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Daily transcripts
Hearing summary
8th November 1999
The Bristol Royal Infirmary Inquiry oral hearings this week will focus
on the Directorate of Anaesthesia within the Bristol Royal Infirmary (BRI). The witnesses
will give evidence regarding the management and organisation of the directorate and also
comment on any concerns that were raised regarding the paediatric cardiac services in
Bristol. Hearings will also be attended by members of the Inquiry’s group of
independent experts who will be invited to comment on the evidence given.
Today’s witness was Dr Stephen Pryn, Consultant Anaesthetist, BRI.
He described his experience in paediatric cardiac practice prior to his appointment to the
BRI in 1993 and commented on the differences in the management of cases between the units
in which he had worked. He went on to discuss audit and focussed on specific audits he had
been involved with at the BRI. He described the process for recording critical incidents
within the Department of Anaesthesia at the BRI and contrasted it against the ad hoc
approach adopted in the Cardiac Unit. Dr Pryn then commented on the reaction of cardiac
surgeons to the establishment of consultant intensivist sessions in the Cardiac Intensive
Care unit and described communications between members of the clinical team, highlighting
confusion regarding decisions made at surgical and anaesthetic ward rounds. He then
discussed his impression of the cardiac service in Bristol, commenting on the length of
time patients were spending in the operating theatre, the age at which children were
referred for surgery and the standard of the clinical environment and the equipment used.
Dr Pryn noted that babies and children returning from the operating theatre following
complex cardiac surgery needed more support from clinical staff in the cardiac intensive
care unit than at other hospitals he had worked at and commented on the surgeons’
professional approach within the operating theatre. He then told the Inquiry about an
audit he undertook of paediatric cardiac surgery during 1993 and commented on audit data
he was shown by Dr Stephen Bolsin and figures presented by the cardiac surgeons, all of
which identified high mortality rates. He went on to comment on a multi-disciplinary
meeting held at the end of 1994, at which Mr Janardan Dhasmana, consultant surgeon, after
discussion of mortality rates for paediatric cardiac surgery, agreed to stop operating on
neo-natal patients. He concluded by describing a meeting held on January 12 to discuss the
case of Joshua Loveday, who subsequently died the following day after surgery performed by
Mr Dhasmana.
Dr Michael Scallan, Consultant Anaesthetist, Royal Brompton Hospital,
attended today’s hearing as a member of the Inquiry’s Expert Group.
|
FULL TRANSCRIPT
1 Day 72, 8th November 1999
2 (10.50 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Miss Grey.
5 MISS GREY: Sir, this morning we have the benefit of hearing
6 from Dr Stephen Pryn. Before I invite him to come
7 forward and take the stand, I should also say that we
8 have the benefit of the attendance of Dr Scallon of the
9 Brompton Hospital, whom the Inquiry has had the benefit
10 of hearing from already. He is here to assist us with
11 the evidence of Dr Pryn by offering either comment or
12 question as it occurs to him throughout the day, and
13 possibly comment at the end of the day.
14 For that reason, in case his interventions, should
15 they arise, are matters of evidence, we will invite him
16 to affirm at this moment.
17 DR STEPHEN SCALLON (AFFIRMED):
18 MISS GREY: Dr Scallon, would you like to introduce yourself
19 briefly for the sake of the wider audience?
20 DR SCALLON: I am a consultant anaesthetist at the Royal
21 Brompton Hospital. I went there in 1977 and in my time
22 there I have been widely involved in paediatric cardiac
23 anaesthesia, and in the first 10 or 15 years of my time
24 there, I had a fair involvement in paediatric intensive
25 care.
0001
1 MISS GREY: It is also right, is it not, that you were one
2 of the experts and assisted the Inquiry on the clinical
3 case review?
4 DR SCALLON: That is indeed correct.
5 MISS GREY: May I invite Dr Pryn to come forward? I should
6 say first he is represented today by Miss Tina Freedman,
7 who sits behind me.
8 Dr Pryn, we have been taking evidence on oath or
9 affirmation. Would you like to stand for that, please?
10 DR STEPHEN PRYN (SWORN):
11 Examined by MISS GREY:
12 Q. Your full name is Stephen John Pryn?
13 A. That is correct.
14 Q. And you have provided a statement to the Inquiry. If we
15 could look, please, at WIT 341/1: is that the first
16 page of your statement?
17 A. Yes, it is.
18 Q. If we turn to page 48, is that your signature which
19 appears at the bottom?
20 A. It is.
21 Q. Are the contents of this statement true to the best of
22 your knowledge and belief?
23 A. They are.
24 Q. If we can go back, please, to page 1, you set out there,
25 Dr Pryn, if we scroll down the page a little, your
0002
1 experience prior to taking up your post in Bristol in
2 August 1993. It is right, I think, that your immediate
3 experience prior to coming to Bristol had been in
4 Oxford?
5 A. That is correct.
6 Q. We get a little further detail of your experience in
7 your curriculum vitae, which you append at the back of
8 the statement.
9 If we just remain, however, on this page, can
10 I ask you about your experience in Oxford? Firstly,
11 does Oxford have, or did it have at the time you came to
12 Bristol, any particular reputation for the nature of the
13 cardiac surgery which it was performing?
14 A. I was under the impression that it had a reputation for
15 its adult surgery, in that it was a very high throughput
16 unit and had, along with the Brompton, pioneered rapid
17 post-operative intensive care.
18 Q. And early extubation?
19 A. And early extubation, yes.
20 Q. If it was a unit which had rapid throughput for adults,
21 was that a matter which bore any relationship or
22 impinged on speed of surgery?
23 A. Well, the surgeons were very quick and precise.
24 Q. What about in the field of paediatric cardiac surgery?
25 A. The same surgeon was doing paediatrics as was doing
0003
1 adults, and he was very quick and precise.
2 Q. What about post-operative intensive care in Oxford, of
3 children? Did you have any experience or involvement in
4 that?
5 A. Some. But not the direct management of cases; that was
6 done by the paediatric cardiologists.
7 Q. So when you say "some", what did that experience entail?
8 A. It entailed visiting patients that I knew had been
9 operated on in that week, visiting them regularly during
10 the week to see how they were progressing, but not being
11 part of the team that decided their management. And
12 then, in the evenings, when I was Senior Registrar on
13 call, assisting them with any airway management that
14 needed to be performed.
15 Q. So to put the matter more broadly, when you were asked,
16 or offer comment in your statement about the comparisons
17 between Bristol, firstly for paediatric cardiac surgery,
18 leaving aside post-operative care for the moment, on
19 what would those comparisons be based?
20 A. Comparisons between Oxford and Bristol?
21 Q. If you are asked to make comparisons between Bristol and
22 your experience elsewhere, what would you be drawing
23 upon to make those comparisons?
24 A. I would be drawing upon my personal experience of seeing
25 children anaesthetised in Oxford, and also in
0004
1 Southampton, where I was a Registrar.
2 Q. And how did the intensity of your experience in those
3 fields vary compared with the extent of your exposure to
4 paediatric cardiac surgery in Bristol after your
5 appointment as a consultant anaesthetist?
6 A. In both Southampton and Oxford, I was part of the adult
7 and paediatric service together, and I suppose about
8 a fifth or a quarter of the workload was paediatric in
9 both those centres. The same could be said for
10 Bristol.
11 Q. In relation to post-operative care at Bristol, what were
12 you drawing upon to make any comparisons?
13 A. My experience primarily with Southampton, because the
14 cardiac surgical intensive care ward there looked after
15 adults and children together, and I was involved with
16 the care of children there.
17 Q. Looking back on those two areas of experience, Oxford
18 and Southampton, how well do you think that they qualify
19 you to draw comparisons between those centres and
20 Bristol?
21 A. I obviously did not have extensive experience in either
22 two centres, but I had experience. I can say no more
23 than that. There is another centre I visited that we
24 have not talked about and that is Alder Hey Hospital in
25 Liverpool. I was there for two weeks just looking at
0005
1 the paediatric cardiac surgery unit and the intensive
2 care. So I had experience --
3 Q. Was that specifically anticipating your move to Bristol,
4 or not?
5 A. No. That was at a time when I was still formulating my
6 ideas as to what I wanted to do with my career.
7 Q. So when was it specifically?
8 A. It was at the beginning of my slot in High Wycombe, so
9 when I first became a Senior Registrar.
10 Q. In March 1991 -- I have just taken the detail from your
11 CV.
12 A. That is when I was a Senior Registrar, but that is not
13 when I went to High Wycombe. It may have been the
14 autumn of 1991.
15 Q. If we look briefly at page 50 of your witness statement
16 and if we go on a page, please, to page 51, we see
17 there, do we, the dates of a visit both to High Wycombe
18 and also to Alder Hey?
19 A. Right, yes. That is obviously right.
20 Q. Coming back to your statement, then, please, and looking
21 at page 4, you turn there generally to various issues
22 under issue B, but you include a discussion of audit and
23 your involvement in audit.
24 When you arrived at the Bristol Royal Infirmary in
25 August 1993, and until, say, January of 1995, were you
0006
1 aware of the presence of any Audit Committee in the
2 hospital?
3 A. No.
4 Q. I think it follows from that, then, that you had no
5 involvement in the affairs of such a committee?
6 A. That is true; I did not.
7 Q. What was the structure that was co-ordinating
8 anaesthetic audit that you were aware of?
9 A. I was only aware that Dr Masey was our audit
10 co-ordinator, but that if anybody wanted to do any audit
11 projects, they should approach her first and that she
12 would co-ordinate the performance of that project and
13 also the dissemination of the information and the
14 closure of the loop.
15 Q. At paragraph 2, page 4 of your statement, if we scroll
16 down a little, you talk about the fact that the
17 Anaesthetic Department Committee meeting coincided with
18 the Mortality and Morbidity Cardiac Surgical Committee
19 meeting.
20 Firstly, can we look briefly at WIT 270/12? This
21 is from a statement Dr Masey has given to the Inquiry.
22 If we scroll down a little, we can see that she says
23 that, as routine operating was cancelled on the half
24 days when there were anaesthetic audit meetings, the
25 cardiac surgeons held their audit meetings at the same
0007
1 time.
2 Is that a reference to the same clash that you
3 were referring to in your statement?
4 A. Yes, it is.
5 Q. You mention that the cardiac surgeons had their
6 mortality and morbidity meetings on those days. Is that
7 another word for an audit meeting, or did you understand
8 something else was happening then?
9 A. They were supposed to be audit meetings, but initially
10 they were just discussions on morbidity and mortality.
11 I believe they evolved later to take on more of what
12 I understand by "audit".
13 Q. Would you like to describe the difference between those
14 two things?
15 A. I believe audit is establishing a standard, monitoring
16 your current practice to see whether you are achieving
17 that standard, and then instituting change so that you
18 can achieve the standard. That is what I mean by
19 "closure of the loop."
20 I think morbidity and mortality is part of that,
21 but is really just monitoring current practice; it does
22 not really --
23 Q. One of the points to be made about it, perhaps, is that
24 unless you look at a series of cases, you may not be
25 able to analyse trends?
0008
1 A. That is true.
2 Q. When you arrived at Bristol in August 1993, then, was
3 the understanding of audit that you have just given to
4 us, the definition of it, something that was familiar to
5 you?
6 A. Yes, it was familiar to me.
7 Q. Was that something that you had seen in practice
8 operating at Oxford?
9 A. No, it was just through reading articles at the time.
10 Q. So how did the anaesthetic audit practice that you
11 saw -- we will stay with anaesthetic for a moment and
12 come back to cardiac surgery -- compare with what you
13 had experienced at Oxford?
14 A. We did not have any audit in Oxford on those lines at
15 all, so this was new to me, but it was in line with what
16 I expected from reading various articles aimed at
17 educating physicians.
18 Q. So what did you find at Bristol, then, amongst the
19 anaesthetic team?
20 A. The audit meetings, as far as I can recollect, were
21 often involved with defining the standards that we
22 should have set and therefore defining what projects
23 need to be instituted for the future. I was a little
24 frustrated having gone to a couple of the meetings
25 because there was no actual data or evidence presented,
0009
1 so audit at that stage was in an early stage of
2 development.
3 Q. But there was at least a clear appreciation of the need
4 to set standards and what, to move on from there to
5 collect data?
6 A. That is right.
7 Q. So, going back to what you had said to be the position
8 in Oxford, how did the state of development of "audit",
9 if I may put it in inverted commas, compare between the
10 two institutions?
11 A. In Oxford there were no anaesthetic audit meetings
12 whatsoever, whereas there were in Bristol.
13 Q. If we could go back, please, to your statement at page 4
14 of WIT 341, and scroll back again, please, to
15 paragraph 2, you there turn back to the audit meetings
16 and mortality and morbidity meetings. How did those
17 compare with the definition of "audit" that you have set
18 out?
19 A. Initially they were, as I mentioned previously, just
20 morbidity and mortality meetings, where we looked at
21 individual cases and decided whether we could have done
22 something differently. It was only at a later stage
23 that true audit was presented and I think I was part of
24 that process, in that it was my audits in intensive care
25 that were presented that illustrated to the meeting how
0010
1 audits should be performed.
2 Q. Can you help us a little bit on the date then if there
3 was a development at a later stage to a fuller ...?
4 A. It would have been throughout the year of 1994, because
5 the audits that I performed in the Intensive Care Unit
6 were, I believe, early 1994 and I believe I presented
7 them at a joint audit meeting with the cardiologists in
8 around the summer of 1994.
9 Q. And after that, you say you saw a gradual change in the
10 cardiac surgery unit?
11 A. Absolutely. I think Mr Alan Bryan was part of that
12 change as well. He tried to develop audit such that we
13 were looking at a particular topic, as well as morbidity
14 and mortality.
15 Q. Those were cardiac surgical meetings. What was the
16 balance of emphasis or interest in children's cases at
17 those particular meetings?
18 A. I believe that it was often mentioned if a child had
19 died as part of the last month's summary, but I cannot
20 remember many children's cases being discussed in those
21 meetings, and I later came to find out they were
22 discussed in other meetings I was not a party to.
23 Q. Those were meetings that took place at the Children's
24 Hospital; is that right?
25 A. I believe they did, but they could have been in the
0011
1 pathology department; I have no idea. I think
2 I attended one. That was before the Joshua Loveday
3 meeting.
4 Q. So was that a particular meeting on a particular child
5 you were interested in, or why did you attend that one?
6 A. That was because the meeting that was called to discuss
7 the Joshua Loveday case was actually following on from
8 a clinicopathology conference, so I thought I may as
9 well go to the conference. That is when I discovered
10 they were actually discussing children in great detail
11 at those meetings.
12 Q. Was that the first time you had realised that those
13 meetings were taking place?
14 A. No. I think I knew in the back of my mind that surgeons
15 were meeting with the pathologists, but I did not know
16 the extent of their discussions about the clinical
17 cases.
18 Q. Was it ever suggested to you that in those sorts of
19 meetings with another group of personnel there might
20 also have been a place where discussion of figures for
21 the children's service was also taking place?
22 A. No, I have never heard that comment made before.
23 Q. You mention the audits that you were involved in. You
24 start at paragraph 3. If we turn over the page, we see
25 the first of those mentioned there was the extubation
0012
1 audit.
2 If we go, please, to that audit, it is to be found
3 at UBHT 151/48.
4 Is this a copy of the paper that you presented
5 after completing the audit?
6 A. It looks like it is the notes that I gave my talk on.
7 This has various jottings on it.
8 Q. I can see there, for instance, that you say, if we
9 scroll down the page a little, "apologise for bullying,
10 but are very grateful"?
11 A. Yes.
12 Q. It took a little work, did it, to collect the data?
13 A. Yes. The nurses were primarily the people who were
14 collecting this data and they felt that they "already
15 had enough work to do without another piece of paper to
16 fill in, thank you very much".
17 Collecting audit data had not been part of their
18 routine practice up until that time, so this was a new
19 development.
20 Q. What impression did you form of the part that collecting
21 audit data on nursing projects for nursing audit might
22 have formed as part of their routine?
23 A. At that stage, I was not aware that any nursing audit
24 was going on.
25 Q. The extubation audit that you performed was in relation
0013
1 to adult patients?
2 A. That is correct.
3 Q. Why adults rather than children, or both?
4 A. Because I came with experience of early extubation in
5 adults. I wanted to achieve the same results in Bristol
6 and I saw an audit project such as this as a way of
7 achieving change, otherwise it is very difficult to
8 achieve change.
9 Q. Oxford, I think we said earlier, had made a deliberate
10 push, if I can call it that, towards early extubation?
11 A. They had.
12 Q. Why was that thought to be important at the time?
13 A. Because there are complications to prolonged
14 ventilation, and if you can minimise those risks to the
15 patient without adding extra risks, then it is a useful
16 clinical manoeuvre.
17 Q. Is that still accepted clinical wisdom, or has the
18 emphasis on early extubation declined?
19 A. If anything, I think the emphasis has increased, but
20 primarily from a financial standpoint.
21 Q. Because early extubation and early exitus from ITU
22 increases throughput of cases?
23 A. Yes, and it is cheaper.
24 Q. Was that a factor you were aware of at the time you
25 conducted your audit as well?
0014
1 A. I was aware that was a factor, but the primary reason
2 for changing was a clinical one.
3 Q. You say there at the top of the screen under the heading
4 "1990s", "Now an economic necessity". What was the
5 importance of that necessity in the thinking of you and
6 your peers at the time?
7 A. I was just pointing out that it may be that if other
8 centres are going to do this, Bristol will be left
9 behind if they do not.
10 Q. The results are shown over the page, page 49. We see
11 that there is quite a large number of patients who are
12 extubated, 50 per cent of patients are extubated by 5.5,
13 and then there is a tail, also representing quite
14 a large number of patients, who are more slowly
15 extubated?
16 A. That is correct.
17 Q. Over the page, page 50, the Oxford comparator is given.
18 Would that have been typical of other centres?
19 A. No. Oxford was very much an outlier at that stage,
20 along with St Thomas's.
21 Q. Do you think that the results you found bore any useful
22 relationship or resemblance to the position of the
23 extubation of children as well as adults?
24 A. I am sorry, do these results relate ...
25 Q. You studied children; what about adults? Can we draw
0015
1 any lessons from this audit in relation to children?
2 A. This audit is about adults, not children.
3 Q. I do apologise, you studied adults; what about children?
4 A. Probably it bears no relation at all to the management
5 of children because these adults, most of them, are very
6 routine cases, bread-and-butter cases where we were
7 doing high throughput. Children were very much all
8 individuals for individualised treatment.
9 Q. So if we go on to page 51, we have lost, I am afraid in
10 the photocopying the part that relates to the largest
11 element on the pie chart.
12 A. It should read "too sleepy".
13 Q. Over-sedation was something I think you identified in
14 this audit?
15 A. That is right.
16 Q. Any useful conclusions to be drawn about the management
17 of children in that?
18 A. No, I do not think so.
19 Q. What about the comment "no anaesthetist available"?
20 A. That reflected two things: (1) the anaesthetist, the
21 trainee anaesthetists that were supposed to be covering
22 the intensive care unit, had other duties, such as
23 cardioversions or assisting transport of patients back
24 from theatre, or, indeed, doing emergency cases in the
25 evening and the night.
0016
1 It also reflected the fact that at night there was
2 no resident trainee anaesthetist. So patients who were
3 still intubated at midnight, or whenever the
4 anaesthetist went home, would have had to be kept
5 intubated until the next morning when the anaesthetist
6 arrived.
7 Q. So that is a finding that is generalised towards the
8 cases of children as well, is it?
9 A. Yes, although we probably would not have timed the
10 extubation of children to the middle of the night.
11 Q. Because ...
12 A. Because there is not enough senior expertise to manage
13 the cases at that time.
14 Q. And it would require the involvement of a consultant
15 anaesthetist, would it?
16 A. It might do, if the child deteriorated.
17 Q. So you would want to have one at least readily available
18 on call, if not physically present in the ward when
19 extubation commenced?
20 A. That is right.
21 Q. What response came out of this particular audit? How
22 responsive do you think that the Anaesthetic Department
23 and those who worked with them were to its findings?
24 A. I think they took on board that we could perhaps do
25 things slightly differently. The sedation policies were
0017
1 changed after that. That took a large proportion of
2 that pie chart.
3 Q. Yes. We can go on, if it helps?
4 A. If you need it up there, the next largest -- the fact
5 that patients were too cold. We purchased two hot air
6 patient warmers subsequent to that. And we had
7 a general discussion about the management of cases that
8 were bleeding. After this audit, we had general
9 discussions about instituting a nurse extubation
10 protocol for routine adults, and in fact, that has now
11 been started and is up and running.
12 Q. That has now been started?
13 A. Well, it is up and running. It has been going for
14 a couple of years now.
15 So we did make quite a few changes, recommended in
16 that audit.
17 Q. Are you intending to paint a picture of an institution
18 that was responsive, or do you think that that would be
19 unduly --
20 A. It certainly responded to that audit, but if you look at
21 the extubation times, although we have changed the
22 process, the extubation times probably have not changed
23 at all, so whether that reflects a responsive
24 institution is your guess is as good as mine.
25 Q. Why do you think they have not changed?
0018
1 A. I think largely it is due to the fact that we have
2 instituted nurse extubation, and although I am very for
3 that, the nurses perhaps are not as confident to be as
4 aggressive as an experienced clinician like myself would
5 have been, and that will take some time before they
6 become as aggressive.
7 Q. If one looks through this audit, and perhaps the others
8 you have cited in your statement, one might perhaps say
9 that they appear to be very thorough and very detailed
10 audits.
11 How do you think your practice in carrying out
12 audits such as these compared with that of the other
13 consultant anaesthetists on the ward at the time?
14 A. I think some of the other consultants contributed to
15 these audits, but they probably, at the time, were not
16 doing as much as I did at that time.
17 Q. Is that a comment on different interests or pressure of
18 work, or what?
19 A. Both, no doubt.
20 Q. You were particularly interested in audit?
21 A. I saw audit as the method of change and it was a way to
22 convince people that there was a need of change and
23 there were simple ways to change, and therefore,
24 I became interested in audit.
25 Q. You talk about a need for change. Can you just sum up
0019
1 to us what your overall impressions were of the cardiac
2 surgical unit at the BRI when you first arrived in it in
3 August 1993 and after a few months you had had some
4 experience of working there?
5 A. It was a unit that was often run minute by minute by
6 relatively inexperienced doctors, with their senior
7 cover not being that available, and it was a unit run by
8 trainees who were not used to general intensive care
9 issues, were quite familiar with managing the
10 cardiovascular system, but were relatively poor at
11 integrating that with the other systems, for instance,
12 the respiratory system.
13 Q. Was that because their background tended to be surgical?
14 A. Their background was not in general intensive care.
15 Q. So what you are singling out there is the issues of
16 post-operative management that you give us more detail
17 on in further parts of your statement; is that correct?
18 A. Yes.
19 Q. That would be the thing that you took away most strongly
20 after the first couple of months or so at the BRI?
21 A. That there needs to be more input from a general
22 intensive care background, and that senior cover needed
23 to be more available.
24 Q. And it was perhaps an awareness of this that had fuelled
25 your appointment and that of Dr Davies in the first
0020
1 place?
2 A. Absolutely.
3 Q. If we turn, then, to another audit that you performed,
4 this is the CICU length of stay, UBHT 184/43.
5 Again, this is an adult audit; is that right?
6 A. Yes, I believe it is.
7 Q. Why, again -- perhaps it may be obvious -- focus on
8 adults?
9 A. The date at the top of that is September 1995. The
10 children moved to the Children's Hospital round about
11 that date, so it would have been not particularly
12 helpful to us at the time to look at children's length
13 of stay.
14 One of the reasons for this audit was to
15 illustrate the inadequacies of databases at the time.
16 Q. If we turn to page 53, your conclusions, we can see,
17 again there the reference to the PATS database needing
18 improvement, and that was a very strong feature of your
19 findings?
20 A. It was.
21 Q. Again, can we take anything from this audit that might
22 apply to children? What did you observe about the
23 length of stay of children on the ITU before, of course,
24 they moved to the BCH?
25 A. I did not collect any data on it, but they obviously
0021
1 stayed a very long time. We had some very long stay
2 children there.
3 Q. If we go down, please, to the third bullet point, you
4 mention there:
5 "Contrary to popular rumours, the problem of
6 prolonged CICU stays is not confined to one or two
7 surgeons when case mix is taken into account."
8 What were the "popular rumours" at the time?
9 A. This is talking about adults. The people thought that
10 cases of Mr Wisheart's were staying longer in intensive
11 care than other patients.
12 Q. And the second surgeon mentioned there?
13 A. I cannot remember. It may have been Mr Dhasmana, but
14 I cannot remember.
15 Q. But in any event, it was a popular rumour related to
16 adults?
17 A. It was. And actually, I think, although I have said
18 I did multivariate logistic regression, I think
19 I probably did not do that, I was probably
20 misunderstanding the statistics I was using. If
21 a experienced statistician went over the data again,
22 I am not sure they would draw the same conclusion.
23 Q. So you think the conclusion set out there might be
24 vulnerable to further analysis?
25 A. Yes, because I did not really have their statistical
0022
1 tools to do that test.
2 Q. In general, what was your level of statistical expertise
3 at the time?
4 A. I obviously had experience of statistics throughout my
5 training, and I had been involved with various research
6 projects, so I had come across statistical methods
7 then. But any sophisticated statistics, I would have to
8 ask advice on, and we were very fortunate having Dr Andy
9 Black in the department who was really very
10 knowledgeable.
11 Q. So you were aware of who to go to and felt you could ask
12 for advice if you needed it?
13 A. I was.
14 Q. And when it came to the issue of Dr Bolsin, Dr Black's
15 audit and figures being shown to you relating to
16 outcomes in paediatric cardiac surgery, was difficulty
17 in analysing figures ever a problem for you?
18 A. It is always difficult to understand what the figures
19 are telling you. The statistical methods used in the
20 Bolsin audit, as far as I can remember, were only
21 chi-squared and that is a pretty standard routine test
22 that I was very familiar with already.
23 Q. If we can go on, please, back to your statement,
24 WIT 341/6, you describe at paragraph 6 the procedure for
25 critical incident reporting within the Anaesthetic
0023
1 Department.
2 Can you explain to us what the "yellow form
3 system" was?
4 A. When a critical incident had occurred, the anaesthetist
5 involved was expected to find one of the yellow forms,
6 which was either in theatres or from the Anaesthetic
7 Department, fill it in with a brief description of the
8 critical incident, various recommendations that ought to
9 follow from it, and then submit that yellow form to the
10 Anaesthetic Department, where it will be reviewed at the
11 next incident meeting.
12 Q. So it was a form for the anaesthetist to fill in?
13 A. It was.
14 Q. And you describe a system which for the Anaesthetic
15 Department as whole appears to be "well-developed", your
16 phrase at paragraph 6.
17 What about in relation to incidents during cardiac
18 surgery? You say there would only be a form completed
19 if the incident was of general interest to other
20 anaesthetists and not just of local significance to
21 cardiac services.
22 Is there a danger it might fall through the gap
23 because of that attitude?
24 A. Absolutely. The point I am making was there was no
25 equivalent system within the Cardiac Services
0024
1 Directorate.
2 Q. Can you think of incidents which should have been
3 investigated further or logged for further analysis
4 which were not?
5 A. There is one very serious one which I think is in the
6 next paragraph, when a child suffered unexpected cardiac
7 arrest on the intensive care ward, and that was
8 investigated on an ad hoc basis. But there was no other
9 method of reporting that.
10 Q. I do not think we need to turn it up, but again, your
11 analysis of that incident is very thorough, very
12 detailed. Is that a characterisation of it that you
13 would agree with?
14 A. I was quite pleased with it, yes. I thought that having
15 had the insult to the child initially, I thought the
16 resuscitation was impeccable and the investigation
17 afterwards was impeccable. It came at a time when my
18 mind was aware of the Beverley Allitt case, and this
19 rang a few warning bells.
20 Q. Because one of the things that you investigated was
21 whether drugs, substances, had been deliberately
22 administered?
23 A. Absolutely. That crossed my mind.
24 Q. But this is an incident which was thoroughly
25 investigated, albeit on an ad hoc basis. What I asked
0025
1 you was for examples, if there are any to your
2 knowledge, of incidents which perhaps deserved further
3 investigation but were falling through an ad hoc system.
4 A. Yes, there were other incidents, less major, that would
5 have fallen through, but I cannot put my finger on any
6 one of them at the moment.
7 Q. Who took the decision that an incident was serious
8 enough to demand investigation?
9 A. The clinicians involved.
10 Q. On a consensus basis, or would one be able to push it
11 through if he or she felt strongly about it?
12 A. I think it was pretty obvious to all concerned that if
13 there had been a serious incident, it needed
14 investigating, so in that respect, it would have been
15 consensus.
16 Q. But the problem tends to come with incidents perhaps at
17 the margin of being serious, where particularly if
18 a number might occur, a trend might be detected, but
19 each one individually might not raise alarm bells?
20 A. There was no mechanism for those being reported, so we
21 just do not have that data.
22 Q. If we turn over the page to page 7, the general
23 impression we get from your discussion of protocols and
24 guidelines and the new ones that you developed was that
25 your impression was, when you arrived at the ward, that
0026
1 there was a need to formalise or to record, as well as
2 possibly to update, the current practice.
3 Is that a fair summary?
4 A. That is fair.
5 Q. Was it a matter of formalising or recording current
6 practice, or of updating?
7 A. I think both.
8 Q. What was the balance between the two?
9 A. I think formalising that was the best practice going on
10 at the time in the unit.
11 Q. So that --
12 A. Choosing the aspects that were already best practice and
13 formalising them.
14 Q. You are saying that best practice, good practice, was
15 already to be found on the unit, but it needed to be
16 made more uniform?
17 A. That is true of some of the protocols. The particular
18 one I am thinking about is, say, the drug infusion
19 protocol, where some people were using that type of
20 protocol already, but others were not. It was 50:50
21 whether somebody was going to use it or not. I thought
22 that needed to be standardised throughout. That was the
23 reason for that protocol.
24 Q. Would it perhaps be natural to see, in the work that you
25 did at the time, if I may call it the "standard
0027
1 response" of a new appointment to an institution?
2 A. I beg your pardon? I missed the question.
3 Q. I am so sorry. Would it be natural for a new appointee
4 such as you to carry out as it were a review of the
5 situation in which you find yourself, and thereby, as
6 a result generate a need or a perception of the need for
7 new protocols?
8 A. Yes, I would have thought so. I would have thought that
9 was my role. When I presented my intentions to the rest
10 of the cardiac anaesthetic group at a meeting at my
11 house shortly after I arrived, they were really very
12 encouraged by my proposals.
13 Q. If we look at firstly the question of the standard
14 practice for diluting drugs, I think we can just for the
15 sake of identifying them look at UBHT 152/99.
16 Is this the standard or protocol that you
17 developed for children?
18 A. It is.
19 Q. How did the absence of such a protocol compare to your
20 previous experience?
21 A. I think in my previous experience, children had needed
22 far less inotropic support than I was used to in Bristol
23 and they may only be on one drug and it was relatively
24 easy to see how much of that drug they were getting and
25 whether the dose was very high, very low or getting
0028
1 higher or lower.
2 In Bristol, many patients received multiple
3 inotropic and vasodilator drugs and it really took a lot
4 of time on intensive care ward rounds just to ascertain
5 how much of each the child was getting at the time.
6 So there was probably not the need at the previous
7 institutions I worked at for protocols like this,
8 because they were much cheaper.
9 Q. Were there generally written protocols or written charts
10 of standard dilutions to be found in Oxford and
11 Southampton?
12 A. Not that I was aware of.
13 Q. You developed protocols for both children and adults.
14 Was the paediatric experience, the experience of
15 nurses making up standard cardiac infusions for
16 children, more or less good than that of the nurses in
17 the work on adults?
18 A. The protocols here are for prescriptions. Prescriptions
19 were written by doctors, not nurses. In terms of how
20 you follow the prescription, the nurses were equally
21 good for adults and children.
22 Q. You talk generally in your statement about some concerns
23 over the availability of the paediatric experience of
24 nurses?
25 A. I mentioned paediatric qualifications rather than
0029
1 paediatric experience. I think the nurses in the
2 Bristol cardiac intensive care were really quite
3 experienced at nursing children; they just did not have
4 the qualifications.
5 Q. So did the absence of formal qualifications make any
6 difference to the standard of care that you were
7 observing from the nurses?
8 A. I think in general, the standard of nursing care was
9 quite good considering the circumstances. I think if
10 more nurses had had paediatric intensive care
11 qualifications, then they would have perhaps brought
12 slightly different techniques, but not a major change in
13 the care.
14 Q. You say "quite good considering the circumstances".
15 What did you mean by "the circumstances"?
16 A. The circumstances being that they were having to look
17 after children one day and adults the next; that the
18 junior doctors that were working with them at the time
19 more often than not were not that experienced with
20 children.
21 Q. And you say they might have brought slightly different
22 techniques without changing the overall care?
23 A. Techniques such as the method of stabilisation of
24 nasopharyngeal airways, or the way in which you can
25 involve parents in the care of their child.
0030
1 Q. Another of the protocols that you developed -- I turn,
2 please, to page 9 of your statement -- was that for
3 analgesia. You say you were concerned that they were
4 not routinely receiving enough post-operative analgesia.
5 Can you explain the nature of your concerns?
6 A. I remember very clearly the first morning that I walked
7 on to the intensive care ward, having started my
8 consultant job: waiting for me at the door was Dr Freda
9 Gardner, who was the clinical psychologist at the time,
10 who accosted me as I arrived at the unit and said,
11 "These children are screaming in pain, you have to do
12 something". The point she was making was that children
13 usually in the nursery, so after they have left the
14 intensive care ward, were having procedures done to them
15 such as removal of chest drains or pacing wires without
16 adequate analgesia and sedation, and she told me she had
17 heard their screams and she wanted something done.
18 This prompted me to look at the whole aspect of
19 provision of analgesia for children, and I came up with
20 a protocol which started from theatres and went all the
21 way through to the low dependency part of the nursery.
22 Q. When she said she had heard children scream with pain,
23 is that something you observed?
24 A. This was on a nursery which was in 5A and no, it was
25 something that I had not come across before, but
0031
1 obviously it is something that needed dealing with
2 pretty --
3 Q. Do you think that the language was highly coloured, or
4 simply accurate?
5 A. I am sure it was highly coloured.
6 Q. You did, then, a lot of work in fact on pain management,
7 sedation, through from the operating theatre to the
8 nursery ward. Could pain management be described as
9 a thorny issue that is quite frequently forgotten about
10 or neglected by the cardiac surgical side of management
11 of children?
12 A. It is an issue that historically has been dealt with
13 poorly throughout many Trusts, and I was aware, when
14 I was a Senior Registrar, that there was a national
15 document published by the Royal College of Surgeons
16 outlining how poor acute pain management was throughout
17 the whole of the UK.
18 Whether it was particularly poor in all the
19 cardiac surgery centres, I cannot comment.
20 Q. Compared to Oxford, say?
21 A. In Oxford, we would routinely run morphine infusions in
22 the early post-operative period. In Bristol we often
23 did, but they were not started in theatre. They were
24 often started in the intensive care ward afterwards.
25 I cannot really comment on the Oxford practice about how
0032
1 those morphine infusions were stopped and replaced with
2 another form of analgesia, because I was not involved in
3 care at that stage.
4 Q. But again you saw the need to standardise existing
5 practice and perhaps to reflect more on the process of
6 care from the theatre through to eventual discharge?
7 A. Yes.
8 Q. If we go on to (c) of your statement, you talk about the
9 Paediatric Interest Group and if we look at UBHT 135/97,
10 we will see an example of that. Those are the minutes.
11 Do you know who took the minutes?
12 A. No, I am afraid I do not.
13 Q. Were they always accurate?
14 A. No. I suspect there was more discussion than is
15 documented.
16 Q. I think if we look at some of the later ones, we will
17 see apologies for absence from Helen Stratton, for
18 instance, after she had left?
19 A. It was never a very formalised meeting with minutes read
20 from the last meeting, apologies given. It was not run
21 like that. It was just an informal group of people who
22 wanted to see things move forward in Bristol.
23 Q. With minutes circulated to inform the members of the
24 group and anyone else who read them?
25 A. Absolutely.
0033
1 Q. If we scroll down the page, please, we can see there the
2 reference to paediatric analgesia. Is that part and
3 parcel of the work that you reviewed?
4 A. Yes. I think the impetus behind this group was after
5 Freda Gardner had talked to me about the problems with
6 analgesia. She then set up this group and chaired it so
7 that we could discuss any other issues, similar issues,
8 on a multidisciplinary basis.
9 Q. Can we turn over the page, please? And scroll down,
10 please. Do you see the heading "Bloods":
11 "It was previously suggested that SHOs should have
12 two attempts at taking blood from paediatric patients
13 before seeking help from anaesthetic staff."
14 Amongst the evidence of parents to the Inquiry we
15 have heard some instances of staff members having
16 difficulty in obtaining blood samples from children and
17 pain being caused to children as a result.
18 Was that a generalised problem?
19 A. I think it is because the surgical SHOs whose job it was
20 to take the blood had very limited paediatric
21 experience. Therefore, they found it technically
22 difficult. They would often have an attempt and if they
23 found that it was beyond their level of expertise, then
24 quite rightly they called for anaesthetic help where we
25 had more expertise.
0034
1 I seem to remember at that meeting some of the
2 nurses had brought up the previous problems where the
3 SHOs had carried on attempting to get blood when they
4 should have stopped and got help.
5 Q. If we can go back, please, to your statement, page 9,
6 you say there -- if we scroll down, please, to (e) --
7 about the fact that you redesigned the daily observation
8 chart and introduced a structured daily clinical note.
9 What did you observe about record-keeping at the
10 ITU?
11 A. The daily observation chart we did because we wanted to
12 tie in fluid management with haemodynamic variables such
13 as pulse and blood pressure, because before that they
14 were all on separate charts.
15 So I brought them all together on a single chart.
16 I believed it was easier to interpret the data, but
17 I did not think that I had changed the quality, because
18 the quality of note recording or the quality of charting
19 was always good.
20 As far as the daily clinical note written in the
21 child's notes, they were of a relatively poor quality
22 because they did not thoroughly assess the level of
23 sickness of the child and in particular, they did not
24 thoroughly assess or document all the organ systems, and
25 they did not document the clinical plan that was in the
0035
1 minds of the clinicians looking after the child.
2 So my attempt at this daily structured note was to
3 make it easy to document the support the child was on,
4 i.e. how sick they were and what the daily plans were,
5 and any changes in the plans throughout the day.
6 Q. How did you structure the note to achieve that?
7 A. It was based on a daily note that I saw from one of the
8 London hospitals, I think it might have been Great
9 Ormond Street, but basically, it was tick boxes to start
10 with, as to what level of support the child was on, and
11 then different sections for the different organ systems
12 and a section at the end for the daily plan.
13 Q. So by introducing sections for every organ or matter
14 that you wanted clinicians to look at, you were
15 increasing the chances of those being considered in
16 a systematic way and documented in a systematic way?
17 A. That is what I wanted to achieve, yes.
18 Q. Did you achieve it?
19 A. Well, unfortunately, what tended to happen was that
20 this was seen as an anaesthetic note and the trainee
21 surgeons would often write their notes separate to this
22 and not use the form. We went with it for probably
23 a couple of years before I finally admitted defeat and
24 went back to an unstructured form.
25 Having said that, by that time we were already, as
0036
1 a routine, looking systematically at all the organ
2 systems, so I had achieved the aim of looking at the
3 child systematically, but not of documenting it
4 particularly well.
5 Q. If we go to Dr Underwood's statement, WIT 318/5, and
6 look firstly at B7 there, where she talks about her own
7 practice in keeping an anaesthetic chart, and then says:
8 "In the ITU, note keeping was more difficult but
9 started to improve with the arrival of the anaesthetists
10 (sic)."
11 Is that a summary you would agree with of what you
12 have just been telling the Inquiry?
13 A. Yes, I hoped I had started the improvement.
14 Q. If we scroll down the page, we see another comment at
15 B12A, at B12D, the last comment there:
16 "I found communicating with other staff relatively
17 easy, but it depends on conversations in theatre, office
18 and intensive care, with little written down."
19 If I could just ask you to hold that comment in
20 your mind for a moment whilst we go, please, to the
21 statement of Dr Bolsin at WIT 80/4, if we scroll down
22 a little, please, we will see that at B7 he says in the
23 third sentence:
24 "The formal documentation of decision-making
25 processes within the Intensive Care Unit was not a high
0037
1 priority."
2 Can you tell us what your experience was of the
3 extent to which communication routine would be
4 documented in notes?
5 A. No, I agree with Dr Bolsin there. It was not a high
6 priority. We would not necessarily have documented that
7 we had had a discussion about it, but what I would hope
8 to have been documented was the overall plan that had
9 been agreed upon.
10 Q. If it was documented, would it reflect the fact that
11 the plan had been agreed as a result of communication
12 amongst the members of the team, or would it simply be
13 a plan with the signature of one member of the medical
14 team appended to the end of it?
15 A. It is likely to have been recorded as a plan with the
16 signature of the person who wrote it, even though that
17 plan was an agreed plan between different clinicians.
18 Q. If we go to the clinical case review, INQ 16/23, we can
19 see there commentary on post-operative management
20 issues, and in particular, if we look at 5.11, we see
21 the commentary that in general, intensive care appeared
22 to have been fragmented and insular in approach, with
23 failure to anticipate clinical problems, a delayed
24 response to post-operative problems and failure to
25 involve other team members.
0038
1 I will come back to the issues of fragmentation
2 and co-ordination of involvement, but to what extent do
3 you think that the clinical notes, as a source for
4 reviewing teams later, would have documented
5 communication amongst members of the team?
6 A. I think the notes would have documented the
7 communication particularly poorly, and therefore I think
8 that would have skewed the impression of the reviewers
9 in that case.
10 Q. Looking at the overall conclusion that they reach there,
11 they say that there was failure to involve other team
12 members. Is that something that you think is a fair
13 reflection of your experience of being involved in the
14 management of the ITU?
15 A. I am sorry, I do not understand who they meant by
16 failure to involve "other team members". Do they mean
17 the paediatric cardiologists?
18 Q. I think that is the primary focus of the opinion, yes.
19 A. Yes, there was a definite failure to involve the
20 cardiologists enough. When they were called, they came
21 down from the Children's Hospital and they were very
22 helpful, but they were not called as a routine, and they
23 were not there as a routine.
24 Q. What about other team members, then: if for instance the
25 SHO who was a trainee wanted to involve another member
0039
1 or should in your judgment have involved another member
2 of the anaesthetic team, do you think that took place
3 often enough?
4 A. Probably not, initially. Their first port of call was
5 often going up the surgical hierarchy, so the Surgical
6 Registrar, Senior Registrar or even consultant.
7 Q. If we can go back, please, to your statement, you
8 describe this issue in more detail, although you talk
9 about -- page 10, please -- the introduction of the
10 anaesthetists to the ward at the BRI.
11 If we can scroll down, please, you start to
12 address this at paragraph 14 and pick it up later again
13 in your statement.
14 Can I be sure that we have understood, firstly,
15 the rota that you were performing at the BRI when you
16 started?
17 When you gave evidence to the GMC, you said this.
18 You were asked the question:
19 "Question: Can I take you back to the ITU now?
20 You mentioned it earlier on, and I got slightly lost in
21 the sums of the rotation, the job share with Dr Davies.
22 I think you mentioned three lists for a week for
23 a month, every three months."
24 Your answer was this:
25 "Every two months. I would be doing one list
0040
1 during that month, one all-day cardiac list, and that
2 was usually Monday, when we often did the children's
3 cases."
4 Is that accurate?
5 A. Yes, that is accurate.
6 Q. Then you went on:
7 "I would then do three mornings in intensive care,
8 Tuesday, Wednesday, Thursday, and on a Friday morning
9 and afternoon I had a non-cardiac list to do. That was
10 one month."
11 A. That is right.
12 Q. "The second month I would be doing two all day lists on
13 either Monday, Wednesday, Thursday, and then one all
14 day, non-cardiac list on Friday."
15 A. That is correct.
16 Q. So that is an accurate statement of the rota you were
17 working to; is that right?
18 A. That is right.
19 Q. Going back, then, to your statement to the Inquiry, you
20 talk at paragraph 14 about the fact that some of the
21 consultant cardiac surgeons were feeling that they would
22 lose control of clinical decisions relating to their
23 patients.
24 Then you mentioned Mr Bryan and Professor
25 Angelini.
0041
1 Was that the main source of this fear or hostility
2 to your presence?
3 A. Was that the main source? You mean Mr Bryan and
4 Professor Angelini?
5 Q. Yes.
6 A. No, I believe it came from all surgeons. I think
7 Mr Bryan and Professor Angelini voiced those opinions
8 openly, but I believe that Mr Wisheart felt that he did
9 not want to lose clinical control and so did
10 Mr Dhasmana, initially, although he warmed to the
11 concept of us taking over some of the management of his
12 cases at a later stage.
13 I have to say that Professor Angelini now has
14 completely gone over to our role and is now very keen on
15 the intensivist's role. This was just initially.
16 Q. If we can just turn over the page, we can see there
17 a description of the ward rounds, set out in both
18 paragraphs 14 and 15, if we scroll down the
19 page a little.
20 When he was giving evidence, Mr Wisheart told us
21 that, as you say, the surgical Senior Registrar and SHO
22 would do ward rounds in the early morning before
23 8 o'clock, before theatre, and he added there would be
24 an Anaesthetic Registrar at that time available for
25 discussion, either present or on call, but did not
0042
1 generally join the round. Mr Wisheart said he would
2 expect them to liaise as appropriate as professional
3 colleagues.
4 Can you recollect that being the case?
5 A. There was also a trainee anaesthetist there, yes, at
6 that time. There was not very much time on that round
7 for any discussion, because this round was seeing 8 to
8 15 patients in half an hour before the start of the
9 morning list.
10 Q. So that is something between 2 and 4 minutes a patient,
11 approximately?
12 A. Yes. When I first started at the BRI, that round, the
13 surgeons used to insist that all the surgical registrars
14 and all the surgical SHOs go on that round as part of
15 their training, so you can imagine a round of maybe 10,
16 12 people, surrounding a bed, thinking about complex
17 issues in 2 to 4 minutes: not conducive to discussion.
18 Q. Mr Wisheart then added that he would try and see his
19 cases when he came in, between 8 and 9 or thereabouts
20 before he started in theatre, and he would endorse
21 decisions or pick up issues in relation to his cases as
22 he did that.
23 Can you recollect that happening?
24 A. Yes. He sometimes would come in and we would have
25 a discussion about the management of his case.
0043
1 A consensus plan would then be formulated or agreed
2 upon. He did not always come; but often he did.
3 Q. Often? Most of the time? Half the time?
4 A. About half, in my experience.
5 Q. If we turn to page 30 of your witness statement, you
6 mention there the anaesthetist's round. If you were the
7 oncall anaesthetist on a Monday, you would wait until
8 your patient in theatre was safely established before
9 visiting the CICU for a complete ward round. That would
10 normally take place at 10 to 10.30.
11 Is there a distinction, then, between the ward
12 round that was being completed in a week in which you
13 were the intensivist and those in which you were the
14 oncall anaesthetist?
15 A. The only distinction was that this was a Monday and
16 there were no intensivist sessions on Monday, so this
17 would be the way the anaesthetic ward rounds were done
18 on a Monday or Friday. On Tuesday, Wednesday or
19 Thursday it would have been as previously stated, around
20 9 o'clock.
21 Q. You talk there about the fact that the anaesthetists
22 were not involved in the main round or the initial round
23 that took place earliest in the morning.
24 Again, how typical was that at the time? Was it
25 normal in the institutions you had been in to achieve an
0044
1 integrated round with both surgeons and anaesthetists?
2 A. It was certainly typical in Alder Hey. As far as Oxford
3 is concerned, from what I remember there was very little
4 anaesthetic input on the round; it would be primarily
5 cardiological, and the surgeons would come in at a later
6 stage.
7 Q. Because when the experts to the Inquiry gave evidence at
8 an earlier stage, we heard from them that the move to an
9 integrated ward round has been a gradual process which
10 is difficult to achieve in view of the commitments of
11 many members of staff.
12 Would you agree with that from your experience
13 both at the BRI and elsewhere?
14 A. Yes, it is certainly difficult to achieve, and, yes, it
15 has been a gradual process, as has the evolution of
16 paediatric intensive care.
17 Q. I think we heard that Great Ormond Street solved the
18 problem at the expense of Dr Macrae's breakfast by
19 having a ward round at 7.30 in the morning, but that on
20 the whole the experts found the process of evolution to
21 all of this, what one might dub a gold standard now,
22 fairly difficult to date. You are nodding?
23 A. Yes. Difficult to involve the surgeons, I think;
24 somewhat easier to involve paediatric anaesthetic
25 colleagues and cardiological colleagues.
0045
1 Q. Your response to the difficulties that you were
2 experiencing in being accepted as an intensivist or able
3 to put significant anaesthetic input into the ward
4 rounds was to opt out of the ward rounds that took place
5 at 8 o'clock in the morning.
6 Was that a constructive or adequate response?
7 A. No, it was not really to opt out; it was to change the
8 emphasis of what should be discussed at particular
9 times. It was to change the emphasis on the 8 o'clock
10 round to just looking at the patients who had progressed
11 well and could be discharged from the intensive care
12 ward to make room for the cases that day, so the
13 surgeons could then go to theatres knowing how many
14 cases they could perform that day; knowing that fairly
15 shortly afterwards an experienced team was going to look
16 round and carefully consider all the more unwell
17 patients.
18 So I do not think it was to opt out; it was to
19 change the emphasis of when the patients were looked at.
20 Q. If we turn back to page 11, please, and scroll down the
21 page to the part of your statement in which you deal
22 with participation or non-participation at 8 o'clock, if
23 you were experiencing difficulty in acceptance in the
24 role of an intensivist on the ward, would it not have
25 been better to have sought to influence decision-making
0046
1 at 8 o'clock?
2 A. Yes, it would have been. That is actually what we do
3 now, but that had to come at the agreement of the
4 surgeons. The way we do it now is we have limited the
5 number of surgeons that are on that round to the
6 absolute minimum. There is only an SHO and a Registrar,
7 who are responsible for the unit that day. They do not
8 have to rush off to theatres; we can take our time to
9 bring the cases and we are not inundated with people.
10 But I could only make that change when I had the
11 agreement from the surgeons that their trainee staff did
12 not all need to be on the round.
13 Q. Can you just describe to us, when you say there were
14 already too many doctors, who was participating in that
15 ward round?
16 A. I think we have mentioned it already: it was all the
17 surgical SHOs and Registrars.
18 MISS GREY: I wonder, sir, looking at the time, whether
19 this is an appropriate moment to have a short break.
20 THE CHAIRMAN: Yes. Thank you, Miss Grey. Shall we take 15
21 minutes and therefore reconvene at around 20 past?
22 (12.05 pm)
23 (A short break)
24 (12.25 pm)
25 MISS GREY: Dr Pryn, we were looking at paragraph 15 of your
0047
1 statement and I was asking you questions about the
2 integration of anaesthetic or intensivist care.
3 In particular, I was asking you why you chose to
4 conduct a ward round at 9 o'clock when decisions had
5 already been made earlier, at 8 o'clock, and you
6 explained the difficulties in participating in that
7 round.
8 If we go over the page, page 12, you say that the
9 pressures were such that it was not possible to have
10 discussions with the Surgical Registrars about the
11 management of the sickest patients in the unit, as
12 inevitably they were required in theatre for that day's
13 list.
14 Does that mean by the time you had conducted your
15 ward round they had already gone or were going off to
16 theatre?
17 A. Yes, they go to theatre to start at half 8.
18 Q. Does that mean by having a later ward round at
19 9 o'clock, that you were almost inevitably creating
20 a situation of conflict in that your decisions were
21 likely to countermand, or might countermand, those of
22 Surgical Registrars who had already left?
23 A. Yes, that is true, if they had made decisions which
24 I think I have addressed before, they perhaps ought not
25 to have made.
0048
1 Q. I appreciate that did not happen all the time, but how
2 does the balance of advantage of doing a slower, more
3 considered ward round later match up against the
4 advantage of trying to participate in an earlier round
5 so as to ensure integration of approach throughout?
6 A. The only way I could answer that is that Ian Davies and
7 myself discussed this and we felt that it was just
8 physically impossible to do at 8 o'clock, so we decided
9 to do it later.
10 Q. And that was because there were too many people?
11 A. Too many people. Too much pressure of time. As I say,
12 now we do it at 8 o'clock, because there are less people
13 on the round and they can take as much time as we like,
14 and it is very effective, doing it at 8. That is the
15 ideal, but we could not achieve that at the time.
16 Q. Did you try and achieve that at the time?
17 A. No.
18 Q. Did you ever discuss that possibility with the cardiac
19 surgeons?
20 A. Part of the problem is that we had only been given three
21 morning sessions. What we needed was to be given five
22 morning sessions, so that we could actually establish
23 a timetable which everybody knows and is fixed for every
24 day of the week. It is difficult flip-flopping between
25 timetables depending on whether there is an intensivist
0049
1 there or not.
2 Q. You have achieved it now but there are now more
3 intensivist sessions?
4 A. There are five morning intensivist sessions, still not
5 ideal but better than it was when I arrived in late
6 1993.
7 Q. So something of a compromise position, then, in 1993,
8 perhaps?
9 A. Yes. The start of an evolution.
10 Q. If we go back to the statement at the bottom of page 11,
11 please. You talk about conducting the ward round at
12 9 o'clock and on occasion complex decisions had been
13 taken at the earlier Registrar's round in a hurry and
14 you were unhappy with those decisions.
15 How often did those problems arise?
16 A. Relatively frequently.
17 Q. How do you think it would have been managed? Do you
18 have any knowledge of how that situation would have
19 progressed in the days before the intensivists had been
20 appointed three days a week and managed that situation
21 as a result of their ward round at 9 o'clock?
22 A. I beg your pardon?
23 Q. Let me rephrase that question, it is badly phrased and
24 I apologise.
25 On the days on which you did a ward round at 9,
0050
1 you would pick up that difficulty. What happened
2 firstly on the remaining four days a week in which there
3 was no intensivist session in the morning?
4 A. How were those decisions made when I was not there?
5 Q. No, what would happen if a decision had been made,
6 hypothetically, at the 8 o'clock ward round which, had
7 you been present at 9 o'clock, you would have disagreed
8 with? What would happen to it? What was the progress
9 of the management of a patient on a day in which the
10 intensivists were not present?
11 A. It would either have been picked up on when the
12 anaesthetists did their round, at 10, 10.30, on Monday
13 or Friday, or it would not have been picked up at all.
14 At weekends, the anaesthetic consultant on for the
15 weekend would always do a thorough ward round, around
16 intensive care, with the Surgical Registrars on for that
17 weekend. It was better at weekends because there was
18 not this pressure of time, assuming we did not have an
19 emergency case. Quite often we had emergency cases to
20 do on a Saturday morning, which meant that again the
21 anaesthetist could not get to do their ward round
22 because we were doing an emergency case.
23 Q. You stress in your statement that for your part you
24 always tried to discuss changes in is the management of
25 a patient with the cardiac surgeons if they were
0051
1 available or their juniors present on the ward.
2 If we look at page 31, you say at the last
3 sentence of the first paragraph, there, that the same
4 courtesy of communication could not always be said to
5 have occurred when the surgeons wished to change the
6 clinical management.
7 Whom are we talking about in that example?
8 A. Not specifically the paediatric surgeons; it could have
9 been paediatric or adult. They basically would come in,
10 have a look at their case and tell the nurses to do
11 something, write it up on a drug chart and go away.
12 Q. So that applies to the paediatric cardiac surgeons and
13 the adult surgeons?
14 A. It applies to both.
15 Q. What do you think is causing that particular attitude or
16 action?
17 A. I think fundamentally, the surgeons have always
18 considered these cases their cases, for their
19 management. If they want to do something to the
20 management, they can; it is their case.
21 Q. How did the presence of the intensivists for three
22 sessions a week impact on that attitude?
23 A. It meant that they could discuss their decisions if they
24 wanted to with another senior colleague on their
25 selected three days, or three mornings, I should say,
0052
1 which is a very small percentage of the week.
2 Q. But did it change, those three mornings a week, the
3 hierarchy of control over the management of a case? Who
4 was in charge of a child when the intensivists were in?
5 A. No, I do not believe it did change the hierarchy.
6 I think Mr Wisheart and Mr Dhasmana always felt in
7 charge of their case. Sometimes, especially early on,
8 I felt more like one of their Senior Registrars than
9 a fellow consultant, and I was there to make sure their
10 bidding was done, so to speak. I think in general,
11 I did not have a big problem with that, as long as
12 I agreed with the management.
13 The main problem I had was with the speed with
14 which we could change management. For instance,
15 Mr Wisheart would often come in and say: "What needs to
16 happen today is that we need to wean these inotropes
17 before we extubate the child", and I entirely agreed; we
18 did need to wean those inotropes. Then he would write on
19 the chart: "These inotropes are to be weaned by 0.1 ml
20 per hour if [so-and-so] happens". Actually, if you work
21 it out, that would have taken three days to wean off the
22 inotrope, so a long time, and the child may be improving
23 more rapidly than that and I would want to cut the
24 inotropes down even faster.
25 Once or twice I did. I remember on one occasion
0053
1 he was extremely angry with me for weaning inotropes
2 faster than he had prescribed, but I did so because
3 I was there with the child and it needed to be done. So
4 he had quite tight control of what happened with his
5 patients.
6 Q. Was that equally true of what happened with Mr Dhasmana?
7 A. Slightly less so with Mr Dhasmana, yes.
8 Q. Because he was less concerned to keep control, or what?
9 A. No, I think he warmed to the concept of intensivists
10 sooner than Mr Wisheart, and I think he saw that we were
11 welcome allies.
12 Q. So in the example, the case of Mr Wisheart you quoted,
13 what did he regard as the proper thing for you to do?
14 Was it to have fetched him and had a discussion before
15 any change was agreed upon?
16 A. Probably. But it is hard to discuss changes which are
17 not changes in management; it is just the change of
18 speed of management. Otherwise you would be for ever on
19 the phone. Mr Wisheart, let us face it, was an
20 extremely busy man, often difficult to pin down and
21 find, and talk to during the day.
22 Q. You have described difficulties in being accepted in
23 your role as an intensivist at the beginning. How far
24 do you think progress was made towards acceptance of
25 that role by January 1995?
0054
1 A. I think we had been accepted on the whole but we still
2 did not have consensus that we could increase the number
3 of sessions and increase our input because as far as
4 I remember, we did not have the five morning sessions
5 until 1996, so in January 1995 we were perhaps
6 discussing our increased involvement, but had not
7 reached a consensus.
8 Q. If there were difficulties in raising the number of
9 intensivist sessions to five a week, was that
10 a difficulty over the importance attached to it or was
11 it purely a funding issue?
12 A. I am sure primarily it was funding, but if you think an
13 issue is important enough, you can drive it forwards
14 faster.
15 Q. So it was not seen as a priority?
16 A. I cannot answer that. I was not involved in the
17 discussions.
18 Q. Put it like this: what do you think your colleagues felt
19 about the presence of the intensivists and the
20 contribution that the anaesthetists made by being there
21 three mornings a week, by around January of 1995?
22 A. All my anaesthetic colleagues were extremely pro the
23 intensivists' sessions and wanted to expand them.
24 Q. Was that from the beginning?
25 A. Yes, it was.
0055
1 Q. What about the cardiac surgeons, then?
2 A. I think Mr Dhasmana had warmed to us and he was quite
3 happy for us to expand our sessions. I cannot answer
4 for Mr Wisheart.
5 Q. Did Mr Wisheart ever say anything to you that gave you
6 any indication of his attitude?
7 A. No. That is why I cannot answer for him.
8 Q. So why the distinction, then, between Mr Wisheart and
9 Mr Dhasmana, in being able to answer for their attitude?
10 A. Because Mr Dhasmana had spoken, I believe, at one of the
11 management meetings in the evening, in our favour, so
12 I understood from that that he valued our sessions.
13 Q. Nurse Disley in her statement to the Inquiry, WIT 85/5,
14 commented on the management of post-operative care, the
15 ITU, from the nurses' perspective. Paragraph 19, if
16 I could invite you to read that. (Pause). She is
17 seeing there, a conflict or a potential conflict between
18 loyalties to cardiac surgeons and the intensivists.
19 Do you think the nurses were stressed by this
20 introduction of intensivists, their loyalties, that is?
21 A. They were obviously stressed if they were given two
22 conflicting amounts of advice. I think what Sheena is
23 referring to there is the discussion between surgeon and
24 anaesthetist, and there were bound to be differences,
25 because that is what the discussion was about, but at
0056
1 the end, we would come to a consensus and it is the
2 consensus you should remember, not opposing views put
3 forward in the discussion.
4 Q. If we go to Mr Wisheart's comments on this statement at
5 this point, page 37, if we scroll down, I invite you to
6 read there the comment on paragraphs 18, 19 and 58.
7 Do you think Mr Wisheart is making the same point
8 you have just made?
9 A. I think so, yes. I think it is extremely fair.
10 Q. If we go back to the question of the co-operation
11 between members of the intensivist team but look at
12 Dr Bolsin's statement, WIT 80/2, if I could invite you,
13 please, to read paragraph (e) there. (Pause)
14 Dr Bolsin's comments or evidence are not
15 restricted in point of time, but he says, if I go on to
16 the fourth sentence, that:
17 "The anaesthetists providing paediatric cardiac
18 surgical anaesthesia had all undertaken extensive
19 training at centres providing paediatric cardiac surgery
20 and were involved in the management of the patients in
21 the post-op period."
22 Is that accurate to the best of your knowledge?
23 A. Yes. We all had some training in it. You can debate on
24 how extensive our training was, but we were all
25 appointed by a consultant advisory committee with
0057
1 representation from the Royal College who assessed that
2 we had adequate training for the job.
3 Q. He then goes on to say that unfortunately the unit was
4 managed on a day-to-day basis by the most junior cardiac
5 surgical staff, who did not necessarily have such
6 experience but remained the key decision-makers.
7 Do you think that is a fair reflection on the way
8 in which the unit was managed after your appointment in
9 August 1993?
10 A. They were there minute by minute. At night they were
11 the key decision-makers, because they were the only
12 doctors in sight.
13 During the day, I would hope that they would
14 discuss instituting new treatment with a more senior
15 colleague. When I was the intensivist, I hoped they
16 would discuss it with me on my three morning sessions.
17 Outside those three morning sessions, then, again,
18 those doctors were not likely to be the only doctors
19 around, apart from the anaesthetic training.
20 Q. Someone can be a key decision-maker because they are
21 making all the important decisions. It could also be
22 that they are key decision-makers because they are the
23 front line of decision-makers, but may have an adequate
24 perception of when it is they need to consult others.
25 Which do you think is the case for those junior
0058
1 staff?
2 A. I think on the whole if they made a big decision, they
3 would consult and sometimes they would want to consult
4 with the consultant surgeon, and that often delayed
5 decisions because they could not get hold of
6 a consultant surgeon.
7 Q. So there was a problem of delay. What about the problem
8 of recognition of what decisions were big? Was that an
9 issue?
10 A. I am sure it must have been.
11 Q. Coming back to your answer earlier in relation to
12 co-ordination with you as an intensivist on your three
13 sessions when they took place, you said that you would
14 hope that the junior staff consulted with you.
15 Is that a hope, or is that reality born of
16 experience?
17 A. They do know. But they did not when I first started, so
18 at some stage there was a change and there was obviously
19 an evolution from when I first started.
20 Q. And by around January 1995, how far have we got along
21 that evolutionary --
22 A. I think things really only got a lot better when we, the
23 intensivists, were there for five mornings a week.
24 There had been some changes up to January 1995, but the
25 next step forward was having five morning sessions.
0059
1 Q. If we look at the report which Dr Hunt and Professor
2 de Leval produced -- this I should say is the first
3 draft of the report, which I think you did not have the
4 benefit of seeing at the time; is that correct?
5 A. I have never seen it.
6 Q. If we look at it now, UBHT 61/356, 357,this sets out
7 a programme of the visit. If we scroll down, we see
8 later you did speak to Professor de Leval and Dr Hunter;
9 that is right, is it not?
10 A. Yes, I was invited to speak to them.
11 Q. They then set out a description of current paediatric
12 cardiac services, and in particular, post-operative
13 care.
14 If we turn to the bottom third of that paragraph,
15 it says:
16 "At the Bristol Royal Infirmary the post-operative
17 management is dealt with by the cardiac surgical team
18 (adult) and the anaesthetic team. The person on site on
19 a 24-hour basis is a surgical SHO. During the daytime,
20 there are currently two or three anaesthetic sessions
21 which are dedicated to post-operative care".
22 We should say three; is that right?
23 A. That is correct.
24 Q. "The paediatric cardiologists help with the
25 post-operative management of the children at the Royal
0060
1 Infirmary. The overall post-operative management at the
2 Royal Infirmary appears to be highly disorganised with
3 conflicting decisions between the Surgical Senior
4 Registrar and the SHO who do rounds at 8 am, the
5 anaesthetists who see the patients at 9 am and the
6 intensivists who work three days a week."
7 How accurate is that as a summary of the position
8 as at January 1995?
9 A. I think that is reasonably accurate.
10 Q. If we go back to your statement, page 12, you set out at
11 paragraph 16 your working relationship with the other
12 paediatric cardiac anaesthetist, Doctors Underwood and
13 Masey. You do not mention Dr Bolsin there. Was he
14 carrying out paediatric anaesthetic work by the time you
15 arrived?
16 A. After my appointment, the bulk of the paediatrics was
17 concentrated within the group of the three of us so we
18 could develop and maintain our expertise.
19 The other anaesthetists, including Dr Bolsin, did
20 do some work, but really, quite a little amount of work.
21 Q. How was the reason for decreasing that involvement
22 presented to you?
23 A. I do not think it was ever presented to me. It was,
24 "Here are the three paediatric trained anaesthetists."
25 Q. What was your relationship like with Dr Bolsin?
0061
1 A. I could talk to him as a colleague; we were not great
2 friends. I do not think I have ever visited his house.
3 I liked him as a person; he was great fun. But it was
4 difficult to know sometimes what he wanted to achieve.
5 The particular example is when he gave me the
6 results of his audit, I was not sure in what context he
7 was giving me those, nor what he wanted to achieve by
8 the audit. I was never really sure what he wanted to
9 achieve by the audit.
10 Q. When he gave you the results of the audit, what did he
11 say about them to you?
12 A. He just said, "Have a look at these". I am sitting at
13 a desk, doing some other work, he put them in front of
14 me, "Have a look at these. What do you think?" None of
15 the background, "I think things in Bristol are X, Y and
16 Z, we need to do this that and the other". It was not
17 that at all, it was just "Here we go, what do you
18 think?".
19 So not a complete understanding of his motives,
20 I think.
21 Q. As a professional colleague, how was he perceived as
22 a cardiac anaesthetist?
23 A. I have no reason to doubt any of his expertise as
24 a cardiac anaesthetist.
25 Q. If we turn on, please, to page 14, you speak there about
0062
1 a particular case in which operation took place at
2 a very late stage, in your opinion.
3 Do you know who was responsible for this delay in
4 operation?
5 A. I have obviously looked back over this case, and
6 although I cannot say who was responsible, you can see
7 where the delays came in. Having been diagnosed, the
8 child was then listed for a catheter study. After the
9 catheter study, there was then delay to present the case
10 at a joint meeting with the cardiologists and the
11 surgeons. Then there was a delay to see Mr Wisheart in
12 his outpatient clinic to discuss the surgery and its
13 merits, and then there was a delay from that to listing
14 on the operating list.
15 Q. Leaving aside the role of individuals, who do you
16 understand to be responsible for managing the timing of
17 surgery?
18 A. I would have thought that should be discussed between
19 the referring cardiologist and the cardiac surgeon,
20 together.
21 Q. If there is disagreement between the two, do you know
22 what the etiquette is, in that case?
23 A. I was never at any of those meetings; I would not know.
24 Q. You talk about this case, in the paragraph. Did you
25 have any contemporaneous involvement in the case?
0063
1 A. Had I been involved in this case before? No.
2 Q. Were you the anaesthetist involved?
3 A. I was the anaesthetist involved in this case. I first
4 was aware of the case when I visited the child and her
5 parents the evening before surgery.
6 Q. So at what point were the concerns that you set out
7 there about the timing of the surgery first raised in
8 your mind?
9 A. I would have felt that evening uncomfortable, but I also
10 felt that I probably ought not to delay things any more
11 just because I was uncomfortable. The best thing for
12 this child probably would have been to proceed.
13 Q. Can you recollect any discussion with the surgeon about
14 the timing of this operation, either before or after the
15 operation and its outcome?
16 A. I cannot recollect speaking to Mr Wisheart before the
17 surgery. I remember thinking about it, but I remember
18 thinking that he was unavailable at the time, and I did
19 not take that forward. It is not a decision I am proud
20 about, in retrospect.
21 Afterwards, there was a general discussion amongst
22 the paediatric anaesthetists that AV canals should be
23 operated on sooner and this was a case in point,
24 illustrating that they should be. I think Dr Masey had
25 always been pressing for AV canals to be operated on
0064
1 sooner.
2 Q. This, I think, was in fact the case after which
3 Mr Wisheart ceased operating on AV canals. Is that
4 correct?
5 A. I do not think I anaesthetised another case of an
6 AV canal for him after this.
7 Q. Are you aware, or did you participate in any discussion
8 of the issue of referral of AV canals to Mr Wisheart at
9 about this time?
10 A. No, not at all. The only comment I would make there is
11 that I remember after an audit meeting in the beginning
12 of 1994 Sally Masey talked to me and said that: "No
13 AV canals are going to be referred to James Wisheart
14 from now on".
15 Q. That was at the beginning of --
16 A. That was at the beginning of 1994. This case obviously
17 came after that, but that was the only time I had ever
18 heard it discussed, referral practices to Mr Wisheart.
19 Q. So if you heard he was not going to be undertaking any
20 further AV canals, was there not some concern in your
21 mind when you saw this one listed as being one of his
22 operations?
23 A. That discussion was corridor-speak 8 months previously,
24 and I did not even recollect it at the time of seeing
25 this child.
0065
1 Q. And after this child had had the operation, can you
2 remember any further discussion, then, on AV canals and
3 whether Mr Wisheart was to undertake them?
4 A. No.
5 Q. Do you know if such a decision was taken, or not?
6 A. No. I have no idea.
7 Q. Looking at the issue more generally of the referral
8 patterns for AV canals, can you recollect whether there
9 was any general discussion of this subject in addition
10 to the meeting you have just mentioned?
11 A. There was general discussion about the timing of
12 AV canals amongst the paediatric anaesthetists, and that
13 happened several times, but I cannot remember personally
14 speaking to the surgeons about it.
15 Q. Did the anaesthetists as a group have any influence or
16 leverage over this timing issue?
17 A. I would have thought that Dr Masey being the senior
18 paediatric cardiac anaesthetist could well have spoken
19 to Mr Dhasmana and Mr Wisheart and could well have had
20 her views listened to, but no, as anaesthetists, we were
21 not involved at all in the decision-making about when
22 surgery was issued.
23 Q. Was any explanation being offered, to your knowledge, to
24 explain the delays in referrals in these groups of
25 operations?
0066
1 A. As I did not have a discussion with the surgeons about
2 it, no.
3 Q. But you had discussion amongst the anaesthetists. Were
4 they reporting to you any explanation, whether from
5 surgeons or cardiologists?
6 A. One of the issues was whether you need to do a catheter
7 study on these children, and that depends upon the
8 degree of confidence you have with your echo study. If
9 you are very confident of the anatomy and the physiology
10 with the echo, then you do not need a catheter.
11 I presume the fact all these children had catheter
12 studies meant they were not that confident with the
13 echo. So that was obviously a delay.
14 Q. "They" meaning the surgeons?
15 A. Whoever, the surgeons or cardiologists, whoever made the
16 decisions on how best to investigate the children.
17 Q. But can you recollect that discussion being specifically
18 held amongst the anaesthetists, or is that an educated
19 surmise on the basis of your experience?
20 A. No, I remember speaking to Sally Masey about whether you
21 need to do catheter studies for these children.
22 Q. Any further explanation of delays?
23 A. The only other issue would be whether the surgeons
24 needed to see these patients in outpatients first, or
25 whether they could have seen them when they came in for
0067
1 their studies in the Children's Hospital.
2 Q. Again, is that something you are asking yourself, having
3 looked through the notes on this particular child, or is
4 that a discussion you can recollect taking place at the
5 time?
6 A. I think, again, I may have spoken to Sally Masey on that
7 issue.
8 Q. Were concerns about the timing of the children
9 presenting for surgery, the age of children presenting
10 for surgery, limited to patients with AV canal defects,
11 or was there a more generalised issue about this?
12 A. The only other issue about timing was on infants with
13 TAPVD, total anomalous pulmonary venous drainage, and
14 Sally Masey had spoken to me about it, saying that in
15 her book those cases are emergencies and needed to be
16 operated on as soon as you can, whereas they often
17 waited several days in Bristol. She, again, said that
18 she had spoken to surgeons and asked them to try and
19 schedule them sooner.
20 Q. In relation to AV canal defects, did you have any
21 experience of patients presenting with this condition
22 either at Oxford or Southampton?
23 A. Yes, I have anaesthetised them in both institutions.
24 Q. Are you able to generalise about the age of children
25 presenting in that centre as opposed to Bristol?
0068
1 A. They would be younger.
2 Q. If we go on, please, to page 19, if we scroll down to
3 the bottom, you talk about your experience as
4 a paediatric anaesthetist, and if we turn over the page,
5 we see there that you refer to the NCEPOD report of 1989
6 and you say, in effect, that you did not meet that
7 rather arbitrary standard.
8 That would be a standard that was set when looking
9 at a general paediatric list; is that correct?
10 A. That is right.
11 Q. So if one was anaesthetising a general paediatric case,
12 there might well be a number of cases in a day, perhaps
13 as many as 10, 12, 13?
14 A. That is correct.
15 Q. Whereas if you are anaesthetising children, you may have
16 only one or two cases a day?
17 A. That is right.
18 Q. Is that the reason why the standard is set as the higher
19 number of procedures in that standard, as opposed to the
20 more specific standards for paediatric cardiac
21 anaesthesia?
22 A. I think the standard set at 50 cases in a year of less
23 than six months would reflect general paediatric
24 expertise, and I think it would have been set at 50
25 because that is how many you need to do for general
0069
1 paediatric expertise, not because people can achieve it;
2 it is set because that is what they felt at the time was
3 a reasonable standard.
4 Interestingly, as I think I point out, very few of
5 the anaesthetists involved in that report actually
6 achieved the standard at the time; only 13 per cent of
7 all the anaesthetists involved in the index cases were
8 achieving that standard in 1989.
9 Q. So if you did not achieve it either, you were falling
10 into a very large category of anaesthetists?
11 A. I was.
12 Q. If we scroll down the page, please, you say that
13 although the arrangement of numbers of paediatric
14 sessions fell within the Royal College of Anaesthetists
15 guidelines, you subsequently came to the opinion that
16 this was "probably insufficient to develop and maintain
17 general paediatric skills to optimal levels."
18 Why did you reach that conclusion?
19 A. When the children's cardiac was being moved to the
20 Children's Hospital, we all obviously had to come up
21 with various arrangements of how we could provide
22 anaesthetic cover for that, and we seriously had to
23 consider whether to take on extra general paediatric
24 lists to maintain our expertise and become out-and-out
25 paediatric anaesthetists, or whether to drop the
0070
1 paediatric sessions altogether and become out-and-out
2 adult anaesthetists. At the time I chose to not become
3 an out-and-out paediatric anaesthetist but to become an
4 adult anaesthetist. I realised that I could not stay
5 a part-time paediatric anaesthetist. That is when
6 I came to the conclusion that I needed extra general
7 paediatric sessions to maintain my practical skills.
8 Q. Because it would be the case, would it not, that there
9 are no full-time paediatric cardiac anaesthetists in the
10 country; there are either, presumably, those who do some
11 paediatric cardiac anaesthesia, together with cardiac
12 anaesthesia, or those who combine paediatric anaesthesia
13 with paediatric cardiac anaesthesia; is that correct?
14 A. Yes, that is correct, and I would have thought the best
15 thing would be to combine paediatric cardiac with
16 general paediatric anaesthesia.
17 Q. But you opted to go instead towards adult cardiac cases?
18 A. I did, and thinking about that focused my mind on
19 whether it was feasible to still be a part-time
20 paediatric anaesthetist. I personally came to the
21 decision that it was not feasible.
22 Q. What difference do you think that the mix of adult and
23 paediatric cardiac work made to your practice as an
24 anaesthetist?
25 A. Paediatric anaesthesia demands an extremely high degree
0071
1 of precision and that probably complemented my adult
2 anaesthesia, because precision in anaesthesia cannot be
3 a bad thing.
4 Paediatric anaesthesia also informs you of the
5 physiological changes, especially in the pulmonary
6 circulation, which sometimes pertains to adult surgery,
7 but not always. So I certainly approached difficult
8 adult problems with a greater insight than if I had
9 never done paediatrics.
10 Q. Taking it the other way round, can you remember any
11 instances where you think that the fact that the
12 anaesthetists were covering both adult and children's
13 cases made a practical difference, an adverse difference
14 to the quality of the care offered to children?
15 A. No, I do not think so, because throughout our training
16 we are constantly flip-flopping between cases from
17 different surgical specialties and from different age
18 groups, and it is just part of our training that we have
19 fairly adaptable mindsets to do that.
20 Q. Going back to page 16 of your statement, you talk there
21 about the assessment of clinical condition of children
22 before operations. If we scroll down, please, we can
23 see that you say that you did not specifically cover the
24 issues of operative risks, although, if asked directly,
25 you covered it in general terms, and referred the
0072
1 parents to their surgical consultant for further
2 discussion.
3 What sort of general terms would you have used, if
4 asked?
5 A. I would say: "Your child is extremely unwell. His is a
6 high risk procedure. You are aware of that", or "Your
7 child is relatively well at the moment. We do lots of
8 these procedures. It is relatively low risk", that sort
9 of general terms, but I would not put figures on it.
10 Q. What about risks associated with anaesthetics? Is there
11 any necessity to explain any of those?
12 A. I thought that that was all incorporated within the
13 overall surgical risk, because the risk associated with
14 an anaesthetic is relatively small in most patients
15 compared with the operative risk.
16 Q. So there was no need to treat that separately at further
17 length?
18 A. I did not feel at the time.
19 Q. At the time?
20 A. I did not feel so, so I did not.
21 Q. Presumably one of the reasons why you might refer
22 a patient, or parent rather, back to the surgeon for
23 further surgical discussion of risk would be if you
24 picked up the fact that they did not appear to be
25 adequately informed about the dangers of the operation
0073
1 that lay ahead.
2 Would that be correct?
3 A. That is true, but Mr Wisheart and Mr Dhasmana were
4 extremely conscientious of documenting in the notes, in
5 their clinic appointment that they had spoken to the
6 parents about risk, and they often would write down the
7 risk that they quoted to the parents.
8 So I knew pretty much what had been told to the
9 parents already.
10 Q. And, knowing what had been told to the parents, were
11 there any occasions when you felt concerned about the
12 adequacy of that explanation that had been apparently
13 offered by the surgeons?
14 A. No.
15 Q. What about parents' perception of the advice that had
16 been given to them? Were there times when, having
17 looked at the notes, you thought an adequate, proper,
18 reasonable explanation of risk had been given, but it
19 did not appear to have filtered through on to the
20 consciousness of the parents?
21 A. I cannot remember any instances when I thought that the
22 parents were not adequately prepared for a very risky
23 procedure.
24 Q. So overall this was an area that did not cause either
25 concern or a need to refer back patients or parents to
0074
1 the surgeons for further discussion?
2 A. Not often, no, and, in fact, the night before surgery is
3 not a good time to have detailed discussions of risks
4 anyway, so I probably did not court those discussions.
5 Q. If we can turn to page 20 of your statement once more,
6 you deal there, towards the bottom of the page, F3, with
7 the question of assistance in the anaesthetic room.
8 Is this an issue about familiarity of staff with
9 equipment and procedures, especially in an emergency if
10 something goes wrong?
11 A. Yes, familiarity with what are the next stages if
12 something goes wrong, so if they need it, they know
13 where it is. So a lot of it is familiarity and being
14 able to think ahead.
15 Q. Presumably those qualities matter most if something is
16 going wrong. That is when you need most skilled
17 back-up?
18 A. Yes, they are critical then. When things are not going
19 wrong, all they do is slow the procedure.
20 Q. Can you remember the instances when the lack of
21 satisfactory support did slow up procedures?
22 A. Yes.
23 Q. In general the question of speed of surgery has been
24 raised. Does this issue have any impact on that, or are
25 the delays happening at a different stage in the
0075
1 procedure?
2 A. The delays are happening during the anaesthetic
3 induction and during the preparation for surgery.
4 Q. Were those delays common or only happened occasionally?
5 A. I would say they happened relatively commonly.
6 Q. Does it make any difference to the quality of the care
7 or the safety of the care offered to the child?
8 A. I believe that, as an anaesthetic group, we were unhappy
9 with the situation and voiced our unhappiness on several
10 occasions, so we must have felt it was an important
11 issue, and although I have no direct evidence that it
12 was a safety issue, it potentially could have been one,
13 if a bad situation had occurred.
14 Q. But you cannot recollect one ever occurring?
15 A. No.
16 Q. You mention the fact that other anaesthetists were
17 concerned. If we look at Dr Masey's statement,
18 WIT 270/6, and scroll down to F3, is that there then
19 a reflection of the same concern and points being voiced
20 by Dr Masey as you just made?
21 A. She is making the point that although people do not have
22 the qualification, they may still be able to provide
23 assistance to an acceptable standard, which is true.
24 They might be able to.
25 Is there something else you wanted me to comment
0076
1 on here?
2 Q. I am asking you whether or not you felt they were able
3 to provide -- following up what you have just said --
4 they have no qualifications but were they able to assist
5 to an acceptable standard?
6 A. I think when I first started, there was an ODA who was
7 able to assist to an acceptable standard, and the nurses
8 who rotated in, the standard they provided was very
9 variable.
10 Q. By the time the cardiac theatres had relocated in the
11 summer of 1996 the matter had changed. What about
12 January 1995? Still a problem then?
13 A. I would say it was still a patchy problem.
14 Q. If we go back, please, to your statement at WIT 341/21,
15 you talk there about the adequacy of equipment, if we
16 scroll down the page, please.
17 You mention there that on the whole the equipment
18 was sufficient for -- I should quote:
19 "Despite relatively old equipment, this was
20 sufficient for full compliance with the RCA standards
21 proposed by the Royal College of Anaesthetists
22 Recommendations for Standards Monitoring during
23 Anaesthesia and Recovery 1994."
24 In general is it fair to say the equipment may
25 have been old, at least in part, but adequate and safe?
0077
1 A. Certainly old, but the number of modalities that we were
2 able to monitor, talking about monitoring equipment, was
3 adequate in terms of the number of modalities. The way
4 they did that was inadequate, because I remember
5 particularly the monitors would suffer from a lot of
6 electrical interference from the diathermy, such that
7 you could not see what the ECG was, nor any of the
8 pressure traces whilst diathermy was proceeding.
9 Q. That is a problem picked up on your list of major
10 equipment which required replacement. Staying here for
11 the moment, you say the one area not available for
12 monitoring was capnography. Is that surprising in
13 mid-1993?
14 A. Perhaps not that surprising. There must have been other
15 institutions that did not have capnography throughout,
16 but in an area like cardiac surgery, where it is
17 extremely technical, you would have expected the
18 state-of-the-art monitoring, and clearly this was not
19 state-of-the-art.
20 Q. If I suggested that this represented what might be
21 called the gold standard as a form of measurement for
22 expired breath, and that it was becoming generalised in
23 the early to mid-1990s but was not uniformly in use
24 during that period, would that accord with your
25 experience?
0078
1 If you cannot say, please do tell me.
2 A. The only thing I can compare it with is what was
3 happening in Oxford at the time, and we had some
4 rudimentary capnography there at the time, and what was
5 happening when I visited Alder Hey, and I think they had
6 capnography.
7 Q. Generally, you were discussing the introduction of
8 capnography. You are saying that it was being
9 introduced and that Bristol was not state-of-the-art.
10 Is that a fair summary of your impression of the
11 equipment in Bristol, that it was adequate but it would
12 not be state-of-the-art?
13 A. Yes. Fair.
14 Q. And full?
15 A. I have already said that the monitors I thought had
16 a serious problem with diathermy interference and the
17 transport monitors had a serious problem with battery
18 back-up, in that they did not have -- they were not
19 battery monitors and therefore we had to take a portable
20 mains generator with us when we transferred patients and
21 that clearly was not acceptable.
22 Q. Can you remember instances when that problem caused real
23 difficulties?
24 A. Yes, that generator could often be overloaded if you
25 were running syringe pumps and monitors and therefore it
0079
1 would fail altogether, and failed altogether on several
2 occasions.
3 Q. With what results?
4 A. No monitoring, no infusions during a relatively long
5 lift journey across two floors, long corridors to
6 intensive care.
7 Q. So one had to hope that nothing went seriously wrong
8 until the full monitoring was re-established on the ITU
9 ward?
10 A. That is right, so in that respect, although technically
11 we could monitor the right number of modalities in
12 transport, I found the system doing it inadequate.
13 Q. We can look at the major equipment list that you
14 produced at UBHT 297/69.
15 The first item you put was "intensive care
16 ventilators, including humidifiers". All this equipment
17 is relevant, is it, to both children and adults?
18 A. Yes. That would have been prepared at the end of 1994,
19 so we were still having children on the unit, and the
20 ventilators that we were purchasing and also the
21 humidifiers were suitable for both children and adults.
22 Q. How would you describe the existing situation on the
23 ward then that led to this recommendation for
24 replacement?
25 A. I think I make the point there that there were an
0080
1 adequate number of ventilators, but several of them were
2 extremely old and obsolete, and it was impossible to
3 obtain spares for them. Therefore, I felt as a safety
4 issue we should not be using that ventilator, which
5 meant that four needed replacing out right there and
6 then.
7 Q. If we go down the page to the "patient monitoring system
8 and theatre", the first bullet point there, the major
9 design faults, the very poor filtration of electrical
10 interference, is that what you were referring to
11 a minute or two ago?
12 A. It was.
13 Q. We can just go through the note. Over the page,
14 "haemofiltration machine", is that something that would
15 be generally used for children?
16 A. No. At the time we had no expertise of using
17 haemofiltration for paediatric patients. I remember
18 discussing it with one of the renal physicians at
19 Southmead, who gave our nephrology back-up, and he also
20 had no experience of paediatric haemofiltration.
21 Therefore, at the time we were using peritoneal dialysis
22 for children who needed renal replacement therapy.
23 Q. Was that not a more common system of managing this
24 problem with children at the time?
25 A. It was at the time, although when I visited the Alder
0081
1 Hey, they were using haemofilters rather than peritoneal
2 dialysis.
3 Q. What would the standard be generally now?
4 A. I have not been involved in paediatric intensive care
5 since 1995, so I cannot comment on that. Maybe your
6 expert witness could comment on that.
7 MISS GREY: Dr Scallon, would you like to comment on that?
8 DR SCALLON: I think when you come to small children,
9 infants and neonates, peritoneal dialysis is still used
10 to a considerable extent, but as you move up the age
11 group, so filtration systems do come into play.
12 Q. Dr Scallon, since you are at the microphone, as it were,
13 perhaps I could ask you: what would be your comment on
14 the importance of, if we can go back to the first of
15 these pages, firstly the intensive care ventilators?
16 A. I think the points that have been made, that where you
17 have old ventilators which cannot be serviced, on which
18 you carry out repairs, it is time to think of replacing
19 them. I think that is absolutely right. The shopping
20 list we see here is the sort of shopping list that you
21 see in many hospitals. There is a constant need to
22 upgrade equipment, to replace equipment. A lot of the
23 equipment that we use these days does not have a life
24 really of more than ten years, and you have to think of
25 moving forward to the next generation of equipment.
0082
1 So what we see here is a very fair shopping list.
2 Q. If we had gone into other NHS units across the UK
3 performing paediatric cardiac surgery at about this
4 time, are we likely to have seen similar issues about
5 the replacement of machines of this nature?
6 A. Yes. I think that is a fair comment, yes.
7 Q. So there is nothing here that strikes you as being out
8 of the ordinary in terms of the needs of this particular
9 unit?
10 A. I think the section on the equipment in the theatres and
11 in intensive care does suggest that that equipment
12 should have been replaced a little earlier. I think
13 that was the middle 90s. What was in existence does
14 appear to have been rather old equipment and quite
15 correctly the need to upgrade it -- the case for the
16 need to upgrade it was made in this list.
17 Q. If we go overleaf, please, is there anything else you
18 need to add on that?
19 A. No, I do not really think so. If we go to the bottom of
20 that page, is there anything further down there? No.
21 I think some of the points made there in relation to the
22 intensive care equipment were made on the previous
23 page in relation to the theatre equipment, the same
24 sorts of comments.
25 Q. We can see there that the equipment is said to have:
0083
1 "... several inherent problems, severely hampering
2 clinical management, especially of our sickest
3 patients."
4 Are you surprised that this was not replaced
5 earlier, or is this fairly typical?
6 A. As I mentioned, it was the middle 1990s. It perhaps
7 should have been replaced a little earlier than that,
8 but to make the general statement again, replacing
9 equipment is an ongoing battle in all intensive care
10 units, theatres, and at any one point in the cycle you
11 would be right up-to-date, but five or ten years down
12 the line you will be at the bottom again.
13 MISS GREY: Dr Pryn, would you like to come back on any of
14 that?
15 A. Yes, I would actually. It is an ongoing battle and
16 "battle" is the right word, because you are competing
17 with other departments in the hospital for very limited
18 funds, and some of the wording on this document is
19 specifically coloured to paint the picture -- a more
20 dramatic picture than perhaps was necessary, just so we
21 could have our voice heard. It is a battle to get
22 money. In fact, the patient monitoring system in
23 cardiac intensive care, this bid was put in in 1994.
24 I think we finally had delivery of a system in 1998.
25 MRS HOWARD: Miss Grey, could I just interrupt for a moment
0084
1 and ask Dr Scallon about the issue of capnography,
2 because I do not think we have mentioned that?
3 MISS GREY: Can I come back to that in a moment, Mrs
4 Howard?
5 Can I just follow that up with you first? You say
6 effectively you are painting a case in this document.
7 You are making out a case.
8 Looking at the equipment you were trying to
9 replace, do you think that any of it was actually or
10 potentially unsafe at the time you made out your case?
11 A. Yes, I think the intensive care ventilators certainly
12 were, because you should not really be using equipment
13 that might fail and you cannot replace.
14 The theatre monitors I believe were unsafe as
15 well, and I think the transport monitors were, too. You
16 have not shown on this document at all. There is
17 another document for minor medical bits, that is
18 equipment valued at less than #15,000 each, and I feel
19 very strongly that the syringe pumps we were using were
20 hazardous, especially to children, and needed replacing
21 very quickly.
22 Q. If we look at the first of your bullet points under the
23 "patient monitoring system" and the last point you make
24 there, you say:
25 "There have been many recent instances where it
0085
1 has been impossible to obtain a clean enough trace to
2 trigger the intra-aortic balloon pump and this has
3 severely compromised patients' survival."
4 That is a record of historical events rather than
5 you making out a case, is it not, or a hypothetical
6 case?
7 A. Yes. We had had some problems at the time with adults.
8 We do not use balloon pumps with children; with adults.
9 Q. If we can go back to your statement then, page 21, and
10 scroll down, please, when you say that there were no
11 mechanisms for replacement, do you mean by that that
12 there was no fixed budget or rolling budget for
13 replacement?
14 A. Yes. It is slightly inaccurate wording of mine, but
15 there was no rolling plan for replacement. There was no
16 fixed budget. There was no clinician identified within
17 the cardiac services directorate whom I should approach
18 if I felt equipment needed to be purchased.
19 Q. Which is why you were making out the bids that we have
20 seen?
21 A. I realised that nothing would be done unless I did it,
22 so I took on that responsibility.
23 MISS GREY: Mrs Howard, we are back on the page dealing with
24 capnography.
25 MRS HOWARD: Thank you, Miss Grey. It was a question for
0086
1 Dr Scallon, because I think that Dr Pryn suggested that
2 he was surprised in mid-1993 that capnography was not
3 available, but in the area of cardiac surgery he had
4 expected state-of-the-art equipment. I wonder whether
5 Dr Scallon could comment at that point as to whether
6 that is a reasonable view to take.
7 DR SCALLON: Yes, I think it is. I think capnography was
8 well-established as a tool for monitoring at that time,
9 and, as is said, in a cardiac centre you would expect to
10 have it available.
11 MISS GREY: Perhaps this might be an appropriate moment to
12 break for lunch then.
13 THE CHAIRMAN: Thank you. Shall we take half an hour for
14 lunch and reconvene at around 2.00?
15 (1.35 pm)
16 (Adjourned until 2.00 pm)
17 (2.05 pm)
18 MISS GREY: Dr Pryn, we were talking about equipment and you
19 have taken us through your list of major equipment. You
20 also provided a list of minor equipment that required
21 updating. If we look at UBHT 84/101, syringe pumps you
22 have mentioned already. What was the existing state of
23 the syringe pumps when you wrote this note?
24 A. There were an adequate number, but they were a very old
25 design, and they were beginning to fail, so I thought
0087
1 they needed replacing.
2 Q. You talk about pulsing of inotropes being a recurrent
3 problem, especially with children. What effect was that
4 having on care?
5 A. It was meaning that every now and again these children
6 would have surges in their blood pressure, either
7 becoming hypertensive or hypotensive for no other
8 apparent reason.
9 MISS GREY: Dr Scallon, would you like to comment on the
10 importance of this item?
11 DR SCALLON: Yes, I think it is an important point, and it
12 applies particularly in children where the volume of
13 fluid that you are using as a carrier for the inotrope
14 is very small, and so minor changes or pulsing will
15 cause quite significant changes in the haemodynamic
16 stability of the patient.
17 MISS GREY: Can you remember this happening?
18 DR PRYN: Absolutely, on many occasions.
19 Q. With what affect?
20 A. The child will then become haemodynamically unstable,
21 and if they are unstable, it delays future progress
22 through the intensive care, because you basically want
23 to try and stabilise them for a bit longer. If they are
24 haemodynamically unstable, the last thing you would want
25 to do is then to make them respiratorally unstable by
0088
1 extubating them, so it would keep them on the ventilator
2 for longer.
3 Q. If we go down to "sequential pacemakers", what was the
4 importance of this item?
5 A. We did have sequential pacemakers on the unit. They
6 were beginning to get a little bit old, and they did not
7 really offer all the up-to-date modes of pacemaking that
8 I would have expected in the unit, particularly tracking
9 a patient's inherent atrial rate and pacing their
10 ventricle following that rate, and actually our
11 electrocardiology colleagues advised us to buy one
12 particular sort of pacemaker that would be suitable to
13 track those fast rates with the children in mind.
14 MISS GREY: Dr Scallon, can you help us on the general
15 availability of the equipment recommended by Dr Pryn to
16 purchase 1994 in the UK as a whole? Was the BRI's
17 position before it was purchased typical or atypical?
18 DR SCALLON: I think the equipment listed here is a very
19 reasonable list. Is it typical or is it not? I find it
20 difficult to answer that. For some pieces of equipment
21 it probably is typical, for others it is not.
22 MISS GREY: Would you see anything of concern in the
23 situation that is described about the current pacemakers
24 that are being used on the unit that Dr Pryn thought
25 needed replacement?
0089
1 DR SCALLON: I think the comments he has made are absolutely
2 right. One does need a sequential pacing system which
3 is up to the standard which he has described.
4 MISS GREY: If you do not have it?
5 DR SCALLON: It is less than satisfactory. There may be
6 situations where the management of a patient in the
7 post-operative period would be made more difficult.
8 MISS GREY: Dr Pryn?
9 DR PRYN: Yes, that is very fair.
10 Q. Going down to the patient warming system, you
11 recommended hot air warming blankets as being the best
12 method of rewarming hypothermic post-operative patients.
13 What was the existing situation on the ward when
14 you wrote this note?
15 A. For adults when I arrived in the BRI, there were no
16 warning systems available at all for adults. Actually
17 when I wrote this note, I think we had already purchased
18 one of these hot air blowers on funds that were donated
19 to us by a grateful patient. So this was for a second
20 blower.
21 They were not used for paediatrics. The
22 paediatric system we had at the time was for overheads,
23 electrical heaters, which I felt were not really
24 state-of-the-art and certainly not up to the job asked
25 of them. They did not have any servo-control, that is
0090
1 they did not monitor the temperature of the patient's
2 skin and monitor their heat output, so they did not
3 maintain a very stable thermal environment for the
4 babies.
5 Q. You talk about the necessity for servo-heaters in
6 another part of your statement.
7 A. I do.
8 Q. Is that important or is good nursing observation
9 a substitute for that automated aid?
10 A. No, I think it is important. I think it has been
11 under-estimated how much haemodynamic instability can be
12 caused by temperature changes in an infant and if you
13 can keep a stable thermal environment, it is much better
14 for haemodynamics.
15 Q. But a nurse surely is capable of monitoring the
16 extremities, the feet, the limbs of a child, and seeing
17 whether or not they are fluctuating in temperature?
18 A. No, I think we are talking about very small temperature
19 changes making a very big difference to the child.
20 MISS GREY: Dr Scallon?
21 DR SCALLON: I think these are very fair comments. It is
22 all part of the detail of post-operative management,
23 keeping an eye on temperature, making sure that the
24 patient is stable in that sense is important, but it is
25 important together with many other things, and while at
0091
1 any one moment not paying close attention to this may
2 not be important, it is where you get a combination of
3 factors coming together that trouble starts to arise.
4 MISS GREY: If we go over the page, then, please, to
5 "breathing circuit humidifier", can you tell us what
6 the existing situation was on the ward that made you
7 recommend this, Dr Pryn?
8 A. We had some hot water humidifiers, not enough for the
9 number of beds that we had, so some beds did not have
10 hot water humidifiers at all. That did not really
11 matter for the straightforward adults, because we would
12 often use disposal -- they are called "Swedish noses".
13 They fit in the breathing circuit and they are efficient
14 enough, but for the longer term patient or the
15 paediatric patient it was important to have adequate
16 humidification of the respiratory gases.
17 The humidifiers we had at the time again were not
18 servo-controlled; they were controlled by the nurse,
19 with a thermometer placed actually in the breathing
20 circuit at the patient end, and they would read the
21 thermometer and change the dial on the humidifier from
22 time to time, but it did mean that we probably did not
23 achieve full humidification and it did mean that from
24 the hot water bath to the patient the air is cooled and
25 a lot of the water rained out into the tubes, which may
0092
1 well then have got siphoned into the patient. So it was
2 not a satisfactory arrangement.
3 MISS GREY: Dr Scallon, if you can cast your mind back to
4 1994, is the situation Dr Pryn is describing there one
5 that might have been encountered in other paediatric
6 cardiac surgical units?
7 DR SCALLON: I cannot say exactly what the situation was in
8 1994, but what he has described certainly applied at
9 some point. We had changed earlier than that, but
10 certainly if we go back to the 1980s, the problems he
11 has described are things which we encountered.
12 MISS GREY: But you at the Brompton Hospital had changed
13 rather earlier than the situation he has described?
14 DR SCALLON: I would rather not be pinned down on that
15 point, because I cannot recall when that change was
16 made.
17 MISS GREY: If we go back then to your statement, Dr Pryn,
18 at page 25, if we pick up the subject of equipment and
19 design again in looking at post-operative care, if we
20 scroll down the page, you comment there on the
21 two-storey lift journey between the intensive care ward
22 and theatres being less than ideal.
23 Can you remember instances in which that caused an
24 actual problem.
25 DR PRYN: I can remember resuscitating an adult patient
0093
1 going back down to theatres who had arrested in the lift
2 on the way down to theatre. I cannot remember any
3 serious incident like that with a child. But it does
4 make you feel extremely exposed when you are in a tiny
5 lift with syringe drivers on a battery backup that may
6 or may not work, with no other assistance around,
7 because there is just not enough room in the lift for
8 anybody else, other than you and a porter. So that
9 makes you feel very exposed. Whether anybody actually
10 came to any harm from it, I could not reliably say.
11 Q. Do you think your experience was typical of other people
12 involved in surgery in the BRI? Were there other
13 problems with the siting of intensive care wards as
14 against theatres?
15 A. Yes. I think whenever you are transferring a patient
16 post-operatively to intensive care, it is difficult, but
17 I think the children that we were transferring were
18 extremely unwell at the time, having just come off
19 bypass with a lot of inotropic support, a lot of other
20 things going on, these were properly the sickest
21 patients in all the hospital at the time.
22 MISS GREY: Dr Scallon, Dr Pryn is in a sense making out
23 a case for being particularly careful in the siting of
24 children's wards, ITU, as against theatres. Is that
25 something you would agree with?
0094
1 DR SCALLON: I think it is a fair comment that in an ideal
2 world you have the theatres and the intensive care
3 adjacent to each other, but we are not in an ideal
4 world. In my own hospital the theatres and paediatric
5 cardiac surgery are on different floors and we have to
6 transport patients in the lift and points have been made
7 on that. It is a worrying time. Touch wood, I have had
8 no problems with it. It is a risk.
9 MISS GREY: If we go down a little further, please, we see
10 that you set out the recommendation in the Paediatric
11 Intensive Care Society that the area for children should
12 be enclosed and physically separate from the adult area.
13 That was only partially achieved at the BRI, if we
14 turn over the page, in that the two areas could be
15 screened off.
16 How important do you think that physical, visual
17 separation, children from adults, is?
18 DR PRYN: I do not think it is that important for the
19 physicians looking after the case, but I think it is
20 very important for the families, and after all, one of
21 tenets of paediatric care is that you do not just look
22 after the children, you look after the family as
23 a whole, and I think a lot of the families were very
24 distressed to see their baby in a massive adult bed with
25 very old sick adults around them.
0095
1 Q. If we go down the page further to "transfer services",
2 you can talk about the fact that there were no transport
3 incubators for neonates.
4 Was that important?
5 A. It is a way of maintaining physiological stability when
6 you are moving these patients, because you can keep them
7 warm and control their ventilation adequately in an
8 incubator. It is very difficult to do on a trolley or a
9 bassinet type thing.
10 Q. Would thermal precautions not be adequate for the short
11 distances we are talking about?
12 A. Although the distances are short, it takes
13 a surprisingly long time to transfer monitors and
14 syringe pumps. There is a relatively long period of
15 time moving the patient off the table on to transport
16 and then leaving. I would say the actual moving them
17 takes shorter than the actual preparation each end.
18 MISS GREY: Dr Scallon, do you think this is an important
19 issue, that is, the lack of availability of transport
20 incubators for the neonates?
21 DR SCALLON: Is this between hospital, we are talking about
22 now, or --
23 DR PRYN: No, it is actually within the hospital. I was
24 commenting on the PICS document which talks about
25 transfers between hospitals, I was just talking within
0096
1 the hospital.
2 DR SCALLON: To use a transport incubator within the
3 hospital does add to the complexity of the transfer.
4 There was mention of preparing the patient for transfer
5 and then once the patient has been transferred,
6 re-establishing the patient at the other end, and an
7 incubator would add considerably to the complexity of
8 this.
9 The use of incubators to transfer from, for
10 example, the operating theatre to the intensive care is
11 not something which is practised.
12 MISS GREY: Do you want to add anything, Dr Pryn?
13 DR PRYN: No, I think that is very reasonable. I was just
14 commenting on the fact we did not have one, although the
15 PICS document said we should. Actually we probably did
16 not need it anyway.
17 Q. If we turn over the page, page 27, you set out the PICS
18 document recommendations for equipment. You mention the
19 fact that various bits of equipment are not being
20 provided. Are there any of those you would see as
21 significant omissions?
22 A. It would be nice to see the end-tidal carbon dioxide
23 monitoring, and occasionally it would have been nice to
24 have use of an EEG, or at least a processed EEG for
25 children who had suffered neurological damage
0097
1 intra-operation.
2 Q. Was that available on demand?
3 A. No. No, it was not. I thought that the ventilators we
4 had were probably adequate and I did not think we needed
5 rigid paediatric bronchoscopes.
6 MISS GREY: Dr Scallon, would you see the omission of any of
7 these items of equipment being surprising at the time?
8 Again we are looking back into 1993, 1994.
9 DR SCALLON: Some of them were not available at other
10 institutions, so in that sense it is not surprising.
11 For example, we certainly had not got an EEG facility
12 immediately available at the Brompton. The other
13 monitoring facilities in the Intensive Care Unit are
14 available. The availability of rigid bronchoscopes,
15 these were not kept in the unit but they were readily
16 available in the theatre, and so, if required, they
17 could be used. Fibre optic bronchoscopes are available.
18 Q. In relation to the EEG, are you saying that one was not
19 immediately available but was available on demand, on
20 call?
21 A. At that time, I do not think we had one available on
22 demand. I cannot recall that. I cannot ever recall
23 using one.
24 Q. So the position of the two institutions is broadly
25 similar?
0098
1 A. I would say that was fair.
2 THE CHAIRMAN: Can I ask a question of our expert in that
3 context? You say that you encountered some of the same
4 difficulties. Would that persuade you to say that
5 therefore one can say that whatever was provided at your
6 institution or at Bristol was adequate and appropriate,
7 or does it persuade one to say that against a different
8 standard, a slightly more absolute standard, neither
9 were up to snuff?
10 DR SCALLON: To answer that question in a slightly indirect
11 way, I think the standards are evolving all the time and
12 as new equipment becomes available and becomes used, so
13 it creeps into what is considered basic monitoring, or
14 basic standards. So in an ideal world, you could say
15 that both institutions were short of the ideal standard.
16 MISS GREY: Dr Pryn, do you want to come back on that
17 question?
18 DR PRYN: No.
19 MISS GREY: If we go back to your statement at page 22, you
20 start to discuss the question of the length of
21 operations in Bristol.
22 At paragraph 10, page 23, you say that it was your
23 impression that both Mr Wisheart and Mr Dhasmana, the
24 bypass time and cross-clamp time were significantly
25 longer than they had been in Oxford, although
0099
1 Mr Dhasmana seemed the quicker of the two.
2 This was purely an impression, you say.
3 How firm an impression?
4 A. Pretty firm, that Mr Wisheart's procedures took quite
5 a long time, and I remember the first time that
6 I anaesthetised for Mr Dhasmana, I had done several
7 Wisheart cases and I said to myself, "here is a breath
8 of fresh air", because things were notably quicker, but
9 they were still prolonged.
10 Q. Was the comparison with Oxford a fair and accurate one,
11 or was the case mix in Oxford perhaps rather different
12 from that in Bristol?
13 A. I think the case mix was different, but we did some that
14 were similar, like AV canal repairs that I mention in
15 the previous paragraph.
16 Q. So some of the case work in Oxford was more simple; is
17 that correct?
18 A. Yes. I do not think in Oxford we were doing things like
19 total cable pulmonary connections, TCPCs, and complex
20 things like that, but we were doing switches and
21 AV canals.
22 Q. So you think when you are comparing length of operation,
23 you are comparing like with like?
24 A. I think so, yes.
25 Q. The transcript here has you saying you were not doing
0100
1 switches and AV canals at Oxford. Is that what you said
2 or have we got our negatives mixed up?
3 A. No. In Oxford I did anaesthetise for AV canals and
4 I was present when switches were anaesthetised.
5 Q. You then talk about the post-operative problems and that
6 you needed a higher amount of inotropic support after
7 surgery in Bristol from elsewhere.
8 Can I ask you first, what is the significance of
9 that requirement? What are its causes, potential
10 causes?
11 A. It means that the heart is not working as well as it
12 might, and therefore it needs extra support, and the
13 problem with that is that if the heart does not work
14 very well, then the rest of the body receives inadequate
15 circulation, and therefore you can expect a multi-system
16 failure to occur on an intensive care ward.
17 Q. So we are talking about a situation where the heart
18 appeared to have relatively poor function at the end of
19 an operation?
20 A. That is correct.
21 Q. Are you able to help us on the causes of that relatively
22 poor heart function, because there are a number of
23 potential ones, are there not?
24 A. There are a number of potential ones. One of them would
25 be prolonged periods of myocardial ischaemia, because of
0101
1 a long cross-clamp time. One of them would be
2 inadequate myocardial protection during that time, and
3 myocardial protection at the time was provided by the
4 anaesthetists, but only on the command of the surgeon,
5 so we could not work without them. We could only do
6 their bidding.
7 Another option why the hearts were not working
8 well could have been rough handling, or even imprecise
9 surgery, and I could not separate from any of those
10 causes.
11 Q. The last issue being about the quality of the surgical
12 repair that was effected?
13 A. That is right.
14 Q. Going back to myocardial protection, where you said you
15 were working at the bidding of the surgeon on that front
16 in Bristol, was that different to your experience
17 before?
18 A. No, that is the only way it can be done.
19 Q. Did that give rise to any occasions where you felt that
20 your judgment was at odds with that of the surgeons, or
21 were you united on that?
22 A. No, not at all. I mean, basically when it is convenient
23 during the surgery, then we can give cardioplegia, which
24 is this cold potassium solution that goes into the
25 aortic route, but it can only be done when the surgeon
0102
1 is ready for it. There is no way that we can do it
2 without the surgeon being prepared for it.
3 MISS GREY: Dr Scallon, we have heard of at least three
4 potential causes for relatively poor heart function by
5 the end of an operation. Can you help us on causes? Do
6 you want to add anything further to that?
7 DR SCALLON: No. I think the points made about inadequate
8 protection, prolonged cross-clamping time, surgical
9 problems, these are all absolutely right. Another
10 possibility is where the pre-operative diagnosis was
11 either inaccurate or incomplete, and so the surgeon has
12 not been able to correct the defect fully. This can be
13 something to think of in a patient who has apparently
14 had a good operation but who is not functioning well.
15 In this situation there can be a case to reinvestigate
16 the child, either by means of echocardiography, or even
17 to take the child back to the catheterisation laboratory
18 to do a formal study.
19 I recall speaking to a colleague where just this
20 situation arose in a child who had had the arterial
21 switch procedure. It was a straightforward operation.
22 It should have gone well, but the child was struggling
23 in the post-operative period. The intensivist said:
24 "This is wrong", took the child back to the catheter
25 laboratory and found that there was some aortopulmonary
0103
1 collaterals. These are additional abnormal vessels
2 which were supplying blood from the aorta to the lungs
3 and so increasing the fluid load on the heart. This was
4 picked up in the catheter laboratory. It had not been
5 anticipated pre-operatively, but it reversed the
6 situation. So that is another possible cause of
7 post-operative problems.
8 Q. From your experience of the clinical case review, did
9 you pick up instances or indications of relatively poor
10 heart function after operations that required increasing
11 support with inotropes afterwards?
12 A. It was not something that we focused on, but if
13 a patient is not doing well, it is inevitable that
14 increasing doses or increasing numbers of inotropes will
15 be used. But we did not specifically focus on that as
16 the crude index of how things were going.
17 Q. Because the point being made by Dr Pryn at paragraph 11
18 is that the level of dosage of inotropic support at
19 Bristol was higher than his previous experience. Was
20 that something you were able to pick up, or comment
21 upon?
22 A. A large number of inotropes, and higher dosage of
23 inotropes, implies the heart is not working well. That
24 stands to reason. We noticed in passing, doing clinical
25 review with those cases that had not done well had high
0104
1 doses of inotropes, but this you would expect.
2 MISS GREY: Dr Pryn, your experience at Oxford of
3 post-operative management had been limited. How, then,
4 were you able to form this comparative judgment that you
5 put in paragraph 11?
6 DR PRYN: Yes, I was relatively underexperienced at
7 anaesthetising for open cardiac operations, open
8 paediatric operations, and I accept that fact and I put
9 it in my statement, but I felt that I was competent in
10 anaesthetising children and I had good backup from my
11 colleagues.
12 That is not to say that I did not have any
13 experience. I had had quite a lot of experience of
14 anaesthetising children for open cardiac operations and
15 you do form an opinion as to what is reasonable and what
16 is not reasonable in terms of inotropic support. I had
17 not been used to using that much ever, at any of the
18 institutions I visited, either in Southampton, Oxford,
19 Alder Hey or even later in Melbourne.
20 Q. Dr Bolsin obviously agreed with you. He discussed
21 management techniques with you. What about Dr Masey and
22 Dr Underwood? Did you discuss this aspect of care with
23 them?
24 A. Yes, I believe I did, and they would also use
25 combinations of inotropes.
0105
1 Q. Do you know if they also were in a position to form
2 a comparative judgment, or not?
3 A. I cannot be certain on that, but I can remember having
4 a discussion with Dr Masey about a colleague who visited
5 from Melbourne once, and he spent the week with her and
6 at the end of the week, he said, you know, "You are just
7 fantastic; you are able to look after cases sicker than
8 we ever see". That was just hearsay from Dr Masey, but
9 that is what he said.
10 Q. So that is something we can pursue with Dr Masey, is it?
11 A. You perhaps could.
12 Q. You discussed with Dr Bolsin how to manage these cases,
13 and indeed with your other colleagues. What about with
14 the surgeons, because clearly in altering the dosages or
15 the treatment post-operatively you are, as it were,
16 treating the systems of poor heart function rather than
17 looking at the reasons why those children were
18 presenting to you in those conditions.
19 Did you ever tackle this issue with the surgeons?
20 A. The reasons why the paediatric cases were not doing very
21 well?
22 Q. The reasons why specifically they were coming on to the
23 ward requiring further dosage, further inotropic
24 support.
25 A. I remember speaking to Mr Wisheart about that issue, and
0106
1 he said, "Well, all my patients seem to need it".
2 I remember doing a TCPC with him, and using, after the
3 conventional drugs, quite a large amount of adrenalin to
4 come off bypass, which I would not have expected to
5 use. "All my patients need some adrenalin", he said.
6 Q. What had you said to him about that case?
7 A. I cannot remember specifically what I said to him.
8 Q. In general, when I posed the question the first time,
9 more generally did you talk to the surgeons about the
10 reasons why children were presenting in post-operative
11 care in poor condition, what is your answer to that?
12 A. No, I do not think I did. But being a junior consultant
13 just arrived in the department, and knowing the
14 personalities involved, it would have been extremely
15 difficult to have spoken to Janardan, for instance, and
16 saying "Why is this heart not doing well?" I think he
17 would have taken that extremely personally.
18 Q. Why is that?
19 A. He tended to take things personally, if you brought them
20 down to specific cases. So I would have found that
21 difficult to discuss with him.
22 Q. If he took it personally, did this mean that he was
23 defensive?
24 A. Yes, defensive, and I would not want to have that sort
25 of confrontation with him, because it would sour my
0107
1 working relationship of future cases. So I would not
2 court that sort of dispute with him.
3 Q. What was that anticipation of his reaction based on?
4 What instances, if any, did you see of Mr Dhasmana
5 behaving in a similar fashion that made you anticipate
6 that result?
7 A. I have obviously seen several, but I cannot remember
8 specifically what they were.
9 Q. Other people talking to him and him reacting in
10 a similar manner, or yourself with him?
11 A. Probably both.
12 Q. What about Mr Wisheart? If you had gone to him and said
13 more generally, "The condition of the patients is
14 causing me some concern", what do you suppose his
15 reaction would have been?
16 A. The previous discussion I had had with him, he seemed to
17 think that was normal for his sort of case, so ...
18 Q. His sort of case being what?
19 A. He seemed to think that it was normal. The amount of
20 inotropes that I was using to help his children off
21 bypass was normal for his children coming off bypass; it
22 is not that I was an outlier amongst other
23 anaesthetists, we were all doing the same, so he would
24 have thought that was normal, I would have thought.
25 Q. Are you able to help us on what aspects of the surgical
0108
1 techniques or events in theatre generated the long
2 bypass time or cross-clamp times that you are commenting
3 on in paragraph 10?
4 A. A quick surgeon is not somebody who stitches any faster,
5 but somebody who continues working and does not get
6 distracted. I think sometimes our two surgeons may have
7 been distracted. It is possible sometimes, when they
8 came across unexpected diagnoses, that they would often
9 have to stop and think what to do next. It would not
10 have been in their original plan. So there are many
11 reasons why they were not as quick.
12 Q. You have said, giving an initial reason, that they may
13 have been distracted. What sort of things distracted
14 them?
15 A. I do not know if you have been to a cardiac operation,
16 but there are a phenomenal number of things going on
17 around you. The surgeon actually has to co-ordinate all
18 those as well as doing his stitching. Stitching is
19 probably the easiest part of it, so there is enough
20 going on to distract him, unless he can just say, "Look,
21 all the other specialists in the room, they can look
22 after their areas, I am just going to look after my area
23 now", but I think often surgeons try and have control
24 over all areas.
25 Q. So you think a significant amount of time was lost to
0109
1 interactions with other members of the team?
2 A. Sometimes.
3 Q. If surgeons were taking time to interact with other
4 members of the team, did that have a positive benefit?
5 Was it done for positive reasons or was it always
6 a negative thing?
7 A. It was negative in that it prolonged the operation time;
8 positive in that everybody's response was co-ordinated
9 and we often used to learn quite a lot. I remember
10 learning a fantastic amount from Mr Wisheart, learning
11 about his thought processes.
12 Q. As a surgeon?
13 A. As a surgeon, yes.
14 Q. Generally, if you are asked to describe how the team was
15 co-ordinated and functioned in the operating theatre,
16 how would you describe it?
17 A. I think we functioned quite well as a team when the
18 chips were down, and there was often a sense of
19 camaraderie, but I think I have also previously
20 mentioned that, especially in the anaesthetic
21 assistants, maybe people were not adequately trained for
22 the job. I do not know whether the same pertained to
23 the surgeon's assistants, I could not really comment on
24 that, but we were all trying our best.
25 Q. If we look again at paragraph 10, what effect does
0110
1 prolonged bypass time and cross-clamp time have on the
2 paediatric patient, in your opinion?
3 A. I thought we had covered the prolonged cross-clamp time,
4 and that is poor myocardial function when the
5 cross-clamp comes off.
6 The prolonged bypass time will reflect in
7 multi-system dysfunction in the early post-operative
8 period, such that patients may well develop SIRS, which
9 is systemic inflammatory response, and behave as if they
10 are septic, with all their organ systems with some
11 dysfunction, a higher incidence of renal impairment, a
12 higher incidence of hepatic impairment, that sort of
13 thing.
14 Q. Do you think you were seeing those consequences at the
15 BRI to a greater extent than you had at other centres?
16 A. Yes, adults and children.
17 MISS GREY: Dr Scallon, would you like to comment?
18 DR SCALLON: I think what has been said is absolutely fair.
19 As a general rule, the shorter time you spend in the
20 operating theatre, the better. I know that others take
21 a different view, but I think where this becomes
22 particularly important is where you are dealing with
23 long and complex operations and the two that come to
24 mind are the switch procedure and the AV septal defect,
25 both of which are difficult and prolonged operations.
0111
1 If you then have a slow operating time added to
2 that you then have very extended times in the operating
3 theatre, and then you run the risk of getting the
4 problems which were mentioned.
5 MISS GREY: Dr Pryn, moving down to paragraph 12 of your
6 statement, you say that you had the impression that
7 cases of Mr Ash Pawade took a much shorter time. This
8 was based on experience of working with Mr Pawade until
9 October 1995; is that correct?
10 DR PRYN: That is correct.
11 Q. So still at the BRI at that stage?
12 A. That is correct.
13 Q. Was the case mix similar?
14 A. People have intimated that we were doing less complex
15 cases during that time. The case mix may have been
16 slightly different, but I think we were doing cases that
17 the BRI had had trouble with in the past. It involved
18 AV canals, it involved re-do operations, which are known
19 to have high risk. It involved a truncus arteriosus
20 operation, which again is high risk and in fact that
21 patient had been ventilator dependent for all seven
22 months of her life. And it involved many young
23 infants. The sort of case that the BRI had had problems
24 with before. In fact, I think I anaesthetised for
25 Ash more children less than 6 months old in the four
0112
1 months I was working with Ash than I had done in the
2 previous two years working with Mr Dhasmana and
3 Wisheart.
4 Q. What was he like as a surgeon in the operating theatre,
5 then?
6 A. Very impressive. Very focused; always there from the
7 start, before we anaesthetised the child, even, unlike
8 Mr Dhasmana and Mr Wisheart; always willing to give
9 a hand during the induction phase of anaesthesia, if we
10 were having trouble with the lines, he would come and
11 assist. Always scrubbed and ready to go when we came
12 into theatre, so no time-wasting there; no time-wasting
13 at all throughout the surgery. Extremely focused: just
14 got on and did the job and a very precise job.
15 Q. Had there been problems before as to the readiness of
16 surgeons to start the procedure when the anaesthetists
17 were ready?
18 A. They were never in theatre scrubbed ready to go when we
19 came in from the anaesthetic room. Quite often,
20 especially with Mr Wisheart's cases, the child would be
21 anaesthetised on the operating table, the case would be
22 started by his Senior Registrar, and the Senior
23 Registrar would then get ready to place the lines to go
24 onto bypass and the operation would then stop, as the
25 nurses madly phoned around to try and find where
0113
1 Mr Wisheart was and ask him to come down, and we would
2 basically be twiddling our thumbs for quite a long time
3 before we could progress.
4 Q. Quite a long time?
5 A. Maybe half an hour. That never happened with
6 Mr Pawade.
7 Q. What about Mr Dhasmana? Had that been a problem with
8 him?
9 A. He was not present when we brought the case into
10 theatres, but he was often present at the start or
11 shortly after the start of surgery, so not so much
12 a problem waiting to go on bypass with him.
13 Q. When talking about surgery with Mr Wisheart and
14 Mr Dhasmana, you were suggesting, I think, that the
15 speed of stitching was perhaps no slower than with any
16 other surgeon, but that they were more readily
17 distracted by other events, things going on in the
18 operating theatre than Mr Pawade.
19 Is that the contrast you intended to make?
20 A. I think so. I think the distraction there -- when you
21 look at a quick surgeon, they only ever make
22 interventions which are meaningful; they do not do
23 meaningless interventions that are just wasting time.
24 A slow surgeon tends to do that. Whether it is talking
25 to people or whether it is stabbing and sucking before
0114
1 they actually do the stitches is neither here nor there,
2 but it is an ineffective manipulation.
3 Q. So when you talk of Mr Pawade and you say he is more
4 focused, does that imply there were fewer ineffective
5 interventions?
6 A. Absolutely, which is why he is a very impressive surgeon
7 to watch.
8 Q. So, in your opinion, then, if you talk about a contrast
9 between Mr Pawade's cases and those you saw before,
10 turning over the page, page 24, what are the reasons
11 that you would give for that contrast to the extent you
12 are able to comment?
13 A. The contrast in the length of time, or the contrast in
14 the less inotropic support?
15 Q. The contrast in general that you are painting there
16 between the rate of progress of one child after an
17 operation, compared to another?
18 A. I think if your heart works more effectively after the
19 operation, then the other organs in your body do not
20 suffer as much; you do not get multi-system failure, and
21 therefore you can quickly progress through intensive
22 care. I think that is what we were seeing with his
23 patients.
24 Q. Did Mr Pawade alter in any way the organisation of the
25 unit, talking again from the period when he arrived in
0115
1 May to October 1995?
2 A. No, but he did bring with him a small protocol book
3 which was one that he had started to write when he was
4 in Melbourne, and we did generally follow that. There
5 were no major changes into the management of patients.
6 Q. You had been off, I think, with Dr Underwood to
7 Melbourne to study the management of patients there.
8 A. Yes.
9 Q. Did you make any changes or make any discoveries as
10 a result of that visit?
11 A. Very minor ones. I think I slightly changed the
12 induction dosage of drugs that I used. I think we began
13 using phenoxybenzamine much more in Bristol since that
14 visit, but we had always used it in Bristol for cases
15 that were likely to have a problem with pulmonary
16 hypertension anyway, so I do not think that was a major
17 change.
18 Q. Because the contrast you are painting seems to be owing,
19 in your opinion, to Mr Pawade's skill as a surgeon.
20 Would that be erroneous, or are there other features
21 that we ought to look at in seeking the causes for that
22 contrast?
23 A. I personally felt that was the main issue.
24 Q. Dr Scallon, do you have any comments on the nature of
25 the changes that Dr Pryn has just outlined as a result
0116
1 coming back from Melbourne? Are these small points?
2 DR SCALLON: I think the small changes in anaesthesia are
3 probably small points, but I think the point is made --
4 the view that is expressed that it was the surgery that
5 was different is an important point. There is no doubt
6 that what happens in the intensive care unit is
7 determined by what happens in the operating theatre.
8 MISS GREY: Dr Pryn, you mentioned, when talking about
9 events in the theatre, that one of the other features of
10 delays in surgery or taking a long time over the
11 procedure might be that the surgeons had to reassess
12 when they were presented with anatomy that they had not
13 expected to see.
14 How often did that occur?
15 DR PRYN: Relatively uncommonly. I can remember it
16 happening occasionally, but not very often.
17 Q. So in general can you help us as to the importance of
18 the accuracy of pre-operative diagnosis of anatomy, the
19 condition of the child and the surgical management of
20 the child? Were there any deficiencies or difficulties
21 in that area that you became aware of?
22 A. I have just said there were a few cases where there were
23 extra things that the surgeon found that they were not
24 expecting, but they were only a very few cases.
25 I cannot remember in my practice whether they made a big
0117
1 difference to those cases. I do not think they did.
2 Q. If we can go on, please --
3 A. Can I go back to a comment made earlier? You asked me
4 what changes Mr Pawade had made to our intensive care
5 management. There was one other thing that we did do
6 that I forgot to mention at that stage, and that was an
7 early institution of peritoneal dialysis on the patients
8 who needed it. He actually inserted a peritoneal
9 dialysis catheter at the time of surgery, so if we
10 happened to need it, we could just turn it on, whereas
11 previously with Mr Wisheart and Mr Dhasmana, if we
12 wanted to do peritoneal dialysis, then we would need to
13 have that catheter inserted at a later date, and that
14 was often done by a paediatric nephrologist, so that
15 involved delays in instituting therapy.
16 So that was one step forwards, I suppose, in the
17 intensive care that was made because of Ash's
18 intervention.
19 Q. How important do you think it was?
20 A. We used it on a few patients. How important? I do not
21 know. I think sometimes, when you need to use
22 peritoneal dialysis, there sometimes is not a very
23 pressing need for time. If the patient is not
24 overloaded, if their potassium is normal and they are
25 not acidotic, then you can wait a little bit longer.
0118
1 Q. If we can go on, please, to page 36 of your statement,
2 you talk there, scrolling down the page, issue N10,
3 about:
4 "The process of regular reviews of the annual
5 results of paediatric cardiac surgery in an open forum,
6 if indeed it had ever existed, had lapsed."
7 Would it be right to say that you, during your
8 time from August 1993 to January 1995, prior to the
9 meeting about Joshua Loveday's case, had only seen
10 results presented on one occasion?
11 A. That is true.
12 Q. Are you able to help us on the reasons why annual
13 reviews might have stopped? Was there any discussion of
14 this amongst the anaesthetists or others?
15 A. No, not at all. I was expecting, as I think I put in my
16 statement, some time in 1994 to have the most recent
17 results ending March 1994 presented as soon as they were
18 available. It was with an increasing degree of
19 frustration on my part that they were not, towards the
20 end of 1994. I had just seen no results.
21 Q. So if we go on to your interview with Dr Hunt and
22 Mr de Leval, WIT 319/16, he says there that you felt you
23 had suffered from a lack of data, most of which you had
24 just seen for the first time the previous day.
25 Is that correct?
0119
1 A. Well, I felt that throughout 1994 there were various
2 discussions with various people about the inadequacies
3 or not, as the case may be, of the service provided by
4 the BRI and grumblings of disquiet, but it is very
5 difficult to say anything meaningful without having hard
6 data to back that up or refute that.
7 So it frustrated me that people were having these
8 grumbling conversations without any data to go with it,
9 and the night before the meeting with Marc de Leval was
10 the first time I had seen those results.
11 Q. Dr Hunter said in his witness statement that, as
12 a result of this, there was great animosity felt by
13 a number of people, but in giving evidence he said,
14 unhappiness, animosity, yes. "He", referring to you at
15 that stage, "felt unhappy about the situation". You
16 have used the word "frustration". Frustration,
17 unhappiness, animosity: what was your state of mind?
18 A. I did not feel victimised. I did not feel it was just
19 me. I was frustrated that we could not move the unit
20 forwards in a constructive way. This was part of that
21 constructive way, to have a thorough review of our most
22 recent results to see whether they identified any real
23 failings and, if they did, then to address those
24 failings.
25 Q. If we look at Dr Bryan's witness statement -- this is
0120
1 WIT 81/20, please -- paragraph 15, he comments there in
2 the last sentence that in his view:
3 "... a culture existed of explaining or justifying
4 mediocre or poor results on the basis of case severity
5 rather than directing attention to producing better
6 results."
7 Were you ever present at any generalised
8 discussion about poor results and the reasons for that?
9 A. No, not with the surgeons, but there is no doubt that we
10 in the BRI used to try and talk about subgroups of
11 patients and specific patients rather than the overall
12 picture, the overall mortality for the under ones, as
13 opposed to looking at sort of very tiny groups of three
14 or four patients.
15 Q. The tiny groups of three or four patients would be the
16 sorts of numbers that you might look at in morbidity and
17 mortality meetings; is that right?
18 A. That is right, but we probably did not really look at
19 the global picture and say: "Look, there must be
20 something wrong here because the mortality rate is X, Y,
21 Z".
22 Q. When you say that little groups might be looked at, what
23 sort of gatherings were looking at them? Are you
24 talking about the cardiac surgical audit meetings there
25 or other groups?
0121
1 A. When I say little groups, I am talking about when
2 Mr Wisheart presented his data at the beginning of 1994,
3 he did not present the overall mortality for under ones,
4 over ones. He presented the mortality rates for each
5 small subgroup of diagnoses. So it was very easy to get
6 lost in the trees and not see the woods.
7 Q. When Dr Bryan gave evidence -- I will have to read this
8 out; it is not on the screen -- he said this:
9 "What happened in 1993, and I think this is
10 important, is that a group of people and a significant
11 number of people came from outside Bristol -- that had
12 not happened for some years -- a group of people who had
13 been practising both in surgery and in anaesthesia in
14 a number of major centres throughout the world, all in
15 different areas, and they would be Professor Angelini,
16 myself, Dr Davies, the anaesthetist, and Dr Pryn. This
17 was a group of people who had all had experience of
18 contemporary cardiothoracic surgical practice in quite
19 major international centres and knew what could be
20 achieved in cardiac surgery, both in adults and in
21 children. They were familiar with contemporary cardiac
22 surgical practice."
23 So he was looking at the group of new arrivals, as
24 it were, in 1993 or thereabouts and saying that they
25 produced a new culture or new standards of criticism
0122
1 within the BRI.
2 Is that something you would agree with?
3 A. Yes, to some extent, although I think he perhaps
4 over-emphasises my experience of contemporary cardiac
5 practice, but, yes, I agree. We were all new blood
6 coming to the department with new ideas.
7 Q. Do you think, if you were new blood and had new ideas,
8 you managed that tactfully?
9 A. I personally was never confrontational, and I always
10 wanted to take a considered view on the basis of
11 evidence, and, if anything, looking back on that time,
12 because I did not have enough well validated evidence,
13 I maybe did not press my concerns far enough, because
14 I wanted to have this considered view. I do not think
15 I was confrontational or -- what was the word you used?
16 Q. Confrontational.
17 A. I do not think I was confrontational.
18 Q. You perhaps criticise yourself with hindsight for not
19 having pressed far enough. Is that fair?
20 A. I think that is fair. I think if I had perhaps somehow
21 managed to complete the 1993 audit and pressed that
22 together with Steve Bolsin's, maybe things in retrospect
23 might have moved faster. I am not sure.
24 Q. We will come back to that, I am sure, but you were not
25 confrontational. What about others? Do you think there
0123
1 were others who were confrontational and perhaps thereby
2 counter-productive?
3 A. I do not think so. I do not think it is the nature of
4 Ian Davies to be confrontational. I do not think it is
5 the nature of Alan Bryan to be confrontational. He is
6 pretty considered. I think Professor Angelini to his
7 credit has a very direct manner, which I appreciate.
8 Q. Does that mean he is, in fact, confrontational?
9 A. No, I think he is just direct; he says what he means.
10 I do not think that is necessarily confrontational.
11 Q. What about Dr Bolsin? He was not part of the 1993
12 group, but how was he in handling these problems or
13 issues?
14 A. I did not know what he wanted to -- I never knew his
15 aims. He never spoke to me specifically about his audit
16 and said: "This is what it shows. This is what we
17 should do next". He did not, to me, approach the
18 problem in the correct way. He did not present all the
19 data to us formally, with its strengths and its
20 weaknesses, so we could assess it, and he did not
21 present that data again, with its strengths and
22 weaknesses, to the service as a whole, including the
23 surgeons. He showed people on their own in corridors,
24 in corridor-speak; it was not a direct method. I think
25 he probably could have advanced things a lot further if
0124
1 he had had a direct method.
2 Q. What do you think he ought to have done? What were the
3 strategies that were available to him in order to secure
4 agreement and progress on his data?
5 A. I think he should, first of all, have presented it to
6 us, to the cardiac anaesthetists at a cardiac
7 anaesthetic meeting, and we would all then have got an
8 appreciation of its strengths and its weaknesses, and
9 its meaning, and then, depending on the relative balance
10 of strengths and weaknesses, I think we should have
11 presented it at a joint audit meeting, and the one in
12 January 1994 would have been a prime example when he
13 could have done that.
14 Q. You say that he should have presented it firstly at
15 a meeting of the anaesthetists?
16 A. Yes.
17 Q. Did you ever ask him to do that?
18 A. No, I did not.
19 Q. Did you ever suggest to him that it would help his audit
20 activities if he did that?
21 A. I personally did not, but I think that Chris Monk had
22 asked him to already, so there was no need for somebody
23 else to ask him the same thing.
24 Q. You say you think that Chris Monk had asked him to
25 present his data; is that correct?
0125
1 A. That is what I was led to believe, yes.
2 Q. By whom?
3 A. By Chris Monk.
4 Q. When?
5 A. Really I cannot remember.
6 Q. Put it like this: is this a contemporaneous memory from
7 events around that time, or is this a memory from
8 discussing matters with Chris Monk more recently?
9 A. Certainly we have talked about it more recently, but
10 I think I may have known about it at the time, but
11 I could not be sure on that.
12 Q. So you have discussed it more recently. What, during
13 the last few months?
14 A. During the last few months.
15 Q. And you cannot be sure as to any recollection of an
16 earlier date; is that correct?
17 A. Yes, that is correct.
18 THE CHAIRMAN: Miss Grey, can I just interject for
19 a moment? Miss Grey asked you a question about -- we
20 were rehearsing whether a number of colleagues were
21 confrontational, and she asked you in turn whether
22 Dr Bolsin was, and your response was to express concern
23 about his motives, but I do not recall your actually
24 answering Miss Grey's question.
25 A. Well, he never -- he did not confront the surgeons
0126
1 outright there and then, so in that respect he was not
2 confrontational. I think it was more his style to make
3 comments from the side.
4 MISS GREY: Just going back to the idea of the 1993 group
5 coming into Bristol, and going back to your statement,
6 page 10, 341/10, we saw there, the bottom paragraph,
7 that Mr Bryan and Professor Angelini openly criticised
8 the concept of intensivist sessions at the beginning at
9 least.
10 So it would be wrong, would it, to think of the
11 1993 influx, or 1992 in the case of Professor Angelini,
12 as being a homogenous group; is that right?
13 A. Yes. No, we were not a homogenous group. We came from
14 all different parts of the country, all different parts
15 of Europe.
16 Q. But were you adding different things or coming to the
17 BRI with different perceptions of the way forward, or
18 similar ones?
19 A. I think we all had different ways that we could perhaps
20 improve things in Bristol. What you are asking me was
21 whether we felt as a group that current practice in
22 Bristol was unacceptable. I think that was very, very
23 hard to tell at the time. We knew that it was not good,
24 but hard to tell whether it was unacceptable.
25 I think Professor Angelini and Alan Bryan came to
0127
1 their conclusion about unacceptability fairly quickly.
2 I was waiting for more hard evidence.
3 Q. So it was a possibility that it might be unacceptable.
4 That had been raised partly by your own experience and
5 observations, had it?
6 A. It was something that was considered. There is no point
7 in grumbling about things that are bad. I mean, the two
8 reasons for grumbling about things that are bad are (1)
9 to identify areas where you can improve, or (2) that it
10 is so bad you have to stop. It is obvious that is what
11 was going on. That is why I felt that I could not make
12 the decision whether this was unacceptably bad, because
13 I did not have any hard data to draw that conclusion
14 from.
15 Q. We will come on, if we may, to the data you were given,
16 but it may be that this is an appropriate place to break
17 for ten minutes.
18 THE CHAIRMAN: Shall we break for ten minutes, until 3.25?
19 (3.18 pm)
20 (A short break)
21 (3.30 pm)
22 MISS GREY: Can we look at page 38 of your statement,
23 Dr Pryn? At the bottom of that page we see that
24 Dr Bolsin showed you some outcome data in late 1993.
25 Can you help us any further on the date?
0128
1 A. No idea. I just know it was late 1993.
2 Q. A few months after your arrival in Bristol?
3 A. Yes.
4 Q. Perhaps we should identify what you were shown. If we
5 could see GMC 16/17 first, is that familiar to you?
6 A. That is the sort of thing that I was shown, but it was
7 in a slightly different format. It did not have the
8 tabulated lines in it.
9 Q. If it did not have the lines on it, are the actual
10 contents of it, other than the lines, the same?
11 A. The headings look the same. I cannot be sure of the
12 numbers.
13 Q. Can we turn over the page to page 18? What about this?
14 A. That looks similar. It is the second page.
15 Q. And 19?
16 A. Yes, I certainly saw that.
17 Q. 20?
18 A. Yes, I saw that.
19 Q. And 21?
20 A. Yes. That looks familiar.
21 Q. Is there anything else that you remember seeing that has
22 not come up on the screen?
23 A. Have you shown me the single ventricle Fontan?
24 I believe I had that.
25 Q. I believe that is page 22?
0129
1 A. That is right. And also a page where three operations
2 were summarised, split into the two different surgeons.
3 Q. You have provided, I think now your papers to the
4 Inquiry, Dr Pryn. They contain, do they, any data that
5 was submitted to you by Dr Bolsin at that time?
6 A. Yes.
7 Q. When Dr Bolsin gave you this data, what was your
8 reaction to it?
9 A. I find it quite hard to interpret because, as you can
10 see from the first page, there is a huge amount of
11 information there.
12 Q. By the "first" page, you mean page 17, is it, if we go
13 back to that?
14 A. Yes. There is a huge amount of information there.
15 There is no summary line at the bottom with the overall
16 numbers. So it is all just split up into individual
17 diagnoses of all relatively small groups. It is
18 actually quite difficult to interpret the whole thing.
19 Also, the tables that he gave me, the chi-square tables,
20 are from a programme called Minitab, which really does
21 not say what the figures in the columns and the lines
22 mean.
23 Q. That is if we go on to, say, page 20?
24 A. Yes.
25 Q. Because the results there are split up into different
0130
1 operative groups, are they not?
2 A. Yes, these are completely different operative groups,
3 but it does not say what columns 1 and 2 are, nor does
4 it say what chi-squares you need for a statistically
5 significant p-value. In fact, there are no p-values at
6 all in any of this data.
7 So it is pretty raw data that needs a lot more
8 processing to make it intelligible. At the time that he
9 gave it to me, Steve Bolsin just said, "What do you
10 think of these?" and I scanned down and thought some
11 aspects looked particularly worrying, but that it needed
12 to be in a more presentable manner to get its message
13 across.
14 Q. What did you say to him at the time?
15 A. I think I probably said, "Well, some aspects look
16 worrying, but is it right?" One particular aspect
17 I picked up on was the results he had for VSDs, which --
18 Q. If we go back to page 17 and scroll down, please. So
19 there were six deaths out of 47?
20 A. VSD operations, we would do one or two or more per
21 month, and I would have seen them on the intensive care
22 and they were not really the cases that seemed to be
23 causing concern, so it was a surprise to me that they
24 had a high mortality in this series.
25 Q. You say you think that you "probably said". What is the
0131
1 state of your recollection of any conversation with
2 Dr Bolsin at this time?
3 A. Not precise.
4 Q. Are you able to help us, then, on what you may have said
5 to Dr Bolsin on, for instance, the VSD data?
6 A. No.
7 Q. Can you recollect whether you raised that issue, your
8 concerns about it, to him or not?
9 A. I cannot recollect for certain, but I had enough doubt
10 in my mind as to whether this data was accurate and
11 presentable, and I believe that other anaesthetists like
12 Chris Monk also had that doubt.
13 When we talked about the data at a subsequent
14 meeting, I believe Chris Monk stated that the Steve
15 Bolsin data maybe was not precise enough and maybe we
16 needed something that was slightly more precise and more
17 up-to-date.
18 Q. At a subsequent meeting of whom?
19 A. Of the cardiac anaesthetists, and I believe it was held
20 in the sister's office in theatre.
21 Q. Was that the meeting that led to your commission, as it
22 were, to gather the 1993 data?
23 A. That is correct.
24 Q. When you were given Dr Bolsin's data earlier, in late
25 1993, who did you understand had had a copy of this?
0132
1 A. I assumed at the time that everybody had a copy, because
2 this data had been collected up until the summer of
3 1992, so it was over a year old, and I assumed he was
4 just filling me in on something that had happened in the
5 past because I was a new appointment to the department.
6 I had just arrived. This is what we talked about in the
7 last year or so, this is where we are.
8 Q. When you say "everybody", do you mean everybody in the
9 Anaesthetic Department, or wider than that?
10 A. No, everybody in the Anaesthetic Department.
11 Q. If you had learned later that Doctors Underwood and
12 Masey had not seen the copies, did that come as
13 a surprise to you?
14 A. It did come as a surprise to me. I read their
15 statements on Friday and was very surprised they had not
16 seen this data.
17 Q. What about the cardiac surgeons? Did you make any
18 assumptions as to the availability of the data to them?
19 A. I assumed that they were aware of it. I know that
20 Dr Monk spoke to them with the concerns of all of us
21 cardiac anaesthetists, and I presumed that as part of
22 that conversation, he would have spoken about these
23 results.
24 Q. When you say that you know Dr Monk did that, when did he
25 do it first?
0133
1 A. Some time early to mid-1994, I would have thought.
2 Q. You would have thought?
3 A. Yes. I cannot be precise. You would have to ask him
4 that.
5 Q. When did you hear that Dr Monk had done this?
6 A. I cannot remember a date.
7 Q. Again, is this something that you were aware of around
8 the time it took place, or is this something that you
9 know now because of later discussions?
10 A. No, I think I was aware of it at the time, that he had
11 had many meetings particularly with the surgeons,
12 particularly Mr Wisheart, and he had brought up general
13 concerns and I was aware of that at the time.
14 Q. So your assumption at the time would also have been that
15 the data would have been produced or discussed as
16 appropriate?
17 A. The Bolsin data, but even if it was not, the surgeons
18 had been collecting exactly the same data on an annual
19 basis. They had all this evidence in their hands
20 already.
21 Q. How did you know they had been collecting it?
22 A. Because all the units in the country were collecting it.
23 Q. For returns to the Cardiac Surgical Register?
24 A. That is right.
25 Q. So you thought that if the anaesthetists had been
0134
1 gathering it, nothing in it should come as news to the
2 cardiac surgeons?
3 A. Absolutely.
4 Q. If we turn back to your statement, page 39, we have
5 dealt, I think, with the first paragraph there.
6 Paragraph 2. Soon after you were given this
7 information, Dr Monk asked you if you would collect the
8 data for 1993 for all open procedures.
9 Did that request come in the context of a meeting
10 with the other anaesthetists?
11 A. That request came during that meeting, when we discussed
12 Dr Bolsin's data.
13 Q. Was Dr Bolsin present?
14 A. No.
15 Q. Was there any discussion at that meeting of the need for
16 Dr Bolsin to present his data, or by that time, was it
17 seen as being out of date?
18 A. I think there was a feeling that it may well have been
19 out of date, and possibly inaccurate and I think Chris
20 Monk's rationale in commissioning my extra study was
21 just to see whether the Bolsin data was in the right
22 ball-park.
23 Q. What was the nature of the concerns about Dr Bolsin and
24 Dr Black's data being accurate?
25 A. A lot of the data were not collected by a physician with
0135
1 experience in paediatric cardiology. I believe they
2 were collected by a non-medic, and therefore that it
3 could lead to potential errors with misclassification
4 and misdiagnosis, because many of the notes may not have
5 been understood.
6 Q. You go on then to talk about the process of collecting
7 the 1993 data from a number of sources. Why not
8 approach the cardiac surgeons for information?
9 A. I was doing what my Clinical Director had asked me to
10 do.
11 Q. Did you ever have any discussion with Dr Monk as to why
12 you were not simply short-cutting this laborious process
13 by going directly to the cardiac surgeons who were
14 collecting this data for the register?
15 A. No, I did not. The laborious process was quite
16 illuminating, in that it illustrated how poor some of
17 our data collection was at the time, and how difficult
18 it was to get accurate information out. I think that is
19 the reason that I have gone through it in some detail in
20 my statement, because it was very difficult for anybody
21 else to get this data.
22 Q. Staying with the meeting which commissioned this for the
23 moment, was there any discussion at that meeting of the
24 sources you would need to draw upon in order to collect
25 1993 data?
0136
1 A. I cannot remember. I cannot recall, but I was obviously
2 aware of the theatre records and I was obviously aware
3 of the PATS database.
4 Q. Did you anticipate that the task would be as difficult
5 as it proved to be?
6 A. No.
7 Q. And presumably the other anaesthetists who were present
8 at the time when you were asked to do it, likewise
9 probably would not have appreciated it either?
10 A. No.
11 Q. So was this a new data collection exercise for the
12 anaesthetists?
13 A. Yes. I think it was very similar to the method that
14 Steve Bolsin had used. I do not know. I do not know
15 exactly his methods, but, yes, this was new.
16 Q. Who can you remember being at the meeting?
17 A. Only Chris Monk, actually. There were others, but
18 I cannot remember who they were, so ...
19 Q. Do you know why Dr Bolsin was not at the meeting?
20 A. No, I have no idea. I have never been to any meeting
21 with Dr Bolsin when he has talked about his data.
22 Q. Was this a formal audit meeting of the Anaesthetic
23 Department, or a more informal meeting?
24 A. No, very informal, called during the working day whilst
25 some people were looking after cases in theatre. It was
0137
1 just a quick five minutes at the end of the corridor.
2 Q. Do you know how people were selected or asked to take
3 part in it?
4 A. I think if anybody was available, they could come --
5 should come.
6 Q. Do you think that the fact that Dr Bolsin was not there
7 reflected any tension between himself and the rest of
8 the anaesthetists on the data collection process and how
9 it should be handled?
10 A. At the time I was not aware of any tension between
11 Dr Bolsin and the rest of the anaesthetists about this,
12 so I was not aware of it at the time.
13 Q. At the time? Did you subsequently become aware of any
14 such tension?
15 A. Yes, I have subsequently talked to Dr Masey, I think you
16 will obviously talk to her, but she felt that Dr Bolsin
17 ought to have collected this data in a more open manner
18 and that it ought to be discussed and, in inverted
19 commas, "owned" by all the anaesthetists so they could
20 move forwards as a group.
21 Q. Was that something that you felt at the time? Or came
22 to feel?
23 A. Well, it was a relatively minor issue. I think the
24 important thing was the data, not the method of
25 collection.
0138
1 Q. But you said earlier that you were never present at
2 a meeting of the Anaesthetic Department, at which
3 Dr Bolsin presented his data.
4 We have heard earlier that anaesthetic audit
5 meetings were taking place on a monthly basis; is that
6 right? Would those have been proper opportunities for
7 Dr Bolsin to present his data?
8 A. A possibility, but it would have been more appropriate
9 for him to present it at the cardiac surgery audit
10 meeting, rather than the anaesthetic audit meeting.
11 Q. Depending on an invitation from that group, as you put
12 it?
13 A. We were all welcome to attend, so I guess if we were
14 welcome to attend, we were welcome to participate.
15 Q. I thought, Dr Pryn, you had said earlier that the first
16 step for Dr Bolsin would have been to present the data
17 to anaesthetic colleagues and then to move outwards from
18 there?
19 A. That is right, cardiac anaesthetic colleagues, not to
20 the Anaesthetic Department as a whole; that would
21 probably not have been appropriate.
22 Q. How would such a meeting have been convened? Were
23 there formal or informal meetings already taking place?
24 A. There were informal meetings already taking place.
25 There were some agendas for those meetings but they were
0139
1 called very much on an ad hoc basis, because after mine
2 and Dr Davies's appointment, we were now a relatively
3 hard group of doctors and it was hard to meet during the
4 working time as my colleagues had done before and
5 therefore extra meetings needed to be called in our free
6 time and evenings so we could talk together and
7 basically have a single unified voice.
8 Q. Going back to the subject of data collection, you knew
9 at the time, as I understand it, that the surgeons were
10 gathering this sort of data in order to prepare returns
11 for the UK Cardiac Register?
12 A. I assume that they were. At that stage, I had never
13 seen any results that they were gathering, but I assumed
14 that they were because I assumed that every unit in the
15 country was doing that.
16 Q. And you knew of the existence of the register at the
17 time, obviously?
18 A. I did.
19 Q. Did you know where the returns to the Cardiac Register
20 for Bristol were kept within the unit?
21 A. No.
22 Q. Were they ever circulated to the anaesthetists?
23 A. No.
24 Q. What about Mr Wisheart's logs? Did you know where those
25 might be available?
0140
1 A. No.
2 Q. At the GMC, again, Mr Wisheart stated that his surgeons'
3 logs were always available in black ring binders outside
4 his office.
5 Did you know that at the time?
6 A. Outside his office is a corridor, is it not? There is
7 nowhere to store ring binders outside his office.
8 Q. Yes, I am sorry, the information lived on a shelf in the
9 office of the secretaries, the cardiac surgical
10 secretaries, "where my secretary was", is what he is
11 indicating, so in his secretary's office?
12 A. I was not aware of that.
13 Q. So would it not have been sensible to have gone to
14 either Mr Wisheart or Mr Dhasmana, or both, to shortcut
15 the process of data collection?
16 A. For this 1993 exercise, you mean?
17 Q. Yes.
18 A. Yes, I think the way Dr Monk put it to me was that he
19 wanted some data independent of the surgeons.
20 Q. How did that comment strike you?
21 A. It struck me as odd, but he was my Clinical Director and
22 I did what I was told.
23 Q. You go on to talk firstly about the difficulties in
24 gathering the data together, and you set that out in
25 your statement in some detail. It was obviously
0141
1 a time-consuming process. How long do you think it took
2 you?
3 A. Many hours. I cannot be more precise than that but
4 quite a long time.
5 Q. Turning over the page, page 40, paragraph 4, the most
6 difficult aspect of compiling the data was to divide it
7 into diagnostic groups, as you are not a cardiac
8 surgeon.
9 That was one of the problems you mentioned as
10 potentially affecting the reliability of Dr Bolsin's
11 data?
12 A. Yes.
13 Q. If that was a concern about Dr Bolsin's data, was it not
14 equally foreseeable that your data might suffer from the
15 same problem?
16 A. Yes.
17 Q. So again, why launch this extremely difficult data
18 collection exercise?
19 A. Because I was asked to do it. I was doing all I could
20 do at the time to try and help things forward in the
21 unit and if it was deemed important to collect that data
22 to help things forward, then I did it.
23 Q. So how far did you get with it in the end?
24 A. I managed to collect I think names and outcomes for all
25 the children operated on in the calendar year of 1993,
0142
1 and I managed to collect either operations or lists of
2 diagnoses for those children, but I never got to the
3 stage where I could simplify the children into groups to
4 present in a straightforward, simple way.
5 Q. If we look, please, at GMC 16/59, can you just help us
6 on what that is, please?
7 A. Well, I had got to a certain stage with this data
8 collection and then I went to the audit meeting at the
9 beginning of 1994 when James Wisheart presented his
10 data. Then I realised that the surgeons who were in
11 a very good position to classify it were collecting the
12 data already and were presenting it, that my sort of
13 exercise was fraught with difficulties and unlikely to
14 help things forward much more.
15 Therefore, I put my audit exercise of 1993 to one
16 side, and it was only in the middle of 1994 when I then
17 got a bit frustrated with the lack of forthcoming data
18 from the surgeons that I revisited my 1993 audit, and
19 this is just a summary, where I went down counting cases
20 and mortality for some specific operations for the two
21 surgeons.
22 Q. Did it go anywhere, this piece of paper, these jottings,
23 except ultimately into the GMC's folders?
24 A. I cannot honestly remember. I do not think it did.
25 I think if it went anywhere, it was not my style to
0143
1 circulate documents as rough as that. I would smarten
2 it up a bit. So it probably did not go anywhere.
3 I think Steve Bolsin may have seen it, but I never
4 presented it to anybody.
5 Q. If we go back to your statement at page 41, you talk
6 there about the audit meeting in January, I think it has
7 been dated by others, of January 1994. You talk about
8 it being a regular audit meeting.
9 Firstly, can I run over some attendees with you?
10 Is it right that Dr Davies, Dr Underwood, Dr Masey,
11 Dr Bolsin, Dr Monk, were all there?
12 A. I really cannot remember, but you obviously have a list
13 of attendees. I cannot remember that at all.
14 Q. Can you remember --
15 A. I remember Chris Monk being there. I cannot be certain
16 about anybody else.
17 Q. I will not go over the rest of the potential attendees
18 in that case.
19 A. The point you are making is that it probably was not
20 a regular meeting, because Sally Masey would not have
21 been there if it was a regular audit meeting.
22 Q. I would ask you, can you recollect anything about the
23 circumstances in which this meeting came to take place,
24 the reason why it was set up?
25 A. No, I was not party to that. I think I discovered
0144
1 a little bit about that meeting recently, but I was not
2 party to why it was called at the time.
3 Q. What did you understand its agenda to be?
4 A. I thought we were going to talk about the recent
5 results.
6 Q. Dr Bolsin's data was not presented to that meeting?
7 A. No.
8 Q. Was there any reason that you can remember that that
9 should be so?
10 A. No. It would have been a good opportunity to present
11 it. It would have been a good opportunity to present my
12 data, but I did not know the meeting was called for that
13 purpose and my data was not ready. If I had been told
14 a few days before, I might have been able to get it
15 ready.
16 Q. So what warning did you have of the meeting?
17 A. It cannot have been that much, otherwise I would have
18 made a big attempt to complete my data.
19 Q. What can you remember about the data that Mr Wisheart
20 presented? First of all, can you remember what year it
21 related to?
22 A. No, I really cannot. I believe it was the year ending
23 March 1993, but it could well have been the year ending
24 March 1992. I really do not know.
25 Q. You cannot help us as to whether it covered a financial
0145
1 year or a calendar year, or can you?
2 A. No, I assumed it was all being done in financial years
3 at that stage, but I really do not know.
4 Q. You do say your data was not comparable because it
5 covered a calendar year, whereas the other one,
6 Mr Wisheart's, was covering a financial year?
7 A. His would not have been as up-to-date as mine, because
8 basically I had cases on my list who were still in the
9 intensive care ward; they had only just been operated
10 on, so there were some outcomes we did not know yet.
11 Q. If we go to Dr Monk's statement about this meeting,
12 WIT 105/22, please, and scroll down, Dr Monk says that
13 he helped organise "a joint meeting of cardiologists,
14 surgeons and anaesthetists in the Department of Cardiac
15 Surgery."
16 He dates the meeting to March 1994, but if we read
17 the remainder of the paragraph, does it appear that you
18 are nevertheless talking about the same meeting?
19 A. Yes, it looks like the same meeting, but James did
20 present his data on a blackboard.
21 Q. He says at the meeting there was no effective chair.
22 What is your comment on that?
23 A. I think that is true. I think somebody at the back said
24 "James, can you present your data" and he got up and
25 presented it, but nobody was questioning him on that
0146
1 data and nobody was chairing the meeting to bring in
2 other people's comments and discussions.
3 Q. Can you remember if Mr Dhasmana was there?
4 A. I cannot.
5 Q. Are you able to help us as to what expectation there
6 might have been that Mr Dhasmana should play a part in
7 this meeting?
8 A. I would have thought it was really important for him to
9 play a part, but I cannot remember if he was there.
10 Q. The suggestion is that it was he who was meant to be
11 presenting the figures for the year, but had been
12 detained in theatre so Mr Wisheart had to take over.
13 Are you able to help us on that?
14 A. No, I could not really comment on that, but you could
15 check on the theatre logs to see whether that is true or
16 not.
17 Q. It says here that the main data presented was presented
18 by Mr Wisheart on a blackboard, or a white board, and
19 then it suggests there was something from you: some of
20 the most recent data available on the 1993 operations.
21 Does that overstate the nature of your
22 contribution?
23 A. I think it does, a little bit. Whilst Mr Wisheart was
24 presenting his data, I was looking down through my very
25 rough workings and was trying to count in my mind.
0147
1 I particularly chose the AV canals, because I think
2 Mr Wisheart had said, "Here are the realities for the
3 AV canals; they are not good but they are tolerable",
4 and I wanted to cross-check that with my data. So I was
5 counting the AV canals and I got a little confused
6 between children who were aged over 1 and under 1, and
7 at the end I made some comment about, I do not know,
8 mortality in children with an AV canal over 1, and both
9 Mr Wisheart and Alison Hayes, the cardiologist, actually
10 said to me, "Your data must be rubbish because we do not
11 do AV canals in the over 1s". So that was it. So I sat
12 down again: basically, I had not prepared for
13 a presentation. I was not in a state to do it. So
14 I got what was coming for me.
15 Q. Can you remember whether Mr Wisheart's figures covered
16 the range of operations and procedures within the BRI,
17 or whether it was related to one or two procedures only?
18 A. No, I believe that he covered the entire range, which is
19 what impressed me, because it all came off from memory
20 and he could write down all these figures, even for tiny
21 groups. He must have known the figures particularly
22 well to do that.
23 Q. If we go on back to this statement:
24 "The meeting resolved little as there was not
25 a frank discussion on outcome, and I believe it did more
0148
1 to consolidate difficulties and differences than start
2 a process to address the problems."
3 What do you have to say about that commentary?
4 A. I think there you come down to the problem that I think
5 Mr Bryan highlighted, where difficulties were often
6 explained away by poor cases such that when Mr Wisheart
7 presented his data, it was all in small subsets of
8 procedures or diagnoses, and it was difficult to see the
9 overall picture of the unit performing poorly for small
10 children.
11 So the conclusion that Mr Wisheart drew and that
12 we all came away from the meeting with was that "Bristol
13 is not brilliant, but some things are quite good; other
14 things are okay; some things are pretty poor, but you
15 know, that is the way all units are and we are no worse
16 than any other unit".
17 Q. Which things were pretty poor?
18 A. I cannot remember the specifics, but I would have
19 imagined he may well have drawn AV canals, saying they
20 are not good, because that is why I was looking through
21 AV canals.
22 Q. Would the switch operation have featured in discussion?
23 A. It may well have done, but I am not sure whether he
24 presented it as a switch or just mixed the switches up
25 with atrial switches and just had them in diagnostic
0149
1 categories as opposed to operative categories. I cannot
2 remember how he presented his data. In fact, there was
3 no hard copy for us to take away from that meeting.
4 THE CHAIRMAN: Interrupting Miss Grey, I hope not too
5 severely, this is a meeting called by your Clinical
6 Director. He said here in front of us that he believed
7 it did more to consolidate difficulties than to start
8 a process.
9 I was just wondering about your reflection on
10 whether that is particularly surprising. If you did not
11 know about the meeting until just before it was called,
12 you were not in a position to present proper data, not
13 everybody who should have been there could have been
14 there, and so on and so forth, no-one is in the chair.
15 If this is a meeting called to address what is deemed by
16 some to be a serious matter, what was your view, did the
17 meeting as it proceeded achieve anything like the
18 objectives claimed for it?
19 A. I did not know the objectives at the time, but in
20 retrospect, it did not address the issue of whether
21 there was a serious problem going on in Bristol at the
22 time.
23 Q. What does that tell you about organising meetings?
24 A. Organising meetings with clinicians is phenomenally
25 difficult, because we all have other commitments. It is
0150
1 very difficult during working hours. We often end up
2 organising meetings in our free time in the evenings.
3 That is just about the only way we can all get
4 together.
5 MISS GREY: If the meeting did little to elucidate whether
6 or not there was a problem in Bristol, was it put to
7 Mr Wisheart that there was a problem in Bristol?
8 A. At that meeting? I cannot recall it.
9 Q. So did anyone suggest that the results were not good
10 enough, or needed dramatic or substantial improvement?
11 A. I cannot recall it, unless Chris Monk spoke from the
12 back and said "Mr Wisheart, there have been some
13 concerns, can you tell us the most recent data that you
14 have?" He may have done it like that.
15 Q. But once Mr Wisheart presented the data, there was no
16 comeback and argument with that, or conclusions?
17 A. I think there might have been a discussion about some of
18 the diagnostic groups, for instance, the Fallots, who
19 had had some particularly poor outcomes in the years
20 preceding, but I think the surgeons had changed their
21 operative techniques and the results were a lot better.
22 So there may have been some discussion about that sort
23 of improvement, but not as a unit as a whole.
24 Q. Dr Monk talks about consolidation of difficulties and
25 differences. What was the overall "temper" of the
0151
1 meeting?
2 A. It is hard to tell that because I did not know what the
3 objectives were at the time. It was amiable and
4 professional. I felt somewhat humiliated because I had
5 not prepared properly. It was a professional meeting.
6 Q. Did Dr Bolsin speak at any point?
7 A. Not that I recall.
8 Q. If we go back to your statement, page 41, you say there,
9 scrolling down a little, please, that after this meeting
10 your audit was effectively abandoned?
11 A. Yes, I put it to one side. I did not think it would be
12 that useful, because I thought it would be very
13 difficult to actually categorise the children and
14 I realised that the surgeons were actually collecting
15 this data anyway and were in a much better position to
16 do it, and I thought they were also presenting it
17 regularly. So I did not think that my efforts would be
18 particularly useful.
19 Q. We have touched on the conversation with Dr Sally
20 Masey. This was the conversation that was, as it were,
21 contradicted when a further AV canal operation took
22 place, operated on by Mr Wisheart in August.
23 Looking at the cessation firstly rumoured in the
24 conversation with Dr Masey for the AV canal and then
25 subsequently one that did take place after August 1994,
0152
1 looking also at the history of the switch operation, in
2 which switches for neonates stopped at one point,
3 non-neonates continued, what comment do you have to make
4 about the process by which these sorts of decisions were
5 taken at the BRI?
6 A. If the decisions were taken, they did not involve me as
7 an anaesthetist; it was a very closed decision.
8 Q. Should they have done?
9 A. If you want to build a good team, they will need to know
10 what is going on in the team.
11 Q. Should you have been involved in the decision to stop
12 these procedures, or should you merely have been
13 involved clearly in what the policy was in relation to
14 operating on them, or both?
15 A. I certainly should have been informed clearly what the
16 policy was, even if I was not involved in the decision
17 to stop.
18 Q. If we look at Dr Monk's statement again, at page 23,
19 105/23, and scroll down, please, at paragraph 12, we can
20 see in the second sentence there:
21 "In concert with Drs Pryn and Davies, we withdrew
22 our support from the programme [the non-neonatal or
23 switch programme] in late spring 1994."
24 What can you recollect about that decision? Is
25 that an accurate way of summarising your involvement in
0153
1 it?
2 A. No, I do not think that is accurate for me, anyway.
3 I think you are talking about the neonatal switch
4 programme, and not the non-neonatal, as you said.
5 Basically, around about that time, Dr Masey spoke
6 to me and said, "We would like to concentrate the
7 expertise for neonatal switches upon two of us, so that
8 we can develop this new programme and concentrate the
9 expertise. Therefore, would you mind if we did all the
10 neonatal switches and not you?"
11 At the time, I knew there were concerns with
12 outcome; I did not have any figures, but there were
13 enough concerns with their outcome for me to be only too
14 happy not to be involved with the neonatal switches. So
15 I agreed, "Yes, I do not want to be involved with
16 neonatal switches. I am very happy for you to
17 concentrate the expertise on the other two".
18 Q. Did you ever anaesthetise for any further neonatal
19 switches?
20 A. I have never anaesthetised for any neonatal switches in
21 Bristol. I anaesthetised for one non-neonatal switch in
22 June 1994, who died on the table.
23 Q. Did that experience give rise to any particular
24 response?
25 A. I felt at the time, although the assessors of the case
0154
1 do not feel it as strongly as I did, that it was
2 primarily a surgical problem which led to the demise of
3 that child. I really did not want to go on and
4 anaesthetise for any more children knowing the surgical
5 expertise now, until there was a full and thorough
6 review of the programme and a discussion of its
7 outcomes.
8 Talking to colleagues, at the time with my
9 disquiet about switches, that is when the letter to
10 Chris Monk was formulated and I was very happy to sign
11 it.
12 Q. Just looking at the operations, if we go to UBHT 54/84,
13 please, it has been anonymised as you see, but firstly,
14 can you identify this document?
15 A. Yes. This was a document prepared by Mr Dhasmana of
16 all his switch operations and he presented it to me
17 a day or two after Joshua Loveday had died, so after his
18 last switch.
19 Q. Had you seen it in another form earlier than that?
20 A. I had seen it in a written format at the meeting the
21 night before Joshua Loveday's death.
22 Q. By "written" you mean handwritten?
23 A. Handwritten.
24 Q. If we look at page 87, we see there, this is the
25 cessation of the neonatals -- one neonatal switch
0155
1 problem, I am sorry.
2 If we can go back a page, my apologies, we see
3 there I think, do we not, the last of the non-neonatal
4 switch programme, 12.1.95?
5 A. Yes, that is right.
6 Q. Does this help you to identify the document?
7 A. Yes, this is obviously given to me after that case, so
8 I was given it a day or two after that case, as
9 a typed-up version complete of the handwritten one I had
10 been given a couple of days before.
11 Q. Which could not involve the details of the death on
12 12th January, for obvious reasons?
13 A. Well, not unless Janardan had remarkable prescience.
14 Q. If we go up to numbers 23 and 24, which of these
15 generated the letter from the anaesthetist? Number 23?
16 A. No, I was involved in case number 23, and I believe that
17 we wrote the letter shortly after that case.
18 Q. You refer there to you taking the view that surgical
19 error played an important part in this. Can you explain
20 that to us, please?
21 A. I thought it did. This child was extremely complex and
22 the surgery was very difficult, but he had his switch
23 operation. It seemed to go well, but the left ventricle
24 really was not functioning at all when we attempted to
25 come off bypass, so talking with Janardan, we reasoned
0156
1 that there was either a problem with the anastomosis of
2 the left coronary artery on to the aorta, or there was
3 a problem with kinking or compression of the coronary
4 artery.
5 He then cross-clamped the aorta and had a look at
6 his anastomosis, which seemed patent, so we then closed
7 the aorta and once again, the left ventricle really did
8 not work. At that stage he put a sling around the
9 pulmonary artery and pulled it to one side, and lo and
10 behold, after a while the left ventricle started working
11 better. He dropped the pulmonary artery back in again
12 and the left ventricle sank. So to me, that was
13 the cause of compression in the coronary artery, which
14 seems to be a surgical problem. At that stage, even
15 though he tried to hitch the pulmonary artery out of the
16 way, at that stage it was too late, basically; the left
17 ventricle was never going to work.
18 Q. And that is something you can recollect from your
19 presence in the operating theatre at the time?
20 A. I can.
21 Q. If we go to UBHT 61/7, please, this is the letter of
22 21st June written and signed by you to Dr Monk. What
23 can you remember about the circumstances in which it was
24 produced? Was it always addressed to Dr Monk?
25 A. The copies that I saw were, but I believe that the
0157
1 original ones were not. I believe it was Dr Monk that
2 asked us to write it to him.
3 Q. And the originals were addressed to whom as far as you
4 know?
5 A. I did not see the originals.
6 Q. Do you have any knowledge of whom they might have been
7 addressed to?
8 A. Only from what you told me this morning.
9 Q. If I take you to Dr Monk's statement, WIT 105/23, and
10 scroll down, please, we can see there his statement,
11 which is what I think you are referring to, that Dr Monk
12 says:
13 "Initially my signature was included but in
14 a revised version it was deleted and the letter
15 addressed to me."
16 I think if we look further in his statement, and
17 turn over two pages, please -- my apologies, we need to
18 find the reference; over the page, if we scroll down,
19 there is the letter I was looking for:
20 "The letter addressed to me from the six cardiac
21 anaesthetists requesting a review of the switch
22 programme was originally addressed to John Roylance."
23 Is that anything you have any knowledge of?
24 A. No.
25 Q. You produce this letter, UBHT 61/7. What response was
0158
1 received to it? What feedback did you get from
2 Dr Monk?
3 A. Well, what I was hoping for was a full and open review
4 of not only the switch programme but I hoped that would
5 lead on to a full review of all our paediatric cardiac
6 practice in an open forum with everybody there, looking
7 to see whether there was a problem and where the problem
8 lay, and an open discussion of where we go forwards, but
9 actually, none of that came. I believe Chris Monk took
10 this letter forwards. I believe he took it to
11 Mr Wisheart, but I do not know what the surgeon's
12 response was.
13 Q. If we go back to your statement, please, at page 46, you
14 say that you believe that during 1994 he presented
15 firstly your concerns and those of the anaesthetists,
16 and also the letter. On what is that belief based?
17 A. Just on informal discussions with Dr Monk, saying that,
18 yes, he did talk to the surgeons on many occasions and
19 he did express our concerns.
20 Q. Did he get any impression from Dr Monk as to what the
21 barriers to any further developments or progress on this
22 matter were?
23 A. No.
24 Q. Why not press Dr Monk further for progress?
25 A. I felt at the time that he shared our concerns and was
0159
1 in a much better position to judge how best to press
2 those concerns than I was, being relatively junior and
3 only just arrived in the department.
4 Q. Did you understand that any decisions had been made
5 about the switch programme after the letter had been
6 sent?
7 A. No.
8 Q. What was the next time the switch programme was
9 discussed?
10 A. At a meeting at Hyam Joffe's house in the winter,
11 1994.
12 Q. Again, can you remember who was there?
13 A. I think the people I do remember I have listed in my
14 statement.
15 Q. If we go back to page 43, paragraph 12, you date it
16 there to late 1994. I think Mr Wisheart has dated it to
17 8th December. Would that accord with your recollection?
18 A. Yes, that is consistent.
19 Q. Again, do you remember why this meeting was called?
20 A. I think it was called just to resurrect this
21 multidisciplinary meeting that apparently used to meet
22 quite regularly and for some reason or other, had not
23 met for a long time and they just wanted to re-establish
24 it as a team-bonding exercise, so we all knew what was
25 going on.
0160
1 Q. Might it have been called to discuss the case of Joshua
2 Loveday specifically, whether he should be scheduled for
3 operation?
4 A. Well, if it was, then it was not obvious from what
5 happened in the meeting that it was called to discuss
6 his case. His case was not mentioned.
7 Q. Was the meeting generally about switches or other
8 aspects of procedure?
9 A. I think it was generally about other things. I can
10 remember the conversation turning to switches at some
11 stage, but it was generally about a lot of things. When
12 it turned to switches, again, my recollection is that
13 there was no hard data or evidence presented at all.
14 Q. Did Dr Dhasmana present handwritten figures about the
15 switch series?
16 A. Not that I recollect.
17 Q. So nothing was handed round to any of you?
18 A. No.
19 Q. What about presenting in the sense of telling you about
20 what the data was for the switch procedure? Did he do
21 that?
22 A. I cannot remember that.
23 Q. Is that because you cannot remember him doing so, or
24 because your recollection of the meeting cannot exclude
25 it one way or the other?
0161
1 A. I cannot remember him doing so.
2 Q. Let me put it more generally: how good is your
3 recollection of this meeting?
4 A. It is not that good, because I cannot remember whether
5 he was there and I cannot remember the other issues that
6 were discussed, so it is not that good.
7 Q. Generally you say over the page, page 44, that
8 Mr Dhasmana reluctantly agreed he would not continue to
9 operate on neonates.
10 Is that a firm impression or recollection?
11 A. Yes. I was quite surprised that that was his view, that
12 he still thought he could do it, but everybody was
13 convincing him, I think particularly Hyam, that he maybe
14 should not, and he reluctantly agreed he would not
15 attempt it again, but he was adamant that he could
16 continue with his non-neonates, assuming that the
17 anatomy of the coronary arteries was well-defined.
18 Q. How would he know whether or not it was well-defined
19 prior to the operation?
20 A. I think it depends on the quality of the echo and/or
21 angiogram.
22 Q. So was he confident that that would enable him to
23 exclude the possibility of unexpected diagnoses,
24 unexpected surprises in the operating theatre?
25 A. It was certainly the thing that seemed to have caused
0162
1 him a lot of problems earlier on with the switch
2 programme, that he was confronted with odd anatomy that
3 he was not expecting that made the operation more
4 difficult than he was expecting. I think earlier on in
5 the programme, he was trying to only concentrate on
6 straightforward cases. It seemed ludicrous to do very
7 complex cases when he was basically still learning.
8 Q. If the group at the meeting were deciding whether or not
9 the switch results were acceptable, what was the
10 comparator being used?
11 A. I cannot recall any data being presented, so there was
12 no comparator.
13 Q. So at the meeting on Joshua Loveday, you at least had
14 papers relating to results elsewhere, but not at the
15 earlier meeting; is that correct?
16 A. That is correct.
17 Q. After the meeting, you have said that the decision was
18 that non-neonatal switches would continue provided the
19 anatomy was defined. How did you feel about that
20 decision?
21 A. I was still somewhat disappointed because we still had
22 not had our formal review, but on the other hand, I did
23 not think there would be any switches because we had not
24 done one for six months. I thought that whatever he
25 said that he wanted to carry on doing, I thought they
0163
1 just were not coming his way, so I did not expect there
2 to be any more switches.
3 Q. But that was surely just a matter of chance, if none of
4 them had come his way in the last 6 months?
5 A. Possibly. I do not know. I think a lot of cases
6 probably were referred out of the Bristol catchment
7 area, but as an anaesthetist, I would not know that.
8 I only saw the ones that came scheduled on our list, but
9 I think you have had evidence presented here that a lot
10 of cases were referred out.
11 Q. The whole of this discussion was premised upon
12 a distinction between neonates and non-neonates: was
13 that something you were happy with at the time?
14 A. It was something I was led to believe was acceptable,
15 because that is how Mr Dhasmana had always split it.
16 He agreed he could not do the neonates but he could do
17 the non-neonates, so he had obviously come to the
18 assumption that they were different. I think it may
19 have been more helpful to have addressed them as one
20 issue.
21 Q. But at the time you did not query the distinction?
22 A. No.
23 Q. Now do you query it?
24 A. I think now that I am a bit older and bolder, I would
25 have presented the data on switches in a slightly
0164
1 different way, pooling neonates and non-neonates
2 together.
3 Q. But at the time, if we look at GMC 16/106, this is the
4 data that you prepared for the Joshua Loveday meeting;
5 is that correct?
6 A. That is correct.
7 Q. We can see that it does accept the distinction between
8 neonates and non-neonates?
9 A. Yes. It presents it like that.
10 Q. Can you tell us what errors were discovered at the
11 Joshua Loveday meeting and why, with this table?
12 A. I think there were three errors, and they are listed on
13 a letter I wrote the next day to everybody. They were
14 discovered in comparing our workings with the list of
15 cases, the handwritten list of cases that Mr Dhasmana
16 presented.
17 One of them related to the fact that one case had
18 been ascribed to Mr Wisheart but was in fact
19 Mr Dhasmana's. One related to the fact that a case was
20 actually in the wrong age bracket. I cannot remember
21 what the third error was, but they were relatively minor
22 errors. You probably have a list.
23 Q. If we look at UBHT 61/190, that is your covering letter,
24 is it?
25 A. That is right. That is listing the errors. One was
0165
1 wrongly classified for surgery, two were in the wrong
2 age group.
3 Q. If we went back to GMC 16/72, again, simply to identify
4 it, is this the table that was then produced afterwards
5 and circulated under cover of the letter?
6 A. That is correct.
7 Q. After the meeting at Dr Joffe's house, what did you feel
8 about the availability of data at that stage?
9 A. As I felt all along, there was no data and we were
10 expected to make these decisions on the basis of no
11 data. I found it intensely frustrating.
12 Q. Did you go off to collect further data at that stage, or
13 did it take something else to trigger it?
14 A. No, I did not collect this data until the morning before
15 or the afternoon before Joshua Loveday's case.
16 Q. So you were alerted to that when Dr Bolsin told you it
17 had been listed; is that correct?
18 A. Well, one of my colleagues. I do not remember who it
19 was precisely.
20 Q. What was your understanding about the status of the
21 switch programme at that time. Was it a surprise to you
22 that that operation had been listed?
23 A. Yes, it was a surprise. As I said, no cases had
24 happened in the last 6 months. I presumed there were
25 going to be no more, until we had this proper
0166
1 discussion, and as we had not had a proper discussion in
2 an open format --
3 Q. But you had had the meeting at Dr Joffe's house?
4 A. Yes.
5 Q. Why was that not good enough?
6 A. It was not good enough, without evidence you can say
7 whatever you like; people will believe you.
8 Q. Did anyone protest at the end of that meeting, "We need
9 a further discussion, we have not had a proper review
10 yet"?
11 A. I cannot remember. I do not think so.
12 Q. Did you protest?
13 A. No.
14 Q. So coming back, then, to the Joshua Loveday case,
15 a meeting took place to discuss whether or not the
16 operation should take place. When did you learn about
17 the meeting taking place?
18 A. Probably that day, or maybe the evening before that.
19 Certainly within a very short period of time.
20 Q. What was your feeling about the adequacy of having
21 a meeting like that the night before the operation was
22 scheduled to take place?
23 A. It is not ideal, but it is better having it before the
24 operation than after the operation.
25 Q. Did you know anything about the clinical urgency of the
0167
1 case before the meeting took place?
2 A. No, I had never seen the child.
3 Q. If we look at UBHT 54/13, these are minutes prepared by
4 Dr Martin about the meeting. He sets out in the third
5 substantial paragraph there a discussion about overall
6 mortality rates and if we scroll down, please, we can
7 see that the conclusion is minuted: reviewing the
8 figures it was clear that mortality at the start of the
9 programme had been high, that it improved significantly,
10 and comparisons are set out. It is said that "It was
11 felt our more recent results were similar to that of
12 published data and therefore acceptable."
13 Was that a discussion you can remember taking
14 place?
15 A. Yes.
16 Q. Is that a conclusion that at the time you were a party
17 to?
18 A. Yes, assuming that you are just looking at non-neonatal
19 switches. As I said before, if you are looking at
20 switches as a whole, I would have thought that the
21 Bristol series was unacceptably high.
22 Q. But at the time, was that a conclusion or a point that
23 you were making?
24 A. No.
25 Q. So is it fair to say that at the meeting, there was no
0168
1 dissent from the proposition that you could take
2 non-neonates and neonates separately and consider the
3 results for each on a different basis?
4 A. Yes, no dissent.
5 Q. Can you remember whether you were part of the decision
6 that the non-neonatal switch procedure should therefore
7 continue?
8 A. As you know, I had to leave this meeting before it
9 finished. I remember presenting my data, comparing it
10 with Janardan's, and coming to a consensus as to what
11 the real data was. I remember also being party to
12 a consensus that although Janardan's data was not
13 brilliant, it could potentially be within the range
14 expected from looking at the UK Registry data.
15 I remember saying that "Therefore, looking at this
16 data, you probably could justify proceeding", but I said
17 that I thought it would be foolish to proceed because if
18 there was an adverse outcome, it could have been very
19 bad on all concerned, and Bristol.
20 Q. So that was, as it were, from a publicity point of view,
21 or what?
22 A. Publicity, but also interpersonal relationships with
23 Professor Angelini saying, you know, "We should not be
24 doing it and Janardan doing it", and then having
25 a problem, you know, it would have caused a lot of
0169
1 problems, as it did.
2 Q. Can you remember a formal vote being taken on this
3 matter, or --
4 A. No, there was never a vote, because the next thing that
5 happened was that Rob Martin, the cardiologist, stated
6 that the child's clinical condition had deteriorated
7 such that he was too sick to wait for the new surgeon to
8 arrive and, indeed, was too sick to be transferred to
9 another hospital. Therefore, in my mind, that meant
10 that we had to do the case in Bristol because we could
11 not halt it from Janardan's previous figures, and the
12 child would suffer if he did not have an operation soon
13 enough because he was deteriorating rapidly.
14 Q. Can you remember explicit discussion or statement from
15 Rob Martin about transfer to another centre?
16 A. Yes. Then, after that, I realised that the decision was
17 almost certainly going to be made that the case was
18 going to go ahead, because I did not think they could
19 decide anything else, knowing the clinical condition of
20 the child. There was nobody else there who knew the
21 clinical condition of the child to dispute him on that
22 point. Therefore, as I had said my piece, given my
23 evidence, I did not have anything more to offer and
24 I left the meeting, going to a prior engagement.
25 Q. If we go to UBHT 54/11, this is Dr Monk's note of the
0170
1 same meeting. If we scroll down to paragraph 2, you can
2 see there a slightly different account in that he says
3 in the last sentence:
4 "These figures did not support the withdrawal or
5 stopping of the present non-neonatal programme. The
6 question was asked distinctly by Dr Monk, and all
7 members with the exception of SP, [which must be you]
8 absent, agreed that the programme should continue."
9 That note implies you were not in fact there
10 during almost a formal vote on the continuation of the
11 programme?
12 A. They may well have gone back over the same issue
13 towards the end of the meeting, so they definitely had
14 a consensus, but I remember I was there at the
15 discussion when we were talking about whether there was
16 evidence or not to stop the programme and people thought
17 there probably was not. At least, a couple of us said
18 that. Maybe not everybody. They may have gone back
19 over that issue after I had left and got a proper vote.
20 Q. Perhaps it is obvious, but we can see that the minute
21 records that the results in Bristol were not in line
22 with the best reports from centres such as, in England,
23 Great Ormond Street or Birmingham, so what was the
24 factor that stopped the child being referred to centres
25 such as that?
0171
1 A. At that time? My recollection is that it was the
2 child's deteriorating clinical condition, such that he
3 could not tolerate any further delay in his surgery, and
4 transferring would involve delay.
5 Q. And that assessment came from whom?
6 A. Dr Martin.
7 Q. So what was the impression of urgency for surgery given
8 to the meeting?
9 A. That was his cardiological assessment. I did not
10 question it.
11 Q. But did that add up to a child that could not be moved
12 or had to have an operation tomorrow, or within the next
13 week, or what?
14 A. I cannot answer that.
15 Q. If we go on to paragraph 3 of this note, we get on to
16 the discussion of the political position of the Trust
17 and the fact that Dr Bolsin had contacted the Department
18 of Health.
19 Were you there for that part of the discussion?
20 A. I knew that he had, but I was not there at an open
21 discussion when they were talking about the Department
22 of Health. To be honest, I do not think I really
23 appreciated the implications of the Department of Health
24 being involved.
25 Q. How did you know they had been contacted?
0172
1 A. I think either Chris Monk or Steve Bolsin might have
2 mentioned it to me before the meeting.
3 Q. But at the time, how did that strike you?
4 A. As I said, I did not really understand the implications,
5 so it was just another issue that I did not understand.
6 Q. You have told us about the cardiological assessment
7 presented to the meeting by Dr Martin. Did anything
8 cause you later to subsequently doubt the accuracy of
9 that assessment?
10 A. Only that it is unusual for children at that sort of
11 age to deteriorate very rapidly. The child had been put
12 on the monthly operating list so it must have been
13 listed at least a week or so before that time. But I do
14 not have any other evidence.
15 Q. Did Dr Martin explain to the meeting how he had formed
16 his assessment of Joshua's condition?
17 A. No, I was not there if he did.
18 Q. Or when he assessed Joshua?
19 A. I assume he would have virtually come from Joshua's
20 bedside, but I was not aware of that.
21 Q. Did he suggest he might have done so in any shape or
22 form?
23 A. No.
24 Q. So that is pure supposition on your part?
25 A. Pure supposition.
0173
1 Q. You left the meeting halfway through. It was because of
2 a personal commitment. Why did you think you had
3 nothing more to contribute to the meeting at that
4 stage?
5 A. Because I thought that I had presented the data -- at
6 least we had some data to go on, whereas at least every
7 other meeting where I had to make decisions we did not
8 have the data, so I had discharged my responsibilities
9 there. I thought I had explained my view that there was
10 not enough evidence in the figures to say that we should
11 stop the programme outright. I thought I had explained
12 my view that I did not think it would be sensible for
13 the operation to go ahead in Bristol, and I had listened
14 to the evidence of the cardiologists saying that the
15 child's condition was such that he could not wait. That
16 was the decider to me. If the child could not wait and
17 there was no hard evidence to suggest that we should
18 have stopped the procedure then it was going to go
19 ahead, so I left thinking that it was going to go ahead
20 whatever.
21 Q. Dr Pryn, I have asked a number of questions over the
22 afternoon. Is there anything else that you want to add?
23 A. No, I cannot think of anything at the moment.
24 Q. It may be that the Panel has some questions for you.
25 THE CHAIRMAN: Mrs Howard?
0174
1 Examined by THE PANEL:
2 MRS HOWARD: Dr Pryn, I have two questions. Can I take you
3 back to quite early in your evidence today? Firstly you
4 talked about risk of anaesthesia when discussing with
5 parents the whole picture of the operation. Am I clear,
6 first of all, that you stated that you assumed that the
7 risk of anaesthesia had been incorporated in any
8 discussion that may have taken place by surgeons with
9 parents?
10 A. I assumed that when parents are told about the risk of
11 the procedure, that risk incorporates all the risks:
12 anaesthesia, surgery, intensive care.
13 Q. Is that integration of risk a normal assumption for you,
14 or do I separate the risk in any other situation, and
15 therefore discuss with parents risk of anaesthesia as
16 a separate issue?
17 A. I think it is normal to group them together. I think
18 the one time you would not group it would be, say, for
19 a cardiac catheter study, where the risk of the
20 procedure is relatively small, the main risk is that of
21 anaesthesia, but for a complex surgical operation, the
22 main risk will be surgery.
23 Q. And that remains your practice today?
24 A. I do not anaesthetise children.
25 Q. The second question was when you talked with Miss Grey
0175
1 about the speed of induction for anaesthesia in the
2 anaesthetic room and the availability of experienced ODA
3 or nursing staff. Can I have some clarity? You talked
4 about it potentially being a safety issue. Is there an
5 issue of the length of time it could take to induce
6 anaesthesia in a small child if you have inexperienced
7 staff, and therefore, an effect on the whole way in
8 which the operation might go?
9 A. I think if there is a prolonged stage in the anaesthetic
10 room, there are minor physiological changes which can
11 occur. For instance, the child can cool down. But I do
12 not think it makes a major difference to the progress of
13 surgery.
14 Q. Just to take you a little further, you did use the word
15 "potentially a safety issue". Could you give me some
16 indication of what that potential is?
17 A. What I meant to say was that if we had problems, let us
18 say, securing the airway, then I would need to get extra
19 equipment and do other procedures and if my assistant
20 was not thinking several steps ahead, each time I asked
21 for something they would then go and have to find it
22 rather than have it ready for me. So it is potentially
23 a safety issue, because they would not be prepared for
24 emergency procedures.
25 MRS HOWARD: Thank you.
0176
1 THE CHAIRMAN: There are no more questions from the Panel,
2 Miss Grey, but you may wish to take the view of our
3 expert before I ask Miss Freedman whether she would wish
4 to re-examine.
5 MISS GREY: If Dr Pryn would bear with me for a moment,
6 I would like to invite Dr Scallon firstly to comment on
7 the practice of quoting risks that Dr Pryn has just
8 discussed, whether or not the anaesthetic risk is
9 properly subsumed in the discussion that a surgeon will
10 have about the operative risks as a whole; what the
11 practice of anaesthetists is in that regard.
12 DR SCALLON: It is not normally the practice for an
13 anaesthetist to give a specific risk figure for
14 paediatric heart surgery. The surgeon will quote
15 a figure and, as he said, that covers the whole
16 procedure which anaesthesia is upon.
17 MISS GREY: Because the relative risk associated with
18 anaesthesia is very small?
19 DR SCALLON: That is true, but like so many things, this is
20 evolving and it is becoming increasingly obvious that
21 the details of the anaesthetic and the risk will
22 probably have to be explained to parents and patients in
23 far more detail in the future. It is not inconceivable
24 that at some future date there may be a separate
25 anaesthetic consent form as distinct from the surgical
0177
1 consent form. We are not yet at that point.
2 MISS GREY: Can I ask you to comment more generally upon the
3 evidence of Dr Pryn and in particular whether there are
4 things which you think either reinforce or cast new
5 light on the clinical case review exercise, or small and
6 subtle indicators which may be important for the Panel
7 to reflect upon, from his evidence?
8 DR SCALLON: I think Dr Pryn has covered very fairly many of
9 the issues that a paediatric cardiac anaesthetist has to
10 face during the course of his daily work. There is no
11 doubt that paediatric cardiac surgery, anaesthesia and
12 intensive care is a very complex issue, and as you have
13 implied, the success or failure depends upon a large
14 number of factors, some of which are subtle, some of
15 which are more obvious. These factors are operative in
16 the pre-operative period, the intra-operative period and
17 indeed in the post-operative period.
18 Dr Pryn has implied that one of the most dramatic
19 things he noted was when there was a change in surgeons,
20 and this I think makes the point that the
21 intra-operative period is far more important than the
22 other periods in the care of a patient, and the success
23 or failure does depend to a large extent on events
24 within the operating theatre.
25 Moving on to the clinical review, I think many of
0178
1 the points which came up in the findings of the reviews
2 were stated in Dr Pryn's statement. I was thinking of
3 the delay in the period between diagnosis and actual
4 surgical procedure being carried out; the interoperative
5 issues of the extended period of time, cross-clamp time,
6 theatre time, that came out quite clearly in both the
7 clinical review and in Dr Pryn's statement; and general
8 post-operative issues also were highlighted, I think, in
9 both.
10 Those are the main points I wish to make, but one
11 other point which has come out very clearly is the
12 difficulty of assembling data. We have had several
13 collections of data apparently from the same clinical
14 set, but with different results. It is extremely
15 difficult to extract reliable and accurate data in this
16 area.
17 Q. Thank you. May I ask you one question which is this:
18 Dr Pryn gave some evidence of the operation, the process
19 of an operation, and the speed or sureness of a surgeon
20 in the operating theatre.
21 How important do you think that is from an
22 anaesthetic perspective in contributing to a good
23 outcome?
24 A. I think to some extent I have answered that question
25 already, in that I said interoperative events, what goes
0179
1 on in the operating theatre is of prime importance. The
2 point is made. You are absolutely right, it does,
3 I think, make a difference.
4 MISS GREY: Thank you. Does the Panel have anything arising
5 out of that?
6 THE CHAIRMAN: No, thank you. Miss Freedman?
7 MISS FREEDMAN: No, thank you.
8 THE CHAIRMAN: I am grateful to you. Therefore, Dr Pryn,
9 thank you very much for coming and spending today with
10 us. We have been greatly helped by your evidence.
11 There may be the occasional matter which occurs to you
12 that you may wish to tell us about further, as something
13 that you recall or wish us to know and if that is the
14 case, please do let us know.
15 If there is not, thank you very much for today; we
16 are greatly in your debt.
17 DR PRYN: Thank you very much.
18 MISS GREY: Sir, tomorrow we start at 9.30 with the evidence
19 of Dr Monk.
20 THE CHAIRMAN: Thank you very much indeed. So it is good
21 afternoon to everyone; good afternoon to you, Miss Grey.
22 (5.00 pm)
23 (Adjourned until 9.30 am on Tuesday, 9th November 1999)
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7 DR STEPHEN PRYN (sworn) ............................ 2
8 Examined by MISS GREY ......................... 2
9 Examined by THE PANEL ......................... 175
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001