14 objective of making an appointment in paediatric cardiac
15 surgery.
16 Q. It is implicit in what you said earlier -- but let us
17 see if I am right in thinking it was implicit -- that if
18 there was to be a paediatric cardiac surgeon appointed,
19 that would take some of the burden off the shoulders of
20 Mr Wisheart or Mr Dhasmana, or both, in terms of doing
21 paediatric work?
22 A. Yes.
23 Q. That must follow?
24 A. Yes.
25 Q. Was it discussed at the meeting or elsewhere exactly how
0152
1 that burden would be lifted, for example by Mr Wisheart
2 not doing any more paediatric work, or would they both
3 lighten their paediatric load a little? How was it to
4 be worked out?
5 A. I think it was to be worked out by James stopping
6 paediatric cardiac surgery.
7 Q. Do you remember a discussion with Mr Wisheart about
8 that?
9 A. At that meeting?
10 Q. Or any other time?
11 A. I think it emerged at that meeting. I think it did.
12 Q. And at this non-confrontational diplomatic meeting,
13 there was no trouble with that suggestion?
14 A. I am sorry, I do not like the non-confrontational
15 diplomatic way. For me there was no element of threat
16 or angst in going to that meeting, so I was not being
17 diplomatic any more than normal, or being any different
18 than normal. If Gianni wishes to interpret my behaviour
19 at that meeting, then perhaps he has not seen me in
20 meetings before, but there was nothing extra. I would
21 wish, with all respect, to be sure that the Inquiry
22 understands that. I was not doing anything additional
23 or extra in terms of style or manner that I felt
24 warranted any alteration.
25 Q. Professor Farndon, to let you know where we are, we are
0153
1 in December 1993. We have one or two relatively minor
2 matters and then we come to the meeting of November 1994
3 and the events which took place after that, which would
4 be the focus of the rest of the questions. Perhaps
5 before we come to that, sir, it might be time for
6 another short break.
7 THE CHAIRMAN: Yes. I think so. Let us take, shall we say,
8 a quarter of an hour and reconvene at 3.20?
9 (3.05 pm)
10 (A short break)
11 (3.20 pm)
12 MR MACLEAN: Professor Farndon, can I take you in your
13 statement, please, to WIT 87/7, paragraph 24. Just
14 before we go to 24, if we just glance at 23. You say:
15 "Once Dr Bolsin had come to see me" -- that is the
16 original conversation with him, is it not, in the early
17 part of 1993?
18 A. Yes.
19 Q. "... I remember speaking with colleagues in passing
20 about the concerns he had raised." You cannot remember
21 the dates and so on. Then you had two or three
22 conversations with Professor Angelini.
23 Then you go on in the next paragraph to refer to
24 specifically four other people who approached you with
25 concerns about paediatric cardiac surgery. Can you just
0154
1 help me with dating those expressions of concern?
2 A. No idea.
3 Q. Is the best that we can do that it would have been some
4 time between Dr Bolsin's initial conversation and
5 the meeting with Mr Wisheart in November 1994?
6 A. I wish I could help you to focus that down, but I am
7 afraid without making any notes of those meetings or of
8 them being logged into my diary or the diary that my
9 secretary keeps, I am not able to help you more
10 specifically. I regret that. I am sorry I cannot.
11 Q. Do you remember what the content of these expressions of
12 concern was?
13 A. They would again be I think based on the data that
14 Dr Bolsin had produced and they would be concerns from
15 these colleagues that perhaps things were not quite
16 right in cardiac surgery. In particular people would
17 voice their concern about paediatric cardiac surgery and
18 that the results were not as good as they should be.
19 Q. At the GMC you were asked about the meeting leading up
20 to the meeting with Mr Wisheart in November 1994 and you
21 said, it is page 15 of my version of the transcript:
22 "I had received in the days before my going to see
23 James approaches from other colleagues. Again those
24 colleagues not providing me with any tangible or
25 objective evidence, and I felt as a friend and colleague
0155
1 of James that I needed with a degree of responsibility
2 to come alongside and see if I could help in
3 the resolution of matters which seemed to be rumbling
4 on."
5 So there were specific approaches to you very
6 shortly before the meeting with Mr Wisheart, so it would
7 seem?
8 A. Yes.
9 Q. Were those from some or all of these people?
10 A. Yes.
11 Q. Some or all of these people had expressed concern to you
12 earlier than that as well, had they?
13 A. I wish I could help you with the dates. I am afraid
14 I cannot. I think it would be fair to say that one
15 reason why I cannot go to my diary is that they were
16 corridor conversations.
17 Q. In paragraph 23 you talk about speaking with other
18 colleagues in passing and you talk about informal, as
19 you put it, "corridor" conversations with Professor
20 Angelini. Apart from the meeting in December 1993 that
21 we have mentioned and the meeting in November 1994 that
22 we will come to, you had not had anything other than
23 corridor conversations about these concerns? It is not
24 necessarily a criticism, it is just a fact.
25 A. No, a fact, I think that is correct.
0156
1 Q. In July 1994 somebody called Dr Doyle from
2 the Department of Health, he was a senior medical
3 officer like Dr Ashwell, came to Bristol for
4 a presentation by some of the anaesthetists to do with
5 an audit project. Was that something that you were
6 aware of?
7 A. No.
8 Q. A few days later there was a letter from Dr Doyle to
9 Professor Angelini, 13th July 1994. UBHT 52/287,
10 please. Scan down the page. I think you have had
11 a chance of seeing this, have you not, recently?
12 A. Yes, recently.
13 Q. When do you recall first seeing this letter?
14 A. I cannot remember. Was it copied to me? I do not think
15 it was.
16 Q. Let us go over the page, page 288. It does not appear
17 to be copied to anybody.
18 A. No. I do not recall it.
19 Q. Do you remember a discussion about this letter with
20 Professor Angelini?
21 A. At some stage, I cannot remember the dates, Gianni
22 talked to me that the Department was aware. I cannot
23 remember the specific details of what "aware" meant.
24 Q. Do you remember any discussions specifically about this
25 letter with Professor Angelini?
0157
1 A. I am sure Gianni told me that he had been in
2 correspondence with the Department of Health.
3 Q. Professor Angelini said, Day 61, page 152, line 23, when
4 asked what was his reaction to this letter, he said:
5 "I discussed this letter with several people and
6 I think with Professor Farndon, with my senior lecturer
7 Mr Bryan and others."
8 So your evidence is you have no clear recollection
9 of discussing this letter with Professor Angelini at
10 the time that it was received by Professor Angelini?
11 A. No. If Gianni is saying, "I think that he discussed it
12 with me," I am afraid I am giving it as much endorsement
13 in saying the same, "I think I heard Gianni talk to me
14 about this letter."
15 Q. Professor Angelini replied on 19th April, UBHT 61/273.
16 Again, when do you remember seeing this letter?
17 A. Again, I cannot remember.
18 Q. I should point out to you that at page 154, Day 61,
19 Professor Angelini said that he discussed this letter
20 with Dr Roylance and Professor Vann Jones and he said he
21 was not sure about you. "I am not 100 per cent sure
22 about that, but certainly Dr Roylance and Professor Vann
23 Jones with no shadow of doubt."
24 A. So many papers have spun around since the Inquiry
25 started and so on. I do not believe that I saw that
0158
1 letter at that time.
2 Q. Dr Roylance wrote a letter to Dr Doyle, UBHT 61/278, on
3 12th September 1994. If we scan down the page. Again,
4 that letter?
5 A. No. That trio of letters I did not receive and did not
6 see.
7 Q. I should have mentioned to you -- it is my fault; I do
8 apologise -- that in Professor Angelini's reply,
9 19th August, if we go to the second page of that,
10 page 274, it is copied to Professor Vann Jones and to
11 Dr Roylance. It is not copied to you or to anyone
12 else.
13 A. Again, I would be sure that if I had been in receipt of
14 those they would have been submitted to GMC and anyone
15 else. They do not ring a bell, that trio of letters.
16 Q. There was a meeting, was there not, involving you and
17 Professor Angelini with Mr McKinlay?
18 A. There was.
19 Q. Mr McKinlay became the chairman of the Trust on 1st July
20 1994.
21 A. I believe you.
22 Q. He did. He says he did, and we have no reason to doubt
23 him. We know that Mr Durie gave up the day before, so
24 it all fits in.
25 A. I am sorry, I cannot remember the dates.
0159
1 Q. It is WIT 87/9. This is your witness statement.
2 Paragraph 30. So this meeting with Mr McKinlay must
3 have taken place in the latter half of 1994, because
4 Mr McKinlay was not there before that. Mr McKinlay has
5 provided a statement. He has done that as well, but he
6 provided a comment on Professor Angelini's evidence. It
7 is WIT 81/36.
8 A. I have the page before me.
9 Q. He says there that the meeting was in September 1994.
10 A. Yes.
11 Q. And you have no reason to doubt that that is right?
12 A. No.
13 Q. Where did this meeting take place?
14 A. His office, I think, in UBHT Headquarters.
15 Q. That I think is what Professor Angelini said. What was
16 it about?
17 A. The main thrust was an anxiety that we had which related
18 to the ability to appoint a potential candidate to
19 the consultant post in paediatric cardiac surgery.
20 Q. Do you remember who that candidate was?
21 A. There was a possible candidate called Ash Pawade who was
22 in fact subsequently appointed from Australia. As far
23 as I can remember, there were anxieties at that time as
24 to whether he would be appointable, not in terms of
25 clinical expertise and knowledge and skill, but more in
0160
1 the red tape of appropriate certification and
2 accreditation to be suitable to be appointed to
3 a consultant post in this country coming from Australia.
4 Q. You will have seen from Professor Angelini's transcript
5 what he says about this, but essentially that is what he
6 says: Mr Pawade had a rather unusual, if you like, sort
7 of training, as he put it, and he was now a consultant
8 in Australia for two years. "We were concerned that
9 somebody may have raised issues, like he has not been in
10 this country for the last three years, so there might be
11 some technical reason why he might fail to be appointed,
12 despite being eminently qualified for the job"?
13 A. I do not recall it being a technical problem, but more
14 one of suitable accreditation or certification to fulfil
15 the requirements for appointment as a consultant.
16 Q. Okay. Mr McKinlay has provided a statement to
17 the Inquiry which I think only arrived today. He is
18 coming to give evidence in a couple of weeks time. Can
19 I just show you three paragraphs of it. It is
20 WIT 102/27, paragraph 16.
21 A. I have that in front of me.
22 Q. I think you have had a chance of reading these, have you
23 not?
24 A. Yes, I have; thank you.
25 Q. 16 to 18. He says, "They", that is you and Professor
0161
1 Angelini, "explained their favourite candidate was
2 Mr Pawade," and so on.
3 "Having explained the situation with Mr Pawade,
4 they went on to say there was a need for a new surgeon
5 since the switch operation which was a touchstone
6 whereby paediatric cardiac surgery units were measured
7 had unacceptable results at Bristol. They quoted that
8 out of 13 operations on neonates, there had been 8
9 deaths. I was extremely concerned and in the ensuing
10 discussion I recall saying that in parallel
11 circumstances in aerospace the activity would have been
12 stopped."
13 Do you remember that discussion with Mr McKinlay?
14 A. That rings a bell because Bob McKinlay I think came from
15 British Aerospace. I think I do remember that analogy
16 with -- I think I remember him discussing that analogy
17 with aero engineering, aerospace.
18 Q. So that does ring a bell?
19 A. It does ring a bell; it does. Now I see it now.
20 Q. Let us go on. "They responded", that is you and
21 Professor Angelini, "that the switch operation had been
22 suspended pending the arrival of a new surgeon."
23 Do you remember if that was your and/or Professor
24 Angelini's perception in September 1994 that the switch
25 operation had been suspended pending the arrival of
0162
1 a new surgeon?
2 A. I am less sure about that. The thing that now comes to
3 me -- the majority of the meeting was talking about
4 accreditation and, since Bob McKinlay was going to chair
5 that meeting, whether a potential candidate was
6 appointable. This reminds me that there was talk on
7 paediatric cardiac surgical results. This rings, I am
8 afraid, a lesser bell than the aerospace analogy.
9 Q. Then paragraph 17, do you remember concern being
10 expressed that Mr Wisheart might block the appointment
11 of Mr Pawade?
12 A. I do not remember that. I do remember your discussion
13 relating to the December meeting that there was
14 a possible senior registrar. I think both Gianni and
15 I wanted to be sure that the best candidate, if such
16 were available, should be appointed, and that it would
17 be a shame if we had to train someone, complete
18 training. So, if a candidate of the stature of Ash
19 Pawade were available, we wanted to ensure that if he
20 wished to attend for interview and he were the best
21 candidate, that he could be so appointed.
22 Q. So you and Professor Angelini were of one mind as far as
23 this meeting was concerned in going to Mr McKinlay and
24 saying essentially, "We are convinced that Pawade would
25 be perfect for this job and we do not want to miss
0163
1 him"?
2 A. One thing I think you told me when Bob started and one
3 thing that, with all respect to him, and I am sure he
4 will speak for himself, and I hope that we did not make
5 an assumption that he would not be aware of the methods
6 by which consultants could be newly appointed -- this
7 might have been one of the first appointment committees
8 that he might have had to check. Meaning absolutely no
9 disrespect whatsoever, but I think we wanted to ensure
10 that from our understanding of the rules and regulations
11 of appointment of a consultant, that Ash Pawade would
12 fit if he were so judged to be the best candidate on
13 the day.
14 Q. Just to summarise where we are: the question of
15 the suspension of the switch operation rings a more
16 vague bell than the business about the aerospace
17 industry analogy.
18 A. Yes, absolutely.
19 Q. You do remember there being some discussion in
20 the December meeting or at some stage of the possibility
21 of training somebody up?
22 A. Yes.
23 Q. As opposed to bringing a ready-made consultant in, if
24 you like?
25 A. Yes.
0164
1 Q. You and Professor Angelini were anxious that, if there
2 was a well qualified, ready-made consultant that could
3 be brought in, he should be brought in?
4 A. Yes.
5 Q. Do you remember the expression about paediatric cardiac
6 surgery being "a young man's game" being used at the
7 meeting?
8 A. I do not recall that.
9 Q. Look at paragraph 18, which is the last paragraph of
10 Mr McKinlay's statement that deals with this point.
11 The message which he took away from the discussion with
12 you and Professor Angelini was that "the concern was
13 centred on the poor performance of the switch operation
14 and the controversy over the time taken by Mr Wisheart
15 on some procedures. The switch operation had been
16 suspended and the position would be resolved by the new
17 appointment."
18 Do you remember there being those two limbs of
19 the concern expressed to Mr McKinlay who had, as you
20 pointed out, a few weeks before come fresh to the job as
21 Chairman?
22 A. I wish my recollection was better, but I do know that
23 some smaller part of that meeting was concerned with
24 paediatric cardiac surgical outcome and performance.
25 Q. Because that concern would make it all the more
0165
1 important to appoint a good consultant to do
2 the paediatric work?
3 A. Absolutely. But for the appointment of any consultant,
4 but in particular here, we did not want to miss
5 the opportunity of someone who had an international
6 standing in performance and to miss that opportunity
7 because of any misunderstanding or enforcement of
8 accreditation details that we felt should not debar that
9 person from appointment, if judged to be the best person
10 on the day by the Appointment Committee.
11 Q. Do you remember Dr Roylance playing any part in this
12 meeting?
13 A. I do not. I thought my recollection was that it was
14 the three of us.
15 Q. Professor Angelini said, Day 61, page 97, about line 19:
16 "We had a meeting towards the August of 1994 [as
17 he puts it] with Mr McKinlay in his office, Professor
18 Farndon and myself and Mr McKinlay called Dr Roylance
19 in."
20 You do not remember Dr Roylance being called in to
21 a meeting with Mr McKinlay?
22 A. I am afraid I do not recall that.
23 Q. Either in August or September?
24 A. I do not recall.
25 Q. We have seen in paragraph 16 that Mr McKinlay says that
0166
1 after he used the aerospace analogy, "If this was the
2 aerospace industry, it would all be stopped", they
3 responded, he said, that the switch operation had been
4 suspended. Then at paragraph 18 he again says that
5 the message he took away was that the switch operation
6 had been suspended.
7 You said that rang a vaguer bell than
8 the aerospace analogy. To what extent are you confident
9 that Mr McKinlay was given the message by you or
10 Professor Angelini or both that the switch operation had
11 been suspended pending the new arrival?
12 A. I do remember that -- I think I spoke most about
13 the accreditation and the mechanism of appointment, and
14 I recall that Gianni spoke more to the topic of
15 paediatric surgical performance. As I say, the recall
16 for the decision with regard to the switch I find
17 difficult.
18 Q. So you cannot remember whether or not Professor Angelini
19 would have said to Mr McKinlay, "The switch has been
20 suspended"?
21 A. It is likely that he did because I know that at some
22 stage that it was suspended, pending the appointment of
23 a new surgeon, provided that surgeon had appropriate
24 skills to carry out that procedure.
25 Q. So, as you understood it, and I am only asking about
0167
1 your recollection, a decision had been taken to suspend
2 the switch before it was known who was going to be
3 the new appointee?
4 A. I wish I could be certain with the precision that you
5 are wanting of me, and I am afraid I cannot, I do not
6 think. I am sure I cannot.
7 Q. There was a protocol produced after the Joshua Loveday
8 operation in March 1995 by Mr Nix, I think, who was a
9 Deputy Chief Executive -- Dr Roylance was away -- which
10 provided for which operations would and would not take
11 place. Do you remember that?
12 A. I do remember that.
13 Q. But the suspension you are talking about is not that
14 one; it is before that, is it?
15 A. I do remember the Graham Nix document, but I am afraid
16 I cannot recall this with certainty.
17 Q. Just bear with me for a second, Professor; I do
18 apologise. (Pause) It may be a point that can be taken
19 up with Mr McKinlay, but can we just go back a page to
20 paragraph 16, page 27. Do you see about four lines from
21 the bottom, just a little bit above that:
22 "Having explained the situation with Mr Pawade,
23 they [that is you and Professor Angelini] went on to say
24 there was a need for a new surgeon, since the switch
25 operation ... [I am missing out the next words] ... had
0168
1 unacceptable results at Bristol."
2 Then there was a quote for figures on neonates.
3 Then the sentence: "They responded that the switch
4 operation had been suspended." Do you remember there
5 being any discussion about whether the suspension was
6 about neonatal operations or non-neonatal operations or
7 switch operations in general?
8 A. I wish I could help you.
9 Q. You cannot remember that level of detail?
10 A. I cannot, I am sorry.
11 Q. Very well. Let us come to the meeting of November
12 1994. Your witness statement at WIT 87/9, paragraph 31,
13 says:
14 "I felt as a friend and colleague of James
15 Wisheart, I needed with a degree of responsibility to
16 come alongside and see if I could help resolve these
17 matters which rumbled on in hospital corridor
18 conversations."
19 I think earlier I read out one of your answers in
20 the GMC which uses that same expression, "come
21 alongside". November 1994 was 18 months or thereabouts
22 after Dr Bolsin had first brought his concerns to you;
23 right? In November 1994 you occupied the same position,
24 Professor of Surgery, Head of Division, as you had in
25 the early summer of 1993.
0169
1 A. Mm-hm.
2 Q. So you had not been promoted, if you like, in
3 the interim?
4 A. No.
5 Q. Why did you decide to have the meeting with Mr Wisheart
6 then and not earlier or later?
7 A. I think I had heard a volume of continued disquiet,
8 noise, and it was almost an exasperation that no
9 resolution had occurred. It still was not within any of
10 my remit, strictly speaking, to be concerned with
11 the results of cardiac surgery, but people kept talking
12 and no evidence was ever handed to me that everybody had
13 agreed upon, identifying that there is a problem or
14 there is not a problem. So there was a feeling of
15 exasperation that the thing had not been resolved.
16 Q. By this time had you seen further data from Dr Bolsin
17 over and above which he had originally shown you?
18 A. Not that I remember.
19 Q. Can we have a look at UBHT 61/46. Do you remember
20 seeing that data on the switch operation, which is dated
21 13th July 1994?
22 A. I do not recall that.
23 Q. Scan down the page. That is all there is. Can we have
24 a look at UBHT 54/3. This is dated 31st October 1994.
25 It is dealing with the AV Canal repair. There are some
0170
1 cases set out.
2 Then this activity represents a 30 per cent
3 mortality on the table, represents a minimum 70 per cent
4 mortality for the period 1992 to 1994. That data, so it
5 would seem, was produced in a couple of weeks before
6 your meeting with Mr Wisheart. Do you remember seeing
7 that at about that time?
8 A. It looks vaguely familiar. It certainly looks more
9 familiar than the previous document. The previous
10 document I do not recall.
11 Q. Professor Angelini said, Day 61, page 176, that he
12 showed this data to you. He was asked about
13 the AV Canal data. I said to him:
14 "Did you discuss this specific data with anyone
15 else apart from Dr Bolsin who showed it to you?
16 "Yes, lots of people, again, Mr Bryan, Mr Hutter,
17 Mr Dhasmana. In fact, we had quite a confrontational
18 meeting some time a few weeks after this", I will come
19 to that, "where I was trying to say that the service
20 should be rationalised. This data was seen by all sorts
21 of other people, but certainly, I showed this to
22 Professor Farndon."
23 So you accept --
24 A. I accept that that is likely.
25 Q. What Professor Angelini was alluding to there, in that
0171
1 answer -- just before I move on I should say, in
2 the GMC, at page 26 of my copy of the transcript,
3 I think you did accept that you had seen the AV Canal
4 data shown by Dr Bolsin?
5 A. This sheet? Yes.
6 Q. What Professor Angelini was alluding to in that answer
7 which I have just read out an extract from was a meeting
8 of the surgeons which took place in Mr Wisheart's house,
9 I think at the beginning of November 1994. I am not
10 suggesting you were at it. Were you aware, by the time
11 of your meeting with Mr Wisheart, that that meeting at
12 his house had taken place among the surgeons?
13 A. I do not believe so, no.
14 Q. Why did you decide --
15 A. No, I do not remember that.
16 Q. Why did you have a meeting only with Mr Wisheart?
17 A. I do not know, except that he was a senior man to do
18 with paediatric cardiac surgery and the cardiac
19 directorate.
20 Q. But did you talk to him because he was a Medical
21 Director of the Trust, or did you talk to him because he
22 was the object of the expression of concerns?
23 A. Both.
24 Q. At the GMC, page 46 you were asked:
25 "As a result of those comments and criticisms, in
0172
1 so far as they came to your ears, you decided to speak
2 to Mr Wisheart?
3 "I did", you said.
4 "Why Mr Wisheart?"
5 You said, "Because that is who people talk to me
6 most about."
7 Does that not suggest that it was because he was
8 the focus of the expression of concern that you had
9 a word with him?
10 A. Many people expressed concern about James and James's
11 performance, but others had also expressed concern about
12 Janardan.
13 Q. So why not have a meeting with him along the same lines,
14 or indeed, have him along to the same meeting?
15 A. Because in my mind I think was what I would hope would
16 be the outcome of that meeting.
17 Q. So should we have a look at the note of the meeting
18 then?
19 A. If you wish.
20 Q. You made a note of the meeting. The handwritten version
21 I do not think you need to trouble with. The typed
22 version is WIT 87/25. I should say that this is not
23 the same typed version as appeared at the GMC, but we
24 discussed this earlier. You are satisfied that this is
25 the appropriate transcription of your handwritten note.
0173
1 Why make a note of the meeting?
2 A. I think I recognised the importance of what we discussed
3 and thankfully what I think we agreed at the end of
4 the meeting. I wanted to be sure that I had made
5 a notation about that meeting.
6 Q. You said in your witness statement that you felt it was
7 your duty to be sure that James was aware of
8 the criticisms. Was he, by the time of this meeting, in
9 ignorance of the criticisms that were made, or did he
10 know about them?
11 A. He seemed to be aware of them.
12 Q. That is bolstered, is it not, by the second paragraph of
13 the note which suggests that it was Mr Wisheart who
14 first broached the subject of the September
15 acceptability of the outcomes?
16 A. Yes.
17 Q. If you felt under duty to make sure that James was aware
18 of the criticisms in November 1994, why were you not
19 under the same duty when Dr Bolsin brought you
20 the concerns in 1993?
21 A. Because there had been no resolution in the time
22 between.
23 Q. So what was the test, if you like, for when the duty
24 kicked in? What was the trigger for the duty imposing
25 itself on you?
0174
1 A. For me to kick in with James?
2 Q. Yes.
3 A. It was the volume of people talking to me about
4 the matter.
5 Q. So it was a function of how many people were raising
6 concerns?
7 A. A function of the noise, if you like.
8 Q. But all they were doing was reflecting the concerns
9 which had originally come from Dr Bolsin's audit?
10 A. But the process had not been addressed.
11 Q. But it still had not been addressed by November 1994?
12 A. It was not addressed by July 1996 or ...
13 Q. If I was to ask you what it was that had changed between
14 the late spring or early summer of 1993 and November
15 1994 to make you want to discuss the matter, fix
16 a meeting with Mr Wisheart and make a note of
17 the meeting, the answer would be that the "noise" as
18 you put it had become too great?
19 A. The noise was continuing. You still had fingers being
20 pointed and nobody was coming -- what tended to get to
21 me was that people who were not -- not that I was close,
22 but people like Sheila Willatts or Professor
23 Prys-Roberts were voicing opinions to me. They were no
24 more close in or away from the situation than I was,
25 with equal responsibility. There was an exasperation
0175
1 that what is going on here? Why has this not been
2 resolved? I felt that I should go to "the top" to try
3 and see what the problem was and why there was
4 a persistent problem.
5 Q. Can we go to your statement, WIT 87/10, paragraph 33.
6 You talk about this meeting, that no agenda was
7 given and so on. You made arrangements to see James.
8 Then towards the latter part of the paragraph:
9 "The main raison d'etre was that as a friend and
10 colleague of James, I could not tolerate hearing oblique
11 criticisms without objective evidence of a colleague's
12 work or performance."
13 To what extent were Dr Bolsin's criticisms of
14 Mr Wisheart oblique?
15 A. For example, the list that you showed me, I have no idea
16 whether James had done any of those operations or
17 Janardan had done any of those operations --
18 Q. Mr Wisheart's initial, I think, is on that sheet,
19 the AV Canal data?
20 A. -- or of the involvement of other people in the outcomes
21 of those patients. Was it the same anaesthetist with
22 the patients who lived? Was it the same anaesthetist
23 with the patients who died?
24 Q. You say you could not tolerate hearing criticisms. Were
25 you intolerant of the criticisms that you heard
0176
1 expressed?
2 A. No. I just wanted resolution, or to try and see
3 resolution of the problems.
4 Q. Let us have a look at the note of the meeting, then,
5 which is the last page we were looking at. It is
6 WIT 87/25. Left hand side, initialled "JW". "Tacit
7 agreement that paediatric figures not good".
8 How was that tacit agreement manifested?
9 A. By a statement, I presume from James.
10 Q. In what way was the agreement tacit, as opposed to
11 explicit?
12 A. I suppose now you ask the question, I do not know why
13 I used that word.
14 Q. Which paediatric figures were not good? Was it across
15 the board or some procedure?
16 A. I cannot recall, but I think in acknowledgment that some
17 procedures were associated with less good results than
18 others.
19 Q. Procedures which he did or procedures which Mr Dhasmana
20 did?
21 A. I cannot remember discussing in that style.
22 Q. There was no surgeon-specific discussion?
23 A. No.
24 Q. Three or four lines down:
25 "He has not been approached by anyone directly",
0177
1 underlined, and it is underlined in the manuscript
2 original, "over doubts over performance figures."
3 A. That is what he told me.
4 Q. But you took from that, as was obvious from the fact he
5 had broached the subject first, that he had picked up on
6 the bush telegraph or whatever?
7 A. Vibrations.
8 Q. "He has been aware of problems and has kept JR
9 informed." Who is JR?
10 A. That must be Dr John Roylance.
11 Q. If we skip to the bottom of this page, scan down a
12 little, the last line there:
13 "JW has kept John Roylance fully informed of these
14 rumblings and developments."
15 Is that note intended to reflect what Mr Wisheart
16 actually said at the meeting?
17 A. Yes, I mean, "rumblings" is my word; but, I mean, yes.
18 Q. What was it you understood Dr Roylance knew about this
19 from Mr Wisheart?
20 A. I have no idea.
21 Q. Did you ask?
22 A. Sorry?
23 Q. Did you ask?
24 A. No. It took me about four or five hours to get to
25 the four positive points on the second page, which was
0178
1 I thought the main reason for my meeting with James.
2 Q. The meeting I think started at 10 to 6 and ended at half
3 past 8, according to the note.
4 A. Fine; whatever.
5 Q. It is at the top of the page.
6 A. Thank you.
7 Q. Did you agree with Mr Wisheart's statement that
8 the paediatric figures were not good?
9 A. I cannot remember.
10 Q. What was the evidence for Mr Wisheart's agreement that
11 the paediatric figures were not good?
12 A. That he believed that the outcome figures for some
13 procedures were not as good as they might have been.
14 Q. But he did not produce any tangible objective evidence
15 agreed by everybody to support that?
16 A. No, he did not.
17 Q. But you accepted it?
18 A. I did not accept it. I made a note of what he said.
19 Q. You put the word "problems" in inverted commas there.
20 A. Yes.
21 Q. What does that word encapsulate?
22 A. It is in inverted commas again reflecting a need and
23 a desire to quantify, make objective, endorse results.
24 Q. If the agreement -- the tacit agreement that paediatric
25 figures were not good, was not consultant specific, did
0179
1 it occur to you that something perhaps ought to be done
2 about the continuation of paediatric cardiac surgery at
3 Bristol in the hands of these two surgeons until
4 the matter had been investigated?
5 A. It occurred to me that here was a group of clinicians
6 where patients continued to be looked after where there
7 is noise about results and how can this be.
8 Q. But it is a different quality of noise now, is it not,
9 than the noise earlier? When Dr Bolsin came to see you
10 in 1993 your response -- and I paraphrase, but I hope
11 not caricature -- was "go away and have this agreed and
12 owned by all the clinicians involved".
13 Here you have the surgeon, who is the focus of at
14 least part of the concern, agreeing that some of
15 the paediatric figures at least were not good. So
16 the step of going away and owning it and agreeing it has
17 fallen away to the extent that there is an agreement
18 from the surgeon. So the noise is qualitatively
19 different now, is it not?
20 A. Not particularly in that if I was asked to take on with
21 my offer of mediating between the groups, that if there
22 were open tacit agreement between the two groups that
23 there was a problem, that a recommendation should come
24 out of that, my next step would have been, "What are we
25 going to do about it? Are you going to continue
0180
1 operating? Are you going to continue to anaesthetise
2 for surgeons with whom you have a major anxiety about
3 performance or outcome? Are you the cardiologist still
4 going to refer the patients?"
5 Q. If the Medical Director of the Trust is agreeing that
6 there is a problem with the paediatric figures, at least
7 in part for operations that he has been conducting, did
8 it not occur to you that perhaps he ought to stand down
9 from carrying out such operations until the matter had
10 been looked at and the patients sent elsewhere or
11 operated on by another surgeon?
12 A. Perhaps.
13 Q. Did that occur to you at the time?
14 A. I am not sure it did because of the moment of
15 the occasion which I found to some extent difficult and
16 very demanding.
17 Q. Let us have a look at your witness statement at page 10,
18 paragraph 37. You say you did not take any data, but
19 you believe that Mr Wisheart provided data on adult
20 patients.
21 "I wanted to discuss general issues of acquiring
22 data, its analysis, the action to be taken upon it, and
23 discuss potential solutions to possible problems,
24 i.e. strategies and principles, not details."
25 But had not the matter moved on rather beyond
0181
1 general issues of acquiring data once Mr Wisheart had
2 accepted tacitly or otherwise that some at least of the
3 paediatric figures were not good? You then had
4 a particular problem.
5 A. It is easy for you to say now. There were more general
6 discussions of the audit process. There had been
7 questions raised about James's performance in adult
8 cardiac surgery. James spent some time showing me data
9 on adult cardiac surgery which I tried to understand.
10 But the generality of the meeting was as described.
11 I wanted to try and help the group with a way forward.
12 One of the solutions or one of the ways forward may have
13 been a recommendation that "you should not do these
14 procedures or you should not do these procedures".
15 Q. If we go over the page, please, to page 11, paragraph 38
16 you say:
17 "I make the following comment about the notes of
18 the meeting. 1, on the first page I have written that
19 he has been aware of problems. The word 'problems' is
20 in inverted commas because I would not accept existence
21 of a problem until I had seen objective evidence that
22 there was a problem."
23 A. I see what you say.
24 Q. You had it from the surgeon's own mouth. Let us have
25 a look back at page 25, back to the note of
0182
1 the meeting. There is a resolution, just above where
2 the page cuts off:
3 "He [that is Mr Wisheart] has talked openly and to
4 advantage to Chris Monk, Steve Bolsin and Gianni
5 Angelini."
6 What was that a reference to? Did he elaborate?
7 A. No.
8 Q. Do you remember being asked at the GMC whether you knew
9 about the dinner in a now lamented restaurant in Bristol
10 known as Bistro 21 in April 1994?
11 A. I do not remember that it was relating to that.
12 Q. As it happens the people who were at that dinner were
13 Chris Monk, Steve Bolsin, Gianni Angelini and James
14 Wisheart. But he did not elaborate there?
15 A. No.
16 Q. There is then a reference to the five cardiac surgeons
17 tabulating results. Those were Mr Wisheart,
18 Mr Dhasmana, Professor Angelini, Mr Bryan and
19 Mr Hutter.
20 A. Yes.
21 Q. So those were surgeons all of whom did adult work?
22 A. Yes.
23 Q. And two of whom did paediatric work?
24 A. That is right.
25 Q. So your discussion with Mr Wisheart is obviously
0183
1 embracing paediatric figures, as we see from the first
2 line of that paragraph, and also adult work as well?
3 A. Yes.
4 Q. And the focus of the meeting which the surgeons had had
5 in November 1994 in Mr Wisheart's house, according to
6 Professor Angelini, as you will have seen from
7 the transcript, was about adult work because he,
8 Angelini, was raising concerns about that.
9 A. He was.
10 Q. Next paragraph: "JW says adverse results must be in part
11 due to 1 weighted patient population re adverse
12 factors."
13 That is a reference to case mix.
14 A. Yes.
15 Q. What did he say about that?
16 A. I cannot remember, except to say that there would likely
17 be an adverse waiting because of higher risk patients.
18 Q. Why was it likely?
19 A. I do not know. I do not understand.
20 Q. Did he provide any evidence for the suggestion?
21 A. No. These are notes of what was said.
22 Q. In your statement, we do not perhaps need to go back to
23 it, it is paragraph 36, you say:
24 "I think I would have made a note if we had [that
25 is, discussed specific procedures]. I also remember we
0184
1 discussed case complexity and risk factors and how these
2 played upon outcome."
3 What was your input into that conversation about
4 case complexity and how those factors played upon
5 outcome?
6 A. Just hearing or trying to understand how poor results
7 might be partly explicable in terms of high risk patient
8 groupings.
9 Q. Did you accept the points that Mr Wisheart made about
10 case complexity?
11 A. I made notes about what he said.
12 Q. Did you believe him?
13 A. No more than I believed anybody else in this affair.
14 Q. Why not?
15 A. Because we were never in a forum where all the people
16 could be together. When I hear that the group --
17 I cannot see the reference in front of me now -- but had
18 met a few days before my meeting with James with an
19 ideal opportunity for all the people involved, my
20 frustration and anger even at this point increases
21 beyond measure. I just really do not want to believe
22 that, that here am I, someone who has no responsibility
23 for patients with cardiac disease, attempting to resolve
24 a problem that whirs around in the Trust, and that
25 people involved are not grappling with the issues.
0185
1 Q. An explanation about poor results based on case
2 complexity or case mix, would that demand tangible,
3 objective evidence that had been agreed by all the
4 people?
5 A. Yes, so that I learned by talking about Parsonnet risk
6 scores and so on and so forth, about adverse coronary
7 artery anatomy that might influence the outcome of
8 switches or AV canals, things I would have no knowledge
9 of otherwise. I am hearing these things but I do not
10 know what they mean.
11 Q. What knowledge did you have about the development of
12 risk stratification techniques or tools for paediatric
13 cardiac patients?
14 A. Nothing until I started talking to these colleagues
15 trying to unravel thing, or doing my bit trying to
16 unravel things.
17 Q. Over the page, at page 26, there is a reference to
18 Mr Wisheart not having approached Dr Bolsin because of
19 "a blood TX", I think that is shorthand for
20 transfusion, "problem, but it must be acknowledged that
21 SB is not an easy character to work with" and some
22 reasons are given for that.
23 Why did the conversation with Mr Wisheart include
24 a discussion of the character of Dr Bolsin?
25 A. I think that was put forward by James as one reason, if
0186
1 I remember the interpretation of that, that James found
2 it difficult, perhaps one reason why at the dinner he
3 felt that he was in a position that if he did bring it
4 forward Steve Bolsin might feel to some extent
5 victimised or that he was pursuing it because of
6 knowledge about a blood transfusion problem, which I had
7 no knowledge of at all.
8 Q. We have seen your letter to Dr Black and we do not need
9 to go over that ground again, the comments that Dr Black
10 makes in his letter about Mr Wisheart and the comments
11 that you made in your letter to Dr Black which are not
12 quite as starkly put as Dr Black's to you, about
13 Mr Wisheart's lack of insight and so on. You remember
14 that discussion --
15 A. Yes.
16 Q. -- on the one hand. Here we have Mr Wisheart on
17 the other hand giving reasons why he, Mr Wisheart, finds
18 Dr Bolsin difficult to approach.
19 A. Yes.
20 Q. So neither party, if you like, is finding it easy to
21 talk to the other?
22 A. No.
23 Q. Did you know that by this time the case concerning
24 the blood transfusion had been dealt with by
25 the Coroner, a point that Dr Bolsin makes in his note on
0187
1 your statement?
2 A. I did not know.
3 Q. There is a reference in the note:
4 "...also note that he [that is Dr Bolsin]
5 developed a referral agency without telling people they
6 were named on his selling document, e.g. James W
7 Westerby (Oxford)?? et cetera."
8 Can we look at UBHT 118/11, please. Can you help
9 us with what this document is about?
10 A. No idea at all.
11 Q. You never had any knowledge of Whitechurch Medical
12 Services Limited, a company of which Dr Bolsin would
13 appear to have been company secretary?
14 A. No.
15 Q. After the meeting with Mr Wisheart the following day you
16 wrote a letter, did you not, to Mr Wisheart?
17 A. I did.
18 Q. WIT 87/28, please. You copied it, did you not, to
19 Dr Monk?
20 A. I did.
21 Q. You say in it that you had spoken to Dr Monk that
22 morning?
23 A. I did.
24 Q. "... and that Chris [Dr Monk] will relay the gist of our
25 talk to Sheila Willatts and Steve Bolsin".
0188
1 A. He agreed to do that.
2 Q. What was the gist of the talk?
3 A. The transcript and the agreed conclusions.
4 Q. You say there, and this is really reflecting
5 the conclusion set out in the note, that the best way
6 forward was for an internal discussion to begin
7 initially with the five cardiac surgeons. What should
8 be done fairly quickly to agree the data and then that
9 would be discussed with cardiology and anaesthesiology
10 colleagues and you suggested that should be completed
11 before Christmas.
12 If we go back, please, a couple of pages to 26,
13 this is a conclusion in your note of the meeting
14 agreeing, if you see 1, 2, 3 and 4. Did 1 and 2 ever
15 take place?
16 A. No. Well, I do not know whether 1 took place. 2, I was
17 not asked to chair or be an impartial chair ever any
18 meeting. Whether a meeting took place or not, I do not
19 know. 3 took place.
20 Q. And 4 in fact is an observation as opposed to
21 the action?
22 A. Yes.
23 Q. So three things were to happen. You were to do number
24 three and you did it?
25 A. Yes, I did that.
0189
1 Q. As far as you are aware, 1 and 2 did not happen?
2 A. I do not know.
3 Q. But certainly you did not chair any meeting?
4 A. I was not asked to chair any meeting, no.
5 Q. Professor Angelini spoke to you about Joshua Loveday's
6 operation before it took place, did he not?
7 A. I believe he did, yes.
8 Q. And he told you that a meeting was to take place of
9 the clinicians from the paediatric cardiac field?
10 A. I think it actually might have been taking place when he
11 talked to me, but I may be wrong on that detail.
12 Q. You knew the operation was the next day?
13 A. I did.
14 Q. You yourself were not at the meeting?
15 A. I was not.
16 Q. Nor was Professor Angelini?
17 A. He was not.
18 Q. Did you know he was at the meeting?
19 A. No, I did not, except that there were representatives
20 from surgery, anaesthetics, cardiology.
21 Q. Can we have UBHT 126/51, please? This is data which
22 certainly Professor Angelini has told the Inquiry was
23 discussed at the meeting the night before Joshua
24 Loveday's operation. Do you remember seeing this data
25 at about that time?
0190
1 A. No.
2 Q. Did you know what the situation was with the patient
3 Joshua Loveday in terms of the urgency or otherwise of
4 his operation?
5 A. No.
6 Q. You did not know whether he was capable of being
7 transferred to another hospital?
8 A. I did not.
9 Q. For such a meeting to take place, had you heard of such
10 an instance before of that type of multi-disciplinary
11 meeting taking place on the eve of an operation?
12 A. Yes.
13 Q. And are those instances, instances of emergency cases or
14 non-emergency cases?
15 A. It could be either.
16 Q. How frequent would be it that such a meeting would take
17 place in a non-emergency case?
18 A. I would not even think of offering an opinion with
19 regard to cardiac surgery. I would not know. But in
20 elective general surgery, there is often time that
21 a meeting can be scheduled in daylight and discussed
22 appropriately. But if there is an urgency, an emergency
23 situation, then it is often more difficult to convene
24 such a meeting. Sometimes patients fall between --
25 sometimes it is not easy to make a judgment on when an
0191
1 intervention needs to be done.
2 Q. So you yourself did not have any direct involvement
3 after Professor Angelini told you that the meeting was
4 taking place?
5 A. I did not.
6 Q. Until after the operation had taken place?
7 A. And even then I had no involvement.
8 Q. Why did Professor Angelini tell you about the meeting?
9 A. I think he was concerned that they were thinking of
10 carrying out a paediatric surgical procedure. I am
11 afraid I cannot remember the nature of that procedure on
12 Joshua.
13 Q. After the operation, Professor Angelini wrote to
14 Dr Roylance on 16th January. UBHT 217/138. I think
15 this is a letter you have had a chance to see, copied to
16 you, I think. Do you remember seeing that letter?
17 A. Yes, I do.
18 Q. Second paragraph:
19 "I share your opinion an enquiry should be held on
20 the paediatric work carried out... from 1988 to the
21 present day. I think this is a minimum requirement
22 given the recent circumstances and the bad feeling
23 present in the unit", and so on.
24 He makes two suggestions as to who might take
25 part: Mr Brawn and Mr de Leval, both of whom were
0192
1 paediatric cardiac surgeons. What was your view of this
2 letter?
3 A. I can understand very much Gianni's feelings. I also
4 can understand the sadness and devastation that those
5 who cared for Joshua would also feel. It also talks of
6 it seems that switch procedures should not be carried
7 out at all in the future. If I remember rightly, Joshua
8 was not neonatal but a slightly older child or baby.
9 Q. Finally, Professor, can we go back to your letter to
10 Dr Black, WIT 87/30. Just a couple of points here. In
11 the third paragraph, fifth line, you say:
12 "I offered to provide this brokerage in September
13 1994 and wrote a letter to James with a copy to Chris
14 Monk."
15 Might that not be a reference to the November
16 letter?
17 A. The November meeting.
18 Q. The next line, Sheila Willatts and Cedric -- that is
19 Professor Prys-Roberts?
20 A. Correct.
21 Q. In the next paragraph, if we scan down a little:
22 "I have aired my grave reservations about the
23 situation with the Dean."
24 Who was that? Was it Professor Dieppe perhaps?
25 A. I think it was Paul at that time.
0193
1 Q. "And subsequently with Hugh Ross when he arrived."
2 A. Yes.
3 Q. He is the Chief Executive?
4 A. Yes.
5 Q. If you shared your concerns with Hugh Ross when he
6 arrived and previously with the Dean, why did you not
7 share your concerns with the previous Chief Executive,
8 Dr Roylance?
9 A. I am not sure about that. I think this was a different
10 circumstance with Hugh Ross coming in, having open,
11 regular meetings with certainly with myself, which
12 I much enjoyed. It came up not through my initiation
13 but at regular meetings that I had with Hugh Ross when
14 he first started in the Trust.
15 Q. If we go to Dr Black's letter to you, which if
16 I remember correctly is UBHT 150/11, page 2, over
17 the page, the first paragraph over the page, it is the
18 last five or six lines, just below the reference
19 to "lack of insight":
20 "You went on further..." et cetera, "so that it
21 might make sense to occupy James as much as possible
22 with managerial responsibilities and as little as
23 possible with cardiac surgical practice."
24 Do you remember making that suggestion?
25 A. No, I do not.
0194
1 Q. If such a suggestion were made, it would suggest, would
2 it not, that Mr Wisheart would be taken out of the loop
3 for both adult as well as paediatric cardiac surgery?
4 A. If that were to occur.
5 Q. But certainly at about 1996, that would be the case?
6 A. I think at that time the volume of concern for James and
7 the burden that he was carrying was such that people
8 felt that his load was too much to try and continue
9 looking after patients and carry a very heavy
10 administrative load.
11 Q. Professor Farndon, those are all the questions that
12 I want to ask you this afternoon. You made a reference
13 earlier to you and I having had an informal discussion
14 yesterday which we did, as we do for all witnesses. Is
15 there anything arising out of what you saw then when
16 I showed you some of the documentation to be referred to
17 today or anything arising out of today's evidence that
18 you want to now add by way of postscript to the evidence
19 you have given orally?
20 A. I do not think so.
21 MR MACLEAN: There may be some questions from the Panel.
22 I am sure the chairman will remind you there will be an
23 opportunity to submit any further evidence if anything
24 does occur to you. May I thank you very much indeed for
25 the evidence you have given.
0195
1 THE CHAIRMAN: Thank you, Mr Maclean. There are no
2 questions from the Panel. I understand, Mr Hoyte, you
3 have no re-examination?
4 MR HOYTE: No, thank you, sir.
5 THE CHAIRMAN: I am grateful to you. Professor Farndon, it
6 has been a long day for you, but we are very grateful to
7 you for coming and spending this time with us. As
8 Mr Maclean indicated, if there are other matters which
9 come to your attention or you remember things that we
10 have been reflecting upon today, we would be very
11 grateful to hear from you. But for the moment, thank
12 you very much indeed.
13 PROFESSOR FARNDON: Thank you.
14 MR MACLEAN: Sir, that concludes the evidence for today.
15 Tomorrow we sit I think at 9.30 when the Inquiry will
16 hear from expert clinicians and also experts from
17 the statistical side of things, in particular from
18 Professor Michael Campbell, Professor Stephen Evans,
19 Dr Paul Aylin, Professor Gordon Murray, Dr David
20 Spiegelhalter. All of those gentlemen will deal with
21 the analysis of the various data sources. The Inquiry
22 will also be assisted by the expertise of Dr Eric Silove
23 a paediatric cardiologist, and Mr Leslie Hamilton whom
24 the Inquiry will recall hearing from previously.
25 So tomorrow is devoted essentially to statistics
0196
1 and we start at 9.30.
2 THE CHAIRMAN: I am grateful to you, Mr Maclean. Good
3 afternoon to you and to everyone else. We will
4 reconvene tomorrow morning at 9.30.
5 (4.30 pm)
6 (Adjourned until 9.30 am on Wednesday, 3rd November
7 1999)
8
9
10 I N D E X
11
12 PROFESSOR GORDON STIRRAT (sworn):
13 Examined by MISS GREY .................... 1
14 Examined by THE PANEL .................... 52
15
16 PROFESSOR JOHN FARNDON (affirmed):
17 Examined by MR MACLEAN ................... 62
18
19
20
21
22
23
24
25
0197
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001