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