Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts     Hearing summary 9th 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 Christopher Monk, former Clinical Director, Directorate of Anaesthesia, BRI. He answered questions about the reaction of clinicians working at the BRI to the public identification of problems within the paediatric cardiac service at the hospital, the recommendations of the subsequent external inquiry by Stuart Hunter and Marc de Leval and his own response to the consequences for his Directorate. He commented on the issue of ‘whistleblowing’ and highlighted the action he took to manage Dr Steven Bolsin’s timetable to maintain a working relationship between Dr Bolsin, Consultant Anaesthetist, and the cardiac surgeons. Dr Monk looked back on when the issue of concerns about the outcomes for paediatric cardiac surgery first came to light in Bristol in the early 1990s and described meetings held, and audits, including those undertaken by Drs Bolsin and Black and Dr Pryn, to investigate mortality rates. He stated that the aim of these meetings and audits was to look for ways to improve the service. He described meetings with the Chief Executive of the Trust at which he expressed concerns on behalf of the anaesthetists and also discussed an evening meeting he organised attended by Dr Bolsin, Professor Gianni Angellini, Mr James Wisheart and himself at which he attempted to initiate debate between Dr Bolsin and Mr Wisheart about the findings of Dr Bolsin’s audit data. He concluded by commenting on the discussions held between clinicians and actions he took prior to the unsuccessful operation performed on Joshua Loveday by Mr Janardan Dhasmana.   Dr Duncan MacCrae, Consultant in Paediatric Intensive Care, Great Ormond Street Hospital and Dr. Ted Sumner, Consultant Anaesthetist, Great Ormond Street Hospital attended today’s hearing as members of the Inquiry’s Expert Group.

FULL TRANSCRIPT

   1               Day 73, Tuesday, 9th November 1999
   2   (10.00 am)
   3   THE CHAIRMAN:  Good morning, everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF:  Good morning, sir. Sir, the advertised time
   6     has now been exceeded by some forty minutes, and not
   7     only the Panel -- we all know the circumstances -- but
   8     the wider public are entitled to a public explanation.
   9        The reason is that Dr Monk's statement -- Dr Monk
  10     is our witness for today -- came in late in the day,
  11     that is his second statement, he having made a statement
  12     some time ago which is his first statement. As a result
  13     of the unfortunately late time of the examination of the
  14     statement, a number of participants in the Inquiry who
  15     would otherwise have wished to comment in some detail,
  16     and indeed to pass questions to me to ask, have not had
  17     their usual opportunity to do so.
  18        Indeed, this morning some time just after
  19     9 o'clock a statement from Mr Wisheart of several pages
  20     in length dealing with matters referred to in Dr Monk's
  21     statement was received and, of course, fairness demanded
  22     that Dr Monk had sight of that and an opportunity to
  23     discuss it before we began, just as indeed we in the
  24     Inquiry counsel team needed to have a look at it and
  25     pass it on to other participants.

   1        Can I, despite the difficulties, pay tribute to
   2     those behind me and others, who have been able, despite,
   3     as I say, difficulties, to pass me at least a number of
   4     questions and information which may be useful to the
   5     Inquiry in the examination of Dr Monk, even although
   6     I suspect that in a number of cases it may not be as
   7     full or complete as it would otherwise have been had
   8     there been a greater time.
   9        So I am sorry that that is the position as far as
  10     they are concerned. I am sorry for myself that that is
  11     the position, and I am sorry for Dr Monk that the
  12     inevitable consequence is a delay in the start of his
  13     evidence.
  14   THE CHAIRMAN:  Thank you, Mr Langstaff. It is fair to
  15     remind everyone, of course, that the opportunity does
  16     exist, has always existed and will always exist to put
  17     in further written comments, and they are as important a
  18     part of the evidence as anything else which is read,
  19     seen or heard within this chamber or elsewhere. So that
  20     opportunity exists, and if people want to take advantage
  21     of it the Panel will be assisted by it.
  22   MR LANGSTAFF:  Sir, I wonder if Dr Monk would now come
  23     forward. At the same time as he is sworn I shall invite
  24     our two experts to be sworn. This is no stranger,
  25     Dr Macrae, but Dr Sumner, I think it is his first time

   1     formally with the Inquiry, although he has taken part in
   2     the expert review panels.
   3            DR CHRIS MONK (affirmed)
   4            DR DUNCAN MACRAE (sworn)
   5            DR EDWARD SUMNER (sworn)
   6            Examination by MR LANGSTAFF
   7   MR LANGSTAFF:  Dr Sumner, you have not yet formally given
   8     evidence to this Inquiry. You have, I think, taken part
   9     in our expert review panels. Perhaps you would like to
  10     introduce yourself to the audience and the wider public.
  11   DR SUMNER: Thank you. Good morning. Thank you for
  12     inviting me to be here. I am Edward Sumner, Ted
  13     Sumner. I am Consultant Paediatric Anaesthetist at the
  14     Children's Hospital at Great Ormond Street. I am aged
  15     59, and I have been there since 1973 as a Consultant.
  16        Over the years my main interest has been
  17     Paediatric Cardiac Anaesthesia and Intensive Care.
  18     For some years I was Director of the Cardiac Intensive
  19     Care Unit and indeed the whole Intensive Care Unit at
  20     Great Ormond Street. I have written chapters and books
  21     on the subject. I am presently the editor of a
  22     successful little journal published by Blackwell Science
  23     called "Paediatric Anaesthesia".
  24   THE CHAIRMAN:  Thank you.
  25   MR LANGSTAFF:  Dr Monk, your full name, please?

   1   A. My full name is Christopher Richard Monk.
   2   Q. So when we see the initials "CRM", that is you, although
   3     I think we see in one of the documents we shall be
   4     looking at "CJM", which is probably you?
   5   A. That is correct.
   6   Q. We have two statements from you. Can we have the first,
   7     please, up on the screen? It is WIT 105/1. Is that the
   8     first page of your first statement to us?
   9   A. That is correct.
  10   Q. Can we go, please, to page 17?
  11   A. Yes, that is --
  12   Q. That is your signature?
  13   A. Yes.
  14   Q. And the second statement begins on page 19, does it?
  15     Do we see that finishes at page 48?
  16   A. That is correct.
  17   Q. We do not have a date or a signature for that scanned
  18     in, but do you adopt that statement together with your
  19     first statement as your evidence to this Inquiry?
  20   A. I do, yes.
  21   Q. And apart perhaps from the odd typographical error, are
  22     the contents true and accurate?
  23   A. As far as I can recall, that is correct.
  24   Q. You say 'as far as you can recall'. If we are looking
  25     at dates, for instance?

   1   A. As we discussed last night, some dates I cannot be
   2     completely clear as to their accuracy and I think one in
   3     particular would be the meeting on level 7 of the
   4     cardiologists, surgeons and anaesthetists, where my date
   5     may not be correct.
   6   Q. Where do you get your dates from?
   7   A. In the main they are from recollection, from having
   8     written down a retrospective diary of the events and
   9     also from my personal diaries.
  10   Q. So you still have your personal diaries?
  11   A. I have my personal diaries, yes.
  12   Q. We may come to various events, when I shall ask you
  13     about the particular dates, and we may deal with any
  14     problems over accuracy at that stage.
  15        There were, I think, diaries in the Department of
  16     Anaesthesia which might have recorded venues and dates.
  17     What happens to them?
  18   A. Those diaries were filled out by my personal assistant
  19     to help me in my duties as Clinical Director.
  20     Unfortunately, they were thrown away at the end of my
  21     period as Clinical Director.
  22   Q. You were Clinical Director from 1993 to 1996?
  23   A. Not -- I finished December 31st, 1995.
  24   Q. Yes, until 1996?
  25   A. Yes.

   1   Q. So that means that you were Clinical Director during
   2     1995, when the Bristol Cardiac Unit came under a certain
   3     amount of press scrutiny?
   4   A. Indeed.
   5   Q. And it might perhaps have been thought important to
   6     retain material which allowed you to place accurately
   7     events and dates during that year?
   8   A. I fully agree.
   9   Q. So why was that not done?
  10   A. The office that I occupied for the three years then was
  11     given to the next Clinical Director. As far as I was
  12     concerned, the diaries were in a safe place, but as the
  13     new broom came in, the diaries disappeared.
  14   Q. So there were three years' worth of diaries there, were
  15     there, at that stage?
  16   A. Yes.
  17   Q. Can you help me then if we can go to page 19: if there
  18     were three years' of dairies sitting in your office when
  19     the new broom came in and swept clean, why do you say in
  20     the last sentence of the "Background" that the diaries
  21     were destroyed annually in the normal course?
  22   A. In my statement I have put "annually". That may not be
  23     correct. I cannot state categorically when my secretary
  24     destroyed the diaries. I have not asked her apart from,
  25     you know: "Did you throw them away?" Answer: "Yes".

   1   Q. You say as part of the normal course when what you have
   2     been explaining to us was something that was not normal
   3     course?
   4   A. Well, the data that was kept was rotas, was the leave
   5     diaries, were the details of meetings and minutes and
   6     letters that came in and out of the Trust. I did not
   7     have access to Brian Williams' diaries, which I presume
   8     he kept, and, therefore --
   9   Q. Forgive me for cutting you short. What I am actually
  10     asking you about is why it is that your recollection to
  11     us in your first few questions and answers appears to
  12     differ from the way you put it at page 19 at the start
  13     of your second witness statement. What you have told us
  14     is, you had three years' worth of diaries. The new
  15     broom came in as the direct offer of anaesthesia, swept
  16     clean and the diaries were disposed of. Here you say
  17     annually. That, you say, is probably a mistake. You go
  18     on "as part of the normal course". What you have
  19     described to us, it was not part of the normal course,
  20     it was the effect of a changeover?
  21   A. Part of the normal course each year was that a lot of
  22     the documentation and papers that would have been
  23     acquired over the years was examined and then some of it
  24     was thrown away as it was seen to have been sorted and
  25     settled. The amount of paperwork that you gather in the

   1     department is immense and yet the facilities are quite
   2     small. Therefore, you go through your files and throw
   3     away the things which are no longer active.
   4   Q. So what you are saying is as it happens a lot of
   5     material is destroyed annually, even though it might be
   6     wrong to say your diaries were part of that process.
   7     That is why you said what you said?
   8   A. That is correct.
   9   Q. Can we begin the questions which I would like you to
  10     answer by focusing not so much on the beginning of the
  11     picture as the end? At page 32 of your statement,
  12     paragraph 40, you say in the third sentence of that
  13     paragraph that in your opinion:
  14        "... at the time", and that appears to be 24th
  15     June 1995, "the attitude of the Trust remained
  16     internally focused, characterised by a failure to audit
  17     the Paediatric Surgical Outcomes, discuss formally the
  18     problem and deny the advice of Peter Doyle".
  19        Can I just be sure that we are talking about 24th
  20     June 1995 in this paragraph?
  21   A. The two paragraphs written there come from a document
  22     that I wrote to myself as an aide-memoire following the
  23     conversation with Peter Doyle. On that document the
  24     date is there and that is my recollection. As far as I
  25     am concerned, that is the correct date.

   1   Q. It is not so much the date of the phone call that I am
   2     focusing on, it is the date that you are ascribing to
   3     the words "at that time" in the fourth line?
   4   A. At that time my impression was that we had not audited
   5     the paediatric cardiac surgical outcomes and therefore
   6     it would be in June 1995, yes.
   7   Q. The attitude of the Trust: the Trust is impersonal, but
   8     the attitude has to be held by a number of people. Who
   9     did you have in mind?
  10   A. The attitude of the person would be Dr Roylance, as the
  11     Chief Executive of the Trust; to some degree
  12     Mr Wisheart; and they would be my main contacts.
  13   Q. So for the Trust here we should read, as it were, John
  14     Roylance and James Wisheart?
  15   A. In addition, it encompasses the whole, as it were, of
  16     the consultant body, because the question of how good
  17     our cardiac service was was raised at the Hospital
  18     Medical Committee. It was discussed obliquely in that
  19     area, and the Trust as a whole supported the cardiac
  20     surgeons, as is minuted in their own documentation.
  21     Therefore, because of that, my feeling was that it was
  22     still very internally focused as an organisation.
  23   Q. What would the alternative have been?
  24   A. An alternative would have been that we had had either an
  25     internal or external examination of the performance of

   1     the unit, being able to compare it to a standard, if
   2     there was one, and then to come to a constructive way
   3     forward.
   4   Q. By June of 1995 the Trust had had, had it not, the
   5     Hunter/de Leval Report?
   6   A. That is true.
   7   Q. That can hardly be called internal?
   8   A. No. That was an external Inquiry, but in itself it was
   9     quite quick in coming to its conclusions. The process
  10     was quite rapid, and perhaps, therefore, it did not
  11     achieve all that it could have achieved had it been a
  12     more considered process.
  13   Q. Well, there are two issues there. One is speed. I do
  14     not know if I dare ask this question in the present
  15     forum, but you are not saying, are you, that length of
  16     time necessarily means a better and more considered
  17     result?
  18   A. No. I think it depends upon the resources that you
  19     have, the time that is spent on the task and the
  20     accuracy of the data that is acquired.
  21   Q. Consideration is very much a subjective view. You are
  22     nodding. I have to say that for the sake of the
  23     transcript.
  24   A. Yes.
  25   Q. So you, do I take it, did not feel comfortable with the

   1     conclusions of the Hunter/de Leval Report?
   2   A. I actually think the conclusions of the report were very
   3     correct and they made a number of suggestions of how the
   4     service could change, but to my knowledge, and I may be
   5     unaware of conversations that went on, the follow-up
   6     that might have been helpful would have been for their
   7     input in getting those changes adopted, and they were
   8     not necessarily adopted at the speed that could be best
   9     accepted.
  10   Q. You say that there was a failure to discuss formally the
  11     problem. What more would you have wished the Trust to
  12     do other than, having had an external audit, albeit
  13     quick, and albeit in your view not fully considered,
  14     though it may have reached the right results, results
  15     you agreed with -- what more should they have done?
  16   A. The difficulties between colleagues still remained. The
  17     questions as to whether the figures were correct or not
  18     still remained. There was still no comparative standard
  19     against which we could compare ourselves and decide what
  20     the most appropriate way forward was. I felt that for
  21     the unit and the hospital to achieve its best
  22     performance, those issues needed to be addressed.
  23   Q. What formal discussion were you then looking for, a
  24     discussion with a view to what?
  25   A. It would have been a discussion of the involved parties,

   1     the cardiac anaesthetists, the cardiac surgeons, the
   2     cardiologists, and obviously with senior managers, in
   3     order to get a balance to the discussions.
   4   Q. What was unbalanced about the discussions in June 1995?
   5   A. I do not quite understand which discussions you are
   6     referring to.
   7   Q. Well, you say in order to get a balance to the
   8     discussions. So I am asking if you need to get a
   9     balance to the discussions. You are suggesting there
  10     was something unbalanced about the process that was
  11     going on?
  12   A. The issues that I have just mentioned were not
  13     discussed, and, therefore, that produces an imbalance.
  14   Q. I see. So, following the Hunter/de Leval report, what
  15     you are saying here is that the Trust should have taken
  16     steps to discuss what happens next with cardiologists,
  17     surgeons, anaesthetists and for that matter I suppose
  18     other clinicians that might be involved?
  19   A. Yes.
  20   Q. Would that be essentially a job for the Director of
  21     cardiac services together with the Director of
  22     anaesthesia?
  23   A. At that stage we are late in the process of what you are
  24     examining here. There were a number of tensions between
  25     the parties and, therefore, I would not think that those

   1     people would be able to produce that discussion.
   2   Q. Because they could not discuss things civilly or what?
   3   A. No, because the issues were very large. They had a
   4     history of two years or more behind them. Therefore, it
   5     would be difficult to get those people at that stage,
   6     with all the press interest and the background, to
   7     produce that meeting.
   8   Q. If a meeting had been called, let us suppose, in order
   9     to discuss the way forward, however one might put it, in
  10     an anodyne fashion, do you think that the clinicians in
  11     the cardiac services directorate would have come to it?
  12   A. I think that people had always wanted to develop the
  13     service and to improve it and make it better. If that
  14     was seen as a way forward, then yes, I think they would
  15     have come to the meeting.
  16   Q. It follows from that answer, does it, if they had come,
  17     they would have participated?
  18   A. I would hope so, yes.
  19   Q. Would the anaesthetists have been prepared to go to such
  20     a meeting?
  21   A. I can see no reason why anaesthetists would not wish to
  22     go to that meeting.
  23   Q. And participate?
  24   A. Yes.
  25   Q. Again, looking at this hypothetical position in June

   1     1995, what, as you see it, were the difficulties between
   2     individuals or between groups of individuals that would
   3     have made the way forward, or establishing a way
   4     forward, problematic?
   5   A. I think it is the history of the period of time you are
   6     looking at, from the start of the process of figures
   7     being produced and right the way through to the fact
   8     that we were now talking about the phone call that I
   9     made to Dr Doyle.
  10   Q. Why did you think it was necessary to phone Peter Doyle?
  11   A. I was in a meeting that had been called, I believe, in
  12     JR's office, and I formed the impression that there was
  13     some confusion over the advice that the Department of
  14     Health had given to the Trust. I was not a party to
  15     those conversations, be they telephonic or as a letter.
  16     Dr Doyle's name was in the conversation. I wished to
  17     speak to Dr Doyle to try to get some understanding of
  18     what his views were.
  19   Q. Does that mean that you did not Trust the version that
  20     you had been told at the meeting?
  21   A. I had no basis to either Trust or believe the version
  22     that was being discussed.
  23   Q. Let me put the question differently then. You were
  24     prepared to think that you may not have been told the
  25     truth at the meeting?

   1   A. I was prepared to think that the interpretation of
   2     whatever the conversations had been may not have
   3     understood what Dr Doyle's points were, and, therefore,
   4     the Trust may or may not have been acting
   5     appropriately. The only way I could get that
   6     information was to speak to Dr Doyle.
   7   Q. What was it, as you saw it, about the attitude or
   8     approach of those at the meeting, Dr Roylance and the
   9     senior managers, that made you think that there may be
  10     a misinterpretation of the Department of Health's view?
  11   A. The clarity of the discussion of how the paediatric
  12     cardiac service would progress. What operations could
  13     be done; what operations could not be done; were they
  14     complex neonatal, were they not complex neonatal was not
  15     clear. I could not enter the discussion, because I had
  16     not had any knowledge or vision of what had been said by
  17     Dr Doyle.
  18   Q. So there was a lack of clarity about the position of the
  19     Department of Health?
  20   A. Yes, and in conversations outside of that meeting,
  21     preceding it, I had had information from Dr Bolsin about
  22     what the Department of Health's stance was, and the two
  23     in my mind were not in balance.
  24   Q. So briefly what was Dr Bolsin saying the Department of
  25     Health's view was?

   1   A. My recollection is that he felt that the Department of
   2     Health had said that complex neonatal and all neonatal
   3     work should not go ahead at the Bristol Royal Infirmary
   4     from that point.
   5   Q. What did you think the view of the meeting, of Dr
   6     Roylance and the senior managers, was?
   7   A. There was some debate about what the advice from Dr
   8     Doyle actually meant, what surgery could go ahead and
   9     what surgery could not go ahead.
  10   Q. So Dr Bolsin's position was no neonatal paediatric
  11     cardiac surgery at all and the position of Dr Roylance
  12     and the others was some but not all surgery; is that
  13     right?
  14   A. That would be correct.
  15   Q. And the bit that was not to be done so far as
  16     Dr Roylance was concerned, which bit was that?
  17   A. You are now getting very specific about a conversation
  18     some way ago.
  19   Q. If you cannot remember, please say so.
  20   A. I believe it was to do with complex neonatal surgery,
  21     and the definition of complex is then difficult in
  22     itself.
  23   Q. So the issue was the definition of "complex"?
  24   A. Part of the issue, yes.
  25   Q. This was a matter of a few months after the operation

   1     which led to publicity and led to problems. Can I ask
   2     you what you meant in your first statement at page 11,
   3     under B12g? You are talking there about the attitude
   4     towards a whistle-blower. You say that Dr Bolsin's
   5     concerns were taken forward -- let me read the whole
   6     sentence, because it is appropriate:
   7        "With regard to Dr Bolsin, his views were listened
   8     to ..."
   9        Just stopping there, you are talking about
  10     yourself, the Department of Anaesthesia, or whom?
  11   A. I am speaking there as his colleague and Clinical
  12     Director.
  13   Q. You are saying there: "I listened to his views"?
  14   A. Yes, and so did others within the Directorate of
  15     Anaesthesia.
  16   Q. So it is from the perspective of the Directorate of
  17     Anaesthesia?
  18   A. It covers both.
  19   Q. "He was requested to clarify and present his data".
  20        That is again from the same perspective, is it?
  21   A. Yes. I asked him to clarify and present his data to his
  22     cardiac anaesthetic colleagues.
  23   Q. "His concerns were taken forward to more senior
  24     management"?
  25   A. Yes.

   1   Q. Again by you or by the directorate?
   2   A. By me.
   3   Q. "He was defended in his absence at meetings".
   4        By whom?
   5   A. I would have defended him.
   6   Q. You would have?
   7   A. I had and have defended him at meetings.
   8   Q. You are talking there about defending him when? Before
   9     or after January 1995?
  10   A. Throughout the whole process of the time after he
  11     produced his audit.
  12   Q. " ... attempts made to restrict the pressures placed
  13     upon him due to his actions".
  14        It is a very dense phrase and I want to unpick
  15     it. What pressures do you see as having been placed
  16     upon Dr Bolsin as a result of his actions?
  17   A. Dr Bolsin, as an anaesthetist, had produced an audit
  18     which criticised his fellow colleagues. That
  19     information and other information found its way outside
  20     of the cardiac surgical directorate. It found its way
  21     outside of the Trust and into the press. Members of the
  22     Trust, both clinical and management, would feel that
  23     that was possibly inappropriate and, therefore, he would
  24     come under criticism in a number of areas, and I would
  25     attempt to make the point that the message he was

   1     bringing forward did have some basis to it, and,
   2     therefore, you would defend that point of view.
   3   Q. So the pressures you are talking about are the pressure
   4     of criticism?
   5   A. Yes. He was criticised on a number -- the data was
   6     criticised as well on a number of points, and, therefore
   7     you have to try to get those figures understood in
   8     context.
   9   Q. Was the pressure any more than criticism?
  10   A. Could you clarify that for me, please?
  11   Q. Yes. It is your expression that I am trying to
  12     understand. You are talking about pressures here placed
  13     upon Dr Bolsin by others?
  14   A. Yes.
  15   Q. So far you have said there was criticism of him and of
  16     his work?
  17   A. Yes.
  18   Q. That, you are assuming or know, placed pressure upon
  19     him. That is a pressure. I am saying, was there any
  20     other form of pressure placed upon Dr Bolsin in
  21     consequence of what he did that you had in mind in using
  22     the word?
  23   A. There were a number of discussions where I was aware of
  24     the feelings towards Dr Bolsin's actions by senior
  25     members in the Trust and that it would make his position

   1     difficult to pursue his career. He had already
   2     discussed that with me himself, and he was aware of the
   3     difficult position that he was now in because of his
   4     actions. They are all pressures. In his absence,
   5     because I believe that there was substance to what he
   6     had produced, I would try to defend his position.
   7   Q. Were there then threats to his career?
   8   A. I did not receive a specific threat to his career, but
   9     I formed the impression, because of a number of
  10     circumstances between him providing paediatric cardiac
  11     anaesthesia and the paediatric cardiac surgeons working
  12     together, that that would cause legal difficulties, and
  13     that was a pressure.
  14   Q. Was there at any stage any question, as you recall it,
  15     of Dr Bolsin being suspended or sacked?
  16   A. To continue what I have just said, the legal difficulty
  17     was explained that Mr Wisheart and Mr Dhasmana had been
  18     advised it would be inappropriate for Dr Bolsin to
  19     provide anaesthesia. I do not know what the basis of
  20     that advice was. If the situation arose where Dr Bolsin
  21     was to provide anaesthesia for a paediatric operation
  22     and one of the surgeons was to perform the surgery, then
  23     there would be conflict. A possibility would be that
  24     either you could cancel the operation, and the child
  25     would not be treated, or you could try to change the

   1     surgeon, or you could try to change the anaesthetist.
   2     Change the anaesthetist would have been one of the
   3     options, and I gained that impression.
   4   Q. That was an answer to a question which was asking you
   5     about the possibility of suspension or dismissal.
   6     Changing the anaesthetist in the circumstances you
   7     describe may involve no more than having someone else on
   8     the rota do the job and the person on the rota do
   9     another job, or for that matter a change of the surgeon?
  10   A. That is correct, but in changing the anaesthetist in
  11     that situation you are suspending him from his work. At
  12     what point does it change from being a change of working
  13     practice to a suspension? I had an impression that the
  14     legal advice would mean that there would be a conflict,
  15     and, therefore, I took, in discussion with Dr Bolsin,
  16     Dr Masey and others -- I changed his rota to avoid that
  17     conflict, and therefore he was not suspended. If I had
  18     not done that and we had produced that conflict, I
  19     cannot say whether he would have been suspended by the
  20     Trust or not.
  21   Q. What do you think would have happened?
  22   A. I think a number of things could have happened, one of
  23     which would have been that Dr Bolsin may have been
  24     suspended, but that would be conjecture.
  25   Q. If that is a realistic possibility, which is how you are

   1     putting it forward, who do you think would have been
   2     concerned in the suspension? It would not have been
   3     you, as his Clinical Director, or would it?
   4   A. I have not thought of that question before. I think
   5     that in my role as Clinical Director I would not have
   6     had the authority to suspend a consultant colleague on
   7     those grounds. If I was aware of an alcohol problem or
   8     a drug abuse problem or some other problem, which
   9     I could clearly document, then I think I would suspend
  10     or stop a person from performing their duty, but this
  11     was not that sort of situation.
  12   Q. So who did you see as taking any action to suspend that
  13     might be necessary?
  14   A. That would have been the senior Trust management.
  15   Q. Anyone in particular?
  16   A. Well, we are now in the realms of conjecture.
  17   Q. We are, but we are also in the realms of perception,
  18     which is why I am asking you?
  19   A. The conflict would have been between the surgeons and Dr
  20     Bolsin and, therefore, that conflict would go to the
  21     highest levels of the Trust. That would be Dr Roylance
  22     and Mr Wisheart, as Medical Director.
  23   Q. What was it about Dr Roylance, on the one hand, and
  24     Mr Wisheart, on the other, that made you think from what
  25     you knew of their attitude that this was at least a

   1     possibility, even although I appreciate the question is
   2     hypothetical?
   3   A. At that time there was a lot of press activity. There
   4     was a great interest in the performance of the cardiac
   5     surgical unit, and, as we have already mentioned, there
   6     was conflict between the personalities. Therefore, if
   7     they had legal advice for the people not to work
   8     together, they would have to solve the problem. If I
   9     had not produced a solution, then they would have to
  10     find one. One option would be to not allow the
  11     anaesthetist to provide support in that situation.
  12   Q. You were in a position in the beginning of May of 1995
  13     when Mr Ash Pawade began his duties as paediatric
  14     surgeon?
  15   A. Yes.
  16   Q. Had it been a consequence of the events of January of
  17     1995 that Mr Wisheart withdrew himself from further
  18     operating upon paediatric cases?
  19   A. I am sorry. I do not quite understand the point.
  20   Q. So far as paediatric cases are concerned, there would be
  21     a new surgeon to work with?
  22   A. Yes.
  23   Q. A surgeon who came with none of the baggage of the past?
  24   A. Yes.
  25   Q. So there would have been nothing presumably to prevent

   1     Dr Bolsin anaesthetising for Mr Pawade?
   2   A. If the rotas had Dr Bolsin anaesthetising on the days
   3     that Mr Pawade was working, there would not have been an
   4     impediment, no.
   5   Q. The conflict between Dr Bolsin's figures and other views
   6     of the data involved paediatric cases, did it not?
   7   A. Yes.
   8   Q. Was there any conflict, so far as you were aware, in
   9     relation to adult cases?
  10   A. Very late in the process Dr Bolsin stated that he felt
  11     there was an increased risk in adult cardiac surgery and
  12     that that was with Mr Wisheart's figures. Therefore,
  13     there was the potential for a conflict to develop in
  14     that area.
  15   Q. You say at page 29 of your statement -- let us have it
  16     on the screen -- paragraph 29, that your impression of
  17     John Roylance's attitude was that the main difficulty
  18     was not with the performance of the paediatric cardiac
  19     services but that a member of the anaesthetic department
  20     had performed a clandestine audit, communicated outside
  21     of the Trust and had broken a professional
  22     relationship. You go on to describe how on many
  23     occasions following the press coverage in 1995 it was
  24     necessary for you to defend Dr Bolsin?
  25   A. Uh-huh.

   1   Q. You go on to describe how you were told, you recall, by
   2     Dr Roylance and Mr Wisheart in Dr Roylance's office that
   3     Mr Wisheart and Dr Dhasmana had received legal advice
   4     that they should not work with Mr Bolsin on planned
   5     paediatric cases?
   6   A. I stated that, yes.
   7   Q. There is no reference in that last sentence to any
   8     difficulty working between Mr Wisheart and Dr Bolsin on
   9     adult cases?
  10   A. The team work in a cardiac theatre is very important.
  11     There was considerable disharmony between Mr Wisheart
  12     and Dr Bolsin. In any case of any age that relationship
  13     would be strained, be that adult or paediatric. So I
  14     would have thought that both Dr Bolsin and Mr Wisheart
  15     would prefer not to work with each other.
  16   Q. That I appreciate, but the question which arises is the
  17     nature of the legal advice that you understood as being
  18     given. You describe it in paragraph 29 as restricted to
  19     paediatric cases. Those are not your exact words, but
  20     that is the impression you give. Is that right?
  21   A. Well, that is my impression, yes, but in the way in
  22     which the rotas work the anaesthetists try and plan
  23     maybe three months of clinical duties, and Dr Bolsin's
  24     work, which was of two days of cardiac a week, was pared
  25     down to any three possible days. Therefore, Dr Bolsin

   1     worked on Thursdays. You would not know, when that rota
   2     was produced, whether paediatric or adult cases were to
   3     be scheduled by the surgeons on those days. Therefore,
   4     if you were to avoid a paediatric conflict, it
   5     necessarily means that you need to avoid
   6     Dr Bolsin/Mr Wisheart on Thursdays. So the change of
   7     Dr Bolsin's working practice in moving him to Tuesdays
   8     meant that both adult and paediatric cases for
   9     Mr Wisheart were not a possible source of conflict.
  10   Q. Forgive me. After Mr Pawade came, did Mr Wisheart
  11     continue operating on paediatric cases?
  12   A. I believe he did, a number of cases, yes. Dr Bolsin did
  13     not provide the anaesthesia, as far as I am aware, but
  14     that is a recollection.
  15   Q. You describe there Dr Roylance's attitude. What you are
  16     suggesting is that rather than be concerned about the
  17     quality of the surgery, he was concerned about the
  18     behaviour of the anaesthetist in breaking the news to
  19     others. I have put it a different way, but is that
  20     right?
  21   A. In that meeting at that time the impression that JR gave
  22     me was that the way in which Dr Bolsin had brought his
  23     data out, the way in which it had been presented or not
  24     presented to people was a problem. In parallel at this
  25     time, as a Chief Executive, he had actioned the changes

   1     which produced the appointment of a new paediatric
   2     cardiac surgeon. We moved the paediatric cardiac
   3     service from the BRI to the Children's Hospital.
   4     Therefore, he would have played his role in that.
   5     Therefore, he must be aware of how to improve the
   6     service and what steps were required.
   7   Q. You said in that last answer that the impression that
   8     Dr Roylance gave you was the way in which Dr Bolsin had
   9     brought his data out, the way in which it had been
  10     presented or not presented to people, was a problem.
  11        Is that not exactly the problem you have just been
  12     describing, as creating, as you would see it, an
  13     inevitable difficulty in personal relationships between
  14     the surgeon who has to operate and the anaesthetist who
  15     has to provide anaesthetic cover?
  16   A. Yes. From the very beginning the questioning has
  17     considered: was there a strain between Dr Bolsin and
  18     Mr Wisheart and others? That strain was there, yes.
  19     That is part or was resultant from the process that the
  20     Inquiry is looking at.
  21   Q. So does your impression of Dr Roylance's way of putting
  22     the problem differ in any way from your own perception
  23     of the inter-personal problem that might have been
  24     created?
  25   A. There are so many facets and aspects to how the affair

   1     developed that it is almost impossible to answer that.
   2     There are nuances which would take all day to discuss.
   3   Q. Leave aside the nuances. Was his view broadly similar
   4     to yours or was your view broadly similar to his?
   5   A. I felt that the correct way forward, after Dr Bolsin
   6     gave me his audit, or his and Andy Black's audit, was
   7     that the data needed to be verified and clarified. It
   8     needed to be more easily understandable, and that as a
   9     first step cardiac anaesthetists should discuss it and
  10     come to a joint opinion on what it meant and what we
  11     should do about it. That did not happen, and was part
  12     of the problem that you are asking about. In that view
  13     I presume I would be in accordance with JR, because he
  14     felt the data should be more open.
  15   Q. So when you say here in paragraph 29 that your
  16     impression of JR's attitude was that the main difficulty
  17     was not with the performance but the behaviour of the
  18     anaesthetic department, you are describing his
  19     attitude. Are you criticising it?
  20   A. There was a need for a clear audit, professional audit,
  21     of the paediatric cardiac service that everybody could
  22     accept as being accurate and true and verified. That
  23     did not occur. Because that did not occur until the
  24     Inquiry has done it, that was a failure. I believe that
  25     that is a step that should have occurred, and it did

   1     not. Therefore, if JR felt the problem was the way in
   2     which the audit was performed and that it was not
   3     communicated effectively within the hospital, and that
   4     was the main problem, that would be incorrect. The main
   5     problem was that we needed to improve the paediatric
   6     cardiac service.
   7   Q. The need to improve the paediatric cardiac service, you
   8     had seen, and this is something which I think appears
   9     throughout your statement, that two essentials needed to
  10     happen. One was the appointment of a dedicated
  11     paediatric cardiac surgeon and the other was the
  12     unification of the services on one site?
  13   A. Yes.
  14   Q. Both of those, by the time to which paragraph 29
  15     relates, were happening, were they not?
  16   A. They were happening. Building was going on. People
  17     were being appointed. Changes were occurring the whole
  18     time, yes.
  19   Q. There had been a quick approach by outside experts to
  20     have a look at the figures for paediatric cardiac
  21     surgery. That had been done and reported to the Trust.
  22     What more are you suggesting that the Trust -- leave
  23     aside Dr Roylance -- could and should have done at this
  24     stage?
  25   A. The measures that the Trust had taken in doing what we

   1     have just described were an effective response to the
   2     problems that had been raised. What was left undone
   3     were the difficult problems of how you deal with
   4     inter-personal relationships, and I think it was
   5     important and still is important that those were
   6     addressed, and they were not.
   7   Q. Did Dr Roylance not go on record as saying that
   8     whistle-blowers should not be penalised or victimised in
   9     any way for being, but who knows?
  10   A. I have not seen that. I cannot quote.
  11   Q. If that is the case, as it has been said is the case,
  12     how does that correspond with his attitude expressed to
  13     you in your meetings?
  14   A. I think that the attitude that whistle-blowers should
  15     not be punished or disadvantaged is a very true one.
  16   Q. Yes. Was it Dr Roylance's?
  17   A. He stated that, and therefore, it must be. He can still
  18     feel upset at the way in which the affair had been
  19     handled and that would still be a valid criticism. It
  20     does not mean that it clashes with his previous
  21     statement.
  22   Q. You say further down this statement that -- about
  23     halfway down 29:
  24        "At another time after the press publicity Dr
  25     Roylance with Mr Wisheart raised the suggestion of

   1     dismissing Dr Bolsin".
   2        Was that in a meeting with you?
   3   A. Yes, it was.
   4   Q. How was it raised; can you remember?
   5   A. The meeting was an early morning meeting in JR's
   6     office. It was an ad hoc meeting and I believe it was
   7     in response to further press coverage. There were a
   8     number of possible ways forward that were discussed.
   9     One of them, to my recollection, would have considered
  10     whether the actions of Steve Bolsin were such that it
  11     was no longer acceptable for him to be working in the
  12     Trust.
  13   Q. What particular actions were being focused on in the
  14     course of that discussion?
  15   A. I think that by that stage there was a lot of press
  16     coverage, including TV coverage, and therefore it was
  17     obvious that Dr Bolsin had had direct contact with the
  18     press.
  19   Q. And the view that you are reporting was a view hostile
  20     to his having had direct contact with the press?
  21   A. As you pointed out, the Trust was working very hard to
  22     put in place the solutions that were required and the
  23     influence of the press and the interest was in itself
  24     harming that process. One of the worst things that
  25     could have happened would have been for Mr Pawade to

   1     decide that he was not going to come to Bristol because
   2     of the publicity and we would then have a service which
   3     would not be as it is today.
   4   Q. So this was before the arrival of Mr Pawade?
   5   A. That statement was not definite in time. It is trying
   6     to encapsulate feelings of what the press activity was
   7     doing to the process of trying to improve the paediatric
   8     cardiac service.
   9   Q. I think we may be at cross-purposes. I am trying to get
  10     a handle on when the meeting occurred. It was an early
  11     morning meeting. It must have been at about the time
  12     there was press coverage, because I think that inspired
  13     the reaction you are talking about?
  14   A. Yes.
  15   Q. Your recollection, given, it may be, without thinking
  16     deeply about it, was that the downside of the press
  17     coverage might be to deter Mr Pawade from coming. If
  18     that is right, this meeting was before he came.
  19   A. That meeting was an example of the concerns over what
  20     the press was doing to the process. It does not --
  21   Q. Just so I get it right, and forgive me for interrupting,
  22     what you are saying is in the course of the meeting
  23     there was, as it were, some review about the damage that
  24     press coverage might do or might have done. It could,
  25     for instance, have deterred Mr Pawade from coming and

   1     therefore it is a dangerous thing?
   2   A. It may already have arrived and I am just using the
   3     example of what the effect would be. It would defer
   4     nurses from applying for jobs. It would defer
   5     consultant anaesthetists from applying for jobs because
   6     it does not portray the Trust in a good light.
   7   Q. This fear of adverse publicity was expressed at the
   8     breakfast meeting, was it?
   9   A. To say it was discussed item by item would be not
  10     correct. It was a feeling that: "There is damage being
  11     done here. Why is this occurring? What can we do to
  12     stop it, so we can implement the changes that we want?"
  13     I am just trying to amplify the thoughts that were
  14     certainly in my head at that time.
  15   Q. Who was it that suggested that in order to get rid of
  16     the dangerous effects of adverse publicity Dr Bolsin
  17     might have to be dismissed?
  18   A. I cannot recall who that would be.
  19   Q. On what basis did you argue that it was inappropriate?
  20   A. I felt it was inappropriate, because Dr Bolsin had
  21     raised a question that over that time as a group of
  22     people we had not been effective in examining it, and
  23     therefore those tensions were still there. To shoot the
  24     messenger may not have been an appropriate response.
  25   Q. Did Dr Roylance accept that view?

   1   A. Dr Bolsin left of his volition to go to Australia. He
   2     was not sacked.
   3   Q. So was it your impression at the conclusion of the
   4     discussion that you had had raising this possibility
   5     that your arguments had convinced Dr Roylance?
   6   A. Yes, because those matters were discussed at a time of
   7     great tension, of great personal difficulties for many
   8     people, and I suspect that it may have been a brain
   9     storming of ideas of ways forward. Unfortunately when
  10     you are there as a Director of anaesthesia, the impact
  11     of those discussions is very different than if you are a
  12     senior manager looking at possibilities.
  13   Q. Can we have a look at WIT 105/53? These are the
  14     comments of Mr Wisheart. He deals here with the
  15     suggestion where he accepts that it is possible, though
  16     he does not remember it, that there may have been -- it
  17     may have been part of a theoretical list of options.
  18     That is very much the way you have just been putting it?
  19   A. If I may read this again. (Pause). Yes. I think the
  20     statement Mr Wisheart has made is quite appropriate, but
  21     I am sitting in the meeting as the Clinical Director of
  22     Anaesthesia. I am aware of the criticisms of Dr Bolsin
  23     and, therefore, what to them may be a theoretical option
  24     in my mind becomes a dangerous option for a member of
  25     the department.

   1   Q. The last sentence there:
   2        "It was never seriously considered in my
   3     presence ..."
   4        Is that right or wrong?
   5   A. He may not have seriously considered it as an option
   6     when we were talking about it, but my interpretation
   7     would be that it was a very serious option.
   8   Q. I understand it would have serious consequences if it
   9     had been adopted.
  10   A. Sorry. Serious consequences.
  11   Q. I think he is saying: "It was one of a theoretical list
  12     of possibilities. We never needed to go that far.
  13     It was not seriously considered". That was the flavour
  14     of it.
  15   A. Thank you for the correction. I would feel it was an
  16     action with serious consequences, so much so that
  17     I discussed the matter with Dr Bolsin.
  18   Q. So you mentioned to Dr Bolsin that one of the options
  19     under consideration was his sacking?
  20   A. The meeting at which that was discussed, or the
  21     possibility was discussed, was in Professor
  22     Prys-Roberts' office with Dr Trevor Thomas, myself and
  23     Dr Bolsin.
  24   Q. Am I right that you relayed to Dr Bolsin that one of the
  25     options that had been considered by others was his,

   1     Dr Bolsin's, sacking?
   2   A. I do not think the term "sacking" would be correct.
   3     I think the term "suspension" would have been more
   4     accurate, and the answer would be yes.
   5   Q. Mr Wisheart goes on here to say he totally supported the
   6     attempts at conciliation with Dr Bolsin which began in
   7     June and July of that year. Leave aside what had
   8     happened until June or July. Is that your impression of
   9     Mr Wisheart's reaction and behaviour from June and July
  10     of 1995?
  11   A. I believe I was not part of that process of conciliation
  12     between the doctors concerned. Mr Wisheart has always
  13     been able to see the greater picture of what needed to
  14     be done, and I am sure that he would have wanted to have
  15     a reconciliation with Dr Bolsin.
  16   Q. Throughout the years from 1990 to 1995 you had
  17     maintained regular contact with Mr Wisheart yourself?
  18   A. Yes, that is true.
  19   Q. You valued your relationship with Mr Wisheart, did you?
  20   A. I value all my relationships with my colleagues. It is
  21     an important way of working.
  22   Q. You had been prepared to suggest and, as it were, host a
  23     meeting of Bistro 21 at one stage in order to reconcile
  24     what you saw as opposing views?
  25   A. At that stage the Bolsin data, the audit, had not been

   1     presented to Mr Wisheart. There were concerns raised by
   2     Dr Bolsin and these had been discussed between many
   3     people.
   4   Q. The point I am driving at is, was it your view
   5     throughout the 1990s that Mr Wisheart was someone who
   6     was amenable to conciliation, someone who regularly took
   7     the bigger picture and would not necessarily hold it too
   8     strongly against someone that he was the object of their
   9     criticism?
  10   A. I think everyone finds personal criticism difficult to
  11     accept, particularly when you are a senior person, but
  12     we would not have got Mr Wisheart to the dining table
  13     with Dr Bolsin unless Mr Wisheart was willing to listen
  14     to the criticisms.
  15   Q. So it is your view that he was someone who was willing
  16     to listen to criticisms, even though they were personal?
  17   A. The function of that meal was to achieve that.
  18   Q. No, I am asking for your view of Mr Wisheart and the
  19     extent to which he would be prepared to listen to and
  20     accept eventually criticisms which were to an extent
  21     personal?
  22   A. I think Mr Wisheart was very proud of his performance.
  23     He was towards the end of his career. To criticise his
  24     performance would be very difficult for him to accept,
  25     but we did discuss on occasions the concerns over the

   1     paediatric service, and he accepted that, with the
   2     appointment of a new surgeon, he would give up
   3     paediatric practice. He had looked to appoint a
   4     paediatric professor of cardiac surgery, and, therefore,
   5     he obviously realised that the service would improve by
   6     bringing in new blood. So in a way he accepted the
   7     criticisms that the service was not as good as it may
   8     well have been.
   9   Q. My reason for taking you to that incident, which I am
  10     going to come back to later on today, is simply to ask
  11     whether the only matter which, as you saw it, knowing
  12     the personalities involved, might have prevented
  13     Mr Wisheart from working with Dr Bolsin as his
  14     anaesthetist was the nature of the legal advice that he
  15     had received, whatever it was, or whether it was a
  16     personal animosity created by the events of January
  17     1995?
  18   A. I cannot state what Mr Wisheart's feelings were to Dr
  19     Bolsin, but there were obvious tensions between many
  20     people over the issues that we have been discussing.
  21     That could affect the relationship within the operating
  22     theatre and Mr Wisheart may rightly feel that it would
  23     be inappropriate to work with Dr Bolsin.
  24   Q. Can I come back, before we take a break, to page 11 of
  25     your first statement and again focus on the last few

   1     words of paragraph B12g? What attempts did you make to
   2     restrict the pressures, that is the criticism and the
   3     threat of suspension, other than adjusting the rota of
   4     Dr Bolsin?
   5   A. Through my actions, in discussions with colleagues
   6     throughout the Trust, my stating that I believed there
   7     was a problem of performance within the paediatric
   8     cardiac service, therefore, trying to separate the fact
   9     that Dr Bolsin had raised a problem in the way that he
  10     did and the fact that it was not Dr Bolsin as the
  11     problem, I supported him in a number of environments,
  12     even with his own cardiac anaesthetist colleagues,
  13     because there was a broad opinion as to what these
  14     figures actually meant, and they would be criticising Dr
  15     Bolsin for his method of audit and for the accuracy of
  16     audit.
  17   MR LANGSTAFF: Thank you, Dr Monk. We have not entirely
  18     finished this particular area, but, sir, perhaps it is
  19     now an appropriate time to take a short break.
  20   THE CHAIRMAN:  Yes. Thank you, Mr Langstaff. Shall we say
  21     fifteen minutes? That means to around just after 11.30.
  22   (11.15 am)
  23               (Short break)
  24   (11.35 am)
  25   MR LANGSTAFF: Can we now have a look, Dr Monk, at the move

   1     of Dr Bolsin from the rota? Can we begin with BMA 1/11,
   2     a letter written to you dated 24th April? The first
   3     paragraph expresses his concern at the lack of
   4     documentation associated with the unofficial change that
   5     has occurred to his contract in the last two weeks.
   6        First of all, the change is one you had made, was
   7     it?
   8   A. Yes. I had made the change to his roster.
   9   Q. Is it right that he was unofficial?
  10   A. In what way he means "unofficial", I am not quite sure
  11     his meaning. In as much as I had not sat down and
  12     changed his job contract to reflect different days of
  13     cardiac working it was unofficial, but I could not have
  14     achieved it without his agreement.
  15   Q. Indeed, he indicates that he had agreed, in the second
  16     paragraph, to go on 13th and 20th April, and records
  17     that you had requested him to work on an alternative
  18     list at Hey Groves?
  19   A. That is correct, I had asked him to do that. That was
  20     so that Dr Masey, who is a cardiac anaesthetist, who has
  21     an all day list on a Thursday, was able to exchange the
  22     clinical duties. Therefore, both of the consultants
  23     could perform anaesthesia on those days.
  24        The cardiac rota, as I have already stated, is
  25     made some time in advance, and when we were aware of the

   1     legal advice that produced the potential conflict, as we
   2     had already discussed, this change was made. It was
   3     then not possible to move Dr Bolsin into a cardiac day
   4     that was not a Thursday. As soon as the new rota was
   5     produced, he went back to his job contract, or job
   6     specification, of doing two days of cardiac permed from
   7     three.
   8   Q. One of the problems with arranging the swap would be
   9     that whoever took over the anaesthetic cardiac list
  10     would know that they had been swapped for the reasons
  11     that you have outlined, would they not?
  12   A. I do not understand why that is a problem.
  13   Q. Would they not feel complicit in an arrangement which
  14     took Dr Bolsin away, shooting the messenger for
  15     delivering the message, as it were?
  16   A. I do not accept that it is shooting the messenger. The
  17     whole basis of the cardiac anaesthetic support to the
  18     cardiac service was that we were flexible. The
  19     contracts that we had meant that we worked on two days
  20     out of three. We were therefore reasonably
  21     interchangeable and should we have a social reason or an
  22     educational reason or a CME reason or a holiday reason,
  23     then the rota was conducted to enable us to provide as
  24     much as possible a cardiac anaesthetist to provide
  25     cardiac anaesthesia each day in theatre.

   1        Therefore it is not exceptional or difficult in
   2     order to change what we did to avoid a possible
   3     conflict.
   4   Q. He goes on in the letter to say that he will not
   5     undertake duties outside his contractual commitment.
   6     Was he saying there that he wanted to go on doing
   7     cardiac anaesthesia on Thursdays, or what?
   8   A. Dr Bolsin states that he has no objection to working
   9     with any of the cardiac surgeons that he has worked with
  10     in the last six and a half years of his contract. It
  11     ignores the fact that the relationship between those two
  12     people at critical times is of paramount importance. If
  13     there is tension and difficulty, then there is a risk of
  14     increasing mortality or morbidity. I cannot prove that;
  15     it is an assumption.
  16        The fact that he was happy shows no insight into
  17     the feelings of the surgeons.
  18   Q. You yourself expressed virtually those views -- it is
  19     the next document I want to take you to, UBHT 146/24.
  20        You are responding to his letter of 24th?
  21   A. Indeed. That is my writing. I think the date for the
  22     file copy is incorrect because the computer gives the
  23     date that the letter is produced. I think the letter
  24     was actually sent earlier than that, and therefore
  25     I crossed it out and dated it 26/4.

   1   Q. You say what has happened in the first paragraph, and
   2     why. And you describe it as being an informal and
   3     temporary arrangement?
   4   A. Yes. The alternative would be to do it formally, and
   5     I could not guess what the end result of that would be.
   6   Q. You go on to say that "work on creating a group to
   7     enable resolution of these conflicts is being pursued by
   8     me with the Chief Executive, Chairman and others as
   9     a matter of importance".
  10        What had you in mind there?
  11   A. I think I had in mind there that the Chief Executive and
  12     the Chairman were mindful of the conflicts that were in
  13     existence and they were starting to try and produce
  14     a process of conciliation between Dr Bolsin, Mr Wisheart
  15     and others.
  16        I did not become part of that group and therefore
  17     I cannot state what their actions were.
  18   Q. What was "the group"? Who did it comprise?
  19   A. I have no direct knowledge of the process because it
  20     was, I presume, felt that if it was of limited knowledge
  21     it would have the greatest success, but I think that
  22     there were a number of other consultants from other
  23     specialties who were outside of anaesthesia and cardiac
  24     who were acting as liaisons and communication channels
  25     between the two cardiac surgeons and Dr Bolsin.

   1   Q. Can I scroll down to the largest paragraph on the page?
   2     You say that "that issue and many others have been
   3     discussed between us on a number of occasions. The
   4     action to temporarily change your programme had your
   5     active agreement."
   6        Pausing there, that is right, is it, as a matter
   7     of history?
   8   A. Yes. This paragraph refers to the fact that we had
   9     external advice. They pointed out --
  10   Q. Simply at the moment I am asking you to confirm what you
  11     say there, that Dr Bolsin actively agreed to a temporary
  12     change in his deployment?
  13   A. Yes, he did, because otherwise he would not have gone to
  14     do the general surgical list; he would have appeared in
  15     theatre to perform cardiac anaesthesia, and there would
  16     have been the resulting sort of exchange of views.
  17   Q. You say in the next sentence:
  18        "Your happiness at working with all the cardiac
  19     surgeons is not reciprocated and displays a lack of
  20     insight into the personal effects of recent events."
  21        Which cardiac surgeons did not reciprocate it?
  22   A. At that point I think you will find I was talking of
  23     Mr Wisheart and Mr Dhasmana.
  24   Q. The lack of insight you have dealt with.
  25        Can I, before I take you to the rest of this

   1     letter, which I will do, move on for a moment to the
   2     next letter, which is 146/26. It is the same date, we
   3     see the same problem has arisen with the dating. You
   4     are writing to Dr Roylance. If we go down, please, you
   5     say in the second paragraph that you have requested
   6     Dr Bolsin in writing that he co-operates in achieving
   7     reconciliation by accepting a temporary change in his
   8     work programme, in order to minimise the contact between
   9     Mr Wisheart, Mr Dhasmana and himself. "Some of the other
  10     cardiac surgeons are unwilling to have an increased
  11     contact with Dr Bolsin, which decreases our flexibility
  12     in accommodating this aim."
  13        Which other cardiac surgeons did you have in
  14     mind?
  15   A. At that time I think we would have had Professor
  16     Angelini, Mr Hutter and I think Mr Bryan working in the
  17     unit. My recollection is that Mr Hutter would have
  18     preferred on the day that he worked to remain with his
  19     anaesthetist with whom he had already formed a good
  20     working relationship, and therefore we have to be aware
  21     of his own needs and wishes to maintain the success of
  22     his own operating.
  23   Q. So that is not a reference to cardiac surgeons, as it
  24     were, sticking together as a club, saying "if you attack
  25     one of us, you attack all of us"?

   1   A. No, I do not think so. What you have is the importance
   2     of maintaining good working relationships, and one of
   3     the difficulties in any large service is that if you do
   4     not have those relationships well formed and continued,
   5     the service cannot work as well as it could, and the
   6     other surgeons may not have wished to change their
   7     programme or their team on those days.
   8   Q. We go back to the letter we were last on, page 24, the
   9     foot of the page. You say:
  10        "As director" -- you are asking him to fulfil, to
  11     agree, the commitments by accepting a small temporary
  12     change in the job plan -- "the request for your
  13     flexibility is based on advice from many quarters but in
  14     the main from our anaesthetic colleagues, who have taken
  15     cognisance of the importance of the close co-operation,
  16     interpersonal relationships and trust that the process
  17     of surgery requires."
  18        What you are saying there is that you are asking
  19     Dr Bolsin to be flexible about where he does his
  20     anaesthesia, and with whom; is that right?
  21   A. I have asked him to change one of the three days he is
  22     rostered to do cardiac anaesthesia from a Thursday to
  23     a Tuesday, if I recall correctly.
  24   Q. The advice upon which you have done that is essentially
  25     from fellow anaesthetists?

   1   A. Within the Directorate of Anaesthesia, there were
   2     a number of systems to give me advice as director. I am
   3     only in the job for three years. Therefore there needs
   4     to be some continuity and support for the
   5     anaesthetists. I would speak to those people openly and
   6     discuss what the possible options were.
   7   Q. But is it the case that the majority of anaesthetists
   8     thought that it was a good idea for the job plan of
   9     Dr Bolsin to be changed in the way that you effected?
  10   A. I think the majority of my colleagues would feel that to
  11     create a conflict, the consequences of which we could
  12     not predict, by keeping Dr Bolsin working on a Thursday,
  13     would not be sensible. If a simple change could be
  14     effected that allowed him to fulfil his job, then that
  15     would be an appropriate action. Indeed, it decreased
  16     the amount of paediatric cardiac work that Dr Bolsin
  17     would have to do. That in itself, I presume, would have
  18     been an advantage to Dr Bolsin.
  19   Q. Two points which arise. The answer, then, is yes, is
  20     it, that the bulk of the advice that you had was from
  21     anaesthetist colleagues and to the effect that there
  22     should be a change in Dr Bolsin's job plan?
  23   A. To be precise, we did not change Dr Bolsin's job plan,
  24     because that would have meant issuing a new one. We had
  25     a temporary reallocation of his time. I did not change

   1     the job plan so that if and when he should wish to make
   2     the stance that he was to return to his original one it
   3     would still be there.
   4   Q. Forgive me, I was simply using the words "temporary
   5     change in the job plan" because those are the words you
   6     have used yourself in this paragraph?
   7   A. Fine, but all I am saying is that the term "job plan"
   8     could be taken incorrectly from this sentence to mean
   9     the actual contract that he had.
  10   Q. But is it right that the change which you effected,
  11     temporary though it was, was done on the basis of,
  12     largely, advice from anaesthetic colleagues?
  13   A. The advice had largely come from anaesthetic
  14     colleagues. The decision to change his job plan would
  15     also have been mine, with the evidence or the
  16     impressions that I had gained from many quarters.
  17   Q. In the letter to which you are replying, Dr Bolsin had
  18     asked that there should be a discussion as to what he
  19     called "surgical direction of anaesthetic provision for
  20     operating lists on the agenda"?
  21   A. May I see that, please?
  22   Q. Certainly: BMA 1/11, at the bottom of the page. It is
  23     the last six lines.
  24   A. Yes.
  25   Q. He was obviously looking for a discussion amongst the

   1     anaesthetists as to what had taken place and what might
   2     take place. Did it happen?
   3   A. I was unable to find any minutes of such a meeting, but
   4     my recollection is that there was a meeting of
   5     anaesthetists within the department, in the department
   6     library, where some of these issues were discussed.
   7     I apologise that I cannot find those, but the movement
   8     of papers in and out of the Directorate of Anaesthesia
   9     makes it difficult for --
  10   Q. Do not worry about an explanation. Your recollection is
  11     that there was such a meeting?
  12   A. Yes, there was.
  13   Q. What was the outcome, briefly?
  14   A. I do not believe that there was an outcome; there was
  15     more of an exchange of views and thoughts on the whole
  16     issue of the relationships between audit, outcomes,
  17     quality and views of how the Anaesthetic Department
  18     should act in this situation.
  19   Q. Can I go back to the letter at 146/24, the foot of the
  20     page? The second matter which arose out of the answer
  21     you were giving me is that the reasoning of your
  22     anaesthetic colleagues was that they placed a prime
  23     importance upon the close co-operation, interpersonal
  24     relationships and trust between themselves and the
  25     surgeons.

   1   A. Indeed. That is an important issue.
   2   Q. Is that something which you, throughout your career in
   3     anaesthesia, have placed considerable store by?
   4   A. I believe it is very important that you can trust the
   5     other person at the operating table, not for routine
   6     work with no difficulties, but when a problem arises you
   7     may have a very short time to produce a solution that
   8     solves the problem.
   9        If those communication channels are impaired by
  10     any problem, then I think it increases the risk to the
  11     patient.
  12   Q. If we can go back to your statement, please, at page 33,
  13     you say in paragraph 44 that the false criticism of the
  14     colleague was in itself a serious action.
  15        Can I just unpick that for a moment? You are
  16     describing, I think, something of the culture which
  17     surrounded the whole question of audit in the early
  18     1990s?
  19   A. I think I am describing there that the GMC regulations
  20     were not helpful in the early part of the procedure
  21     in -- of the affair -- in dealing with matters of the
  22     performance. They were very helpful if you had somebody
  23     who had a problem with substance abuse or was mentally
  24     unwell, but it did not address performance. It did,
  25     however, address the false criticism of a colleague

   1     which could be used to gain an advantage for someone
   2     else in furthering their career. It was quite specific
   3     in that, in that if you were to criticise somebody and
   4     you had no basis for it that in itself could be referred
   5     to the GMC.
   6   Q. Yes. So essentially, if one was to embark upon
   7     a process which was seen as critical of a colleague, you
   8     would have to be right? Was that in practical terms the
   9     position?
  10   A. In practical terms you need to be sure that your data
  11     was correct; that you had involved those people in that
  12     data and you had taken it forward.
  13        If you then had a response that was negative or
  14     not helpful, you would have to look at different
  15     pathways of advancing it.
  16   Q. We have been looking at the moment at the period
  17     essentially after January 12th 1995. There is one other
  18     part of your statement I want to ask you about in this
  19     context in the light of the questions I have been
  20     asking. It is page 35, paragraph 51 --
  21   A. May I just make a statement before that goes? That
  22     paragraph 44 does not just apply to the period after May
  23     1995; it applies for the whole time.
  24   Q. I did not mean to suggest that it did.
  25   A. I am sorry, I misunderstood you.

   1   Q. Not at all. Page 35. Dealing with the Hospital Medical
   2     Committee, you deal here specifically with the period of
   3     time after January 12th 1995. You give your opinion as
   4     to where the Hospital Management Committee believe the
   5     problem lay.
   6        That was your view, was it, of that which the
   7     Medical Committee thought?
   8   A. The hospital medical consultant body, which is slightly
   9     different from the committee, because I presume you are
  10     talking there about the people who run the group, the
  11     development of unidisciplinary and then
  12     multidisciplinary audit was still relatively early. The
  13     feeling that the audit data belonged to the responsible
  14     clinician was still there; the data to the Hospital
  15     Medical Committee was not presented by either side as it
  16     were; and there is a degree of resistance in accepting
  17     that anaesthesia, as a group, that is, should be
  18     auditing surgery and as a group then producing
  19     criticisms.
  20        So the way in which the audit had been produced,
  21     and the way in which it had been or had not been taken
  22     forward in an open manner, meant that the consultant
  23     body felt that there was a problem with the way in which
  24     it had been raised.
  25   Q. The way you put it, "the Hospital Medical Committee",

   1     that is composed of a number of consultants, is it not?
   2   A. The committee can be attended by any consultant with
   3     a contract or honorary contract within the Trust.
   4   Q. So the consultants committee, if one calls it that,
   5     believes that the problem lay more with the fact of
   6     audit than with that which the audit revealed?
   7   A. That was my opinion, and that was the impression that
   8     I gained at that time. That may or may not be correct
   9     for the consultants who were there.
  10   Q. What was it that was said or fed back to you, if you did
  11     not go to one or other of the meetings, that made you
  12     think that they were really concerned more with the
  13     process than the outcome of the audit?
  14   A. The HMC body did not receive the data that I think they
  15     would have needed to come to a decision to support the
  16     surgeons, the medical directorate, in their actions.
  17     That is my viewpoint. I felt at the time that the
  18     correct thing to do would have been to look at the
  19     problem and then come to a decision about what was the
  20     right thing to do.
  21   Q. Were criticisms expressed at the HMC of the way in which
  22     Dr Bolsin had gone about it?
  23   A. I cannot recall specific statements about that.
  24   Q. You may not be able to recall specific statements, but
  25     what was the generality of view, as you saw it?

   1   A. There were a number of points made with regards to the
   2     accurate -- I can only recall an impression of what went
   3     on, rather than accurately give you statements. I think
   4     I would be misleading you.
   5   Q. The fact that throughout the period (not just after
   6     1995, as you point out) false criticism of a colleague
   7     was something which could be treated seriously by the
   8     GMC, the comments you have made about suspension and
   9     dismissal being at least options on a piece of paper,
  10     even if they were not seriously considered -- I do not
  11     think we have quite resolved whether they were seriously
  12     considered or not -- may lead one to think that after
  13     January 1995 Dr Bolsin was, as it were, under siege for
  14     having -- I use pejorative words here deliberately to
  15     provoke a response -- exposed the true state of affairs
  16     in paediatric cardiac surgery.
  17        To what extent would that be a fair reflection of
  18     what happened after 1995?
  19   A. I think it is wrong to try and separate 1995 from the
  20     preceding years, as they have an effect on how the Trust
  21     reacted. For whatever reasons, we had failed to make
  22     Dr Bolsin's audit be open and discussed amongst the
  23     relevant clinicians. The press were then involved in
  24     opening up this debate in a way that was uncontrolled.
  25     It may or may not have been factual, and therefore, many

   1     people were, to use your words, "under siege" in trying
   2     to fulfil their roles.
   3   Q. So would it be right to say, for whatever reason and
   4     however justified it may have been, that Dr Bolsin was,
   5     in your view, under siege following January 1995?
   6   A. I find the words "under siege" difficult to accept and
   7     answer. The process of bringing the data to the
   8     attention of the surgeons should have occurred between
   9     1993 and 1995. When headlines are across the Daily
  10     Telegraph and you have television programmes, in my view
  11     it becomes very difficult to try and manage the
  12     situation. Everybody is under siege, as it were, from
  13     an external influence. You go from a position where you
  14     can try and discuss matters constructively to one where
  15     you are fire-fighting, trying to respond to external
  16     factors that you have no control over.
  17        So we were all under siege in different ways.
  18   Q. So people working clinically in the Royal Infirmary
  19     would react to the press publicity by concern about that
  20     publicity and a wish, no doubt, to stop any further such
  21     publicity occurring?
  22   A. I can only speak for myself in the way in which
  23     I reacted and therefore many levels at which I reacted
  24     or felt I should react. It became important that we
  25     audited the figures and could conclude there was

   1     a problem or there was no problem; how big was it or how
   2     small was it? You think "I do not wish this publicity
   3     to go out to the press", because it is causing more
   4     havoc and disruption to the process than anything else.
   5        To take you back in time, the Private Eye issue.
   6     What was said in Private Eye actually inhibited the
   7     openness at which people could discuss --
   8   Q. That is just what I was going to go on and ask you
   9     about, because you describe it at the top of page 36.
  10     This is in relation to the Private Eye article "creating
  11     a furore concerning the leaking of confidential data to
  12     the public arena."
  13        Did one have, albeit on a lesser scale, a similar
  14     reaction in 1992 to the reaction that there was in
  15     1995?
  16   A. Preceding 1992, as a junior consultant, I had been aware
  17     of published --
  18   Q. I am sorry to go back to the question. The question is
  19     really directed towards people's reactions to press
  20     publicity. You said in 1995, "After that it was
  21     difficult. Look what happened in 1992 when Private Eye
  22     published, because that made honest and frank talking
  23     amongst ourselves about our figures much more
  24     difficult."
  25   A. Yes.

   1   Q. I am using different words --
   2   A. That is what I was going to say. We had audit, we had
   3     published figures that went to the Department of Health,
   4     to the Registry. Those were presented by the surgeons
   5     to us in that format. When such data or inferences from
   6     that data became leaked from Private Eye, when that was
   7     meant to be reasonably confidential data, it caused
   8     great concern because it then impinged upon the openness
   9     that you could have between clinicians. Private Eye is
  10     not a peer review journal, people do not check the
  11     figures or the facts; it is something that people pick
  12     up to read whilst travelling on a plane.
  13        As a way of bringing forward really serious
  14     concerns about performance, it is not an appropriate
  15     channel. In my opinion, it caused more inhibition about
  16     figures and talking than anything else I have seen,
  17     until 1995.
  18   Q. So essentially the fact of making public one way or
  19     another in the manner described in the press had,
  20     amongst those with whom you worked, the effect of making
  21     them much more cautious about discussing and looking at
  22     data?
  23   A. It made them more cautious about talking about their
  24     data with their colleagues, and therefore, inhibited the
  25     ability to take Dr Bolsin's audit forward, because there

   1     were already concerns about this information finding its
   2     way into the public arena where it would be displayed in
   3     perhaps a not very helpful form.
   4   Q. At page 10 of your statement -- this is your first
   5     statement -- under B11, you add to that, I think,
   6     further difficulties that there may have been to open
   7     dealing with questions of performance. You say in the
   8     last sentence there, that there were institutional
   9     barriers to open criticism of professional competence.
  10        Are you talking subsequently as to the medical
  11     profession throughout the country, or specifically in
  12     relation to Bristol?
  13   A. You can take that sentence from the very widest sense
  14     down to the sense of the Trust. Anaesthesia is a fairly
  15     modern specialty. We have only just left the auspices
  16     of the Royal College of Surgeons and become a Royal
  17     College. Therefore, it may be difficult for some areas
  18     of medicine to accept the viewpoint or criticism that is
  19     raised by anaesthesia.
  20   Q. So that is part of the institutional barrier you are
  21     talking about, the fact that anaesthesia is the "new kid
  22     on the block"?
  23   A. To some degree, yes.
  24   Q. Was there any other institutional barrier that you had
  25     in mind?

   1   A. At that time, I think that audit itself was new. The
   2     Trust was trying to deal with how it was introduced and
   3     it remained unidisciplinary. To my knowledge, cardiac
   4     surgery was the only area of the Trust where surgeons
   5     and anaesthetists met regularly to discuss ways of
   6     improving performance. But even so, audit was felt to
   7     belong very much to the person performing the task or
   8     who had responsibility for the patients. Indeed, there
   9     was quite a considerable battle for audit to be placed
  10     on a half day rolling programme through the week to
  11     enable the whole hospital to audit.
  12   Q. You have explained in the context of looking
  13     principally, as we have been doing, at the period after
  14     January 1995, the way in which people's reactions took
  15     place to the events which they perceived as having
  16     happened, and the importance, I think you stress
  17     throughout, of maintaining teamwork and reliance between
  18     the surgeons and anaesthetists so operations could be
  19     performed effectively and one did not prejudice the
  20     patient because there was some tension between the
  21     professionals involved in his or her care.
  22        You have also expressed the importance of
  23     verifying the data. You say this is really what the
  24     Trust failed to do after 1995, although they had the
  25     Hunter/de Leval report, there was no further attempt by

   1     the Hospital Management Committee or management to find
   2     out what was really happening. That is a criticism you
   3     have made a number of times in a number of different
   4     ways this morning?
   5   A. The criticism applies from the very beginning of the
   6     process of the audit until that time. In 1995, de Leval
   7     came with Dr Hunter and they produced, or had figures
   8     and produced, opinions. What was left undone that far
   9     was a resolution of the conflicts between all the
  10     people, because already put in place were the solutions
  11     to the problem that had been raised -- well, not raised
  12     but clarified to some degree by the Bolsin/Black audit.
  13   Q. Could I ask you to look at page 26 of your statement,
  14     paragraph 20?
  15        It is six lines down. You are explaining why it
  16     is that you had not taken forward data which you had
  17     had, such as you had, to Mr Wisheart, but it is the
  18     sentence beginning "latterly" that I want to focus on
  19     for a moment. I will come back to the bulk of the
  20     paragraph later:
  21        "Latterly, I believed the unverified audit would
  22     create immense tensions between [Mr Wisheart] and me,
  23     and also as a consequence, between the other surgical
  24     directorates and the Directorate of Anaesthesia, and
  25     also the Directorate of Anaesthesia with the Trust

   1     management."
   2        You say that would stop you being able to further
   3     the paediatric cardiac surgical issues and problems
   4     which would be transferred to a difficulty with the
   5     anaesthetists as a group, an anaesthetist producing
   6     a clandestine audit and the breaking of a professional
   7     relationship.
   8        The word "latterly": over what period of time did
   9     you have this particular view?
  10   A. It was an evolving process and therefore it was
  11     difficult to place a time upon it, in that as I tried to
  12     produce a forum to discuss the question of performance
  13     and failed to achieve that exchange of views, it became,
  14     you know, more obvious that if I actually went forward
  15     and said, "Here is the data. What do you think of
  16     that?", it would not have been an appropriate action and
  17     it would have caused me personal difficulties, and the
  18     directorate within the hospital.
  19        At that time, and we are talking now March, April,
  20     May 1994, we had formed a committee to try and unify the
  21     service. That was the solution to the problem. If
  22     I then created disharmony by my actions and distracted
  23     from that process, then I think I would have not acted
  24     appropriately as the Director of Anaesthesia.
  25   Q. What was informing your action, then, was the desire

   1     that you express here to avoid creating tensions and the
   2     tensions you are referring to, first of all, between
   3     Mr Wisheart and yourself?
   4   A. The data challenged Mr Wisheart's quality of work.
   5     Mr Wisheart had always audited his figures and he was
   6     aware of that. Therefore, that would be a difficult
   7     meeting.
   8   Q. Just for the point of clarification, the data related to
   9     cases upon which he had acted as the surgeon.
  10     Is cardiac surgery a team effort?
  11   A. I do not understand how you mean, "team".
  12   Q. Is the outcome of an operation upon a patient
  13     a combination of pre-operative investigations, measures,
  14     discussions between cardiologist and surgeon as to the
  15     appropriate timing of treatment, the performance of the
  16     operation itself, the post-operative phase in the ITU
  17     and so on: several different elements making up an
  18     outcome?
  19   A. I agree absolutely with that. It is a very complex
  20     process which starts from the very moment that the child
  21     is diagnosed with heart disease and all these elements
  22     are reflected in the mortality, morbidity and success of
  23     the cardiac service.
  24   Q. So why would a surgeon performing an operation
  25     necessarily see the outcome results of cases in which he

   1     had acted as the surgeon as being a reflection upon him
   2     personally rather than the team as a whole?
   3   A. Because he is a focal point at that time and that in
   4     cardiac surgery it is very easy to measure mortality.
   5     It was something that had been discussed over many
   6     years. Each year we would review the mortality figures
   7     and try to improve it. Mr Wisheart, as was I, was well
   8     aware that it was a multifactorial process and that is
   9     one of the criticisms that I had of the audit, in that
  10     it should have been targeting the whole issue of the
  11     start to the finish and not really just focusing down on
  12     figures JDW and JD, because the impression it formed is
  13     incorrect.
  14   Q. The tensions it would cause between you and him, you are
  15     talking here about an audit performed by another member
  16     of the Directorate of Anaesthesia, an anaesthetic
  17     consultant, not yourself?
  18   A. It was not performed by me. Mr Wisheart and I had
  19     a long relationship. We had always found it relatively
  20     easy to talk about the broad picture and how things
  21     would change, and he was aware of the desire to improve
  22     paediatric practice. Therefore, we could talk about
  23     ways forward to develop it. Indeed, it was not my
  24     suggestion that we should amalgamate the service at the
  25     Children's Hospital; that was something that I think he

   1     had been promoting since about 1989 or 1990.
   2   Q. The point of my question is, why should your
   3     presentation as director of anaesthesia, of an audit
   4     performed by an anaesthetist, leave aside whether it is
   5     a fellow consultant or some other anaesthetist, an audit
   6     with which you had not yourself been concerned save to
   7     present it to a surgeon, tarnish relations between you
   8     and a surgeon with whom you had got on previously got on
   9     well?
  10   A. I think because I would wear the same badge of being an
  11     anaesthetist, and therefore it is a criticism from one
  12     specialty to another specialty. I may have done
  13     Mr Wisheart a disservice by having that impression.
  14   Q. You go on to say here, in paragraph 20, that also as
  15     a consequence, between the other surgical directorates
  16     and the Directorate of Anaesthesia.
  17        Can you tell me how your presentation,
  18     hypothetically, of data which another anaesthetist had
  19     prepared independently of you, to one surgeon involved
  20     with cardiac surgery, would or could prejudice the
  21     relationship of the Directorate of Anaesthesia as
  22     a whole with all the other forms of surgery and all the
  23     other surgeons involved in surgery throughout the Royal
  24     Infirmary?
  25   A. Because the issue could have become the fact that

   1     a clandestine audit had criticised a surgeon without
   2     knowing what the facts were, what the conclusions were,
   3     what the problems were. People would make opinions on
   4     whether that was an appropriate activity in the climate
   5     at that time to perform, and people, I believed, would
   6     have taken the conclusion that the action was
   7     inappropriate and lost the message. The important thing
   8     was the message that said that our performance needed to
   9     be improved.
  10   Q. Why would it have prejudiced the Directorate of
  11     Anaesthesia in its relationships with the other surgical
  12     directorates?
  13   A. Because I was its head and therefore it would be seen as
  14     anaesthesia. There is a global relationship between the
  15     various directorates, and anaesthesia is a group and
  16     this would have been an activity ascribed to
  17     anaesthesia.
  18   Q. So you were fearful that your action of taking forward
  19     such data as you had, and are referring to in
  20     paragraph 20, would be seen as an action by the
  21     anaesthetists against the surgeons?
  22   A. I was not fearful of that being seen. It was the
  23     conclusions that would be drawn from it and the fact
  24     that it would impair our abilities to progress the
  25     solutions of developing a new unit at the Children's

   1     Hospital, of appointing new staff, of getting through
   2     the very difficult negotiations of who goes where and
   3     does what, and where does the funding come from, which
   4     are all very complex issues.
   5        If you take however much money it would be,
   6     a million or two million, how much it cost to go up to
   7     the children's, that money is not going somewhere else
   8     to a different area to develop its service.
   9        The dynamics of that situation goes way beyond
  10     a simple "I am challenging you with these figures", but
  11     the conclusions that come from it have ramifications
  12     across the Trust.
  13   Q. I appreciate that it is now some time ago and what I am
  14     asking for is a judgment, really, on how you read people
  15     around you, but what you seem to be saying -- please
  16     correct me if I am wrong -- is that you thought, from
  17     your knowledge of those people, that they would draw
  18     a conclusion that the anaesthetists were, as it were,
  19     making mischief, rather than attempting to highlight
  20     what might be a problem that required collective action
  21     to resolve?
  22   A. I think that people make many judgments of many
  23     different aspects. But the Hospital Medical Committee
  24     when challenged with some of these issues formed the
  25     opinion that they supported the surgeons, and I think

   1     that mirrors my impression at that time. I may have
   2     been completely wrong, but that was my impression.
   3   Q. So you are saying that your impression which you had
   4     here back in the mid-90s is actually borne out in the
   5     event by what happened after 1995?
   6   A. That is my opinion, yes.
   7   Q. Did it happen after 1995 that there was a tension
   8     between other surgical directorates, other than Cardiac
   9     and the Department of Anaesthesia?
  10   A. I had a number of conversations in a variety of venues
  11     which questioned the action of anaesthesia, yes, but
  12     also questioned, was there a problem with the cardiac
  13     service and how big was it? A number of people outside
  14     the Trust have rung me for advice because they have
  15     a similar problem to deal with.
  16   THE CHAIRMAN: Mr Langstaff, may I interrupt for a moment?
  17     The reference in your statement is to the HMC actually
  18     taking a vote. Did they take a vote? They voted to
  19     support --
  20   A. The process of a vote in submitting papers, I think it
  21     was in response to a question asked, there was no
  22     criticism and therefore it was held that the HMC had
  23     supported the surgeons, that was not necessarily what
  24     I felt was an appropriate minute to that meeting.
  25     Indeed it was later questioned, in particular by

   1     Dr Black.
   2   Q. Are you saying that there was a vote, or that there was
   3     not a vote?
   4   A. There was not a vote in as much that we submitted pieces
   5     of paper. If we had done that, there would have been
   6     a number of objections placed and therefore you could
   7     not say that the meeting supported, without criticism,
   8     the Medical Director.
   9   Q. It is just that I was concerned to enquire whether that
  10     would be an ordinary way of proceeding within the HMC to
  11     take a vote on the matter?
  12   A. This issue was a whole new experience for me in the
  13     forum of the HMC, which does not, and never had,
  14     I believe, dealt with such a problem and in itself, I do
  15     not think, knew what to do with it as an organisation.
  16     There is still debate about what the role of the HMC
  17     would be if a similar thing occurred.
  18   Q. Expressing a view -- because I can ask no more of you --
  19     do you think that the approach adopted was appropriate?
  20   A. What, then?
  21   Q. Yes.
  22   A. My view at that time was that the HMC -- and that would
  23     have been the committee of the HMC -- should have taken
  24     the matter on to find out what the real problems were
  25     with the figures and the performance, and then take it

   1     forward. But it had never had to do that before, and
   2     people are trying to react and come to a conclusion in
   3     the middle of debate.
   4        I have subsequently put forward that if a clinical
   5     problem arises like this again, then it is part of the
   6     HMC's duties to actually say "Yes, we will look at this,
   7     we will put the resource there and we will try and solve
   8     the issue with people independent to the work going on".
   9   THE CHAIRMAN: Thank you very much.
  10   MR LANGSTAFF: Going back to the sentence that I was
  11     focusing on from paragraph 20, why was it that you
  12     foresaw that the handing over by you to Mr Wisheart of
  13     unverified audit data would lead to problems between the
  14     Directorate of Anaesthesia as a whole and the Trust
  15     management?
  16   A. For the reasons we have already elucidated: because the
  17     action will be seen without a knowledge and discussion
  18     of the facts and conclusions would occur, and it would
  19     be seen as an anaesthetic action and that would cause
  20     difficulties.
  21   Q. Is it then the corollary of what you say in paragraph 20
  22     that the only data that you could have submitted without
  23     risk to the relationships between anaesthesia, surgery
  24     and the Trust management, would have been verified data?
  25   A. I felt that the data I would need to take forward would

   1     have to be stronger than just the opinion of Dr Bolsin
   2     plus the support of me as a Clinical Director of
   3     Anaesthesia.
   4        I felt that the appropriate way forward was for
   5     the cardiac anaesthetists to discuss the audit and then
   6     form an opinion, because in my mind, and other people's
   7     minds, there were some problems over the audit that was
   8     done. Because had I taken forward an audit that I had
   9     difficulty in understanding, despite the fact that I was
  10     part of the process, to someone who had a very good
  11     understanding of their own performance, that I would not
  12     be able to stand by the data effectively. Therefore,
  13     the opportunity to say "here is a problem", would have
  14     been lost.
  15        That gave me considerable concern.
  16   Q. One other question before I take you through the
  17     chronology. You described for us, way back at the start
  18     of your statement, page 22, [WIT 105/22] that your role
  19     as Clinical Director of Anaesthesia was to bring
  20     together as much relevant data as possible to act as
  21     a facilitator to bring the two sides together and
  22     achieve uniformity of agreed data.
  23        What were the two sides you were there referring
  24     to?
  25   A. I was referring to the opinion of Dr Bolsin and Dr Black

   1     versus the opinions of the cardiac surgeons who had been
   2     auditing their data in a different format, and the two
   3     of them did not sit together. The data did not sit
   4     together and therefore their opinions were different.
   5   Q. I want to move away from that and I will come back to
   6     it. I want to deal by way of background with what will
   7     follow.
   8        May I invite your agreement or disagreement to the
   9     chronology, which I think I have extracted from your
  10     statement, and let me see if this is right or not.
  11        You were a Senior Registrar before you became
  12     a consultant in January 1989, in anaesthesia here in
  13     Bristol?
  14   A. That is correct.
  15   Q. For how long had you been a Senior Registrar here?
  16   A. I came to the South West rotation in 1982, but I went to
  17     Plymouth, so I would have come to Bristol in 1983.
  18        I then worked as a lecturer with the University
  19     Department of Anaesthesia with Professor Prys Roberts,
  20     before I returned to becoming a Senior Registrar. Those
  21     jobs are almost equivalent, except that I would have no
  22     contact with cardiac as a lecturer because I had my own
  23     research and my own fields.
  24        I returned to being a Senior Registrar for
  25     approximately four months, when I did some cardiac, and

   1     I did two months with paediatric anaesthesia before
   2     I then left to go to the States for 15 months.
   3        Upon my return, I then --
   4   Q. Whereabouts are we now in time?
   5   A. About 1986. I then worked as a Senior Registrar within
   6     the Bristol Royal Infirmary and did many things, but
   7     mainly cardiac.
   8   Q. You say in your statement, I understand it was some time
   9     before you were a consultant, that there might be
  10     problems with paediatric cardiac surgery?
  11   A. Yes. There were always discussions in a positive way to
  12     look at methods of improving performance of the unit,
  13     and had we been -- even if you were the top one, you
  14     would still sit down and talk about how you would
  15     improve your performance. But it was accepted that the
  16     performance at Bristol was not as good as many other
  17     centres.
  18   Q. So was it the general perception that performance was
  19     poor?
  20   A. We had no standards to say what is poor and what is
  21     good.
  22   Q. Was it the general perception?
  23   A. The perception was that the performance of the unit was
  24     in the lower part of the data that was sent out by the
  25     Cardiac Register, and therefore the only way was up.

   1   Q. Did you see that data at that time?
   2   A. I cannot say, as a Senior Registrar, that I can remember
   3     seeing data on outcome. I would have expected that to
   4     have been kept within the consultant body. However,
   5     people knew my interests and one of them may have shown
   6     it to me. But even when Dr Bolsin came to visit the
   7     Bristol Royal Infirmary to look at his job, I was
   8     a Senior Registrar in the unit and we had a fairly
   9     wide-ranging discussion about the unit's potential and
  10     its performance.
  11        Dr Bolsin, as he states, was well aware of the
  12     fact that Bristol was not the best performing unit in
  13     the UK.
  14   Q. Did you in fact discuss the less than favourable
  15     results, as you saw it, with him at that stage?
  16   A. I do not know whether I could discuss with him the
  17     results at that time, but Dr Bolsin's job meant that
  18     there would be three anaesthetists with a paediatric
  19     interest. I gathered rumours that said that when
  20     Dr Burton retired he would not be replaced, which would
  21     then have taken the department back to only two
  22     paediatric cardiac anaesthetists, and I actually
  23     withdrew from the job that Dr Bolsin applied for on the
  24     basis that two paediatric anaesthetists was not
  25     sufficient to provide the care that was needed.

   1   Q. Then very shortly after that, you were appointed?
   2   A. It takes time to move the monies around to create
   3     consultant posts, so Dr Bolsin was appointed in
   4     September 1988. But he had a six-month period of time,
   5     I think, or some period of time, before he took up his
   6     post, and I was appointed three months after him.
   7   Q. So there you are, both in posts, new consultants at the
   8     start of 1989. From the beginning of his being in
   9     Bristol, did he discuss with you a view that the results
  10     were poor and required improvement?
  11   A. He had those discussions with me. I discussed them with
  12     him and at a number of meetings, including surgeons,
  13     including cardiologists, in different relationships and
  14     numbers, ways in which the performance of the unit --
  15     were discussed.
  16   Q. In 1990, UBHT 61/126, what is described is an audit
  17     meeting dealing with open-heart surgery under 1 year in
  18     1989:
  19        "Clinical details and outcome of patients who
  20     underwent open-heart surgery reviewed. 39 patients
  21     treated, 14 deaths, an overall mortality of 35 per
  22     cent".
  23        There is no comparison given there, in the
  24     document. How did you relate to figures such as that?
  25   A. I related to the fact that the mortality of the 35 per

   1     cent was high.
   2   Q. The figures themselves, if we look at UBHT 61/134, 19th
   3     March 1990, open-heart surgery under 1 year appears to
   4     be broken down between surgeons. These were figures
   5     produced by the surgeons, were they?
   6   A. I believe so, yes.
   7   Q. If we look at the very bottom of the page, that is the
   8     CJM that I anticipated we might come upon?
   9   A. As you showed me last night, they are my wife's initials
  10     and not mine.
  11   Q. But that is you, is it?
  12   A. I am sure it is me.
  13   Q. If we flick through the next few pages, 61/134, 61/135,
  14     please, 61/136, then if we go to 137, looking here at
  15     cardiology as well as having looked at the cardiac
  16     surgery -- are we -- correct prediction of anatomy, and
  17     so on?
  18   A. I believe that is an audit of their use of echo.
  19   Q. Surgical results, the next page, with particular
  20     details.
  21        Although 35 per cent seems to be quoted in the
  22     minute that we have seen, if we go back to page 134 and
  23     scroll down to the "total" column, there has been some
  24     amendment there, there may be 14 out of 39, there having
  25     been a handwritten amendment to make it two deaths

   1     instead of one in the VSD column at the top?
   2   A. Right.
   3   Q. That appears to be broadly 35 per cent.
   4        These are surgeons, are they, being open about the
   5     data that they have collected over the previous year?
   6   A. Indeed the surgeons are being very open about the data.
   7     The function of that meeting was to try and look at our
   8     performance and see ways in which we could improve.
   9        The date of this was 1990?
  10   Q. March 1990. At that meeting, do you recall whether you
  11     raised any queries or not about the performance?
  12   A. I cannot recall raising a specific point about the
  13     performance. But the function of the meeting was to
  14     look at ways in which we could improve performance, and
  15     I presume that the data with the cardiologists would be
  16     to look at how effective they were at using that to
  17     diagnosis children to expedite their surgical treatment
  18     of their condition, because they then would not have to
  19     wait for cardiac catheterisation.
  20   Q. Do you recall whether Dr Bolsin, who was there as we
  21     have already seen, asked anything about performance or
  22     made suggestions that it was not acceptable, or anything
  23     to that effect?
  24   A. I would not be able to state categorically -- or even
  25     state what the discussion was in that meeting. My

   1     recollection is not good enough.
   2   Q. One of the difficulties that there seems to be from data
   3     such as this is that it records but it does not put in
   4     context, does it? There is no comparative data here?
   5   A. No, there is no comparative data there, whether or not
   6     the UK figures were available at that time I am not
   7     sure, but I would expect that the cardiologists or the
   8     cardiac surgeons may have those figures in mind as
   9     a comparator. But there are a number of differences
  10     between the presentation of the data on the central
  11     register and the way in which this data is placed which
  12     makes it difficult to interpret. There are no standards
  13     deviations, there are no means. It is, and was, hard
  14     for this group to make certain comparisons between the
  15     groups.
  16   Q. Was there any reluctance that you can recall for the
  17     surgeons splitting their operation rate and death rate
  18     in the particular way we see on page 134?
  19   A. The data in front of me here, in particular, looks at
  20     the under 1 age group, which was an area that the
  21     service was trying to develop and improve on, because it
  22     was felt to be the way forward for the unit to develop,
  23     because other centres, such as Great Ormond Street, were
  24     already operating on many of their children at a much
  25     younger age group than we were and therefore the figures

   1     are separated.
   2        The data that was sent to the Registry was as
   3     a unit and therefore did not separate the surgeons, but
   4     I have no evidence that they had any difficulty in
   5     separating their figures for this meeting.
   6   Q. Dr Monk, it is now just come up to a quarter to one. We
   7     would normally have a break at this stage. Would that
   8     be convenient, sir?
   9   THE CHAIRMAN: Yes. Shall we have a break for lunch until
  10     1.30?
  11   (12.50 pm)
  12            (Adjourned until 1.30 pm)
  13   (1.30 pm)
  14   MR LANGSTAFF:  We have been looking then at March 1990.
  15     Did you during 1990 become aware of any further
  16     concerns, following this meeting, about the progress of
  17     paediatric cardiac surgery?
  18   A. There would be a number of conversations about the
  19     performance, as you would amongst clinicians. I cannot
  20     think of anything specific.
  21   Q. At some stage you and Dr Bolsin, and there may well have
  22     been others, had a concern, did you, about the arterial
  23     switch results?
  24   A. Yes, indeed. The arterial switch programme had started
  25     before my appointment as a Consultant and, although I

   1     was there as a Senior Registrar, I was not aware of how
   2     that was structured to begin, and that the number of
   3     deaths in that programme was high, and that concerned me
   4     and I would have spoken to a number of people about it.
   5   Q. Such as?
   6   A. Dr Bolsin, Dr Masey.
   7   Q. All anaesthetists?
   8   A. I would have spoken to Mr Dhasmana about it, because it
   9     affects the whole -- as we intimated before, it is the
  10     whole process from referral, diagnosis, preparatory
  11     assessment, anaesthesia, surgery and the intensive care,
  12     but my personal sort of professional network would have
  13     been more with anaesthetic colleagues and with surgeons
  14     than with the cardiologists.
  15   Q. So you recollect, do you, in 1990 discussing the
  16     mortality from arterial switch operations with
  17     Mr Dhasmana?
  18   A. I think that Mr Dhasmana would speak about why a certain
  19     operation had not gone well or had gone well, whether it
  20     was the death of a child or not. He did not retreat to
  21     his room and not discuss it.
  22   Q. Was this a discussion about particular operations or
  23     about that series of operations in general?
  24   A. I anaesthetised four switch cases, two of whom died, and
  25     he and I would have had specific conversations about the

   1     reasons for the death of the child. We would speak as a
   2     group about how better we could perform in that field.
   3     It was new. It was not -- it was something that was
   4     being introduced and, therefore, required discussion.
   5   Q. In 1991 there was a meeting, was there, chaired by a Dr
   6     Williams, who I think was then, was he, the Director of
   7     Anaesthesia?
   8   A. He was my Director of Anaesthesia.
   9   Q. And the cardiac anaesthetists, I am asking, did they
  10     meet, do you recollect, in 1991 in order to discuss in
  11     particular the switch operation and mortality at it?
  12   A. We had had a number of meetings where we met informally
  13     to discuss globally anaesthesia, and switch would have
  14     been a subject for discussion, and the mortality figures
  15     would have been spoken of.
  16   Q. Can we have on the screen, please, UBHT 61/49? This is
  17     a calendar of events which was produced by Dr Bolsin,
  18     even although, as you can see, it was supplied to our
  19     files from Mr Wisheart.
  20   A. Uh-huh.
  21   Q. If you look down at the third bullet point:
  22        "Meeting of Cardiac Anaesthetists with Director of
  23     Anaesthesia and President of the Association of
  24     Anaesthetists ... agrees:
  25        (i) results of arterial switch not acceptable.

   1        (ii) matter to be taken up by Directorate.
   2        (iii) Dr Bolsin not to be vehicle for criticism".
   3        Does that particular meeting ring a bell with you?
   4   A. Yes. I think that the three conclusions that the
   5     meeting came to reflect the fact that we discussed the
   6     results of the arterial switch and that the view put
   7     forward was that the mortality was high; that Dr Bolsin
   8     had already written a letter, as pointed out in bullet
   9     2, which meant that he had been criticised for the
  10     format of that, and, therefore, the Directorate should
  11     take it forward. My understanding is that Dr Williams
  12     did speak to Mr Wisheart.
  13   Q. So is this right then, that the meeting agreed that the
  14     results, as the anaesthetists saw them, of the arterial
  15     switch programme were unacceptable?
  16   A. Well, this is the calendar of events recorded by
  17     Dr Bolsin.
  18   Q. Which is why I am asking for your recollection?
  19   A. Therefore, my recollection would have been there were
  20     concerns over the number of deaths that had occurred in
  21     that programme and that the way forward would need to be
  22     discussed and changed. I would not have been able --
  23     I do not think I at that time said that the programme
  24     was not acceptable and therefore must stop, because
  25     there were reasons why it was not necessarily the

   1     surgeon's fault, or the cardiologist's fault, or the
   2     anaesthetist's fault that the child had died, and that
   3     the system in the light of that experience could
   4     improve. It becomes very difficult when you are in the
   5     middle of the process to determine with clarity at which
   6     point it is unacceptable, and I doubt that the meeting
   7     came to that conclusion in the tenor of that sentence or
   8     bullet point.
   9   Q. What then do you recollect that Dr Williams was going to
  10     raise with Mr Wisheart?
  11   A. The conversation between Dr Williams and Mr Wisheart I
  12     presume would have reflected the discussions of that
  13     meeting. I do not know what he said to him.
  14   Q. Well, presumption is one thing. Do you recollect there
  15     being a meeting at which it was agreed that Mr Williams
  16     would speak to the cardiac surgeons?
  17   A. Dr Williams and I after this discussed it, and he said
  18     that he would take responsibility of speaking to
  19     Mr Wisheart, and I believe he did so.
  20   Q. On what do you base your belief that he did so? Did he
  21     report back to you?
  22   A. I think he told me, yes.
  23   Q. What Dr Bolsin said about this particular meeting at the
  24     GMC was this, and for those who have the GMC transcript
  25     it is Day 6 of that transcript from line 22 onwards. I

   1     will just read it out to you, because I have not got it
   2     scanned in to show you, and so I will take it slowly:
   3        "The advice of the meeting", he said, "was partly
   4     to the Director of Anaesthesia and Dr Monk, who at that
   5     stage had been nominated to a sort of ex officio post of
   6     Cardiac Liaison Anaesthetist, so that he was the person
   7     of the Cardiac Anaesthetists who would convey
   8     information between the Cardiac Anaesthetic speciality
   9     and the Cardiac Surgeons".
  10        Pausing there, as a matter of fact, did you occupy
  11     a position such as that?
  12   A. I occupied that position. It was ex officio and --
  13   Q. As he says. He goes on:
  14        "The advice to me", that is Mr Bolsin, "and it was
  15     from Peter Baskett, and it was in his particular style,
  16     as he is a Territorial Army officer -- what he said was,
  17     'Steve, you've got to keep your head down. We're going
  18     to take this one on for you and you've got to give us
  19     the information and we'll go and deal with this'. The
  20     advice to Brian and Chris was that this information had
  21     to be conveyed to the surgeons and it had to be dealt
  22     with, and it was not now Steve's job to continue, and
  23     I think Peter probably said something like 'to harp on
  24     about the paediatric results'".
  25        Do you recollect something along the lines of

   1     Peter Baskett saying to Dr Bolsin: "Steve, you've got to
   2     keep your head down. We're going to take this one on
   3     for you and you've got to give us the information and
   4     we'll go and deal with it"?
   5   A. The advice to Dr Bolsin was that the format of the
   6     letter in 1990 was an inappropriate way forward. The
   7     information that Dr Baskett alluded to beyond the
   8     results of the switch, I do not think there was any more
   9     data requested or looked for, and that the concern at
  10     this point was specifically about the arterial switch
  11     programme. Whether Dr Baskett took the matter on
  12     himself, as seems from the tenor of Dr Bolsin's evidence
  13     to the GMC, I do not think he did so.
  14   Q. Partly that is the problem of not having the words in
  15     front of you. What Peter Baskett is recalled by
  16     Dr Bolsin as having said was: "We", and I think that
  17     means the Cardiac Anaesthetists as a group, "are going
  18     to take this one on for you and you've got to give us
  19     the information and we'll go and deal with this" and
  20     then the suggestion that Brian Williams and Chris --
  21     that is you, I think -- had to convey that information
  22     about the switch to the surgeons?
  23   A. Okay. Dr Williams did approach Mr Wisheart with the
  24     views of this meeting. The Liaison Cardiac --
  25   Q. Can I stop you there? I will let you finish in a

   1     moment. Was there something to the effect to Steve
   2     Bolsin of: "Let us deal with this. You don't bother for
   3     the moment", something along those lines?
   4   A. On the issue of arterial switches at that meeting that
   5     would be a reasonably accurate impression that I would
   6     have gained from it. Dr Bolsin had written a letter
   7     which produced upset amongst colleagues and, therefore,
   8     for him to go to Mr Wisheart and say: "This is a
   9     problem" would be difficult.
  10   Q. Just so that there is no misunderstanding about the
  11     letter, the letter we are talking about is UBHT 52/290.
  12     Can we have that on the screen? It is addressed to
  13     Dr Roylance as the District General Manager pre-Trust.
  14     It is talking about the application for Trust status.
  15        Scroll down to the bottom. It is the penultimate
  16     paragraph:
  17        "I would have thought the management directive to
  18     improving quality of patient care should have attempted
  19     to address the unfortunate position of the South West
  20     Regional Cardiac Centre's mortality for open heart
  21     surgery on patients under one year of age. This, as you
  22     may or may not know, is one of the highest in the
  23     country, and the problem should be addressed".
  24        He had sent a copy of that to Dr Williams, amongst
  25     others, as we can see from the bottom. That is the

   1     letter, is it?
   2   A. That is the letter, yes.
   3   Q. What were the criticisms addressed to Dr Bolsin about
   4     the letter?
   5   A. The knowledge I have of this is when Dr Williams asked
   6     me for my opinion on this letter, when I think
   7     Dr Roylance had questioned Dr Williams on why Dr Bolsin
   8     had written it. It says quite clearly that the
   9     mortality for the unit was one of the highest in the
  10     country, and that it needed to be addressed, and I think
  11     that is a correct statement. Why there was such
  12     difficulty over that statement I am not sure, but the
  13     response was that it was not an appropriate -- my
  14     impression was that the method of raising the matter in
  15     this form with Dr Roylance was inappropriate.
  16   Q. That message had come back to Dr Bolsin just from Dr
  17     Williams or --
  18   A. I do not know whether it came back to Dr Bolsin, but
  19     that is my knowledge of the letter, because Dr Williams
  20     spoke to me about it.
  21   Q. So it was this letter that was discussed together with
  22     the arterial switch programme at the meeting in 1991,
  23     was it?
  24   A. I cannot recall this letter being discussed at the
  25     meeting. The effect of the criticism of Dr Bolsin in

   1     raising it this way may well have been discussed and,
   2     therefore, Dr Bolsin's profile would have been higher
   3     than perhaps was thought suitable to raise the
   4     paediatric switch programme with Mr Wisheart.
   5     Therefore, Dr Williams took it on, as the Chairman of
   6     the Anaesthetic Department at that stage and then the
   7     Director.
   8   Q. Because presumably that is part of the function of the
   9     Chairman of the Department of Anaesthesia, is it?
  10   A. The responsibility for this had been put upon
  11     Dr Williams by that group of Cardiac Anaesthetists. The
  12     data was clear and, therefore, I would expect him to
  13     take it.
  14   Q. What Dr Bolsin went on to say at the GMC was this. He
  15     was asked a question:
  16        "Question: You weren't to be the conduit, but
  17     somebody else was or two people were. Tell us: to whom
  18     was this concern to be taken?"
  19        The answer, and this is the answer I want you to
  20     concentrate on:
  21        "Answer: The two people, Brian Williams and James
  22     Monk, were to go to James and Janardan and try to find
  23     out what the figures were, how they compared and what
  24     the route for improvement was."
  25        You are going to tell me in a moment that you and

   1     Dr Williams discussed the matter and decided that
   2     he would take matters forward. In terms of the meeting,
   3     is that an accurate reflection, as you recall it, of
   4     what the meeting had said; basically: "Dr Williams, you
   5     are the Chair of Anaesthesia. Dr Monk, you are Liaison
   6     Cardiac Anaesthetist. Would you take this forward for
   7     us, the anaesthetists?"
   8   A. It was taken forward, and the task was given to
   9     Dr Williams and myself, as Liaison Consultant. The form
  10     in which it was taken forward was not discussed.
  11        If I may, a point of clarification. The title
  12     "Lead Cardiac Anaesthetist" reflected more the fact
  13     that when you were trying to run the service, to adapt
  14     it, to give Dr Williams advice in how many consultants
  15     would be needed if you increased the service by 200
  16     cases a year, that was more the role of the Lead Cardiac
  17     Anaesthetist. We were equal people and one person had
  18     to handle some of the paperwork. That was my role. It
  19     is not really a person who is leading the group onwards
  20     with his own, clear, personal vision of the future. We
  21     were very much a cooperative group of anaesthetists.
  22   Q. You say that Dr Williams told you later on that he had
  23     raised the matter with Mr Wisheart. What was the upshot
  24     of that? Any further developments?
  25   A. I think that the surgeons were aware of the switch

   1     programme, and there were discussions ad hoc to try to
   2     see ways in which it could be improved. I do not think
   3     that there was any greater intent to this meeting than
   4     that.
   5   Q. Moving then from this stage in 1991, can we have a look
   6     at UBHT 54/84? What we can see, if we look at this list
   7     -- can we turn over the page, please? Thank you. Can
   8     we go on? It takes us through the whole period up to
   9     1995 -- a list of the various different switch
  10     operations. Go back, please, to the first page. Can we
  11     have the second? Thank you.
  12        By the end of 1991 there had been, I think, a
  13     death rate of some 50 per cent in the operations looked
  14     at on information such as this. Was that the sort of
  15     information which you had at the end of 1991 or not?
  16   A. As part of the Cardiac Anaesthetists who were providing
  17     anaesthesia, I was aware of the mortality and morbidity,
  18     yes. In this level of detail, on a piece of paper
  19     I would not have it.
  20   Q. So did you make any particular requests yourself for any
  21     data as to the switch operation?
  22   A. To whom?
  23   Q. Well, you were the Liaison Lead Cardiac Anaesthetist.
  24   A. As I have already said, that was a matter of a person
  25     dealing with administrative roles that arise between the

   1     coordinating of two services which are in the
   2     Directorate. I did not feel that I had a role in
   3     producing audit for the group or producing figures for
   4     the group. Therefore I did not see that that was my
   5     responsibility.
   6   Q. Immediately or very shortly after this, 1992, there were
   7     publications in successive editions of "Private Eye", to
   8     which you have already referred. Then at some stage you
   9     went on a trip to Russia with Dr John Zorab, amongst
  10     others, no doubt?
  11   A. Yes.
  12   Q. When was that trip?
  13   A. I think that is earlier than 1992. I think it was in
  14     1990 or 1991.
  15   Q. What time of the year?
  16   A. It was autumn. It was cold -- or was it -- April. It
  17     was April, because it was springtime. They had two days
  18     of snow, two days of rain and two days of sun.
  19   Q. Your wife went with you, did she?
  20   A. She did indeed.
  21   Q. Did you talk to Dr Zorab about any worries and concerns
  22     that you had about the operative treatment?
  23   A. We had a conversation in the hotel room that I was
  24     staying in, which had an area to sit in, and the
  25     conversation was concerning the paediatric cardiac

   1     programme. My impression at that time was that Dr Zorab
   2     had already had a conversation with Dr Bolsin and he was
   3     asking for my impression. My impression at the time, as
   4     I have said in my statement, is that it was not a unit
   5     that was performing at the top of the table and,
   6     therefore, it needed to be improved.
   7   Q. I was obviously in error in taking you into 1992 from
   8     your recollection of your meeting with Dr Zorab, and you
   9     say the impetus for that conversation came from Dr Zorab
  10     rather than from yourself?
  11   A. I could not recall where the impetus for that meeting
  12     came from. All I said was I had the impression that
  13     Dr Zorab already had some insight into it. He was one
  14     of Bristol's, the UK's and the world's senior
  15     anaesthetists. He was aware of many things that were
  16     going on throughout Bristol, and he came to me and we
  17     discussed many, many things, one issue of which was the
  18     cardiac surgical performance in Bristol, and I gave him
  19     what insights I had into that, because I was part of it.
  20   Q. Did he suggest any way forward?
  21   A. I believe that he went and spoke with the Royal College
  22     of Surgeons.
  23   Q. Is that what he told you he was going to do or is that
  24     something you know after the event?
  25   A. This is an addition. If you asked me what my

   1     recollection is of what he said we should do, it is
   2     none. I cannot recall what we decided to do.
   3   Q. In any event, may I ask you to look now at UBHT 61/145?
   4     You see what this is. It is attached minutes of
   5     meeting. It is from Dr Bolsin to, amongst others,
   6     Mr Dhasmana, Mr Wisheart, Dr Burton, Dr Masey and
   7     yourself.
   8   A. Uh-huh.
   9   Q. The date is September of 1991. Can we look over the
  10     page and see the minutes themselves? It is July 1991.
  11     Can we go down to the "Introduction", please? Before I
  12     ask you more about the first paragraph and
  13     "Introduction", do you recollect how this particular
  14     meeting came about? It is the Paediatric Cardiac
  15     Surgical and Anaesthetic Group.
  16   A. There was a series of meetings that were held before --
  17     I think it started before I was appointed, where the
  18     Paediatric Cardiologists, the Paediatric Cardiac
  19     Surgeons and Paediatric Cardiac Anaesthetists met to
  20     discuss the performance and the treatment protocols in
  21     its broadest sense, not written down, of how they dealt
  22     with the children to be treated, and that they used it
  23     as a forum to look at ways in which they could develop
  24     the service and to reflect upon problems of the past
  25     year. It would be broad both in the context of the

   1     meeting, and I think occasionally specific if a certain
   2     problem had arisen, but this meeting seemed to be only
   3     with the surgeons and anaesthetists, and I think the
   4     number one item on the agenda is quite important,
   5     because it was over the question of pulmonary
   6     hypotension, which at that time -- and I remember it
   7     well, as a Senior Registrar, because it predates this --
   8     was a major problem for the unit for a number of
   9     reasons.
  10        There was an initiative, a feeling, amongst the
  11     anaesthetists that the use of phenoxybenzamine, which is
  12     a drug that is commonly used in this condition, should
  13     be introduced to our unit. It was. We then had to look
  14     at what the dosages were, when we gave it, how we gave
  15     it and what we did about it. It was adopted as a
  16     technique and it made quite a difference to the unit.
  17   Q. Just a bit of background to see if I am right on this,
  18     and it may be that I shall be corrected from my right.
  19     Phenoxybenzamine is a vasodilator, is it?
  20   A. Yes. It is a drug that specifically binds irreversibly
  21     to the receptors to produce both arterial and venous
  22     dilatation. That affects the cardiovascular system and
  23     changes it from one -- tends to make it go to a high
  24     flow/low resistance system as opposed to what is
  25     possibly a low flow/high resistance system. It is the

   1     former which is preferable.
   2   Q. So if you have, for instance, problems with pulmonary
   3     hypotension, high resistance in the lungs, if you dilate
   4     the vessels, then there can be a greater flow through
   5     and that has a general systemic improvement?
   6   A. Yes, and if you can improve the oxygen delivery
   7     throughout the body, you decrease the chances of
   8     multi-organ failure and the child is much more able to
   9     deal with the stresses of having had an operation.
  10   Q. This is a drug which the keenness for had something to
  11     do with Roger Mee's work in Melbourne, did it?
  12   A. Yes.
  13   Q. So it is --
  14   A. It had been adopted in other centres throughout the
  15     world, and at that meeting or a previous meeting about
  16     that time Dr Wolfe, who is a paediatric anaesthetist at
  17     the BCH now, had come along with his experience as
  18     well. There were two or three meetings to discuss the
  19     drug, to produce a protocol of using it, to use it and
  20     then to reflect upon the experience.
  21   Q. If I may just have a bit of expert input here, it is a
  22     drug which is not without its critics, is it?
  23   DR SUMNER:  I am a critic of the drug actually. I think
  24     the problem -- Dr Monk has beautifully explained it
  25     really. We are looking for drugs in pulmonary

   1     hypotension that act on the lungs. Unfortunately until
   2     very recently all the drugs we used acted both on the
   3     systemic resistance and the pulmonary resistance. So
   4     what we were seeing with the use of phenoxybenzamine,
   5     which is a profound vasodilator and hypotensive agent,
   6     which causes a major fall in blood pressure, is the fact
   7     that its effect was not confined to the lungs. So I
   8     never liked its use, because the patients were always
   9     far too hypotensive. I acknowledged that it was used in
  10     other centres. I personally never liked it, and I was
  11     very glad when we decided to give it up.
  12   Q. So what we are talking about here is not something which
  13     in any way one could criticise Bristol for not having
  14     used before. It is a drug of choice and there are pros
  15     and cons to be weighed. Is that the position?
  16   A. Absolutely. I like the way this problem was obviously
  17     discussed and they took on board what other centres were
  18     doing and went ahead and did it themselves, but I do not
  19     like the drug and I never wanted to use it.
  20   Q. So there inevitably would have to be discussion,
  21     agreement and you approve of the process. I saw, as you
  22     were talking, Dr Macrae from his experience nodding, so
  23     there is general agreement, I think, on this. There is
  24     no criticism of it not having been used, approval of the
  25     process by which it is introduced and reviewed. Plainly

   1     an important issue that justified it being number one on
   2     the agenda.
   3        Can I come to the "Introduction," because the
   4     "Introduction" does not perhaps relate to the agenda as
   5     such, but Mr Wisheart is described as providing tables
   6     of the results with a comparison. Then this is said:
   7        "Mr Wisheart said that he thought the tables
   8     demonstrated that the problem which had been thought to
   9     have been reaching crisis proportions in the Bristol
  10     unit when put in context was actually not as serious as
  11     had been thought".
  12        Are those words, "thought to have been reaching
  13     crisis proportions", an accurate reflection of what was
  14     said at the meeting, so far as you recollect it?
  15   DR MONK:  I do not recollect that we were describing it as
  16     a crisis, and I think that this is a recollection put in
  17     the terms of Dr Bolsin's own thoughts on that meeting.
  18     It was not a meeting of such heat or emotion that we
  19     would be going around saying: "We have a crisis", and,
  20     therefore, that would not be my recollection of the
  21     tenor of the meeting.
  22   Q. I think, to be fair to Dr Bolsin, what is being
  23     suggested here is that if there had been a crisis, it
  24     was now over, and it may be that people are prepared to
  25     talk about a crisis in retrospect in a way they may not

   1     be inclined to talk about it in the present?
   2   A. I cannot say if he was saying that. It actually says
   3     that the problem was not as serious as had been thought,
   4     which seems to mean that with reflection and data the
   5     problem was not as prominent in reality as it seemed to
   6     be in coffee room discussion.
   7   Q. What is implied by that is that there was a recognition
   8     in Mr Wisheart's mind and in what he said that there had
   9     been problems which were thought to be problems of high
  10     mortality rates. Is that a fair reflection of what was
  11     said or not?
  12   A. You can deduce from the fact that we were at this
  13     meeting discussing how we improve our outcome that he
  14     was aware of the figures, yes.
  15   Q. The next paragraph:
  16        "Dr Bolsin ... thought that the data ... in which
  17     the Bristol mortality was higher than the UK average for
  18     the two years prior vindicated the vigilance of the
  19     anaesthetic staff in recording their mortality data and
  20     vigorously pursuing requests for a combined meeting.
  21     This point of view was supported by Dr Burton, Dr Masey
  22     and Dr Monk".
  23        Is that a fair recollection of the discussion
  24     which you recall taking place?
  25   A. It would be important to continue to collate the data of

   1     the unit's performance and discuss it, and anaesthesia,
   2     cardiology and surgery should be involved in those
   3     meetings, and to put it in black and white, to emphasise
   4     that, would be quite reasonable, yes.
   5   Q. There are two parts to the question really. Plainly
   6     what you say is sensible. The question that I was
   7     actually asking you is, albeit it is sensible, was it
   8     said, as far as you recollect, at this meeting? Leave
   9     aside whether it is true or not. Was it said, something
  10     along those lines?
  11   A. It may well have been said.
  12   Q. And, if it had been said, you think it is the sort of
  13     view you might well have supported?
  14   A. Absolutely, but I am a bit concerned that the opposite
  15     could then be drawn, that the surgeons were not giving
  16     the data to the group, because it says quite clearly
  17     that the figures were presented, but the figures were
  18     presented in the format of the Cardiac Surgical
  19     Register.
  20   Q. Yes. So there is a reflection of a meeting in which
  21     Dr Bolsin is saying: "Look how well we have done
  22     examining this". The surgeons themselves are saying:
  23     "This is the data and it is not actually as bad as we
  24     thought". That is a reflection of what is said or
  25     recorded in the "Introduction". Do you know how bad the

   1     surgeons or anaesthetists had, prior to this meeting,
   2     thought that the data was probably?
   3   A. The anaesthetic opinion on the performance of the unit
   4     varied between individuals. There was a spectrum of
   5     opinion, and it was expressed by the anaesthetists
   6     differently, and there was a range with, I suspect, Dr
   7     Bolsin on one end of the spectrum and others at the
   8     other end, and, therefore, our own perceptions of the
   9     performance varied markedly.
  10   Q. Where were you in the spectrum?
  11   A. I was closer to the Bolsin end than the other side.
  12   THE CHAIRMAN:  May I ask one question about that memo which
  13     is in front of you? Where it says:
  14        "The vigilance of the anaesthetic staff in
  15     recording their mortality data",
  16        who is the "their" there?
  17   A. I imagine it is the data that belongs to the individual
  18     anaesthetists in looking at their work during the year.
  19     It is not -- I would read it as it is not "their
  20     mortality" as in referring to the surgeons, but if you
  21     summate each of the anaesthetic log books, you should
  22     end up with the unit's activity. However, in reality if
  23     you asked us to do that, and looked at the PATS forms
  24     and the surgical register and any other register, the
  25     figures would not be in accord. It vindicates that

   1     "vigilance" is hyperbole really.
   2   Q. Following "their mortality data", it is suggested that
   3     the anaesthetists had vigorously pursued -- leave aside
   4     the hyperbole -- requests for a combined meeting. Had a
   5     combined meeting of anaesthetists and surgeons then been
   6     sought for some time?
   7   A. Reading the minute, I cannot put that sentence together
   8     with a meeting that had occurred or not occurred. It is
   9     a statement and it does not fit with my recollection of
  10     what was going on. There were meetings of all the
  11     specialties together to discuss the paediatric
  12     programme. This meeting was called because it was
  13     looking specifically at the treatment of children within
  14     the BRI area and, therefore, reflected intra-operative
  15     and post-operative care rather than the pre-operative
  16     care, because, although the viewpoint of the
  17     cardiologists would be important in the use of
  18     phenoxybenzamine, we were trying to talk about how we
  19     would do it in reality.
  20        Beside this would be another conversation at this
  21     meeting that would talk about the age of referral of
  22     children with anatomical lesions that would produce
  23     pulmonary hypotension, because it is a change in the
  24     lungs that occurs with time. Therefore, if you can
  25     intervene earlier, then perhaps your requirement for

   1     phenoxybenzamine is less, but the style of the unit was
   2     that we operated on children later than you would have
   3     done at Great Ormond Street. A goal that would have
   4     been reiterated or discussed at this meeting would have
   5     been to move the children towards a younger age group.
   6   Q. There is material which supports you on that, if we go
   7     to 61/150. It is the same meeting. At the top of the
   8     page Mr Wisheart is recorded as saying:
   9        " ... in view of the Melbourne and recent Great
  10     Ormond Street experience, these patients suffering from
  11     AVSD should be operated on at a younger age",
  12        and the proposal was accepted at the meeting.
  13        Given the time, 1991 -- again may I turn to our
  14     experts -- there been recent research at that stage
  15     published, had there, as to the age at which it was
  16     desirable to operate?
  17   DR SUMNER: Well, I think that it was a collective view that
  18     it was desirable to operate on patients with pulmonary
  19     hypotension as early as possible, because if you leave
  20     it too long, they get irreversible changes in the lungs,
  21     which may make operative procedures impossible.
  22     I think, as often in Great Ormond Street, we were
  23     following or in parallel with other major centres such
  24     as Boston, Massachusetts, and their policy was always to
  25     operate on patients at the very earliest opportunity,

   1     and with bypass procedures and intensive care improving
   2     all the time, we were getting greater successes.
   3     I think the long-term follow-up -- I am not a
   4     cardiologist -- of early operated patients was better
   5     than if they were operated later.
   6   Q. May I ask, Dr Macrae, does a failure to operate at a
   7     young age and thereby begin to develop the changes in
   8     pulmonary vascular resistance compromise the chances of
   9     survival in ITU?
  10   DR MACRAE:  Yes. I think the later the operation, the more
  11     complicated one expects the intensive care to be, the
  12     main complication being a far higher risk of severe
  13     pulmonary hypotension, which is potentially, at its most
  14     extreme form, life-threatening.
  15        To go back to the issue of the era, I think the
  16     Roger Mee's group in Melbourne published their results
  17     of early repair in the early 1990s. I am aware of that
  18     paper. I am afraid I cannot quote the exact reference,
  19     but it is not difficult to track it down. That is the
  20     time when I think people really took seriously the
  21     concept of early operation in the first months of life
  22     rather than waiting until nine or twelve months.
  23   Q. In terms of timing, Bristol here were in line, were
  24     they, with what one might have expected?
  25   A. I think they were in line with the situation as it

   1     existed in Great Ormond Street in the late 1980s, early
   2     1990, yes.
   3   Q. That then was a meeting in July 1991.
   4        Moving on to 1992, as we said, we had the letters
   5     published in "Private Eye", and the response to that,
   6     was that to inhibit the further free discussion of the
   7     sorts of statistics that had been looked at, as we have
   8     seen, in 1990 and, as mentioned in these minutes,
   9     comparative data in 1991?
  10   DR MONK:  As I said this morning, I believe that was so.
  11     For background information, my attendance at these
  12     meetings was difficult, because they were frequently
  13     scheduled to be a Thursday, which gave me personal
  14     conflicts that meant I was not always at all of the
  15     meetings and, therefore, at meetings things may be
  16     discussed, may be put forward and acted upon that
  17     I would not be aware of.
  18   Q. The meeting that we have just been looking at, still on
  19     the screen, does not appear to have discussed the switch
  20     operation as such. This is looking at other concerns in
  21     relation to paediatric cardiac surgery. Were the
  22     concerns then about outcome general and not just limited
  23     to the switch?
  24   A. The data that you could get from the UK Registry showed
  25     that our unit was not the best. It was at the bottom of

   1     the table. Therefore, you would look across the whole
   2     of the service, at all the operations, at the way in
   3     which the patients were referred, the way in which they
   4     were treated in intensive care, and you would try to
   5     make improvements.
   6        From my point of view, something that was
   7     important was to get the funding, to get intensivists
   8     appointed into the Cardiac Intensive Care. This was a
   9     lead that was going on around the world, but it was an
  10     evolving situation where people have different ideas and
  11     viewpoints and come to different conclusions on
  12     different occasions. But the Intensive Care would and
  13     did and has benefited by having a clinician in that
  14     specific role. At that time we did not have it.
  15        So that would be a concern about the whole
  16     programme. It could go right down to: "What are we
  17     doing about Fallot's?", because we were doing very
  18     successfully in 1986 to 1989, or whatever, but look at
  19     1990. Many issues would be talked about at these
  20     meetings in order to look at the whole system.
  21   Q. Can I go back to the chronology? We have dealt thus far
  22     with the period of time from 1986 or thereabouts through
  23     to the end of 1992. During the period from 1989 to
  24     1992, when you were both Consultants, you and Dr Bolsin,
  25     he had on a number of occasions discussed with you his

   1     various concerns about the performance of the Paediatric
   2     Cardiac Surgical Unit?
   3   A. We spoke on a number of meetings, ad hoc, coffee rooms,
   4     wherever, as did the other Cardiac Anaesthetists, about
   5     the performance of the unit.
   6   Q. Because you met and you chatted. It was common
   7     knowledge that that was his view, was it?
   8   A. Yes, and we worked on similar days. Therefore, we are
   9     in joint theatres, with a joint scrub-up room, with a
  10     single coffee room. You have trainees with you. You
  11     are moving around. You are covering each other to go to
  12     meetings, because there are other duties apart from
  13     being a Paediatric Cardiac Anaesthetist at that moment
  14     in time. Therefore, we would have discussed many
  15     issues, one of which would be this.
  16        Anaesthesia covers seven hospitals. It has
  17     multiple specialities. All these discussions would be
  18     going on much of the time to see how you would improve
  19     things. If you took me to another room and sat me down,
  20     doing an orthopedic list in a different theatre, and put
  21     me in the coffee room, someone would come and say:
  22     "Excuse me. We still do not have three sessions of
  23     Adult Intensive Care for general surgery for the
  24     different level of the hospital. This is risking the
  25     patients. Surely you should be treating this".

   1        So there were many, many issues that I was
   2     involved with both as an Anaesthetist and then as a
   3     Clinical Director and, indeed, now back to being an
   4     Anaesthetist again.
   5   Q. There were not only the coffee conversations and
   6     corridor conversations, but there were weekly meetings
   7     of the Department, were there?
   8   A. On a Friday morning there was an educational meeting
   9     held in the Department during term time, the aim of
  10     which was to educate both Consultants and training staff
  11     in aspects of anaesthesia, which again would be the full
  12     range from pain clinic, eye hospitals, right the way
  13     through, and also morbidity and mortality meetings,
  14     where we had a critical incident reporting system.
  15   Q. So in terms of contact between one anaesthetist and
  16     another and discussion amongst them, most anaesthetists
  17     would meet at least once a week, if not more often?
  18   A. The Friday morning meetings were difficult to attend for
  19     a number of the anaesthetists, because they were in
  20     separate hospitals. Their lists would start at 8.30.
  21     The meeting started at 7.50 and went on to 8.40. In
  22     Cardiac the list normally started at 8 o'clock.
  23     Therefore, you may find that, because of some problem or
  24     other, you could not go to the meeting. Not everybody
  25     got to Friday morning meetings consistently.

   1   Q. So far as the Cardiac Anaesthetists were concerned, did
   2     they generally get to the meetings or not -- generally?
   3   A. Generally, yes. If you took a Friday, there would be
   4     two theatres running and there would be four
   5     anaesthetists who could be rostered to be there on a
   6     Friday. Therefore, if I was rostered to be in a
   7     theatre, I was actually more concerned about providing
   8     the clinical service to the theatre than I was to go to
   9     the meeting. It is a balance. If I was not in the
  10     theatre, then my response would be to go to the Friday
  11     morning meeting.
  12   Q. Once a month on a Tuesday there would be a meeting of
  13     the Associate Directorate of Cardiac Surgery?
  14   A. That was usually in the evening at about 6.00 or 6.30.
  15   Q. Did Cardiac Anaesthetists go to that?
  16   A. Yes, Cardiac Anaesthetists went to that, again with a
  17     variable success rate, because what often happened on a
  18     Tuesday was the theatre would continue to run well past
  19     6 o'clock. Although a Consultant Surgeon could leave at
  20     that point, the Consultant Anaesthetist could not leave,
  21     because their duty of care would continue.
  22   Q. In general, given the number of meetings and the
  23     opportunity for chatting in the corridor, did most of
  24     the anaesthetists know each other pretty well?
  25   A. As colleagues, yes. Socially it varied.

   1   Q. They had a chance to chat about anything that might be a
   2     concern of theirs?
   3   A. They would have that opportunity. Whether it would be
   4     felt that it was an appropriate place or time or whether
   5     there was enough time to do it --
   6   Q. Whether they took it is another matter, but they had the
   7     opportunity?
   8   A. The opportunity would be there.
   9   Q. The concerns that you knew of and talked about with
  10     Dr Bolsin about the general performance of Paediatric
  11     Cardiac Surgery, because that was an area of work in
  12     which you were both involved, were they shared by the
  13     other anaesthetists who did that sort of work?
  14   A. I think I have said that the views on the performance of
  15     the cardiac service varied between the anaesthetists and
  16     therefore --
  17   Q. There is a spectrum.
  18   A. -- there is a spectrum, yes.
  19   Q. But you talked about it?
  20   A. Yes.
  21   Q. After the events of 1991 and the "Private Eye" article
  22     came out, what was the response of the Paediatric
  23     Cardiac Anaesthetists to the data which they had seen
  24     paraded in the columns of that journal?
  25   A. I think the main response was to do with the shock of

   1     seeing that information in that magazine, and the shock
   2     that sort of -- the confidentiality of audit had been
   3     broken, that patients' -- not direct details -- details
   4     of patient care were there to fill column inches and to
   5     sell a magazine. It was felt that that was very
   6     unprofessional.
   7   Q. Was there any further discussion about whether, although
   8     it was unprofessional to have it leaked to the press,
   9     the results were actually broadly accurate?
  10   A. It is as though "Private Eye" made the problem visible
  11     to us. That is not true. We had already had these
  12     meetings when we were discussing how we improve the
  13     service. There is an awareness throughout the whole
  14     unit of what the performance was. What there was not --
  15     what was not to hand was a mirror which said: "Here is
  16     our performance. We look in the mirror and we can
  17     compare it easily and accurately with the other
  18     institutions throughout the UK and say how good or how
  19     bad it is". The "Private Eye" articles did nothing at
  20     all to improve that situation.
  21   Q. You were appointed as the Director of Anaesthesia in
  22     1993, January?
  23   A. Correct.
  24   Q. When was it you first became aware that Dr Bolsin had
  25     conducted a survey or audit of the results of Paediatric

   1     Cardiac Surgery?
   2   A. I believe in September 1993.
   3   Q. Why do you believe that is the case?
   4   A. Because I did not write it in a diary to say that that
   5     was the date that --
   6   Q. Then how can you place it?
   7   A. Because I then asked Dr Bolsin to show me the audit on a
   8     number of occasions, and he then came to my office on an
   9     afternoon and showed me the audit. I had been told --
  10     I knew from Gianni Angelini that he had seen or had
  11     talked about the audit. The perfusionists, who had
  12     supplied Dr Bolsin with some of the information on the
  13     patients, also told me that Dr Bolsin was doing an
  14     audit.
  15   Q. Forgive me. How did it come about that you found out
  16     that he was doing the audit? Did he tell you or did you
  17     ask him if he had been?
  18   A. No. I found out about the audit because I went into the
  19     perfusionists room, where they store their profusion
  20     equipment, maintenance equipment, and indeed their
  21     computer, where their data was recorded, and one of
  22     them, or one of two people, said to me: "Do you know
  23     that Steve is looking at the data and trawling through
  24     the patients' notes?", or some similar phrase.
  25   Q. Mr Nicholson?

   1   A. Mr Nicholson and Lee Lawrence. I have and had a good
   2     working relationship with these people and they told me
   3     for whatever their reasons were.
   4   Q. Did they say it to you in passing or with concern?
   5   A. I believe they were concerned, because they understood
   6     the significance of what would be a clandestine or
   7     secret audit at that time, because it was occurring
   8     across speciality without the knowledge of the people
   9     who were performing the work. Therefore, it was obvious
  10     that it was going to cause a negative reaction rather
  11     than a positive reaction.
  12   Q. Why do you call it clandestine if Gianni Angelini knew
  13     about it and had spoken to you about it and if
  14     Mr Nicholson and Lee Lawrence also spoke to you about
  15     it?
  16   A. Because it did not involve the process of speaking to
  17     the Consultant Anaesthetists providing the anaesthesia
  18     or the Consultant Surgeons who were performing the
  19     operations in providing the information. If he wanted
  20     to audit appropriately, then you should determine the
  21     areas and the fields that you are going to audit and get
  22     the data, so that people own the whole package. If you
  23     go off and produce an audit, the message will be valid
  24     if the data collection is good, but the methodology of
  25     acquiring that data produces a reaction, and you have to

   1     look at it in terms of 1992, when audit nationally was
   2     only just being introduced. The impressions were that
   3     the people who did the work owned the audit.
   4   Q. Well, you first knew of it, you say, September, although
   5     you are not absolutely sure of the date, I think?
   6   A. I saw the audit in October 1993.
   7   Q. And you first knew of it in September?
   8   A. Yes.
   9   Q. How was it, as you look back on it, that with the
  10     regular meetings which you have described, with the
  11     coffee conversations that you have talked about, with
  12     the close contact that there was amongst anaesthetic
  13     colleagues, with the team of anaesthetists as you
  14     describe it in your statement, that you had not known
  15     that any of this was going on until September of 1993?
  16   A. Either it was not discussed in those meetings or it was
  17     felt that it was inappropriate for Dr Bolsin to tell me
  18     that that is what he was doing.
  19   Q. How did you get on with him?
  20   A. In what period of time?
  21   Q. 1992/1993?
  22   A. Dr Bolsin and I have worked together closely. We have
  23     published papers together. We have written a chapter
  24     together. We have spoken about the way in which people
  25     are treated. In 1992 and 1993 we were close

   1     colleagues. I was a little surprised that he had done
   2     what he had done, but he may have felt that to get the
   3     data he had to restrict the people who were aware of it
   4     going ahead and, therefore, he did not tell me.
   5   Q. If he had told you that he thought the data should be
   6     collected, would you have said to him: "Do not go ahead,
   7     Steve. There are better ways of doing this", or would
   8     you have said: "You do not need to. The surgeons
   9     already have the data. We had better get it from them.
  10     We can get comparative date that way", or what?
  11   A. The data that Steve produced was very different to the
  12     other data that we had, because it looked at the
  13     operations performed rather than the anatomical
  14     diagnoses. That is quite critical when you look at how
  15     you compare your activity against the registry, because
  16     the same anatomical condition can have different
  17     operations. Therefore, when you compared our
  18     performance against the UK performance, you were not
  19     quite sure which operations went ahead. Also Steve
  20     Bolsin was surgeon-specific. Because of the impact of
  21     the "Private Eye", the amount of information we were now
  22     getting had decreased. What Steve's data did was it
  23     started to pull out specific areas more clearly than had
  24     been apparent previously and, therefore, his data was
  25     quite different. I am not sure how easy it would have

   1     been to have got that data from the surgeons, but it
   2     would have been more appropriate, in hindsight, to have
   3     approached the surgeons and said: "We want this data in
   4     this format".
   5   Q. What I asked you -- I am not sure you have answered it
   6     -- is if he had come to you at the stage, whenever it
   7     was, that he began to collect his data and said:
   8     "I think we need to collect data on this", what would
   9     you have advised him to do? To go ahead or not to go
  10     ahead?
  11   A. I think I would have been sympathetic to his intentions,
  12     but I think it should have been open as opposed to
  13     private in the way that he did it, because, having got
  14     the data, it then becomes difficult to disseminate it.
  15     The whole thing of audit, the ethos of audit that has
  16     been brought in and which has been a radical change in
  17     medicine is to make it open and owned by the people who
  18     are doing that work. Even now we have an audit system
  19     that looks at surgical and anaesthetic performance. We
  20     discuss new operations and ways in which we develop. We
  21     look at our figures. They are currently very good.
  22     Therefore, the conversations are easy.
  23        But when you get to a specific area where the
  24     performance, because it is a high risk area, that year
  25     may not be very good, then obviously, because you are

   1     examining people's performance very carefully, the
   2     conversations are difficult, but that is what we do
   3     now. In terms 1992/1993 that culture was not widely
   4     disseminated throughout the UK or within Bristol.
   5   Q. In September then you get the knowledge that he is
   6     collecting data. You say you first saw the data in
   7     October?
   8   A. Yes, that is correct.
   9   Q. At your request or not?
  10   A. I had asked Dr Bolsin on a number of occasions to show
  11     me this data.
  12   Q. How many occasions, do you think?
  13   A. Three, four.
  14   Q. And what response had you had?
  15   A. He said that he would show me the data. I would see him
  16     in the coffee room and say: "I have not seen this data.
  17     I need to see it", because people were becoming more and
  18     more aware of it. Professor Angelini had seen it and
  19     yet I had not. Therefore, I was blindsided by
  20     conversations that Professor Angelini could have with me
  21     to say: "What about this data?" "I do not know,
  22     Professor".
  23   Q. Was there a time at the end of 1993 when you went away
  24     to Trinidad with Gianni Angelini?
  25   A. That is correct. We flew to Trinidad together and back,

   1     because it was part of the team that set up cardiac
   2     surgery for Trinidad, and I was the anaesthetist that he
   3     took.
   4   Q. When?
   5   A. I am sure it is in your records.
   6   Q. It is not, the precise date. Roughly?
   7   A. Beginning of November 1993.
   8   Q. And you spoke to Gianni Angelini on that flight?
   9   A. We sat side by side. It was ten hours there and ten
  10     hours back. Apart from sitting in the cockpit of the
  11     plane, that is all we did.
  12   Q. You talked about the results of the audit, did you?
  13   A. We spoke about many issues, and I cannot recall -- we
  14     did not have the audit figures with us. We did not go
  15     through each section of what operation was doing what,
  16     but we would have talked about the concept of how we
  17     needed to improve the unit and how we would take it
  18     forward.
  19   Q. At that stage had you seen the figures?
  20   A. I am sure I had seen the figures. I did not have a copy
  21     of the audit.
  22   Q. So does that mean that you were first shown the figures
  23     but not given a copy?
  24   A. That is correct.
  25   Q. When you saw the figures in October 1993, in what form

   1     were they presented to you?
   2   A. I think the form changed between early versions and
   3     later versions, and I cannot recollect precisely, if you
   4     give me a version, which one I saw, but there was a list
   5     of operations with surgical activity and deaths. It was
   6     then followed by a page with less than -- a whole series
   7     of numbers, and then there were a series of chi-squared
   8     analyses of the data which were operation-specific.
   9     Some of those squares were also specific for surgeons.
  10        The data was expressed as a number and there were
  11     no P values attached to it, and, therefore, even though
  12     I was in the unit and I was working in it, and I was
  13     aware of what the operations were, I found the data
  14     quite difficult to interpret.
  15   Q. You say there are two or three different versions of the
  16     data?
  17   A. That is my impression, yes. I only find one version in
  18     my -- that I own, as it were, but I felt that the data
  19     evolved with time.
  20   Q. And how was it that you were able to realise that the
  21     data evolved with time if you did not have a paper copy
  22     of the data itself --
  23   A. Because I think that --
  24   Q. -- to compare with later versions?
  25   A. Because I think that the headings of dates in one

   1     version was handwritten or hand altered. In other
   2     versions the dates were more clearly laid out. But the
   3     changes were relatively superficial. I do not know
   4     whether the numbers within the data changed or not.
   5   Q. So you do not actually know that there were different
   6     versions?
   7   A. I will say categorically there were different versions,
   8     because, to my recollection, the headings on the pieces
   9     of paper with the different charts changed.
  10   Q. To what extent did it affect your confidence in the data
  11     that there were different versions of it presented
  12     sequentially to you?
  13   A. I think the work that Dr Bolsin undertook was very
  14     difficult and was time-consuming. That the data altered
  15     with time merely reflected the time he was able to spend
  16     in producing the audit in a format that you could look
  17     at. Therefore, it does not surprise me at all that
  18     there was one or two or three versions. In an audit or
  19     in a research paper you come out with your preliminary
  20     findings. You may present those, but when you actually
  21     come to publish the paper, the numbers are quite
  22     different, because you have had more time to process
  23     it. It does not surprise me at all that it changed.
  24   Q. What did the data purport to show, according to Dr
  25     Bolsin?

   1   A. Dr Bolsin said that it showed that there were
   2     differences in outcome that were significant between the
   3     two surgeons, and that he felt in three areas particular
   4     concern should be raised. At that time, when I had a
   5     copy and I looked at it, because the chi-squared tables
   6     did not have these P values attached to them, it was
   7     very difficult afterwards to understand what he had
   8     said. I, therefore, went at some point to see Andy
   9     Black, having sat down with a scientific table, which
  10     would give me the P values to look through the data.
  11   Q. When was that?
  12   A. It would be some time in the latter part of 1993 or
  13     early 1994. I would suspect the latter part of 1993.
  14   Q. Did you speak at all to either Mr Wisheart or
  15     Mr Dhasmana?
  16   A. As I have said in my statement, I did not take the audit
  17     to either Mr Wisheart or Mr Dhasmana. I spoke with both
  18     of them about my concerns. The reason for that is that
  19     the audit I had got from Steve was not verified. He
  20     showed it to other colleagues, who felt that the VSD
  21     data in particular was not accurate, and their opinions
  22     as to what the data meant varied. To take that forward
  23     to James Wisheart, who was fully conversant with his own
  24     figures, I think would have been inappropriate, because
  25     I would not be able to achieve the change that I wanted,

   1     which was that we looked anew at the paediatric process
   2     and got a joint opinion of what was good and what was
   3     bad in a different way. Therefore, I needed to get a
   4     joint opinion of my colleagues, and that is specifically
   5     the Cardiac Anaesthetists, in order to discuss this
   6     data, to put it into context, to be able to challenge
   7     some of the figures within it and then go forward with
   8     what would be a team approach.
   9   Q. So what you were looking to achieve by having data
  10     available was a review of the effectiveness of
  11     Paediatric Cardiac Surgery, was it?
  12   A. Dr Bolsin had produced data which looked at the
  13     paediatric programme in a different way to the ways that
  14     we had previously considered it. Therefore, it gave a
  15     different light, and in that light I thought it was
  16     appropriate that we should, as a global group, because
  17     this is an institutional process -- it is not just, you
  18     know, the surgeon -- that we should look at that
  19     information.
  20        I did not feel that it was strong enough, robust
  21     enough, that I could take it directly to Mr Wisheart and
  22     say: "Here you are", because I think that he would have
  23     raised points that I could not answer about: "How did
  24     the audit take place? How was it performed? What were
  25     your criteria for selecting these epochs?" Therefore,

   1     very quickly I would be unable to make the point I
   2     wished to make.
   3        The other Cardiac Anaesthetists were similarly
   4     shown the data in coffee rooms, etc. What I wanted was
   5     to produce a forum where initially the Cardiac
   6     Anaesthetists spoke about the data, and I asked Steve,
   7     and we discussed the need to present the data to the
   8     Cardiac Anaesthetists, and he appeared to agree with me,
   9     but we did not achieve it. We had meetings and Dr
  10     Bolsin did not come or did not --
  11   Q. Did not come?
  12   A. Did not come, because we would have these meetings ad
  13     hoc -- not ad hoc, but as planned as we could within
  14     work time, when somebody was not doing a general list, I
  15     was not away at a meeting, somebody else was not away on
  16     holiday, and you try to get everybody together to talk
  17     about it. Yet that conversation did not occur. So at
  18     that time and much later we never had a joint opinion on
  19     what the Bolsin/Black audit actually meant.
  20   Q. Were there meetings which Dr Bolsin attended and a
  21     considerable number of anaesthetists attended or not?
  22   A. I think I can recall a meeting in the Sister's office on
  23     Level 4 outside the Cardiac Theatres. Therefore, you
  24     are talking about a very small room, which has two
  25     chairs, two desks, lots of computers and filing

   1     cabinets. You have various anaesthetists perched within
   2     that room, and you are trying to discuss something as
   3     important as this. I think at that stage the main
   4     conversation may have been more about the switch
   5     programme than it was about the audit, but to discuss
   6     this, we needed to be able to sit down in a reasonably
   7     sized room and give the dedication of time to discuss
   8     it, and that did not occur.
   9   Q. So this is right, is it, that there were regular
  10     meetings involving a number of anaesthetists, that all
  11     the anaesthetists knew that Dr Bolsin had performed an
  12     audit of the sort that you have described, but that
  13     there was never any collective discussion of it?
  14   A. I cannot say that all anaesthetists knew or had seen the
  15     Bolsin data, because I do not know whom he gave it to.
  16     We did have regular --
  17   Q. Let us restrict the question -- sorry for butting in --
  18     to Cardiac Anaesthetists.
  19   A. I meant Cardiac Anaesthetists. Sorry. I was not clear
  20     in what I said. We had meetings. They were not regular
  21     in that it was the third Wednesday of the fourth week of
  22     each month, because when we tried that, it just fell
  23     apart, because of leave, etc. We had irregular meetings
  24     where we met, and the data was not presented.
  25        The final meeting that I put in my statement was

   1     just preceding the de Leval/Hunter external audit. Even
   2     at that stage we had still not sat down with Dr Bolsin
   3     and said: "What about this data?" We held that meeting
   4     and he did not come. So even when I went in to see
   5     de Leval and Hunter, we still did not have a joint
   6     opinion amongst the Cardiac Anaesthetists of what the
   7     data actually meant, nor, as a group, what we should be
   8     doing about it.
   9   Q. If I may just go back to the question which I asked you,
  10     it is, therefore, right that the data was never
  11     discussed collectively by the anaesthetists at any rate
  12     before the middle of 1995?
  13   A. It was not presented in a formal way which would enable
  14     us to discuss it. It was discussed at an individual
  15     level, which does not give you a corporate decision.
  16   Q. Essentially what I am suggesting to you is right; there
  17     was no collective discussion of it? The answer is: "No,
  18     there was not"?
  19   A. There was not.
  20   Q. Am I right in thinking that you, as Director of
  21     Anaesthesia, would have been in regular contact with
  22     others, particularly those doing cardiac anaesthesia, as
  23     part of your general job?
  24   A. I work with them, yes. I did not have to be the
  25     Director of Anaesthesia to meet them.

   1   Q. So on an individual level you would have discussed the
   2     audit?
   3   A. Yes.
   4   Q. Is it or is it not the case, as you recollect, that all
   5     the Cardiac Anaesthetists must have known that Dr Bolsin
   6     had done something along the lines that you have
   7     described?
   8   A. Yes, but whether they have seen the data I cannot say.
   9   Q. But they knew that something along those lines had
  10     happened?
  11   A. Yes.
  12   Q. Was there any pressure amongst the anaesthetists to
  13     discuss the issues?
  14   A. If by the "issues" you mean the paediatric performance,
  15     yes, we wished to discuss the audit and the performance.
  16   Q. At those meetings at which Dr Bolsin was present, at
  17     which other Cardiac Anaesthetists were present, did the
  18     other Cardiac Anaesthetists never say to him: "Well,
  19     come on, Steve. Show us your data. When are you going
  20     to make a presentation? What about this? How do we
  21     take this forward?"
  22   A. At the meeting that I can think of in the Sister's
  23     office, where we were all there, including Dr Bolsin, we
  24     asked about the data. He could not discuss it, because
  25     people were being pulled out to theatre, to go back and

   1     take people off bypass or put them back into the
   2     anaesthetic room. It was not the atmosphere or the
   3     meeting place to discuss these incredibly important
   4     figures, because what it would necessitate is that we go
   5     ahead and ask for, you know, a major formal audit, and
   6     there were very varied views on what these figures
   7     meant. We did not achieve, as I have said, a global
   8     opinion on what should be done.
   9   Q. Well, one more topic quickly before we come to our next
  10     break. You asked Steve Pryn to carry out an audit in
  11     1993, did you not?
  12   A. I did indeed, yes.
  13   Q. You were expecting him to report that audit to the
  14     anaesthetists at a meeting?
  15   A. I asked Steve Pryn to get more up-to-date information on
  16     the performance of the unit, because time had passed.
  17     Dr Bolsin's audit was over a certain epoch. I knew that
  18     that data would be important. When he was doing that,
  19     through a conversation with Professor Angelini, etc, we
  20     made another attempt to produce a forum where everyone
  21     could meet and discuss figures. Therefore, I do not
  22     think I set out with the task for Dr Pryn to produce the
  23     data to go to a meeting to present it. It was that at
  24     some -- that that data would be useful and, you know, we
  25     could then use that in context with Steve Bolsin's

   1     audit.
   2   Q. Why did you ask Steve Pryn to do it and not Steve
   3     Bolsin?
   4   A. I had already asked Steve Bolsin to verify his data.
   5     I had asked Steve Bolsin to present to us and that was
   6     not occurring. Steve Pryn is a very methodical and
   7     obsessional person about completing tasks. He was to
   8     some degree the least involved in the process, because
   9     he was the most recent appointee. It seemed
  10     appropriate, therefore, to ask him. Dr Davies did
  11     minimal, if any, paediatric anaesthesia. Dr Underwood
  12     and Dr Masey were part of the programme and Dr Pryn
  13     therefore remained.
  14   MR LANGSTAFF: Sir, would that be a convenient moment?
  15   THE CHAIRMAN:  Yes. Thank you, Mr Langstaff. Shall we
  16     take fifteen minutes and reconvene, therefore, at 3.05?
  17   (2.55 pm)
  18               (Short break)
  19   (3.10 pm)
  20   MR LANGSTAFF: Are you, then, saying, Dr Monk, that despite
  21     being the director of anaesthesia and having had some
  22     time as the liaison cardiac anaesthetist, you were not
  23     yourself able to convene a meeting of the six or seven
  24     anaesthetists, of which not all perhaps but most would
  25     turn up, at which you might discuss this data?

   1   A. Meetings were convened to discuss the data. We needed
   2     to have the data and for Dr Bolsin to present it. He
   3     did not do that. Therefore, despite having those
   4     meetings, if you cannot discuss the main subject there
   5     is little point.
   6   Q. There was a meeting for which we have variable dates.
   7     One of those dates is January 1994 -- your recollection,
   8     I think, is March 1994 -- at which a number of
   9     anaesthetists -- that is Dr Davies, Dr Pryn,
  10     Dr Underwood, Dr Masey, Dr Bolsin and yourself -- met
  11     with Mr Wisheart, Mr Bryan, Mr Hutter and possibly
  12     Drs Joffe and Martin in the seminar room at the
  13     University Department of Cardiac Surgery.
  14        To your best recollection, may that meeting in
  15     fact have been in January 1994 rather than, as you first
  16     thought it, March 1994, or for that matter as Dr Bolsin
  17     has a recollection, put it, in November 1993?
  18   A. The date I would now prefer would be January 1994.
  19   Q. Who called the meeting?
  20   A. The meeting arose because Professor Angelini and I were
  21     discussing how we would create a forum for the issues
  22     and problems of data to be discussed, and we looked at
  23     dates, we looked at venues and the meeting happened.
  24     I did not put out an agenda or a date, or whatever, so
  25     I suspect that the actual timing and venue of the

   1     meeting came from the Professor's office. However,
   2     I did contact the consultant anaesthetists, so perhaps
   3     we did look to divide that task.
   4   Q. At your statement, WIT 105/30, paragraph 30, you say,
   5     dealing with Professor Angelini "specific meetings to
   6     discuss the implications of the ... audit were ...
   7     1993 ... the outcome of the meeting between
   8     [Mr Wisheart] Professor Farndon and [Gianni Angelini] in
   9     January 1994".
  10        Was that meeting one at which you were present?
  11   A. Yes.
  12   Q. So the meeting to discuss the implications of the audit
  13     was one you had with others after those three, Professor
  14     Farndon, Professor Angelini and Mr Wisheart, had met?
  15   A. Because I had the date wrong of when the meeting
  16     occurred on level 7, I cannot put into context which of
  17     those came first.
  18   Q. What did you understand to have been discussed between
  19     Mr Wisheart, Professor Farndon and Professor Angelini
  20     before the meeting on level 7?
  21   A. I presume that the course of events, to answer your
  22     previous question, would have been that because
  23     Professor Angelini felt that the issues that they talked
  24     about in bringing forward the figures on the paediatric
  25     cardiac service had not achieved what he wanted, he, and

   1     I, may have said, "Then we must try a different route
   2     and we will have a meeting in level 7 of all the
   3     cardiologists, surgeons and anaesthetists, and get the
   4     figures presented".
   5        So it may have been that the January meeting was
   6     a direct consequence of Professors Angelini's feelings
   7     that enough had not been achieved between the meeting of
   8     these three surgeons.
   9   Q. So this meeting was by way of an unusual meeting?
  10   A. Yes.
  11   Q. And everyone participating would have realised it was
  12     a meeting for a special purpose?
  13   A. I think the people that attended the meeting expected
  14     data to be discussed about the cardiac programme.
  15   Q. The area of concern that they would have understood the
  16     meeting was called to discuss was what?
  17   A. It would have been the performance of the paediatric
  18     cardiac surgery service.
  19   Q. Did anyone prepare an agenda?
  20   A. There was no agenda produced and, as I noted, there was
  21     no Chair of the meeting. That is only in retrospect and
  22     I realise that was one of the reasons that the meeting
  23     was not as effective as it should have been.
  24   Q. Presumably at this stage Mr Dhasmana, as the Associate
  25     Director of Cardiac Surgery, might have been expected to

   1     have been in the Chair, but he was not there.
   2   A. Mr Dhasmana did not attend the meeting. I am not sure
   3     whether he expected to be in the Chair or not.
   4   Q. If he had been, he would have been?
   5   A. If he had been there, he would have chaired the meeting,
   6     but then it is difficult because of course he is part of
   7     the process being questioned, and now you have the
   8     difficulties of conflict of role and objectivity.
   9   Q. So from that description, it was understood, was it,
  10     that the meeting was a meeting to question the
  11     performance of the unit?
  12   A. My understanding of the meeting was that it would give
  13     an opportunity for the surgeons to present their
  14     paediatric data and an opportunity for Dr Bolsin to
  15     raise his data and that afterwards we could try and find
  16     a way forward to get these two groups, or parties,
  17     together and that we could resolve the differences that
  18     occurred.
  19   Q. What I am trying to probe is the views of those going
  20     into the meeting as against what they might hope to
  21     achieve.
  22        If I were a cardiac surgeon, one of the cardiac
  23     surgeons, I might ask myself what on earth am I, being
  24     a busy man, being called to this meeting for, and what
  25     would my understanding be if I were Mr Dhasmana called

   1     to the meeting or Mr Wisheart? Why should there be
   2     a meeting to discuss the results of the cardiac unit on
   3     this particular occasion as a special meeting? What was
   4     the particular concern?
   5   A. I cannot say what the feelings or thoughts were within
   6     the cardiac surgeons attending that meeting. The issue
   7     that I thought was going to be addressed was the overall
   8     performance of the meeting and that data would be
   9     presented, and, indeed, data was presented.
  10   Q. So is it your view, having been at the meeting, that the
  11     cardiac surgeons had some idea as to why they were
  12     there?
  13   A. I would have that view, yes.
  14   Q. Why do you think Mr Wisheart thought that he was there?
  15   A. I think because Mr Wisheart expected that he was going
  16     to present his data and he duly did.
  17   Q. Your perception from the time, please: why would it be
  18     that he should think he was being called upon as an
  19     unusual step in this ad hoc specially convened meeting
  20     to present his data?
  21   A. Because of the concerns that had been raised about the
  22     performance of the unit.
  23   Q. So he knew the concerns that had been raised?
  24   A. Yes.
  25   Q. And raised specifically in a manner that required

   1     addressing -- it may be perfectly capable of answer: in
   2     a manner which required addressing?
   3   A. Yes, but you are asking me what his thought processes
   4     were, and I cannot know that.
   5   Q. So far as his thought processes may have been -- and
   6     there is a purpose in this line which you will see in
   7     a moment -- from where would he have understood, as you
   8     picture it, the impetus for the meeting to have come?
   9   A. I would think that because Professor Angelini had
  10     discussed the meeting; it may well have come from him
  11     that he was activating the surgical group and I was
  12     bringing in the anaesthetic group.
  13   Q. So this may well be a case, might it, Mr Wisheart can
  14     tell us in due course, of the cardiac surgeon knowing
  15     that the anaesthetists were raising concerns about the
  16     performance of cardiac surgery?
  17   A. It could be an instance or circumstance, yes.
  18   Q. How quickly do you recollect the meeting was convened?
  19   A. It was quite short notice.
  20   Q. When you spoke around to the anaesthetists to get them
  21     there, obviously you were able to do that, did you tell
  22     them what was on the agenda?
  23   A. That there was no agenda. But I think we would have
  24     discussed the fact that this was an opportunity to
  25     discuss the data, or the lack of agreed data. But we

   1     were still, at that time, trying to produce an
   2     environment where people could talk about the
   3     differences of data and we could find a way forward. To
   4     do that, it had to be presented.
   5   Q. This would have been a perfect opportunity, one
   6     suspects, for Dr Bolsin, had he thought his data
   7     presentable, to present his data.
   8   A. The whole point of the meeting was for the data to be
   9     presented. It seemed to me to be a time at which it
  10     could be presented, yes.
  11   Q. And for Dr Pryn to present the results of the work that
  12     he had been doing at your request up until then?
  13   A. I think that Dr Pryn -- I have not spoken to him on this
  14     matter -- may not have had adequate time to produce the
  15     data in a form that was useful. I think his data was
  16     lost to discussion, as I said in my statement, because
  17     it did not match the format of the data that Mr Wisheart
  18     presented on a blackboard from memory.
  19   Q. So there was no effective Chair, you say?
  20   A. No.
  21   Q. By which I think you mean effectively no Chair?
  22   A. Yes.
  23   Q. And somehow Mr Wisheart begins the discussion, does he,
  24     by putting the figures on the board?
  25   A. Within that meeting, James Wisheart presented his data

   1     from memory, or the unit's data from memory, on the
   2     blackboard. If I recall correctly, he had expected that
   3     Mr Dhasmana would be there because Mr Dhasmana had been
   4     collating data. So what you have are a number of
   5     threads which are all happening simultaneously, that we
   6     had hoped, or I had hoped, would come together at that
   7     meeting.
   8   Q. And a small point: blackboard? White board?
   9   A. I think it is a white board, to be precise. My
  10     department has a blackboard.
  11   Q. It is just a question of, as it were, testing
  12     recollection, the one against the other, you will
  13     appreciate.
  14        Mr Wisheart presents the results. Was there any
  15     discussion about them?
  16   A. There was some discussion, but the point of the meeting
  17     was to hear another side and to look at it in
  18     a constructive way. From that point of view, the
  19     meeting did not succeed.
  20   Q. Why?
  21   A. Because there was not a Chair of the meeting and there
  22     was not an agenda. Looking back from where I sit today,
  23     or in the past few weeks, the correct path for me would
  24     have been to set an agenda and either I chaired it or
  25     Gianni Angelini chaired it and it was done in a formal

   1     way. Because it was done in a way which was not as
   2     clear as I would like to have done it if I did it
   3     tomorrow, then the meeting was already flawed.
   4   Q. At the meeting did Dr Bolsin present any of his data?
   5   A. Dr Bolsin, to my recollection, did not present his
   6     data.
   7   Q. Did he question the data that was in fact presented by
   8     Mr Wisheart?
   9   A. My recollection is that Dr Bolsin played a very minor
  10     role, if any at all.
  11   Q. Dr Pryn raised, did he, some of the figures that he had
  12     collated, and then fell into an argument as to whether
  13     he should have divided it between particular age groups?
  14   A. One of the issues that is very hard to deal with when
  15     you are looking at retrospective data, particularly in
  16     this field, is that the definition of the operation, the
  17     diagnosis of the operation, what epoch or age group you
  18     define them in, varies. Indeed, it even varies from the
  19     point whether you do it from January 1st, December 31st
  20     or whether you do it for a financial year. Whereas it
  21     seemed sensible for me to do it for a calendar year, in
  22     fact the data given centrally is for a financial year.
  23        In fact Dr Pryn discovered, to the cost of his
  24     data, that the way in which he presented it did not
  25     quite accord with the way other people were thinking and

   1     therefore, rightly or wrongly, it was dismissed as being
   2     inaccurate.
   3        But that was the atmosphere at that time, which
   4     was difficult, and his data was not in the correct
   5     format and he was unable to get his message across.
   6   Q. So the atmosphere was difficult?
   7   A. The atmosphere, as people have discussed, is where
   8     people were aware of criticisms, so it was a difficult
   9     meeting.
  10   Q. So the data presented by Mr Wisheart were inevitably
  11     presented defensively, were they?
  12   A. No, he put data on the board and in putting data on the
  13     board he listed it quickly. Data is data.
  14   Q. Can we look for a moment at UBHT 61/91? You recognise
  15     that?
  16   A. I think this is the start of Dr Bolsin's and Dr Black's
  17     audit. Am I correct?
  18   Q. Yes, and I think this -- if you turn over the page,
  19     please, and again, you see a number of figures comparing
  20     Bristol, the rest, 1989, the rest, 1991, with various
  21     percentages, and operations put down the left-hand side?
  22   A. Yes.
  23   Q. One of the points you make is that that was operations
  24     not diagnoses, and diagnoses are what appear in the
  25     Cardiothoracic Register?

   1   A. Yes.
   2   Q. If we can go on to page 95, this is the key square that
   3     you were referring to earlier?
   4   A. Yes.
   5   Q. Which you could not make sense of without assistance.
   6        Whose are the annotations in the fairly faint
   7     pencil mark?
   8   A. It is pencil and I believe they are mine, because that
   9     is the copy that I used to take to the library to find
  10     the books that enabled me to get the -- I think it is
  11     freedom of expression or some technical term, in order
  12     to find what the significance is of the data, because
  13     the significance varies depending upon the number of
  14     operations, the number of deaths and the comparators,
  15     and reading 9.884 does not necessarily convey what the
  16     significance is. That says that there was a significant
  17     different for tetralogy of Fallot under 1 year in
  18     Bristol compared to the rest of the UK.
  19        What the surprise is about that is that my
  20     experience as a Senior Registrar, and then as
  21     a consultant, was that tetralogy of Fallot was not
  22     a major problem in my mind, and yet suddenly here we
  23     have data that says we are not doing very well.
  24        Here you enter the problem of personal
  25     perception. Because I only did a little bit of

   1     paediatrics, and because some of these problem occurred
   2     without my being aware of it, I did not see them in
   3     intensive care because I was not on call; things could
   4     happen that as Clinical Director I was unaware of.
   5        So this was probably the very first time that
   6     I knew that tetralogy of Fallot was a possible problem.
   7   Q. If we go over the page to page 96, the single ventricle
   8     Fontan and the all single ventricle Fontan, there is
   9     a faint -- you can just about read an 'N' to the
  10     right-hand side?
  11   A. It seems even worse than the document I gave you. The
  12     answer is 'NS', no significant difference for the single
  13     ventricle operations for the over 1 year --
  14   Q. Scroll down a little bit?
  15   A. What you have there is a chi-squared block where the
  16     difference between Bristol and the rest is not
  17     significant.
  18   Q. If we go over the page, 97, again we have no
  19     significance, I think, in the AV canals down at the
  20     bottom. But when we look at VSDs, page 98, there
  21     appears -- move down a bit, please -- a statistical
  22     significance attracting to the VSDs over 1 year?
  23   A. Yes.
  24   Q. Again, from your own knowledge of the area, how did you
  25     relate to that?

   1   A. I think, as I recall, I was again surprised about the
   2     VSDs over 1 year, because again my perception was that
   3     this was an operation that had previously been displayed
   4     in the unit figures as being adequate. Here we have
   5     data showing that we had a difference.
   6        I think -- Dr Masey will confirm -- that Dr Masey
   7     had seen the audit, although she had not got a copy, or
   8     it was Dr Pryn suggested to me that there were problems
   9     over the accuracy of the VSD data because the numbers
  10     did not fit with their clinical recollection.
  11        Subsequent to that, I am told in 1995 it was
  12     confirmed that there was an error, although I have never
  13     seen, to my recollection, that documentation in 1995.
  14     I think I have now seen a letter, or some document, in
  15     the evidence that has been given to me that shows that
  16     in 1995 there was discussion about the VSDs.
  17   Q. So the meeting in January 1994, this data was not
  18     presented. Dr Pryn got shot down, effectively, did
  19     he --
  20   A. Dr Pryn was not successful in putting forward his data.
  21   Q. And Mr Wisheart's was therefore the only data
  22     effectively presented to the meeting?
  23   A. Yes.
  24   Q. Did that show an acceptable picture of paediatric
  25     cardiac surgery in Bristol at the time?

   1   A. The determination of "acceptable" is very difficult,
   2     because we did have not a standard to say "that is
   3     acceptable" or "that is not acceptable". If we had
   4     a standard that was UK-wide and it said "you can accept
   5     this level of mortality or this level of morbidity" and
   6     you cross it, you can say it is unacceptable. You are
   7     talking about a judgment that is being made in the
   8     middle of the experience.
   9        So that is one of the cruxes of the whole problem.
  10   Q. Let me approach it this way: was there any challenge to
  11     the accuracy of the data that he produced, leave aside
  12     their interpretation?
  13   A. Mr Wisheart's data was not challenged from the floor.
  14   Q. So the only question was how one interpreted that data.
  15   A. It was one of the questions that you could ask, yes.
  16   Q. Was there any discussion about how one should interpret
  17     that data?
  18   A. I am sure there was at the time. But --
  19   Q. Do you recollect any?
  20   A. I could not tell you words. You recall from these
  21     meetings the impact and what your actions were going to
  22     be afterwards, and I had great frustration because what
  23     I had hoped to achieve was that other data was presented
  24     and then you could say "We need to go forward and have
  25     an audit that looks at our work in the way". When you

   1     have got that, we can sit down and talk about it and we
   2     can truly analyse the problem.
   3        We needed to try and bring everyone together.
   4   Q. Do you think, looking back on it, that perhaps part of
   5     the problem was that there had been insufficient time
   6     for preparation before the meeting, for those who might
   7     have presented rival data to get their tackle in order
   8     to present it?
   9   A. There are many things that should have been in place
  10     before that meeting, one of which was a joint opinion of
  11     the cardiac anaesthetists so we could say "This is what
  12     we as a group say". It would have been helpful if we
  13     had put an agenda on the table with a Chair to run the
  14     meeting, but we had not done it. The meeting happened
  15     in a very Latin way, as it were, in that Professor
  16     Angelini and I still recognised there was a problem and
  17     we had an idea, and we thought "Let us go and do it".
  18     It developed an impetus of its own.
  19        Yes, looking back, I should have, somebody should
  20     have, been more structured in the meeting, and because
  21     it was not structured the point you are making was not
  22     achieved.
  23   Q. Continuing with the chronology, what then happened after
  24     this meeting, you say it did more to consolidate
  25     difficulties and differences than resolve them. There

   1     was a meeting between Professor Angelini and Dr Roylance
   2     and you?
   3   A. And me, yes, there was.
   4   Q. You have dated that for us to March 1994?
   5   A. Yes, I believe that is correct.
   6   Q. Before I go into the detail of the meeting am I right in
   7     thinking that at no stage did you ever present any audit
   8     data to Dr Roylance?
   9   A. I did not give Dr Bolsin's audit data to Dr Roylance.
  10   Q. But you never proposed to him, at any time, that
  11     paediatric cardiac surgery, or any part of it, should be
  12     suspended?
  13   A. I did not suggest to him that I should suspend any part
  14     of paediatric surgery, no.
  15   Q. Am I right in thinking that at this stage, or at any
  16     stage, you never discussed with him whether neonatal
  17     switch operations should cease?
  18   A. What date are we talking about?
  19   Q. From March 1994 onwards, through into 1996?
  20   A. There were four anaesthetists who withdrew their support
  21     from the neonatal switch programme. That was Dr Bolsin,
  22     Dr Pryn, Dr Davies and myself. And Dr Underwood and
  23     Dr Masey differed in their opinion.
  24   Q. I will come to that.
  25   A. Okay, but I approached Dr Roylance with my viewpoint

   1     that there was a problem of performance in the
   2     paediatric cardiac service, did not have the clear data
   3     that said I should stop any one part, or the whole of
   4     the service, and therefore you are correct in saying
   5     I did not tell him that.
   6   Q. Can you help me with what the topic was when you and
   7     Professor Angelini met with Dr Roylance in March 1994?
   8     What was on the table?
   9   A. There was nothing on the table. My intention, and
  10     I believe Professor Angelini's intention, was to go to
  11     the Chief Executive of the Trust and inform him that we
  12     had concerns over the performance of the paediatric
  13     cardiac surgery unit and that we were having
  14     difficulties in resolving that issue. We requested his
  15     help in doing so.
  16   Q. What did you think was the way forward? That there
  17     should actually be some collective audit that everyone
  18     should have ownership of, or what?
  19   A. That is what I hoped to achieve and that is what we
  20     tried to achieve.
  21   Q. Had you yourself asked Mr Wisheart to arrange such an
  22     audit?
  23   A. Over the time Mr Wisheart and I had numerous
  24     conversations, and that included the production of
  25     cardiac figures, paediatric cardiac figures. To put

   1     those two together as it was the same time, I am not
   2     sure.
   3   Q. Had you approached Mr Dhasmana to say -- because he was
   4     the Associate Director -- "What we need is a much more
   5     detailed audit than the sort of audit you have been
   6     producing. You have been producing figures which show
   7     your results measured against the national results for
   8     the register, but that is not good enough"?
   9   A. I spoke to Mr Dhasmana on the subject of presentation of
  10     figures and asked him to separate his figures from
  11     Mr Wisheart's, but --
  12   Q. And his reaction?
  13   A. His reaction was that the unit should be considered as
  14     a whole and he was unwilling to do so.
  15   Q. So both Mr Wisheart and Mr Dhasmana knew at this stage,
  16     at the time you went to John Roylance for his help, that
  17     part of the view that was being examined was whether one
  18     surgeon or the other might be incompetent.
  19   A. I think the word "incompetence" is not one that I would
  20     have used. What we were asking for was that -- or when
  21     I spoke to Mr Dhasmana -- that he separated his data.
  22     In doing so, it brought it more into line into the
  23     questions that Steve Bolsin's audit was raising. We had
  24     a dichotomy of opinion across many people, and the only
  25     way to try and resolve it was to get us all talking

   1     about oranges or apples, and it was no good trying to
   2     compare different ones.
   3   Q. So what was Dr Roylance's reaction to this?
   4   A. Dr Roylance listened to what we had to say. He told us
   5     that he was a manager of the Trust and that this was
   6     a clinical issue and therefore it was for the clinicians
   7     to resolve.
   8   Q. How helpful did you find that?
   9   A. I had gone to John Roylance on my own and with Professor
  10     Angelini in order to enlist his help in solving the
  11     problem. I am obviously going to find it frustrating
  12     that I cannot get that help.
  13   Q. Did you indicate to him that that was not what you
  14     wanted: you actually wanted him to intervene and do
  15     something?
  16   A. Yes, I did, but we had had previous conversations on
  17     matters outside of the paediatric cardiac problem. We
  18     had difficulties within anaesthesia, in general ITU. We
  19     had difficulties in obstetric anaesthesia. We had
  20     difficulties in maintaining the service in general
  21     surgery. And his use of the flat management structure
  22     and referring it back to clinicians did ultimately
  23     produce solutions in those fields. Therefore, in that
  24     circumstance, his management structure was useful in
  25     that I could solve the problems.

   1        But the problems of anaesthesia are very, very
   2     many and I was coming to him with an issue of paediatric
   3     cardiac surgery, one that I felt I could not address,
   4     and yet he did not help me address it. But that may
   5     well be because he had already seen me solve other
   6     problems, saying it was a clinical problem, "you must go
   7     and solve it".
   8   Q. His evidence to the GMC on this was to the effect that
   9     the discussion between you and Professor Angelini and
  10     him involved you urging the desirability of having
  11     a paediatric cardiac surgeon appointed, and
  12     consolidating the service within the Children's Hospital
  13     as the way forward?
  14   A. I could not disagree with that. The conversation would
  15     have been about the whole paediatric service and that
  16     runs from the referral of the child until the child is
  17     discharged. We were talking about concurrent paths
  18     here. One path is, let us try and resolve the
  19     differences of opinion amongst audit. Another path we
  20     were working very hard on was, let us solve the
  21     problem. And the solution that I felt was most
  22     appropriate was to move the cardiac service to the
  23     Children's Hospital, to appoint a new cardiac surgeon,
  24     to try and integrate the service, and that meant
  25     changing the paediatric intensive care, it meant making

   1     more cardiac anaesthetists. So that is going in
   2     a parallel way.
   3        John Roylance has a business of #175 million, and
   4     there are lots of people telling him, "we must do this
   5     to make the service better", so I am not going to allow
   6     an opportunity to promote what I think is the right
   7     thing for the Trust to do go by.
   8        So obviously John Roylance's recollections of that
   9     meeting would include the fact we are talking about
  10     a new consultant surgeon and moving up to the Children's
  11     Hospital.
  12   Q. Did you discuss figures and outcomes at all at the
  13     meeting, even if you did not present data?
  14   A. I did not give him the audit figures. We went into
  15     a loop where we would raise a problem that we have
  16     concerns and then we would come back to being a clinical
  17     problem. Therefore, I did not get past "go" in order to
  18     put forward these figures.
  19   Q. That was March 1994. You tell us that on 24th March
  20     1994 you spoke with Andy Black to clarify the analysis.
  21     In April there was a meal which you organised, I think
  22     at Bistro 21 in Bristol?
  23   A. That is correct, yes.
  24   Q. There is some doubt as to whether the date is 5th April
  25     which others have recollected was the date used at the

   1     GMC, or 13th April which is the date you quote in your
   2     statement?
   3   A. I do not think it is material to the function of the
   4     meal.
   5   Q. The function of the meal, then, was what?
   6   A. The venue was chosen because I had recently organised
   7     a large meal there. I had asked the restaurateur to use
   8     the upstairs room, which would be private and quiet. It
   9     would enable me to produce an environment outside the
  10     hospital and to be non-confrontational. I had James
  11     Wisheart, who was aware of the concerns but did not have
  12     any details. I had Dr Bolsin, who had produced an audit
  13     and was asking me to act upon it but was not willing to
  14     present this audit to people who could help me form
  15     a corpus of opinion and take it forward. And I had
  16     Professor Angelini, who was aware of Dr Bolsin's audit
  17     and was willing to support it.
  18        I therefore produced an environment in which
  19     I thought we could, with the least amount of conflict
  20     possible, bring together these divergent opinions.
  21        To get Dr Bolsin and Mr Wisheart to sit around
  22     a table, I would have had to go through a number of
  23     conversations in order for them to understand why we are
  24     going there. I do not think that Dr Bolsin and
  25     Mr Wisheart would just wish to go for a meal to chat

   1     about football.
   2   Q. In fact, did you end up talking about football?
   3   A. We did indeed. I am a keen Manchester United supporter,
   4     having lived there for many years. Professor Angelini
   5     had helped me organise a holiday in Italy. Therefore
   6     much of the meal was spent, as these meetings are,
   7     I presume, talking about generalities before we start to
   8     get down to the meat of the conversation.
   9   Q. What you have said already suggests that you had spoken
  10     to Mr Wisheart because -- you arranged the meeting, you
  11     had spoken to Mr Wisheart, Professor Angelini and
  12     Dr Bolsin?
  13   A. Correct.
  14   Q. And your purpose was to get them talking?
  15   A. That is correct.
  16   Q. Did each of them know that that was your purpose?
  17   A. I believe so, yes.
  18   Q. Did Mr Wisheart -- what did Mr Wisheart -- let me change
  19     the question.
  20        What was he given by you to understand he should
  21     expect to deal with at the meeting?
  22   A. I believe he knew Steve Bolsin had raised criticisms and
  23     he would want to know from Steve Bolsin what those
  24     criticisms were.
  25   Q. What would Dr Bolsin have understood from you?

   1   A. He and I had numerous conversations about the form of
   2     his audit: that, in my opinion, it had been performed in
   3     a clandestine manner and therefore its value was lost
   4     because it was not owned by people, it was not open; it
   5     had not been verified and therefore could be criticised;
   6     and that it would be appropriate in this non-threatening
   7     environment, supported by me as the Clinical Director
   8     and also Professor Angelini, to put forward his data.
   9        The danger that I had in having this data and
  10     putting it forward to James is that I may not be able to
  11     support it from criticism, because my knowledge of it is
  12     literally what you have in front of you.
  13   Q. So at this stage Mr Wisheart would have understood your
  14     role to be effectively that of the United Nations,
  15     trying to bring peace between the rival views?
  16   A. I think that is a little excessive in a description.
  17     What we had were people with different views upon
  18     outcome, and the views were that it was --
  19   Q. What I am asking is whether he appreciated the role that
  20     you sought to fulfil?
  21   A. Who appreciated?
  22   Q. Mr Wisheart?
  23   A. I believe so. I may be mistaken about that, but I would
  24     have thought that he understood it.
  25   Q. Was the meeting, the meal, relatively amicable or not?

   1   A. It was a difficult meeting because people were there
   2     with an agenda, and therefore it is difficult to be
   3     amicable in those terms where you were there just for
   4     a social meal for the pleasure of your colleagues.
   5   Q. You discussed it and you discussed Manchester United.
   6     At any stage, did the conversation at the meal turn to
   7     the issue that had brought everyone together?
   8   A. It was raised in a very peripheral way on a number of
   9     occasions. I felt it was important that we did discuss
  10     the issue. Towards the very end, my personal
  11     frustrations in not succeeding led me to ask a direct
  12     question. I cannot recall the exact words that I used,
  13     but I did say, "Do you have any difficulties with the
  14     paediatric cardiac service?"
  15   Q. You were addressing whom?
  16   A. I was looking across the table at Dr Bolsin and next to
  17     him was sat Gianni Angelini. It was a table for four,
  18     obviously. There was no reply. There was no denial;
  19     there was no assertion that there was; there was no
  20     answer. At that point my frustration rose to a very
  21     high level because I realised that my intent in bringing
  22     these people together to discuss the issue that is on
  23     the screen now had failed.
  24   Q. Did you consider going further and saying, "Look, Steve,
  25     you have raised concerns with me. Do you now want to

   1     raise them with James?", or anything to that effect?
   2   A. After asking the direct question and receiving no
   3     response my frustration was such that I did not ask
   4     those questions. To my recollection, the meal, the
   5     meeting, whatever, just disintegrated and we all left.
   6   Q. And no attempt was made by Professor Angelini on the one
   7     hand, Dr Bolsin on the other, or for that matter
   8     Mr Wisheart, to raise and grapple with the issue which
   9     had in fact brought them to Bistro 21?
  10   A. All four of us failed to achieve that. An option would
  11     have been for me to have put the data on the table and
  12     say, "What about that?" I did not do that.
  13   Q. Did anyone have the data with them?
  14   A. I certainly did not. James could not because he had not
  15     got the data. Whether Professor Angelini or Dr Bolsin
  16     had the data, I do not know.
  17   Q. Did James Wisheart know something of the nature of what
  18     had been going on, that there had been a collection of
  19     data which showed paediatric cardiac services in a bad
  20     light?
  21   A. I cannot answer for his knowledge based at that time --
  22   Q. Had he been told in front of you, in your hearing?
  23   A. I did not tell him that I had in my possession an audit
  24     of this form, because of the reasons that were
  25     previously outlined earlier today.

   1   Q. There may have been suggestions in other forums -- you
   2     did not give evidence at the GMC, did you?
   3   A. I was not asked to give evidence by any of the people
   4     involved.
   5   Q. But there may have been a suggestion that there were two
   6     camps at this restaurant: you and Mr Wisheart on the one
   7     side and Professor Angelini and Dr Bolsin on the other.
   8        Would there be any truth in that or not?
   9   A. I did not see my role as being in any "camp". I was the
  10     Clinical Director of Anaesthesia, and therefore I had
  11     a management role, but I had worked closely with
  12     Dr Bolsin for many years, and I had discussed our
  13     concerns. He and I had spoken beforehand, and I had
  14     taken it to a non-threatening environment. Had we had
  15     this meeting in the Medical Director's office, within
  16     the Trust headquarters, then I think that could be
  17     a reasonable supposition. But it was not, it was held
  18     outside of the Trust.
  19   Q. You had had the view before this meeting that the
  20     concerns which Dr Bolsin had, which you tended to share
  21     because you tended to be towards his wing, as it were,
  22     of the spectrum of anaesthetist opinion, were major
  23     concerns?
  24   A. They were concerns -- I had such concerns that I was
  25     willing to work hard to try and resolve the issue.

   1   Q. After this meal -- can we look at your statement,
   2     page 23? [WIT 105/23], paragraph 11, the last sentence:
   3     that describes Mr Wisheart's reaction to the meal. He
   4     was effectively saying to you, "Well, if you are not
   5     prepared to raise it to my face", or something along
   6     those lines, "then there cannot be much in it". Was
   7     that the flavour of it or not?
   8   A. I think it was an impression that I gained from him that
   9     if we had gone to the effort to sit at the table, it was
  10     an opportunity that was of such low impact as regards to
  11     the Trust management situation, because he was probably
  12     the Medical Director at this stage, if they cannot raise
  13     it then, when he is at his most open, then what were
  14     these concerns?
  15        I do not know what JDW actually thought at that
  16     time, but I felt -- maybe it represents also some of my
  17     frustrations -- that that was a reasonable summary.
  18   Q. In any event, very shortly after that meeting I think
  19     Dr Bolsin reports that he went to speak to Janet Maher,
  20     and that the following day, he suggests, you came to him
  21     and said in effect that it was the wrong approach to go
  22     to the Manager of the surgical department in order to
  23     take his concerns further.
  24        What do you say about that?
  25   A. Yes, I believe I did tell him that.

   1   Q. So the way in which it worked was, what? Janet Maher
   2     had had a word with you and said one of your
   3     anaesthetists had come to you with this concern, and you
   4     then went to Steve Bolsin and said that is not quite the
   5     way to do it?
   6   A. The culture of the Trust at that stage was that the
   7     managers at that level had very little input into
   8     clinical management and decision-taking.
   9   Q. I do not want to press you on that, as to why you said
  10     it, but just the fact that you did?
  11   A. I just felt that an explanation of why I said it would
  12     be quite appropriate. The person that Dr Bolsin needed
  13     to give his data to were the surgeons or the cardiac
  14     anaesthetists, not a manager who had no obvious way in
  15     which he could influence that problem.
  16   Q. The next event in the cause of concerns that I want to
  17     focus on is the letters which came to be written in the
  18     middle of 1994.
  19        Can we have a look at GMC 4/64? There are various
  20     editions of a letter like this. This one is signed by
  21     Dr Davies.
  22        Having looked at that, can I ask you to note the
  23     words: "increasing concern" in the first line; in the
  24     second line, "mortality is apparently unacceptably
  25     high"; and in the third from last line, "this

   1     responsible approach to what is obviously an
   2     unacceptable clinical practice ..."?
   3   A. Yes.
   4   Q. UBHT 61/6: let us look down at the bottom for a moment.
   5     There are four signatories to that and the same words,
   6     UBHT 61/7. There are five signatories to that. We can
   7     see by comparing the two that indeed all the six people
   8     named have at some stage appended their signature to
   9     a copy of a letter in this form.
  10        But the wording here shows a change from "we wish
  11     to express our increasing concern" in the first line to
  12      "our concern".
  13        In the second line, the "unacceptably high" has
  14     been dropped. In the second last line, it is now "this
  15     responsible approach to our clinical practice" instead
  16     of this responsible approach to what is obviously an
  17     unacceptable clinical practice."
  18        Do you know why it was that those words were
  19     changed?
  20   A. I believe that it changed because to get all six
  21     signatures, the wording had to change.
  22   Q. Who would not sign it in its original form?
  23   A. I do not know and did not know at that time, but
  24     I believe it was Dr Masey.
  25   Q. The letter was drafted by whom?

   1   A. The first time that I saw this letter was in yet again
   2     the Sister's office on Level 4 outside the cardiac
   3     theatre, when Dr Bolsin and I met. He had drafted the
   4     first version of the letter, which is not here, and he
   5     and I discussed it at some length and we would have
   6     edited the form.
   7        The letter then returned and as you saw from the
   8     first copy, I think Dr Davies had signed it because he
   9     felt capable of doing so, and then a later version was
  10     produced that Dr Masey and Dr Underwood were able to
  11     sign.
  12        The initial version of the letter, because it was
  13     penned by Dr Bolsin, actually had my name at the bottom
  14     of the letter, and I am not sure that it had
  15     Peter Baskett's.
  16   Q. So your recollection is that it had 6 names, probably
  17     not Dr Baskett's, but certainly yours?
  18   A. I am not even sure it had six names. I think Dr Masey's
  19     name may not have been added at that point, or
  20     Dr Underwood's. I am not clear. But this letter will
  21     initially reflect the strong feeling that Dr Davies,
  22     Pryn Bolsin and myself had already expressed about the
  23     arterial switch programme.
  24   Q. The arterial switch programme; you are talking about
  25     both neonatal and infant?

   1   A. That letter concerned the arterial switch programme, and
   2     it would be globally, yes.
   3   Q. And indeed, a reference to a 14 month-old child is
   4     looking at a child beyond the infant period?
   5   A. Indeed.
   6   Q. How did it come about that your name came off the bottom
   7     and you became the addressee?
   8   A. When I discussed it with Steve, I wanted to think about
   9     how I would take the letter forward. I believe that the
  10     letter was addressed to Dr Roylance in its first form,
  11     but it may have been to the Medical Director. You have
  12     to forgive me for not being completely accurate.
  13        If I had signed the letter, it was difficult to
  14     take forward and to discuss it so it was felt, and
  15     supported by some of the others, that it should be
  16     addressed to me; that I should not sign it and I could
  17     then take it forward. I agreed to that. It may have
  18     been better if I had signed the letter and posted it.
  19   Q. What did you mean by "taking it forward"?
  20   A. My intent was to approach the Chief Executive with this
  21     letter and use it to explain that we, as consultant
  22     anaesthetists, had concerns about the switch programme,
  23     and, in addition, the paediatric cardiac surgical
  24     programme. It says quite clearly that there should be
  25     a confidential review and that it should take place

   1     amongst the entire multifactorial process and the
   2     clinicians involved to look at what the figures were.
   3   Q. So, having got this letter, what was it intended you
   4     should do with it?
   5   A. My intent was to visit the Chief Executive with the
   6     letter. Whether they had other intents for it, I am not
   7     aware.
   8   Q. Did you not discuss with them, then, what you were going
   9     to do with it?
  10   A. To have changed the letter I must have discussed it with
  11     Steve Bolsin, because he penned it. Whether we had
  12     a joint conversation, I cannot recall, because my memory
  13     is clear about the letter and what happened. Whether
  14     they discussed what I should say or do, whatever,
  15     I cannot recall.
  16   Q. Because the very purpose of changing the addressee of
  17     the letter from either the Medical Director or the Chief
  18     Executive, whoever it was, was with the purpose that you
  19     would take it forward and discuss it with that
  20     individual?
  21   A. Yes, and that is why I think it is a very reasonable
  22     question to ask, and a good supposition to make. But
  23     you asked me what are my recollections, and I cannot
  24     recall the word or format or whatever was said at that
  25     point because I can remember just the key points or

   1     issues.
   2   Q. At the GMC, Dr Bolsin said when asked about this, that
   3     it was -- that you had asked to get the anaesthetist to
   4     sign the letter to allow him to raise the matter with
   5     the cardiac surgeons?
   6   A. Allow him to raise it, or me?
   7   Q. To allow you to raise the matter with the cardiac
   8     surgeons. Do you remember that?
   9   A. That may have been, but please remind me of the date of
  10     the letter again.
  11   Q. 21st June 1994?
  12   A. By that stage we had already been through a number of
  13     difficulties in trying to get people together amongst
  14     the group and I felt that the only way I was going to
  15     achieve this was by the action of someone very high up
  16     in the Trust. I could not use the Medical Director
  17     because he was one of the people being criticised.
  18     Therefore, I determined that I was going to John
  19     Roylance with it.
  20   Q. But you determined that without necessarily discussing
  21     it with the signatories?
  22   A. I was quite clear in my mind what I would do with this
  23     letter.
  24   Q. Let me repeat the question: you were determined, what
  25     you would do, but without necessarily discussing that

   1     with the signatories?
   2   A. I cannot recall whether I said that I would take this
   3     letter to John Roylance.
   4   Q. Did you in fact take the letter to John Roylance?
   5   A. Yes, I did.
   6   Q. What you were doing -- did you present it to him?
   7   A. Yes, I did.
   8   Q. Did you consider that in presenting it to him you were
   9     deceiving him?
  10   A. I think my intent was to manipulate Dr Roylance in order
  11     to achieve what I wanted, which is a confidential review
  12     between all those people involved in the paediatric
  13     cardiac service.
  14   Q. On the face of it, the purpose of eliminating your name
  15     from it was so that you would not be associated with the
  16     view expressed in there, you would simply be the bearer
  17     of it?
  18   A. That is correct.
  19   Q. So to that extent, there was a deliberate deception,
  20     manipulation, however you put it, of Dr Roylance, was
  21     there not?
  22   A. Yes, there was a ploy, that I was taking to him a letter
  23     that I would be happy to sign in its first version and
  24     that I would discuss that matter with him.
  25        The fact that I was implicit in its production

   1     would not have been obvious to Dr Roylance and therefore
   2     it could be deemed a ploy.
   3   Q. Did you tell Dr Roylance that you agreed with its
   4     contents?
   5   A. That would have been obvious, because I took the letter
   6     to him, and I supported it and I asked what is there.
   7     But it would not have been just the switch programme, my
   8     issue would have been with the entire paediatric cardiac
   9     service.
  10   Q. If in fact it was obvious that you supported it, why was
  11     the letter not actually addressed to him and you take it
  12     to him and say "Look, John", or "Dr Roylance", "you have
  13     to know, this is a view that we all have and I have
  14     signed the letter too. Will you do something about
  15     it?" Why was it necessary to cut your name out of it?
  16     How did that ploy advance your cause?
  17   A. Because it maintained my independence, as it were, from
  18     the issues that were being put forward and would enable
  19     me to discuss it from a more objective viewpoint.
  20        If I was to approach him in a subjective way, then
  21     his view of what I was saying may not be as effective.
  22     I was going wearing my hat of Clinical Director of the
  23     Directorate of Anaesthesia. I was not going wearing my
  24     paediatric cardiac anaesthetic hat.
  25   Q. Dr Roylance had, in the earlier discussion you told us

   1     about in March 1994 -- I cannot recollect whether you
   2     told us that he agreed with you that the way forward was
   3     to have a new surgeon and a combined site. Did he
   4     express a view on that, or not?
   5   A. I think my comment earlier was to the fact that because
   6     the Trust had decided that a movement to the Children's
   7     Hospital was sensible, we had appointed new surgeons
   8     which meant big funding issues, that obviously John
   9     Roylance realised the value of those changes.
  10        Whether we at that stage had a specific
  11     conversation about the merits and demerits with the
  12     conclusions, I am not sure, but we spoke about, "How do
  13     you deal with the problems of paediatric cardiac?"
  14   Q. The conversation that you recollect is one which you may
  15     know is denied by John Roylance. He says that he never
  16     saw the letter.
  17   A. Yes.
  18   Q. What do you say about that?
  19   A. I can state that I went to his office with this letter
  20     and we discussed it. I can recall that quite clearly.
  21     Dr Roylance is running a major business and he has many
  22     issues on his agenda, as did I as a Clinical Director
  23     because I had many other issues apart from the
  24     paediatric cardiac problem.
  25        My recollection -- because this is very big in my

   1     life -- is quite clear. He may have thought, "I have
   2     got everything in place, give it time it will get better
   3     because I am doing this, I am doing that". I do not
   4     know why he cannot recollect this conversation.
   5   Q. What was the response, when you showed him the letter?
   6   A. The response was that it remained a clinical problem and
   7     that he was the Chief Executive of the Trust and it was
   8     for the clinicians to solve.
   9   Q. So he was not going to arrange for the --
  10   A. He felt that it was a responsibility that the clinicians
  11     should deal with.
  12   Q. In other words, he was saying 'no' to the review that
  13     you were asking for?
  14   A. I think he was saying 'no' to the fact that it was him
  15     that should implement the review; that it was
  16     a clinicians problem to go and deal with. But I was
  17     saying that I could not deal with that problem and I had
  18     come to him as one of his Clinical Directors.
  19   Q. In your statement, when you deal with this, page 28,
  20     [WIT 105/28] you set out that response. You say that
  21     you spoke to him on an individual basis --
  22     paragraph 26 -- on a number of dates which you quote
  23     specifically?
  24   A. Yes.
  25   Q. Four dates. Yet you cannot recall what date you

   1     actually took this letter to him?
   2   A. No, because I knew that it would be very important, if
   3     I could put a date for when I went to see Dr Roylance at
   4     this meeting. These dates were gleaned retrospectively
   5     from my personal diaries and from other documentation
   6     that I met. I could not find, and it would have been
   7     greatly to my benefit to find, a date that said I was in
   8     Dr Roylance's office at this time. I do not have that
   9     data. I cannot give it. That does not mean I did not
  10     go to see Dr Roylance to discuss the letter.
  11   Q. Having failed in the objective to get Dr Roylance to
  12     act, did you consider at all redrafting the letter so it
  13     was written from all of you to him as a matter of
  14     record?
  15   A. I was greatly frustrated by my failure to achieve the
  16     goals and there were a number of issues or actions that
  17     I thought I could take. It would have been appropriate
  18     to write to him and give him a copy of that letter.
  19     I did not believe it would make any difference at all in
  20     the process that we were now in and I did not do so.
  21   Q. How did the meeting end? Did you leave him with a copy
  22     of the letter, or not?
  23   A. I offered him a copy of the letter and he stated that as
  24     it was addressed to me why should he keep the letter --
  25     a copy of it.

   1   Q. And you said?
   2   A. I informed him I thought he should have it. But his
   3     logic is quite correct. It is to me and he has
   4     a mountain of paper; why does he want to keep that
   5     letter?
   6   Q. You say at the top of page 29 that not only did he
   7     refuse a copy of the letter but he did not accept the
   8     existence of a problem.
   9        I thought you were telling me a moment ago what he
  10     had said to you is that there is a problem but it is for
  11     the clinicians to sort out?
  12   A. You are ascribing the problem there to the cardiac
  13     performance. The problem I had -- I was trying to
  14     explain to him -- was that I could not initiate
  15     effective moves to get people together to address the
  16     paediatric cardiac surgery. That is my problem as the
  17     Clinical Director and manager, as it were, in that
  18     situation. That is why I had gone to him. Because we
  19     had had ad hoc meetings with lots of people in a room
  20     that had failed to achieve the figures owned by anybody;
  21     we had non-clinical meetings in restaurants that had
  22     failed; we had had a number of discussions.
  23        Therefore, looking at my reactions and activities,
  24     I had not succeeded in all of my aims and goals.
  25     Therefore, I went to him to help.

   1   Q. There may have been a further meeting, may there, in
   2     November of the same year, 1994, at which John Roylance
   3     was present? You have given us, I think, two separate
   4     recollections of this meeting. If we look at page 28 of
   5     your statement, at paragraph 26 you say you spoke with
   6     Professor Vann Jones in the presence of Mr McKinley,
   7     22nd November 1994?
   8   A. I think that is correct. But it may be in a later
   9     document. I do not have the date correct; it may have
  10     been the 12th of the 11th 1994, which would have been
  11     Saturday. It is unlikely that an anaesthetist would be
  12     present on the Saturday.
  13   Q. I think your own date, which you have given us, in
  14     dealing with Professor Vann Jones, and perhaps nothing
  15     turns on it, but you have described on one occasion
  16     Mr Nix being present at the meeting.
  17        Was he?
  18   A. The people I can clearly remember at the meeting were
  19     myself, John Vann Jones, Mr McKinley and John Roylance,
  20     and I think that Mr Nix may have been there but if he
  21     was to tell me that he clearly did not attend that
  22     meeting I would not wish to gainsay him.
  23   Q. We have seen, I think, the comment he has made?
  24   A. I have not seen the comment, no.
  25   Q. Let me tell you what he says about it. He says that he

   1     was not at the meeting which you refer to at
   2     paragraph 53 as having taken place on 12th November
   3     1994. Let us look at paragraph 53 and confirm it is
   4     indeed the same meeting we are talking about. It is on
   5     page 35. That is the same meeting, is it?
   6   A. It is the same meeting but, as I said, I thought Mr Nix
   7     was there. But if he says he was not, then I would
   8     believe him entirely and accept that it is an error on
   9     my part.
  10   Q. So you have given us two separate dates for the meeting,
  11     both specific, and you may be wrong on the attendance of
  12     Mr Nix.
  13        In the two different descriptions you give of the
  14     meeting there are different attendees. Can you help as
  15     to why in one part of your statement you should describe
  16     a number of people and not another?
  17   A. My error is, I think, Mr Nix. Or are there other
  18     differences?
  19   Q. You have John Roylance, Professor Vann Jones, Mr Nix,
  20     yourself and possibly Mr Wisheart there, and if we go
  21     back to page 28 you have Professor Vann Jones and
  22     Mr McKinley?
  23   A. And JR.
  24   Q. Yes.
  25   A. I think that the focus of the two paragraphs are

   1     answering different questions. It may have been a
   2     fuller version in one than I have in the other to
   3     illustrate different points. But at the meeting,
   4     Mr McKinley asked a clear question: was there
   5     a problem? I recall very clearly saying, yes, there
   6     was. That is why I am able to recall the meeting, the
   7     clarity of which I can recall. Who attended it I am
   8     afraid is misted by the fact that it is five years ago.
   9   Q. Then can I move on to the events, which bring the
  10     chronology perhaps full circle, surrounding the Joshua
  11     Loveday operation of 12th January 1995.
  12        At some stage towards the end of 1994, did you
  13     become aware of the fact that it was proposed to operate
  14     upon Joshua Loveday?
  15   A. The planned surgical operations were sent around
  16     surgeons, anaesthetists and theatres. Dr Bolsin came to
  17     me and informed me that a non-neonatal switch was
  18     planned for some days in the future. That is how
  19     I became aware of it.
  20        I was a little busy with other issues within the
  21     directorate, and therefore would not have read that list
  22     without being given it, and pointed to the fact that
  23     there was a non-neonatal switch planned.
  24   Q. So Dr Bolsin raised this with you?
  25   A. Dr Bolsin was the first person to tell me that it was

   1     planned.
   2   Q. What was your reaction to this?
   3   A. My reaction was that here was an operation on a child in
   4     whom I thought that the Trust had stopped the programme
   5     and that I was surprised at the listing of that child.
   6   Q. To whom did you speak about it?
   7   A. I had a conversation with Dr Bolsin and we discussed
   8     that. I spoke to Professor Angelini about it. I spoke
   9     with Dr Sheila Willetts, the intensive care lead
  10     consultant. I spoke to Dr John Roylance. I spoke to
  11     Mr Wisheart, and I spoke to Mr Dhasmana before the
  12     meeting that occurred at the Children's Hospital.
  13   Q. Let me see that I have the chronology right, as I picked
  14     it up from your statements to us: that before the
  15     meeting of 11th January which you are going to tell us
  16     about in a moment, at which you attended, you had been
  17     spoken to by Dr Bolsin. As a result you made the
  18     conversation you told us about. You spoke to John
  19     Roylance in his office?
  20   A. Yes.
  21   Q. Then you spoke with Mr Wisheart?
  22   A. In his office.
  23   Q. In his office. Then you spoke with Mr Dhasmana in his
  24     office?
  25   A. Correct.

   1   Q. In that order?
   2   A. Yes. I am not -- there was a need for a clinical
   3     meeting to discuss the issue of whether the operation on
   4     Joshua Loveday should go ahead. I spoke with John
   5     Roylance on that matter and that, I think, preceded the
   6     clinical meeting.
   7        If I recall correctly, I think that James Wisheart
   8     was away from the hospital in the days before the 11th,
   9     and therefore the meeting was scheduled just prior to
  10     the operation date.
  11   Q. When was it that you spoke to Dr Roylance?
  12   A. It was before the 11th.
  13   Q. Roughly how long?
  14   A. I think it would have been in the order of the preceding
  15     week. I may not have -- I am not sure of the interval
  16     between when I knew that Joshua Loveday was being
  17     operated on and the actual meeting, but I think it was
  18     only in the order of a week, anyway.
  19   Q. What were your views about the operation?
  20   A. My views were that I thought that the switch programme
  21     had been stopped and therefore to restart it at this
  22     point in time, when Mr Pawade was to come to the Trust,
  23     was ill-advised.
  24   Q. Because?
  25   A. A number of issues. We had a cardiac surgeon who would

   1     hopefully be coming to the Trust who had a good track
   2     record; we had a number of patients who had not survived
   3     the operation in our institution; and that the delay of
   4     a few weeks or a few months, however long it would be
   5     for that child, could mean that we could start with
   6     a new surgeon in a new way and improve our outcomes.
   7   Q. So you were looking at this, were you, from the child's,
   8     the patient's, point of view, to secure the best outcome
   9     for the child?
  10   A. Yes.
  11   Q. Did you know, when you spoke to Dr Roylance, how urgent
  12     the operation was?
  13   A. No, I did not. I had not seen the child. Indeed,
  14     I never saw the child and therefore I could not form
  15     that opinion.
  16   Q. The points you have made about waiting for Mr Pawade to
  17     begin operating obviously would depend upon the degree
  18     of urgency of the child's operation?
  19   A. Absolutely. Mr Pawade was not coming for some time,
  20     I think. You would have the date of his appointment to
  21     the Trust. Therefore if the child was particularly ill,
  22     that would cause a problem.
  23   Q. 1st May?
  24   A. 1st May? That would mean a wait of four months.
  25   Q. When you spoke to Dr Roylance about it, had you spoken

   1     to either Mr Wisheart -- probably not, because he was
   2     away, I suspect -- or to Mr Dhasmana about it?
   3   A. No, I went straight to the Chief Executive of the Trust.
   4   Q. Why did you go straight to Dr Roylance when you must
   5     have expected that what he would say is, "Why come to me
   6     with this problem; this is after all a clinical problem
   7     for you to deal with at a clinical level"?
   8   A. Because I still wanted to persuade him of my viewpoint.
   9   Q. Did you persuade him of your viewpoint?
  10   A. I thought I had, yes.
  11   Q. What made you think that?
  12   A. Because of his responses to my arguments and
  13     discussions.
  14   Q. Did he perhaps not say to you, "Well, this is really
  15     a clinical matter for the clinicians to decide, and
  16     I will abide by the result of the clinical meeting"?
  17   A. He made that point, but in doing so I understood that he
  18     felt the operation should not go ahead, but that the
  19     clinicians would be important in that process because
  20     his stance was that he was a manager of the Trust and
  21     not a clinician. Like me, he had not examined the
  22     child. He did not have the clinical acumen to be able
  23     to make a decision the cardiologists would make that the
  24     operation should or should not go ahead at that time.
  25   Q. So what he was expressing was perhaps a personal

   1     sympathy with the position, but saying "As manager I am
   2     going to rely upon the result of the clinical meeting"?
   3     Is that the upshot of it?
   4   A. I did not organise the meeting --
   5   Q. No, I am focusing upon the message that he was giving
   6     you, if you please. Is that what he said?
   7   A. Could you repeat the question, then, please?
   8   Q. Was he effectively saying, "I may have some sympathy
   9     with you myself but I, as a manager, am going to depend
  10     on what my clinical conference tells me"?
  11   A. I could accept that logic, yes.
  12   Q. Is that pretty much what he was saying to you?
  13   A. Yes, but he -- the answer is yes.
  14   Q. So having spoken to him and got some sympathy, but an
  15     expression that he is going to rely on the clinical
  16     conference, you then speak to Mr Wisheart?
  17   A. Well, some time has elapsed between those conversations
  18     and a meeting has been arranged to be held at the
  19     Children's Hospital with the interested clinicians.
  20     I presume, as I did not organise that meeting, that
  21     Dr Roylance may have had a hand in organising that
  22     because I do not think Mr Dhasmana called it and I do
  23     not think that the cardiologists called it, and
  24     Mr Wisheart may well have been away. Therefore somebody
  25     got the group together.

   1   Q. You spoke to Mr Wisheart beforehand?
   2   A. I did, yes.
   3   Q. In his office. What did he say?
   4   A. We discussed the issue of this child being operated
   5     upon.
   6   Q. And ...?
   7   A. And I put forward my view that, with the tension that
   8     has we had within the unit, my feeling, as anaesthetist,
   9     would be that it may impair the performance of the
  10     team. Therefore, if delay was possible, it would be
  11     appropriate.
  12   Q. So your view was that there was an additional risk to
  13     the child simply because of the tensions within the
  14     team?
  15   A. My view was that there was the potential for external
  16     influences, tension whatever; that the team could be
  17     affected in its efficiency.
  18   Q. Did Mr Wisheart seem to accept that or not?
  19   A. I think Mr Wisheart, after some vigorous testing of
  20     that, accepted that that was an issue, yes.
  21   Q. That was an issue, or did he agree with it?
  22   A. I think he agreed with it, but the clinical needs of the
  23     child, in his mind as Medical Director, would be
  24     paramount.
  25   Q. You spoke to Mr Dhasmana, then, in his office?

   1   A. I did, yes.
   2   Q. The same day?
   3   A. The same day, yes. I went from one room to the next.
   4   Q. What was the upshot of that discussion?
   5   A. I followed my same logic in that it was inappropriate,
   6     in my view, for the operation on Joshua Loveday to go
   7     ahead.
   8   Q. He reacted how?
   9   A. It was a very difficult conversation and he understood
  10     my concerns.
  11   Q. Understood your concerns or accepted them?
  12   A. He accepted that I had those concerns and he thought
  13     about them, and he himself must have been considering
  14     how he would feel the next day doing the operation.
  15   Q. Did he give you any indication as to whether he said,
  16     "I would rather not operate", or --
  17   A. I felt that at the end of our conversation he would be
  18     of the view that he would rather not operate, but of
  19     course, it does depend upon the state of the child at
  20     that time.
  21   Q. At page 27 in your statement -- I shall not be very much
  22     longer --
  23   A. I am at your service.
  24   Q. At the top of the page you are describing Mr Wisheart's
  25     response. He was accepting that it would be

   1     inappropriate to operate on the child, you say, and that
   2     he would support Mr Dhasmana in deciding not to operate
   3     at the meeting scheduled that evening at the BCH.
   4        It is the use of those words, "he would support
   5     Mr Dhasmana in deciding not to operate". If we go
   6     overleaf to page 28, the first full sentence on the
   7     page:
   8        "He appeared to accept my viewpoint, but was
   9     concerned that he might be persuaded to operate."
  10   A. This is Mr Dhasmana's paragraph, correct?
  11   Q. That is right. The position you are painting there is
  12     that this is Mr Dhasmana, a reluctant surgeon.
  13     Mr Wisheart is going to support Mr Dhasmana in his
  14     already expressed reluctance. Am I reading too much
  15     into the words you are using or not?
  16   A. No, I think I am seeing Mr Wisheart first, not
  17     Mr Dhasmana first, and the persuasion that would occur
  18     would be relative to the sickness of the child.
  19     Mr Dhasmana could see, or he told me he could see, my
  20     logic, but that obviously depending upon the sickness of
  21     the child he might be persuaded to operate, accepting
  22     the reservations that I had. He had to make the
  23     judgment as to whether he should operate or not.
  24   Q. What Mr Wisheart tells us -- let me get the scanned-in
  25     document because these have come in, as you know, late

   1     in the day. It is WIT 105/52. He says he believes that
   2     he agreed the considerations referred to were important
   3     but not that they amounted to an absolute reason not to
   4     operate.
   5        Is that then, in the light of what you now
   6     recollect, correct?
   7   A. He has put down exactly what he believes his
   8     recollection of the conversation was. It would seem
   9     quite sensible. He and I had had a long conversation,
  10     discussion and debate about the various factors that
  11     could be affecting performance on that day. I was of
  12     one viewpoint and he is saying here that his
  13     recollection is only different in the degree, and that
  14     obviously is the difference between two people being
  15     party to the same conversation.
  16   Q. The meeting itself that took place, can we look at UBHT
  17     54/11? This is your note, is it?
  18   A. Can I just screen down a bit, please? Yes, it is my
  19     note.
  20   Q. If we look at it, paragraph 1, everyone seems to have
  21     agreed that the figures for mortality were the most
  22     accurate that could be obtained?
  23   A. Everybody?
  24   Q. "All members agreed".
  25   A. Yes.

   1   Q. That included you, despite your earlier reservations.
   2        Shall we go down?
   3   A. I am sorry, I am not being difficult, I have just lost
   4     your point here.
   5   Q. What we are looking at is your minute of the meeting
   6     which took place on 11th January?
   7   A. Yes.
   8   Q. What you are describing here, minuting, is the
   9     discussion that took place?
  10   A. Yes.
  11   Q. There you record in your own writing your own agreement
  12     to the fact that the figures were the best you could
  13     get?
  14   A. Yes, I am sorry, I just jammed the paragraph. I missed
  15     the last sentence and therefore I did not understand the
  16     point.
  17   THE CHAIRMAN: Let me interject. You are being very patient
  18     with us; it is not a question of your upsetting us,
  19     quite the opposite.
  20   A. Even at that stage there was not complete clarity on the
  21     switch figures. Indeed, I believe that Dr Underwood and
  22     Dr Pryn had again gone back to the books and tried to
  23     ascertain precisely what the programme had done and
  24     there was a little bit of a change here and there
  25     between the figures, whether it was over 1, under one,

   1     or whatever, and I think on the attacked figures there
   2     was a pencil or ink change to the numbers. At the end
   3     of that, people within the room agreed the figures were
   4     the most accurate that could be obtained.
   5   Q. At the end of paragraph 2 there is a record that all
   6     members with the exception of Dr Pryn agreed that the
   7     programme, the non-neonatal programme, should continue?
   8   A. That was a summary of the discussion as to whether you
   9     could subdivide the non-neonatal and the neonatal
  10     switches, what the performance figures were from the
  11     data that we had and comparing them from an American
  12     paper, which I think was in 1992. I do not have a copy
  13     of that paper. That paper was supplied by the
  14     paediatric cardiologists, and the line of argument that
  15     was put forward was that (1) you could separate the two
  16     age groups; (2) that this was our performance which had
  17     improved in that age group; and (3) it was similar to
  18     those of a centre quoted from America.
  19        With that logic, there was no objection raised
  20     from those figures that the programme could not
  21     continue.
  22   Q. There was no request at this meeting for the
  23     wide-ranging review which your letter of July had asked
  24     for?
  25   A. Sir, the question here was whether it was appropriate to

   1     proceed with an operation. I think that that was the
   2     focus of the meeting and had been the focus of my day in
   3     talking to people, to try and influence the decision.
   4   Q. If we go down to the bottom of the page we see, I think,
   5     that Dr Bolsin gave an explanation for telling the
   6     Department of Health about the Loveday operation and was
   7     talking about the working relationship between himself,
   8     Peter Doyle, the Department of Health funding for his
   9     audit programme being such that he felt unable not to
  10     tell them?
  11   A. Yes.
  12   Q. That is what he said, was it?
  13   A. Yes. The meeting in my mind, at that point had deviated
  14     from the path it should have been following, which is:
  15     how do we consider the most appropriate thing to do for
  16     this child?
  17   Q. Overleaf, paragraph 4:
  18        "The meeting devolved with support for the
  19     continuation of the programme ... Drs Dhasmana, Wisheart
  20     and Martin discussed the need for the child's operation
  21     and decided that its clinical condition merited an
  22     immediate intervention and considered a delay
  23     inappropriate. This was accepted with a greater or
  24     lesser degree of happiness ...", and it goes on.
  25        The turning point, as it were, in the decision was

   1     this, was it: that it was said to the meeting, "This
   2     child urgently needs an operation"?
   3   A. There were a number of sequential points. Point 1 was
   4     that we could separate the two age groups; point 2 was
   5     accepting that the figures that we had in front of us
   6     would not allow someone to say "This programme cannot go
   7     ahead"; and (3) was that the child having been listed
   8     for an operation on examination needed the operation.
   9        So it was the third step along the path to making
  10     the decision.
  11   Q. Who said what to make the meeting think that you needed
  12     to get on with the operation?
  13   A. My recollection would be that it was Dr Martin's child
  14     and that he had examined it. I do not know whether
  15     Mr Dhasmana had examined the child at that stage and
  16     also made comments. I cannot recall.
  17   Q. What was the greater or lesser degree of happiness?
  18   A. I think that reflects a personal feeling of unhappiness
  19     with the decision.
  20   Q. But if you are unhappy with the decision, why were you
  21     party to it? Because you were, were you not?
  22   A. I am a cardiac anaesthetist. My responsibilities and my
  23     job and my expertise are in that field. We have
  24     cardiologists who have seen the child, examined the
  25     child and know its state, and that is their abilities

   1     and their function. We have a cardiac surgeon, or two
   2     cardiac surgeons who have the skills within that field
   3     and therefore I did not feel able to say, "Well, this is
   4     my viewpoint and we must not go ahead" because the logic
   5     had already been used. I would only be able to say this
   6     operation cannot go ahead on clinical grounds when
   7     I will be able to stand on my own knowledge as an
   8     anaesthetist that there were additional problems or
   9     a failure of treatment, or something that could be
  10     improved.
  11   Q. Can we look at the other note of this meeting, UBHT
  12     54/13, at the foot. This is Dr Martin's note?
  13   A. Yes.
  14   Q. He says there: "The child is 18 months, quite severely
  15     blue, recently reviewed the clinical and angiographic
  16     data", and felt he is suitable for arterial switch.
  17     With cyanosis being quite severe, it was felt unwise to
  18     postpone surgery for a month of months?
  19   A. Yes.
  20   Q. That is the way he presents his input?
  21   A. Yes.
  22   Q. If that is right that is not an immediate urgent need
  23     for operation, is it?
  24   A. From that sentence, that is correct, yes.
  25   Q. Would there be anything in that description which would

   1     justify going ahead with the operation with the
   2     additional risks as you describe them?
   3   A. He has made a very brief note of a clinical examination
   4     and investigation of a child and, in shorthand, he may
   5     not have included data that would mean the operation had
   6     to go ahead in a matter of days or hours.
   7   Q. So he may have left something out. But on the face of
   8     what he has written there?
   9   A. On the face of what is written there, from his
  10     recollection, there is no reason why the child could not
  11     be postponed for a shorter period.
  12   Q. If this had been the way that you had perceived the data
  13     would you have wished to continue, with your opposition
  14     to the operation going ahead?
  15   A. If the data said that he could have been delayed by
  16     a month, then I would have argued in the meeting that
  17     the operation should be delayed.
  18   Q. So far as Dr Roylance is concerned, he was not at the
  19     meeting?
  20   A. No, he was not.
  21   Q. He would only get a report back which might be either of
  22     these reports, or something similar?
  23   A. He would not receive my report, because that was
  24     a document that I did for myself the next day in order
  25     to recollect in the future what my thoughts were at that

   1     meeting.
   2   Q. But if he had already indicated that he was going to
   3     abide by the result of the meeting, the result then
   4     could not possibly be to announce that the operation
   5     should and could go ahead?
   6   A. I do not know whether Dr Roylance was contacted with the
   7     results of this meeting but, as he had said it would be
   8     a decision for the clinical team, that logic would
   9     apply.
  10   Q. Did anyone suggest transferring the child elsewhere?
  11   A. I recall that was the suggestion put forward.
  12   Q. Do you recall why, if at all, it was rejected?
  13   A. I think there were a number of barriers, of which
  14     I cannot be more specific, that meant we could not
  15     transfer the child.
  16   Q. One or two other matters I have to pick up with you.
  17     I shall do it fairly quickly.
  18        Before you got Dr Bolsin's statistics, did you
  19     have any feeling that there was any cause for concern
  20     about the number of children who died in the ITU
  21     following paediatric cardiac surgery?
  22   A. We are now back in 1992 to 1993?
  23   Q. This will be a ragbag, I am afraid. Forgive me for
  24     that.
  25   A. If I can give a broad answer to that, I had been

   1     a Senior Registrar who had worked on the intensive care
   2     in that capacity and then as a consultant anaesthetist.
   3     There were a number of aspects of intensive care that
   4     could be improved and therefore I would have been
   5     concerned about any morbidity or mortality that occurred
   6     to adults or children within the intensive care.
   7   Q. So far as the discussion of anaesthetic risk is
   8     concerned you deal with that as part of your statement,
   9     but I have not asked you about it. Is that something
  10     you now think ought to be discussed as a separate set of
  11     risks with parents, or not?
  12   A. Two points: firstly, when I worked in America I had to
  13     tell each parent of any child that I anaesthetised that
  14     there were many risks but that the child could die
  15     during my anaesthetic. Therefore, I had been used to
  16     telling parents of those risks.
  17        It is a very difficult thing to do and is probably
  18     inappropriate when somebody is having a tonsillectomy in
  19     order to produce that stress in parents when the risks
  20     of anaesthesia are exceedingly small.
  21        My current clinical practice is that I will inform
  22     the patients that the general risks of anaesthesia are
  23     'X', depending upon their age and their age groups, and
  24     that they have specific risks over and above those of
  25     the surgery that may relate to renal function, it may

   1     relate to respiratory function, it may relate to cardiac
   2     function if I am doing an orthopaedic risk because it is
   3     only reasonable that the patients should be aware of
   4     what the problems are.
   5        So my current practice is to inform them of
   6     separate risks that come from anaesthesia.
   7   Q. Should the parents of Joshua Loveday have been told
   8     about the concerns that there were in relation to the
   9     operation upon that child?
  10   A. My concerns related to the issue as we discussed it and
  11     the fact that I felt that all the tensions it produced
  12     could impair the team. The decision that was taken
  13     meant that they felt that those tensions were not going
  14     to affect the outcome. Therefore, I do not suppose
  15     there should have been a change in the way in which we
  16     approached that problem.
  17   Q. It is a simple question, really. This was an unusual
  18     meeting for everyone to discuss this particular
  19     operation and the particular background against which it
  20     came about. Was that not something the parents had
  21     a right to have known about and ought to have known
  22     about?
  23   A. I considered speaking to the parents myself, but I did
  24     not do so.
  25   Q. The final matter is that if you had had throughout

   1     a concern -- you told us about it -- about the figures,
   2     about the performance, and you appreciated that what was
   3     needed was some sort of objective review of the data so
   4     that people might look at what they were doing and take
   5     it forward, was this not something which you, as
   6     Clinical Director of Anaesthesia, could yourself have
   7     asked to be done and arranged to be done?
   8   A. As Clinical Director, I neither had the resource nor the
   9     abilities to produce the review that would be required.
  10     It would take many people a lot of time to perform that
  11     review. I do not know how long it had taken Dr Bolsin
  12     to produce his audit, but I expect it was a long time.
  13        Secondly, as Clinical Director of Anaesthesia,
  14     this issue was only one of many that was affecting me at
  15     the time as Clinical Director. I had issues within the
  16     Children's Hospital itself about anaesthetic staff;
  17     I had issues within the obstetric unit, the Maternity
  18     Hospital. I had issues about training within the
  19     general surgical field. I had issues of how we provided
  20     the service out of hours for the Eye Hospital. How did
  21     I get multidisciplinary audit to be effected through the
  22     Trust on a rolling programme when it was objected to by
  23     the majority of the surgeons?
  24        So to ask me to go ahead and to produce this audit
  25     is simply beyond my capabilities and my resources.

   1     Therefore, the answer is no.
   2   Q. You had concerns expressed to you. You, for the reasons
   3     you have given, did not want to take the data themselves
   4     to Mr Wisheart or Mr Dhasmana. Could you not have said
   5     to Mr Dhasmana and Mr Wisheart words to the effect,
   6     "Look, there is serious concern. We are not in
   7     a position to establish the figures; can you have
   8     a detailed survey and let us know what the figures
   9     are?". Or do you think that is actually what you did?
  10   A. I do not think that my actions would have been so
  11     clearly presented by that sentence. I tried to produce
  12     change and acceptance of figures and, as I have said in
  13     my statement, I had a number of goals to try to
  14     achieve. That was only one of them.
  15   Q. You certainly, it was recollected by Mr Dhasmana when he
  16     gave evidence at the GMC, took the concerns of the
  17     anaesthetists to him about the switch operation, at any
  18     rate, and discussed those matters with him?
  19   A. That is correct.
  20   Q. Did you take the letter to him?
  21   A. No --
  22   Q. Because it was at that same time that the letter was
  23     written, was it not?
  24   A. The discussion I had with Janardan was in his room and
  25     I had already talked the matter through with Mr Wisheart

   1     beforehand because that was the direction that
   2     conversations always took. I spoke to Mr Dhasmana about
   3     my concerns about the outcomes of the switches, but what
   4     I said to him was that it was important that we improved
   5     the performance and in my view the right thing would be
   6     for a multidisciplinary group to go to a nearby centre
   7     to try to improve our performance.
   8        Indeed, that is exactly what happened. He readily
   9     accepted that suggestion. He organised it, not me, the
  10     visit to Birmingham. He organised it with Mr Brawn and
  11     took with him Dr Underwood and at a later date Dr Masey,
  12     and the other way round, whichever it may be, and they
  13     came back from Birmingham with changes in the surgical
  14     technique which was within his responsibility and his
  15     camp, as it were, and Dr Underwood and Dr Masey came
  16     back with the influences that Birmingham gave to them.
  17        The reason we had concentrated on those two people
  18     is that the number of anaesthetists had increased to
  19     a sufficient number that the paediatric practice was
  20     being diluted amongst us.
  21        Therefore we took the decision that we would try
  22     and concentrate the work amongst three of them,
  23     Dr Masey, Dr Underwood and Dr Pryn.
  24   Q. Could I just cut you short? It is late in the day and
  25     it may help to finish things off if you focus on the

   1     last couple of questions I have for you.
   2        You had spoken to Mr Dhasmana in the middle of
   3     1994 about the continued switch series. Was it
   4     a consequence of that discussion that you had with him
   5     in mid-1994 that you understood he probably was not
   6     going to do any more switches?
   7   A. I was never aware of when and how the decision was made
   8     to stop the switch programme. It just ceased. I do not
   9     know how or when that happened, or who made the
  10     decision.
  11   Q. When you spoke to Mr Dhasmana and raised the concerns
  12     which he recollects you raising with him, did he give
  13     you to understand he was not going to pursue any more
  14     switches?
  15   A. My understanding was that the unit was not going to do
  16     any more switches.
  17   Q. From Mr Dhasmana, or not?
  18   A. I am not being evasive. I just cannot remember who gave
  19     me that impression.
  20   Q. The significance of the point is this: that this was at
  21     about the time, would have been about the time, you had
  22     the letter from 6 anaesthetists in your hand, and you
  23     appreciate that Dr Roylance denies having had it from
  24     you?
  25   A. I appreciate that.

   1   Q. It may well be suggested that if you had spoken to
   2     Mr Dhasmana, as he recollects you did, and if he,
   3     Mr Dhasmana, had said, "Look, I am anxious about my
   4     performance, I have been twice to Birmingham and I am
   5     not happy with it, I am not going to do any more", that
   6     you would have achieved the result without needing to
   7     take the letter to Dr Roylance, and therefore it may be
   8     suggested that you did not do so?
   9   A. That is a suggestion. I took the letter to
  10     Dr Roylance. That was my action. There were a number
  11     of options that the letter could be used for.
  12   Q. Thank you for your patience.
  13   A. It is no problem.
  14   Q. I have not asked you about a number of other matters in
  15     your statement, as you know. I forget whether I said at
  16     the start of today, of course your statement is taken as
  17     read and stands for those, and I have asked you about
  18     matters of particular interest to the Inquiry, but there
  19     may be something you think I have missed which is
  20     important; there may be something you wanted to add or
  21     put in context. This is your first chance to do so;
  22     your second, perhaps, when you are less tired and more
  23     relaxed and can think back on today. You can, of
  24     course, add to anything which you have said orally by
  25     giving us a view or clarification in writing.

   1   A. Right.
   2   Q. But this is your first chance to say anything more that
   3     you think should be said.
   4   A. I feel I would like to take the opportunity to reply to
   5     you in writing, but of course if you wish me to return
   6     I will do so in person, if that is what you want.
   7   THE CHAIRMAN: I think Mr Langstaff is really saying we have
   8     asked you lots of things; if there is anything you would
   9     like to add, this is the moment you can do so but you do
  10     not have to.
  11   A. It has been fairly wide-ranging discussion, flipping
  12     backwards and forwards in time, so I do not think I can
  13     recall issues that have not been covered that I really
  14     ought to bring up now.
  15   THE CHAIRMAN: The Panel has no questions for you, Dr Monk.
  16     Miss O'Rourke?
  17   MISS O'ROURKE: No, sir.
  18   THE CHAIRMAN: I am grateful to you.
  19        Dr Monk, it has been a long day and you have been
  20     very patient with us. I am very grateful to you. The
  21     Panel have been completely helped by your evidence. If
  22     there are other things you would like to draw to our
  23     attention, whether through your representatives or
  24     anyone else, please feel free at any time to do so.
  25   A. Thank you, I will do so.

   1   MR LANGSTAFF: There is one matter which will detain us
   2     a little. Mr Francis, on behalf of Dr Roylance, would
   3     like to make a short application.
   4   THE CHAIRMAN: Mr Francis?
   5            APPLICATION BY MR FRANCIS
   6   MR FRANCIS: Thank you sir. This will not detain you very
   7     long. I appreciate your kindness in listening to it at
   8     this time of day.
   9        An unsigned statement from Dr Monk on the real
  10     issues you have heard about today was received from the
  11     Inquiry by those representing Dr Roylance on
  12     4th November. It appears from the fax heading it was
  13     transmitted to the Inquiry the previous day.
  14        Dr Roylance's solicitors had formally asked
  15     Dr Monk's solicitors if they agreed to send a copy of it
  16     at the same time one was sent to the Inquiry but this
  17     facility was refused.
  18        It had been anticipated for some time by those
  19     representing Dr Roylance that Dr Monk's evidence was
  20     likely to be important in relation to Dr Roylance's
  21     stewardship of the UBHT, but it has been impossible to
  22     undertake helpful preparatory work before the receipt of
  23     this statement as we have never previously had the
  24     benefit of a statement or evidence from Dr Monk. He did
  25     not give evidence to the GMC hearing; he provided the

   1     GMC with no statement which was disclosed to us, with
   2     the exception of a letter outlining his observations in
   3     relation to certain allegations made against him, and
   4     through his solicitors, he declined to be interviewed in
   5     connection with Dr Roylance's defence.
   6        Originally, Dr Monk was scheduled to give evidence
   7     on Thursday, 11th November. We had anticipated having
   8     some time to discuss Dr Monk's written evidence with
   9     Dr Roylance before Dr Monk attended to give oral
  10     evidence, but it has not been possible to have more than
  11     the briefest discussions with Dr Roylance about the
  12     evidence.
  13        Dr Monk's evidence, and indeed his statement, has
  14     contained allegations of contact with Dr Roylance with
  15     which he has taken, and continues to take, issue. Many
  16     of these alleged contacts have been described scantily,
  17     so much so as to render it impossible to discern what is
  18     said to have occurred.
  19        While the oral evidence has supplied certain
  20     further details, Dr Roylance has not been here to
  21     provide us with his immediate instructions.
  22        In these circumstances, our contribution to the
  23     process of examining Dr Monk has not been as full as we
  24     would have wished and we feel obliged to make it
  25     clear -- this is why I am here -- that we may wish,

   1     having had a further opportunity to take full
   2     instructions from Dr Monk, to apply for Dr Monk to be
   3     recalled. We would obviously hope that is not necessary
   4     but in view of what is, perhaps even for this Inquiry,
   5     a fairly stark conflict of recollection we feel it is
   6     necessary to make this point now and perhaps to have an
   7     indication from you as to whether that application can
   8     be made.
   9   THE CHAIRMAN: Mr Francis, you will forgive me, I thought
  10     you were going to make an application. I understand you
  11     are asking me: should you make an application would
  12     I hear it? Of course I will hear the application.
  13   MR FRANCIS: Thank you.
  14   MR LANGSTAFF: Sir, that was my observation, that you might
  15     like to treat this as technically it should have been an
  16     application, as an application for Dr Monk's recall,
  17     which, it is accepted, should be adjourned and may be,
  18     if necessary, reviewed and revisited later.
  19   MR FRANCIS: I felt I had to make the point.
  20   THE CHAIRMAN: I understand, Mr Francis. The Panel is
  21     anxious to get, gather and garner whatever information
  22     can be put before us. It does not have to be in oral
  23     form; it does not have to be in the form of examination
  24     from witnesses. But I would assure Mr Francis that if
  25     Dr Roylance wishes to put matters in -- and obviously he

   1     does because there is a clear, adopting your word,
   2     "stark" contrast in evidence here -- we would be happy
   3     to receive it. It does not, however, have to be in the
   4     form of calling Dr Monk, as you yourself have said.
   5        Let us see what form it should be in, but we would
   6     be grateful clearly to hear from you in due course and
   7     we give you the assurance obviously that we will take
   8     account of everything you let us have.
   9   MR FRANCIS: Thank you, sir.
  10   MR LANGSTAFF: Sir, I think the only thing that needs to be
  11     done, to be provided by my words, is that those who read
  12     the transcript on the Internet should not draw any
  13     conclusion adverse to Dr Roylance from the absence of
  14     a rebuttal statement at this stage.
  15   THE CHAIRMAN: I think that also helps. We just note that
  16     what would have been the normal circumstance, namely
  17     that a witness would have been able to make observations
  18     on another witness, has not been possible on this
  19     occasion and that in due course that will be rectified.
  20        That is entirely proper, and we look forward to
  21     hearing whatever is put before us.
  22   MR LANGSTAFF: Sir, tomorrow we hear from Dr Masey at 9.30.
  23   THE CHAIRMAN: We adjourn, then, until 9.30.
  24        Good afternoon, everyone.
  25   (5.10 pm)

   1     (Adjourned until 9.30 am on 10th November 1999)
   2
   3
   4
   5                I N D E X
   6
   7
   8     DR CHRIS MONK (affirmed)
   9        DR DUNCAN MACRAE (sworn)
  10        DR EDWARD SUMNER (sworn)
  11     Examination by MR LANGSTAFF .................. 3
  12
  13     Application by Mr Francis .................... 194
  14
  15
  16
  17
  18
  19
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Published by the Bristol Royal Infirmary Inquiry, July 2001
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