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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