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Hearing summary10th 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.
Todays witness was Dr Sally Masey, Consultant Anaesthetist, BRI, since 1984. She began by commenting on the referral of younger patients for complex cardiac surgery during the period of the Inquiry and the establishment of the arterial switch operation across the country, commenting that Bristol introduced this new surgical technique later than other centres. She described how decisions were taken within the multi-disciplinary team regarding which operation would be undertaken. She went on to discuss the responsibility of the anaesthetists for the care of patients both before, during and after an operative procedure. Dr Masey then addressed the subject of audit within the departments of anaesthesia, where she was audit co-ordinator from 1992 to 1997, and cardiac surgery. She commented on the medical staffing in the Anaesthetic Room and Operating Theatre and noted the introduction of two surgical assistant posts in 1994. She then discussed responsibilities within the cardiac intensive care unit and the role of the anaesthetist post-operatively. Dr Masey described her input into discussions about the transfer of paediatric cardiac service to the Bristol Childrens Hospital (BCH) and commented on preparations for the arrival of the new surgeon Ash Pawade; including a training visit she made to Melbourne, Australia, with Dr Susan Underwood, to work with Mr Pawade before his arrival in Bristol. She then commented on her working relationship with Mr Pawade and other staff at the BCH and confirmed that she stopped anaesthetising for paediatric cardiac work in 1996. Dr Masey then told the Inquiry about a visit she made with Mr Dhasmana to Birmingham Childrens Hospital in 1992 to observe the unit and to see whether there were any differences between the management of cases in Birmingham and Bristol. She then commented on data relating to operations she recorded in her anaesthetic log and on data shown to her by Dr Stephen Bolsin. She concluded by describing discussions which led to the suspension of neo-natal arterial switch operations in 1993 and the decision to proceed with the operation on Joshua Loveday (non-neonatal) in January 1995.
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FULL TRANSCRIPT
1 Day 74, Wednesday, 10th November 1999. 2 (9.30 am) 3 THE CHAIRMAN: Good morning. 4 MR LANGSTAFF: Good morning, sir. Before Mr Maclean calls 5 our witness for today, may I just release information 6 about referrals? As you and the wider public will know, 7 one of the themes which has emerged from the review of 8 case notes and indeed is perhaps hinted at by the 9 statistical evidence that we looked at last week is the 10 question of the referral pattern to Bristol and the 11 reasons why children were or were not referred by 12 clinicians in the South West and elsewhere to the Royal 13 Infirmary and the Children's Hospital here. 14 The paediatricians have been approached. They 15 have supplied written comments. We are very grateful 16 for the virtually unanimous response that we have had to 17 the request to address what was and is Inquiry Issue D, 18 Referrals. Just to remind you, that is to establish the 19 information upon which decisions to send children to the 20 BRI were based, whether by parents or by referring 21 clinicians. 22 Today we have published the responses. The 23 comments that the paediatricians have made are focused 24 upon the following specific issues: first of all, the 25 judgment or impression which referring paediatricians or 0001 1 other clinicians formed of the paediatric cardiac 2 surgical services here; secondly, the sources of 3 information they had available for the standards of 4 treatment and care here; thirdly, the factors that 5 influenced them in deciding whether to refer children 6 here or elsewhere; fourthly, whether there is evidence 7 to suggest that clinicians based outside the BRI, but 8 within its catchment area, chose to go elsewhere and 9 why; and the information, if there was any, given to 10 parents or guardians at the time of referral to the BRI 11 about the standard of service and care that they might 12 expect when their children came here. 13 The responses are, of course, written evidence. 14 They will, I know, be read by the Panel, and they will 15 serve to inform the conclusions and recommendations 16 which we may expect next year. 17 THE CHAIRMAN: Thank you, Mr Langstaff. Mr Maclean? 18 MR MACLEAN: Sir, good morning. This morning's witness is 19 Dr Sally Masey. Could Dr Masey take the witness chair, 20 please? Could you stand, please, to take the oath? 21 DR SALLY MASEY (sworn) 22 Examined by Mr MACLEAN: 23 MR MACLEAN: Do sit down and make yourself comfortable. 24 Could you tell us your full name, please? 25 A. Sally Ann Masey. 0002 1 Q. You are a Consultant Anaesthetist at the UBHT? 2 A. I am, yes. 3 Q. I think, Dr Masey, you have given two statements to the 4 Inquiry so far. If we have a look, please, at 5 WIT 270/1, is that the first of a two-page statement 6 that you have made about your anaesthetist log? 7 A. Yes, it is. 8 Q. If we go to page 2, that is your signature, is it? 9 A. It is. 10 Q. And if we go to the next page, page 3, a more 11 substantive statement, that is the first page of your 12 second statement to the Inquiry; is that right? 13 A. It is. 14 Q. Now I know there is something you want to change, 15 Dr Masey, in the penultimate page, but if we first of 16 all go to page 17? I think unusually we do not find the 17 signature there. I think it is right, is it not, that 18 you are going to provide us with a signed copy of this 19 statement in due course? 20 A. Yes, I will. 21 Q. I think you want to make a change, do you not, at the 22 top of page 16, if we can have a look at that? 23 A. Yes. At the top of page 16, having seen a copy of the 24 letter to which I refer, I wish to change the phrase 25 "unacceptable results" to -- "the mortality is high" to 0003 1 the "mortality being apparently high", because that is 2 the wording in the letter. 3 Q. This is dealing with the letter which the anaesthetists 4 signed, which we will come to. You want the statement 5 to read that the change that you made or was made on 6 your behest amongst others was to insert the word 7 "apparently" before the word "high"? 8 A. Yes. 9 Q. Now you have been a Consultant in Bristol since May of 10 1984? 11 A. Yes. 12 Q. You are still a Consultant today? 13 A. I am. 14 Q. So you span almost the entire period that this Inquiry 15 is concerned with? 16 A. I do. 17 Q. You worked previously at the Royal Brompton Hospital, 18 amongst others? 19 A. Yes. 20 Q. When you came to Bristol in 1984, to what extent would 21 you have been classed as a paediatric anaesthetist? 22 A. My training included sufficient training in paediatric 23 anaesthesia to be classed as a paediatric anaesthetist. 24 Q. And how many other people like you were there 25 initially? How many other paediatric anaesthetists? 0004 1 A. Working doing cardiac anaesthesia at the Bristol Royal 2 Infirmary? 3 Q. Yes. 4 A. There was just one other, Dr Geoffrey Burton. 5 Q. How long did that situation persist? 6 A. That persisted until the appointment of Dr Bolsin in 7 September 1988. 8 Q. Now we heard yesterday from Dr Monk, and he mentioned 9 that there were rumours circulating when Dr Burton 10 retired towards the end of the 1980s that he might not 11 be replaced, and that the unit would be, therefore, back 12 to two paediatric cardiac anaesthetists, having risen to 13 three with the appointment of Dr Bolsin. Do you have 14 any recollection of that? 15 A. I have no recollection of that. 16 Q. I think Dr Monk was appointed, was he not, shortly after 17 Dr Bolsin had been appointed? 18 A. Dr Monk took up his appointment in the January of the 19 following year. 20 Q. So when he took up that appointment there would be, 21 what, three paediatric cardiac anaesthetists? 22 A. Dr Burton had not yet retired at that stage, so there 23 would have been four. 24 Q. Dr Short and Dr O'Higgins, did they do any paediatric 25 cardiac anaesthesia? 0005 1 A. Dr O'Higgins, as far as I recall, had been doing 2 anaesthesia for open heart surgery until my appointment 3 in May of 1984, but did not do any anaesthesia for open 4 heart surgery after my appointment. 5 Q. Now do you recognise the description or the phrase 6 "paediatric cardiac club"? 7 A. No. 8 Q. There were meetings, were there not, which took place 9 now and again in the home of one or other of the 10 consultants engaged in cardiac care at Bristol? 11 A. Yes, those meetings did take place. 12 Q. And those meetings would embrace surgeons, cardiologists 13 and anaesthetists, for example? 14 A. Amongst other people, yes. 15 Q. Could I have a look on my screen only please to 16 JPD 1/6? Could we just scan down the page so that we 17 can only see to "present", please? Okay. Can we stop 18 there. Can we just go back up to... that is it. Stop 19 there. Can we put that document on to the screens, 20 please. 21 Dr Masey, this is a minute of a meeting of 5th May 22 1987. Can you just take that from me? 23 THE CHAIRMAN: Just for clarity, we have just taken an 24 address out. That is all. 25 MR MACLEAN: Yes. We see that present at this meeting are 0006 1 cardiologists, Drs Joffe and Jordan, anaesthetists, 2 Dr O'Higgins and yourselves, cardiac radiologists, 3 I think, Dr Wilde, and the two surgeons. 4 Now do you remember attending this type of 5 meeting, first of all? 6 A. I remember attending this type of meeting, yes. 7 Q. Can we have a look down the page? Can you see the 8 paragraph beginning "Mr Wisheart is going to 9 arrange..."? 10 A. Yes. 11 Q. Can I ask you just to read that paragraph, please? 12 (Pause.) Do you remember a discussion about referring 13 patients with transposition of great arteries earlier 14 than had hitherto been the case? 15 A. Can you repeat that question? 16 Q. Do you remember it being discussed that it would be 17 desirable to refer patients with transposition of great 18 arteries earlier than had hitherto been the case? 19 A. Yes, I do remember having those conversations. 20 Q. And specifically do you remember there being 21 a discussion about those children being operated on 22 before their first birthday? 23 A. I do remember those discussions. 24 Q. Why was it important that the patients should be 25 operated on before their first birthday? 0007 1 A. My recollection is that there was not a particular 2 clinical need to operate on those children before the 3 age of one year, but it was in order to increase our 4 experience at operating on children at an earlier age. 5 Q. What would the benefit of that be? 6 A. The benefit would be that we were increasing our 7 experience in a younger age group. 8 Q. And was there any downside for these patients that they 9 should be used in order to increase the experience of 10 the centre as opposed to operated on at a later date? 11 A. In my experience, no. 12 Q. At this time Bristol was a supra-regional centre for 13 neonatal infant cardiac surgery? 14 A. I believe it was, yes. 15 Q. And funding from the supra-regional centre applied for 16 operations on those carried out under one year of age? 17 A. I do not have a particular recollection for that. That 18 may be the case. 19 Q. If we proceed on the basis that I am right in that 20 assertion, there was no supra-regional funding for an 21 operation carried on in the 13th month where there would 22 be funding for an operation carried on in the 11th or 23 12th month. Might that not have provided a good reason 24 for referring children with this or other conditions 25 rather earlier than had hitherto been the case; in other 0008 1 words, a financial incentive? 2 A. It might make a difference if there was a financial 3 incentive. 4 Q. Did you ever have any reason to suspect that there was 5 a financial motive, at least in part, driving the early 6 referral of patients? 7 A. I do have recollections that these sorts of discussions 8 did take place at these meetings, yes. 9 Q. You told me a little earlier there was no clinical 10 reason for the earlier referral in terms of the needs of 11 the particular patient. Do you understand that 12 correctly? 13 A. I think I put it the other way round, that there was not 14 any disadvantage to operating on them earlier, and there 15 may have been advantages to actually operating on them 16 earlier and having the correction performed earlier. 17 Q. What would those advantages be? 18 A. The advantages would be that these children would be 19 cyanosed before their operation, and following the 20 operation, they would not be cyanosed, and it is 21 preferable for any child to not be cyanosed if it is 22 possible to do the correction so that they are not in 23 that condition. 24 Q. Now we know there are various distinctions drawn in the 25 presentation of audit data, for example, between the 0009 1 ages of patients, for example those under one month or 2 28 days or those under 90 days, or whatever it might 3 be. Is there any distinction in principle between 4 operating on a child who is a little under one and 5 operating on a child a little over one in terms of the 6 physiology or the anatomy or whatever it might be of the 7 patient? 8 A. Are you suggesting the difference between operating at 9 11 months and, say, 13 months? 10 Q. For example. 11 A. In my experience I do not think there is a difference. 12 Q. Are there any distinctions, lines, if you like, to be 13 drawn in terms of the age of the patient such that one 14 could say the operation on patient age X is different in 15 type, qualitatively different, from the operation on 16 patient age Y, and if there is such a line or lines to 17 be drawn, where are they to be drawn? 18 A. I think it is very difficult to draw an absolute line 19 between a child of one age and another age, but the 20 newly born child is a different case, because the 21 physiology of a newborn child is different and the way 22 in which a newborn child deals with drugs that are given 23 can be different. So the newborn child I would agree is 24 different from a child of, say, 11 months, but where 25 I would draw the exact distinction between that child 0010 1 and an 11 month child I do not feel it is easy to draw 2 an absolute distinction. It is a spread as the child 3 develops. 4 Q. So there is a line to be drawn somewhere in the first 5 year of life, is there not? 6 A. I would never wish to draw an absolute line, because 7 different children will develop at a different rate, and 8 so it is not necessarily right to compare two six month 9 old children as being the same from the point of view of 10 how they will respond to anaesthesia and surgery. 11 Q. We will come back in due course to some of these 12 distinctions that have been drawn. Can I just ask you 13 whether or not you were aware of there being any success 14 after this meeting we have seen of May 1987 in achieving 15 the earlier referral of transposition patients? Did it 16 happen? 17 A. I do remember anaesthetising a number of children who 18 were under the age of one year for transposition of the 19 great arteries, but I would not like to say whether 20 there was a very definitive change in the time at which 21 we operated on them. 22 Q. Now in 1987 in Bristol at least there was no such thing 23 as the arterial switch operation? 24 A. We were not doing the arterial switch operation in 1987. 25 Q. The arterial switch operation did, however, commence in 0011 1 non-neonates I think in 1988? 2 A. It did commence in 1988. 3 Q. And the neonatal switch commenced some years later, 4 I think in 1992? 5 A. I believe in 1992. 6 Q. Does it follow from that that there was a reliance 7 placed, if you like, on there being a line between 8 neonates on the one hand and non-neonates on the other 9 in that the operation was begun on the non-neonates but 10 not begun on the neonates? 11 A. I think this issue is very complicated in that the 12 arterial switch procedure is performed for a number of 13 different complex heart conditions, and many of the 14 operations that are done in children in the older age 15 group are operations which would not necessarily be 16 appropriate to do in the neonatal phase. 17 Q. So there was a reliance placed on neonates being, as it 18 were, different, because the operation was not begun for 19 that category of patients? 20 A. I find it difficult to give a straightforward answer to 21 that, because the operation in the older age group is 22 often done for a very different and complex heart 23 condition, which is not the same heart condition that 24 the operation for a neonatal switch is done. 25 Q. So although it is the same correction, the plumbing is 0012 1 being moved in the same way, the condition of the 2 patient is qualitatively different; is that right? 3 A. The heart lesion can be a different heart lesion that is 4 being corrected in the non-neonatal operations as what 5 is done for the neonatal type of operation. 6 Q. So why was it that Bristol collectively decided not to 7 commence the switch operation on the full range of 8 children, but only on those who were non-neonates? 9 A. At that stage in the late 1980s the other operation that 10 was being performed for the heart condition for which 11 a neonatal switch would be performed was the Senning 12 procedure, which is what I would describe as 13 a physiological correction rather than an anatomical 14 correction. 15 The results for this particular operation in 16 Bristol at that stage were very good indeed. Even in 17 the best centre the peri-operative mortality for the 18 neonatal switch is higher than it is for our mortality 19 for the Senning procedure in Bristol. So there was 20 hesitation to start performing a more complex operation 21 with a higher mortality when our mortality figures for 22 the operation we were already doing were excellent. 23 Q. So it was your impression that Bristol's results for the 24 Senning's operation compared very favourably with 25 elsewhere in this country? 0013 1 A. My impression was they compared very favourably. 2 Q. What was that impression based on? 3 A. My impression was based on results that I saw frequently 4 in relation to our results, which would be compared to 5 the UK cardiac register. 6 Q. So the comparison was the registrar? 7 A. The comparison was the register. 8 Q. And the Senning's operation was carried out by which 9 surgeon or surgeons at Bristol at that time? 10 A. Both Mr Wisheart and Mr Dhasmana carried out Senning 11 procedures. 12 Q. Was it your impression that both of those two surgeons 13 had results that compared very favourably with the rest 14 of the country? 15 A. That was my impression. 16 Q. By "very favourably" we mean what? In the top handful, 17 two or three centres, top centre? What was the 18 impression? 19 A. There is a difficulty on looking at these figures, 20 because when looking at the UK cardiac register, the 21 register does not look at operations that are performed, 22 but looks at the definition of the heart lesion. So the 23 UK cardiac register would include neonatal switch 24 procedures in these figures. So that would tend to move 25 the figures on the UK cardiac register to being higher 0014 1 than those in Bristol. 2 Q. Because those other centres were at their learning stage 3 of doing the switch? 4 A. Other centres were already doing neonatal switches at 5 that stage, but my recollection was that we had few 6 deaths. I cannot, in my experience, remember one death 7 during the Senning procedure, although I believe the 8 results would show we did have one death during that 9 period. 10 Q. Now it was your practice, was it not, to attend some of 11 these pre-operative meetings, discussions, about 12 upcoming paediatric cardiac patients? 13 A. There were meetings to discuss upcoming paediatric 14 cardiac patients, but I would not describe these as 15 pre-operative meetings. 16 Q. They were planning meetings, were they? They were not 17 immediately pre-operative? 18 A. They were quite often not immediately pre-operative. 19 Q. Can we have a look at UBHT 188/147, please? Is this an 20 example of a note of such a meeting. Have a look at 21 it. Can we scan down a little? 22 A. Yes, this is a record of one such meeting. 23 Q. This is attended, as we see from those present, by 24 cardiologists Dr Jordan, Dr Joffe, Dr Wilde, yourself, 25 the surgeon Mr Dhasmana, and I think two junior staff? 0015 1 A. That is correct. 2 Q. There is a discussion there of a patient -- the 3 patient's name would obviously be known at the meeting 4 -- the age of the child, the referring cardiologist, 5 and then there would be a discussion as to the diagnosis 6 and whether or not the child was suitable for surgery 7 and, if so, which procedure? 8 A. Those were the sort of discussions that took place at 9 these meetings. 10 Q. Who took the decision as to, first of all, whether to 11 have a surgical correction or a palliative surgical 12 procedure and, secondly, who decided which particular 13 procedure would be carried out? 14 A. Those issues would be raised by the people at the 15 meeting and a consensus would be agreed as to the way 16 forward. 17 Q. If there was a disagreement but a decision had to be 18 made, who had the casting vote? 19 A. I cannot recall as to whether there was a casting vote 20 made. It would be by consensus. A discussion would 21 take place and an agreement would be reached. 22 Q. Can we have a look at UBHT 188/121? The previous one 23 we have just looked at that is disappearing was March 24 1988. This is a little later, 1st February 1989. If we 25 scan down the page, again it is another similar type of 0016 1 meeting. You see from the last main paragraph: 2 "... could not agree in a switch operation. 3 Mr Dhasmana is going to look in greater detail of the 4 reports of coronary artery anatomy and Dr Hartnell will 5 see whether there is any possibility of arranging an MRI 6 scan in the next few weeks". 7 The case was to be discussed again. If we scan 8 down a little more: 9 "Mr Dhasmana has restudied the anatomies described 10 in Kirkland's book ..." 11 That is one of the leading texts, I think: 12 "... and together with the MRI scan now feels this 13 is suitable for switch operation. 14 "Please check that ... is on Mr Dhasmana's 15 waiting list for operation within the next month or six 16 weeks. 17 "Mr Dhasmana", and a tick. 18 Does that not suggest there had been a lack of 19 agreement originally? The surgeon went away, looked at 20 some more data and he, the surgeon, decided this was 21 a case for a switch operation and it was listed? 22 A. This would seem to be the case from this document. 23 Q. Therefore in this case at least the final decision was 24 taken by the surgeon who would perform the operation? 25 A. In this case it would appear that the final decision was 0017 1 made by the surgeon. 2 Q. Would that be typical or atypical of this type of 3 situation? 4 A. I think it is impossible for anybody to do a procedure 5 if he does not agree with the consensus decision. 6 Q. So ultimately the consensus only exists if the surgeon 7 is on board? 8 A. In order for the surgeon to do an operation the surgeon 9 would have to agree to do the operation. 10 Q. Yes. We are agreed? 11 A. I think we are agreed. 12 Q. Did you attend these meetings for Mr Dhasmana's patients 13 only or for Mr Wisheart's as well? 14 A. The meetings were not separated into one or other 15 surgeon, so when I went to a meeting, there would be 16 patients who would be referred to both surgeons. 17 Q. The reason I ask is that I have seen various of these 18 documents, and I am not going to weary you with any 19 more, but at all of them that I have seen Mr Dhasmana 20 was present and at none of them Mr Wisheart was 21 present. Is that simply because we have not got all the 22 records after all this time? 23 A. I do not know the reason for that. I certainly went to 24 meetings where Mr Wisheart was present or even if he was 25 not present, that the cardiologists had chosen to refer 0018 1 those patients to Mr Wisheart. 2 Q. Were you the only Consultant Anaesthetist who attended 3 this type of meeting? 4 A. It is my recollection that I was the only anaesthetist 5 who went to those meetings. 6 Q. Are you able to help me with why your Consultant 7 colleagues, who shortly afterwards would include Dr Monk 8 and Dr Bolsin, did not attend similar meetings? 9 A. I do not know why they did not attend the meetings. 10 Q. You are aware -- in fact, you refer in your statement to 11 a document called "Guidance on Contracts and Workload 12 for Consultant Anaesthetists"? 13 A. Yes. 14 Q. I think the latest version of that is published in 15 1997. Could we have a look at WIT 65/1068? Turn it 16 round. That is the document, is it not? 17 A. I have not got it on my screen. 18 Q. Have you not? Is it on there now? 19 A. Yes. 20 Q. That is the document, is it? 21 A. "Guidance on Contracts and Workload for Consultant 22 Anaesthetists 1997". I have that document, yes. 23 Q. 1997. If we go to page 1077, paragraph 4.4(i), 24 "Peri-Operative Care", can we blow up that left-hand 25 paragraph: 0019 1 "To maintain good standards, anaesthetic services 2 include the pre-operative assessment and preparation of 3 patients and the provision and supervision of immediate 4 post-operative care including the management of 5 post-operative pain", and so on. 6 Was it your understanding that the guidance in the 7 time we have been discussing, the late 1980s and through 8 to the early 1990s, similarly provided that to maintain 9 good anaesthetic standards should include the 10 pre-operative assessment and preparation of patients? 11 A. I cannot say when these sorts of recommendations were 12 first written down in documents of this sort. The first 13 document of this sort from the Association of the 14 Anaesthetists you said was in 1994? 15 Q. 1990, I think. 16 A. 1990. Certainly it has throughout my anaesthetic 17 career, from the very first day I started in anaesthesia 18 -- I was told and taught that the pre-operative 19 assessment of patients was part of my job and my 20 responsibility. 21 Q. Now these meetings we have been discussing are the 22 planning meetings before surgery. There were also 23 meetings after surgery, especially where the operation 24 had been unsuccessful in the sense that the child had 25 died. There would be a review meeting? 0020 1 A. The surgeons did hold regular morbidity and mortality 2 meetings where children who had died would be discussed. 3 Q. And who would attend those? 4 A. I am sorry. Could you repeat that? 5 Q. Who would attend those meetings? 6 A. They would be open to anybody to attend who wished to 7 attend, so cardiologists, cardiac surgeons, 8 anaesthetists, and we also held meetings with 9 pathologists. 10 Q. Did you attend any of those? 11 A. I did attend some of them. 12 Q. Did any of your Consultant Anaesthetist colleagues 13 attend those meetings? 14 A. Some of the meetings that occurred in the early 1990s, 15 once we had started to hold definitive audit meetings, 16 some of my colleagues did attend cardiac surgery audit 17 meetings where morbidity and mortality would be 18 discussed. 19 Q. Now you date that to the early 1990s, because of the 20 introduction of medical audit? 21 A. Yes. 22 Q. Which of your colleagues started to attend those 23 meetings then? 24 A. Because the cardiac surgery audit meetings would often 25 take place at the same time as the Anaesthetic 0021 1 Department audit meetings my colleagues would decide, 2 depending on the agendas of the meetings, which meetings 3 they felt it was more advisable for them to attend, so 4 different anaesthetists would attend the cardiac surgery 5 meetings from month to month. 6 Q. Depending on whether it was their case being discussed 7 perhaps? 8 A. Depending on the agenda and what was on the agenda for 9 the meetings. 10 Q. But the agenda was a discussion of a series of patients' 11 cases? 12 A. The agenda did include that, but the agenda might 13 include other items as well. 14 Q. You mentioned audit a couple of times. I will come to 15 audit in a minute. I will come to it now, in fact. 16 What is the purpose of audit? 17 A. The purpose of audit in the broadest sense is to have 18 a mechanism to look at our practice in order to improve 19 the quality of care in the broadest sense. 20 Q. Would you look at UBHT 66/267? Are you familiar with 21 this document? 22 A. Yes. 23 Q. Can we have 269, please, second paragraph, first 24 sentence: 25 "Clinical audit involves systematically looking at 0022 1 the procedures used for diagnosis, care and treatment, 2 examining how associated resources are used and 3 investigating the effect care has on the outcome and 4 quality of life for the patient". 5 This is dealing with clinical audit published in 6 1993. Is that a summary of what audit is all about? 7 A. I think that is basically saying the same as what I have 8 just said, yes. 9 Q. Now you were the co-ordinator for anaesthesia from 10 I think you say in your statement September 1992 -- 11 I think we will see a suggestion in a document in 12 a minute that it may have been July 1992; perhaps not 13 much turns on that -- until September 1997? 14 A. That is correct. 15 Q. What was your role as audit co-ordinator for 16 anaesthesia? 17 A. My role was to oversee audit for the Directorate of 18 Anaesthesia. This involves organising audit meetings, 19 looking at any audit projects that had been suggested 20 and in discussion with a small Audit Committee that 21 existed to discuss the merits of these planned audits 22 and to decide whether they should be taken forward and 23 performed. We also held departmental audit meetings 24 during my tenure eight times a year, where these 25 projects could be discussed in the larger forum, and 0023 1 this also acted as a mechanism to look at the results of 2 already performed audit projects. 3 Q. So there was a committee and then there would be wider 4 plenary sessions held regularly throughout the year? 5 A. Yes. 6 Q. Were paediatric cardiac surgery and the outcomes and 7 results ever discussed at the anaesthesia audit meetings 8 either by the committee or the wider session? 9 A. As far as I can recollect, no. 10 Q. Dr Williams was a Clinical Director of Anaesthesia 11 before Dr Monk; is that right? 12 A. Yes. 13 Q. And then Dr Coates subsequently? 14 A. Yes. 15 Q. Can we have a look at UBHT 58/167? This is a memo from 16 Dr Williams. It is to a very long list of people. If 17 we look down to the ccs, those who were copied into the 18 memo, we see your name third from the bottom, "Chairman, 19 Audit Committee, BRI". Is that an accurate description 20 of your role? 21 A. No. 22 Q. Were you ever the Chairman -- forget about the sex of 23 the chair for the moment -- of the Audit Committee of 24 the BRI? 25 A. I was not. 0024 1 Q. Now there was some difficulty, was there not, in 2 agreeing whether or not the audit sessions were going to 3 be at the same time every month or at different times; 4 is that right? 5 A. There was a lot of discussion as to the timing of the 6 Directorate of Anaesthesia audit meetings. 7 Q. If we have a look at UBHT 27/150, this is a letter to 8 you, 15th February 1993. If we look down the page, you 9 will see this is from Mr Baird, from the Directorate of 10 Surgery. It is the middle paragraph. The surgeons were 11 unhappy with the rolling system of audit. That is the 12 gist of it, is it not? 13 A. Can I please finish reading the paragraph? 14 Q. Do. (Pause.) 15 A. Yes. The surgeons were unhappy at the rolling programme 16 that the Directorate of Anaesthesia had suggested. 17 Q. So there were two rival concepts, if you like. One is 18 a rolling programme and another is a fixed programme? 19 A. Yes. 20 Q. The surgeons were unhappy about the rolling system, 21 which I think you had suggested? 22 A. It had been suggested by the Directorate of Anaesthesia 23 through me, as the anaesthesia audit co-ordinator. 24 Q. What were the pros and cons of the two systems? 25 A. The pros of the rolling rota were that all surgeons 0025 1 would lose an equal number of sessions. As I explained 2 before, we had eight sessions a year. We never held 3 audit meetings on Mondays, because we felt a sufficient 4 number of Mondays were lost to the surgeons who worked 5 on those days through bank holidays. So we chose eight 6 half-day sessions from the Tuesday through to the 7 Friday. We felt that this would impact equally and 8 fairly on all surgeons, as each would have an equal 9 number of sessions cancelled. 10 Q. Just to be clear, we are not here discussing whether the 11 surgeons themselves can attend the meetings. We are 12 discussing the impact on the surgeons of their 13 anaesthetists attending the meetings and therefore not 14 being in theatre? 15 A. That was part of the issue. We did also hope, as 16 clinical audit took over from medical audit, and so we 17 were, therefore, asked to look at audits across 18 specialities, that by holding audit meetings at the same 19 time that we would be able to hold joint audit meetings 20 with different surgical specialities. 21 Q. We will come to see a limb of that in a moment. So why 22 did the surgeons object to the system which you have 23 described as being fair in the sense that all surgeons 24 would lose the same number of sessions? 25 A. It is difficult for me to answer this, because I felt 0026 1 that this was a fair way to cancel sessions. Surgeons 2 obviously did not, so it would be easier to ask the 3 surgeons why they felt it was unfair. 4 Q. It is right, is it not -- we do not perhaps need to go 5 to the documentation -- by the summer of 1993 the 6 rolling rota was established? 7 A. Yes. 8 Q. And some surgeons were still unhappy about that? 9 A. Yes. 10 Q. If we have a look at UBHT 304/369, that is a letter to 11 Dr Roylance. If we scan down the page, please, this is 12 from a Consultant Orthopedic Surgeon, Mr Newman. So 13 this issue did exercise the surgeons to the extent that 14 this one at least went to the very top and he wrote to 15 Dr Roylance? 16 A. Yes. 17 Q. Then the annotation is: 18 "James, 19 I have written to Sally to protest! on 9th March 20 you wrote around proposing a cross-directorate meeting; 21 maybe the time has come for us to meet". 22 Then it says what? 23 A. "Roger". 24 Q. Who was that? 25 A. Roger Baird. 0027 1 Q. He was the surgeon we have just seen wrote the letter to 2 you? 3 A. Yes. 4 Q. And the "James", if we scan back up the page, is 5 Mr Wisheart? 6 A. Yes. 7 Q. Why should this be something to do with Mr Wisheart? 8 A. I cannot remember but your documentation may be able to 9 put me right. Mr Wisheart at this stage was either the 10 Chairman of the Hospital Medical Committee or was the 11 Medical Director. I cannot remember in June 1993 which 12 capacity, which office he held. 13 Q. I think, Dr Masey, he held both at this stage. If we 14 have a look then at UBHT 137/13, still on the same 15 point, there is not a date at the top of this letter, 16 but it is dealing, as you see, with audit for 17 1993/1994. If we go over the page, please, and scan 18 down that page, we can see that the dates are given 19 there for what must be the latter part of 1993 and the 20 beginning of 1994? 21 A. Yes. It says: "The dates of audit for 1993/1994". 22 Q. You see the letter is signed by Mr Wisheart in his 23 capacity as Medical Director? 24 A. Yes. 25 Q. If we go back then to the first page, the reference to 0028 1 the meeting convened on 19th July therefore must be 2 19th July 1993; right? 3 A. It would appear to be so. 4 Q. Then he is dealing with a meeting representing 5 ophthalmology, obstetrics, gynaecology and ENT. You see 6 a reference in paragraph 1 to: 7 "... joint decision taken today will enable 8 multidisciplinary audit to take place as and when 9 desired." 10 A. Which paragraph? 11 Q. Paragraph 1. 12 A. Yes, paragraph 1. 13 Q. To what extent did that come to pass? 14 A. We did not find that we were able to frequently meet 15 with our surgical colleagues. 16 Q. I am dealing here with cardiac anaesthesia and cardiac 17 surgery in particular obviously, but also more generally 18 between anaesthesia and surgery. 19 A. Yes. We did have some joint meetings with different 20 sub-specialities of surgery during this time. 21 Q. That is a letter from Mr Wisheart, as Medical Director. 22 You mentioned his role as Chairman of the Hospital 23 Medical Committee. In due course he became as well 24 Chairman of the Clinical Audit Committee, did he not, of 25 the Trust? Do you remember that? 0029 1 A. I cannot remember that clearly. The chair seemed to 2 change fairly frequently. 3 Q. If we have a look at UBHT 30/63, Clinical Audit 4 Committee. We are moving ahead now to 9th November 5 1994. That is the agenda set out. You see that the 6 invitation is sent out by Mr Wisheart. This time he is 7 Chairman of the Clinical Audit Committee. 8 A. Yes. 9 Q. I think he had replaced Dr Thomas, who had previously 10 been the Chairman? 11 A. Dr Thomas had previously been the Chairman, yes. I do 12 remember that. 13 Q. Now that Committee, the Trust's Audit Committee, 14 produced Annual Medical Audit Committee reports, did it 15 not? 16 A. It did. 17 Q. For example, UBHT 58/198, which is a 1992 report, and 18 I think you have seen this recently again, Dr Masey? 19 A. Yes. 20 Q. Now if we go to page 200 and scan down the page a 21 little, "Terms of Reference", paragraph 1: 22 "To review the reports of the individual audit 23 groups to ensure that effective audit is being 24 undertaken, within the limitations of appropriate 25 confidentiality of individual data". 0030 1 Now you, as co-ordinator of audit for anaesthesia, 2 would be responsible for submitting anaesthesia's audit 3 reports to this committee? 4 A. I was responsible. 5 Q. To what extent were you aware of this Trust Audit 6 Committee reviewing the reports that you sent in? 7 A. I did not know what form its review took. 8 Q. Did you ever receive any criticisms, constructive or 9 otherwise, praise, complaints or other feedback from the 10 Trust committee about the substance or the form of the 11 reports that you submitted? 12 A. I did not ever receive any criticism of the substance or 13 the format of the reports that I sent back. 14 Q. Or any other feedback from this committee, other than 15 a copy of the annual report perhaps? 16 A. Over the years of my tenure as the audit convenor for 17 anaesthesia, my impression was that anaesthesia was felt 18 to be dealing with the issue of audit relatively well. 19 Q. Now the audit topics for anaesthesia, how were they 20 selected? 21 A. We had a variety of mechanisms whereby we generated 22 audit topics. We would use NCEPOD, the "National 23 Confidential Enquiry into Peri-Operative Deaths", as 24 a reference for looking at topics that we should audit. 25 We had brainstorming sessions within the Directorate of 0031 1 Anaesthesia for people to suggest audit topics. 2 Guidelines that were produced either by the Royal 3 College of Anaesthetists or the Association of 4 Anaesthetists were also used as documents from which we 5 would design audit projects. 6 Q. So to that extent the topics were self-generated by the 7 anaesthetists themselves with reference to these 8 publications and other works? 9 A. During my tenure they were self-generated by the 10 Division of Anaesthesia, Directorate of Anaesthesia. 11 Q. Was there ever any pressure or direction from the Audit 12 Committee or from higher up the management tree in the 13 Trust to say to the anaesthetists: "We think you should 14 audit X this year rather than Y"? 15 A. During my tenure, no, I had no pressure. I did know 16 from sitting on committee meetings at Trust level that 17 purchasers were able to ask for audit projects to be 18 generated, but during my five-year tenure I was never 19 asked to initiate any such project. 20 Q. Now you attended meetings of what was known as the 21 Cardiac surgery Boards through 1993, for example, where 22 cardiac issues would be discussed? 23 A. I am not familiar with this term "Cardiac Surgery 24 Board". Could you explain that to me? 25 Q. Let me give you an example. UBHT 84/0163. This is 0032 1 23rd November 1993. It is called the Cardiac Surgery 2 Meeting Board. The title may have altered slightly over 3 time. Do you remember this type of meeting with that 4 sort of line-up: surgeons, managers, anaesthetists? 5 A. Yes, I now understand the meetings to which you are 6 referring. 7 Q. If we look at the bottom of the page, do you see the 8 last paragraph: 9 "Sally Masey asked what quality information we 10 supplied to purchasers. James Wisheart explained that 11 they had asked for little except reduced waiting times, 12 but we had shared out audit results with some". 13 What did you understand had been shared? What was 14 the substance of what had been shared with the 15 purchasers? 16 A. I cannot recall from this meeting what I understood as 17 being the substance as to what had been shared. 18 Q. Do you remember why audit results of whatever nature 19 should have been shared with some but not other 20 purchasers? 21 A. No. I do not know what the reason might be for audit 22 results to be shared with some but not others. 23 Q. Can we turn to something else? In the theatre there was 24 a change, was there not, in 1994 in the organisation of 25 the theatre in that surgical assistants were appointed? 0033 1 A. Two part-time surgical assistants were appointed, but 2 I do not know the date. 3 Q. Why was that change made? 4 A. I do not know the reason why the change was made. 5 Q. What was the professed reason for it? 6 A. I cannot recollect professed reasons -- reasons given 7 for it, but I can think of reasons why this move was 8 made. 9 Q. What would they be? 10 A. The reason would be that the surgical assistants would 11 be able to perform operative tasks that at that time 12 were being performed by surgical senior house officers. 13 This would free up those SHOs for other duties, if these 14 duties could be performed by surgeons' assistants. 15 Q. What was your attitude to this change, this attitude of 16 surgical assistants? 17 A. I felt it was a positive move. 18 Q. Was that shared by the other Consultant Anaesthetists? 19 A. I do not know. 20 Q. Can we have a look at UBHT 84/145? This is a meeting of 21 the Cardiac Surgery Management Board, 24th May 1994. I 22 am not sure to what extent this is a different body from 23 the one we have just seem. There is a rather similar 24 line-up. It is called something slightly different from 25 that. Can we look at paragraph 2: 0034 1 "Sally Masey wished it to be minuted that she had 2 expressed her disappointment at the loss of an 3 anaesthetic nurse with the appointment of the surgeons' 4 assistants". 5 Why should the appointment of the surgeons' 6 assistants mean the loss of an anaesthetic nurse? 7 A. Because one of the people who took up an appointment as 8 a surgeons' assistant was one of our anaesthetic nurses. 9 Q. Who was that? 10 A. Kay Bennett, or Kay Armstrong as she is now. 11 Q. The Panel will recall Mrs Armstrong giving evidence 12 a few weeks ago. During a paediatric cardiac operation, 13 who would be present in the operating theatre? 14 A. During the whole procedure from the beginning to the 15 end? 16 Q. To the end, yes. 17 A. Starting off in the anaesthetic room? 18 Q. Very well. I will start there. 19 A. Is that where you wish me to start? 20 Q. Yes. 21 A. In the anaesthetic room, when the child was brought into 22 the anaesthetic room the child would be accompanied by 23 a ward nurse and quite often by one or other or both 24 parents. In the anaesthetic room would be a Consultant 25 Anaesthetist, quite often a Trainee Anaesthetist and an 0035 1 Anaesthetic Assistant. 2 Q. Okay. The patient would be anaesthetised? 3 A. The patient would be anaesthetised. 4 Q. And then taken to theatre? 5 A. The patient would be taken into the operating theatre. 6 Q. Which would be next door? 7 A. Which is next door. 8 Q. Who would we find there? 9 A. In the operating theatre would be at the beginning the 10 Consultant Anaesthetist; if a Trainee Anaesthetist was 11 present, that person would be present as well; the 12 Anaesthetic Assistant. In the operating theatre would 13 be the scrub nurse and another nurse or assistant who 14 acted as a runner and at the beginning of the case from 15 the surgical side would be a Surgical SHO and then 16 a Surgical Registrar or Senior Registrar. 17 Q. How frequently did one find paediatric cardiologists 18 making an appearance in the theatre during the 19 operation? 20 A. Infrequently. 21 Q. In what circumstances would one find such a situation? 22 A. The situation would arise if the surgeon, while doing 23 the operation, discovered something within the anatomy 24 of the heart which was unexpected, and would ask for 25 a cardiologist to come and advise, or on other occasions 0036 1 if we were experiencing difficulties later on in the 2 operation a cardiologist might be asked to come and 3 advise and occasionally we were able to do echo 4 examinations in the operating theatre. 5 Q. The cardiologist would be based at the Children's 6 Hospital, not the BRI? 7 A. At the Children's Hospital, yes. 8 Q. And open heart surgery we know was carried out in the 9 BRI, not the BCH? 10 A. Yes. 11 Q. So if there was a anatomical problem or something 12 unexpected turned up when the patient was on the 13 operating table, would the cardiologist, if you like, be 14 hanging around BRI in case the surgeon did want to 15 contact him, or would he or she be back at work at the 16 Children's Hospital and have to be summoned from there? 17 A. He or she would have to be contacted at the Children's 18 Hospital. 19 Q. And if any cardiological procedure was to be carried 20 out, then the cardiologist would have to get him or her 21 down the hill from one hospital to the other? 22 A. The cardiologist would have to come down the hill. We 23 did also have the ability to ask radiologists to come 24 and some of those radiologists would be based in the 25 BRI. 0037 1 Q. Now, when the patient came out of the operating theatre, 2 they would be taken to the Intensive Care Unit? 3 A. Yes. 4 Q. All the time we are concerned with when surgery was 5 carried out at BRI on children, the Intensive Care Unit 6 was mixed as between adult and children? 7 A. It was. 8 Q. Who was in charge of the care of the patient in the 9 Intensive Care Unit? 10 A. The care of the children in the Intensive Care Unit was 11 done by a team. 12 Q. Who was in charge of the team? Who was the "captain"? 13 A. I think it is very difficult to use the terminology "in 14 charge". Each member of the team had a responsibility 15 to a child in the Intensive Care Unit, so it is 16 difficult to talk about somebody being in charge. 17 Q. Last Thursday -- I do not know whether you saw the 18 transcript -- we had some of our experts present. One 19 of those Consultant Paediatric Cardiologists was from 20 Birmingham, Dr Silove. He said -- the reference is page 21 146: 22 "Somebody has to be in overall charge of the 23 patients and all members of the team have to work with 24 that leader. Whoever the leader may be, you must have 25 the whole team working together". 0038 1 Do you agree with that? 2 A. I agree it is important for a team to work together. 3 Q. That is the second part of Dr Silove's statement, "You 4 must have the whole team working together". So we are 5 agreed about that. The first part of his statement was: 6 "Someone has to be in overall charge and the team has 7 to have a leader". Do I understand that you are 8 disagreeing with the proposition that he advanced that 9 the team has to have a leader? 10 A. How I would put it is that I always felt that the child 11 belonged to the cardiac surgeon, and so from that 12 respect I would always wish to discuss any issues with 13 the cardiac surgeon who had operated on that child. 14 Q. So the surgeon was the leader? 15 A. I find using the term "leader" -- I find it a difficult 16 term. I am having difficulty in finding the words to 17 try to express what I am trying to say, in that I feel 18 we all had a responsibility, and we each maybe had 19 a lead for various parts of the care. For instance, in 20 relation to respiratory care for a child that I was 21 responsible for or had a responsibility for, I would 22 feel that I would be the leader for that aspect of the 23 care, and I would expect queries as to that part of the 24 management to be directed through me rather than through 25 the cardiac surgeon. So that is why I find it difficult 0039 1 to say that there is somebody in charge or a leader. 2 Q. You are a member of the Paediatric Intensive Care 3 Society? 4 A. Yes, I was. I am no longer. 5 Q. Yes. For the period we are concerned with you were? 6 A. Yes. 7 Q. And that Society was established in 1987, following 8 a working party report from the British Paediatric 9 Association? 10 A. I cannot remember why the Society was formed. 11 Q. I think the Panel have heard evidence to that effect. 12 It does not much matter at the moment. That Society 13 produced standards or guidelines which have developed 14 over time. I think you make a reference to them in your 15 statement? 16 A. Yes. 17 Q. And in particular produced some standards in 1992. If 18 we have a look at WIT 60/11, please, those are the 19 standards? 20 A. Yes. 21 Q. If we go to page 15, I hope we will find somewhere in 22 this page a heading "Paediatric Intensive Care". There 23 we are. If we go to page 17, the middle paragraph, if 24 we just stop there: 25 "The unit medical staff will usually be paediatric 0040 1 anaesthetists, paediatricians or both. One Consultant 2 should be designated to take full administrative 3 responsibility for the unit", and so on. 4 Is there a distinction to be drawn between 5 administrative responsibility of the unit, on the one 6 hand, and the clinical responsibility for the patient, 7 on the other? 8 A. I would feel there is a difference, yes. 9 Q. And so these standards are aimed at the organisation and 10 the management, if you like, of the unit as opposed to 11 dealing with who is actually in charge of the care of 12 the individual patient? 13 A. I think it is very difficult. I would agree that in the 14 development of paediatric intensive care units that this 15 is correct, that there should be a Consultant who is 16 designated to take full administrative responsibility 17 for the unit. As to the care of the individual child 18 within that unit, I agree it is difficult to say who is, 19 if you wish to use the words, "in charge" of that child, 20 because it is so multidisciplinary that each member of 21 the team would take responsibilities to a greater or 22 lesser extent for certain parts of it. 23 Q. Throughout the period that the Inquiry is concerned 24 with, 1984 to 1995, what was the nature of the surgical 25 presence in the Intensive Care Unit? 0041 1 A. During that period there was a resident Senior House 2 Officer in the surgery and also a more senior surgeon, 3 Registrar or Senior Registrar level, who was not 4 necessarily resident but would sleep in the hospital if 5 there was considered a reason to be so. 6 Q. You say "not necessarily resident". You mean not 7 ordinarily resident; not a full-time resident Registrar? 8 A. He was not expected to be resident. It was not in the 9 contract to be resident. 10 Q. So the usual position would be that the resident Senior 11 House Officer in surgery would be the permanent presence 12 in Intensive Care? 13 A. During the whole 24 hours. During the working day there 14 was also an anaesthetist of Registrar or Senior 15 Registrar level who was designated to be on the 16 Intensive Care Unit. 17 Q. And at night what was the position for anaesthesia? 18 A. At night that Registrar or Senior Registrar was not 19 resident. 20 Q. So what was the anaesthetic cover in Intensive Care at 21 night? 22 A. The anaesthetic cover was from home both for the Trainee 23 Anaesthetist and the Consultant Anaesthetist. 24 Q. And so you would have, I imagine, some provision in your 25 contract that you must live within X miles of the 0042 1 hospital, something of that sort? 2 A. I believe my contract states a mileage, although I think 3 some contracts now or in certain parts of the country 4 state a time within which one should be able to get into 5 the hospital rather than a mileage. 6 Q. Now the Senior House Officer in surgery, to what extent 7 would he or she have training in paediatric surgery, 8 first of all? 9 A. That Senior House Officer may have very little training 10 or no training at all in paediatric surgery. It would 11 depend on the rotation that person had been involved in. 12 Q. Paediatric cardiac surgery would be yet more 13 specialised? 14 A. It would be more specialised. 15 Q. Do you know whether that surgical cover in Intensive 16 Care is still the same today? 17 A. In 1999? 18 Q. Yes. 19 A. At the BRI? 20 Q. At the BRI. I appreciate there are no cardiac children 21 there any more. Is that still the position? 22 A. No. There is now a resident more senior surgeon, what 23 is known as a Specialist Registrar. 24 Q. Under the new Calman nomenclature? 25 A. Under Calman. 0043 1 Q. Now the Inquiry has heard a bit of evidence about the 2 development perhaps towards the latter part of the 3 period we are concerned with of the concept of the 4 Intensivist in Intensive Care? 5 A. Yes. 6 Q. Can you help me with a brief description of the 7 development of Intensivists in the Intensive Care Unit 8 at the BRI over the period we are concerned with? 9 A. When I came to Bristol in 1984 and was visiting the 10 hospital prior to consideration as to whether I would 11 apply for the appointment, in my discussions with the 12 anaesthetists at that time who were involved in cardiac 13 anaesthesia I gained the impression that there was 14 little involvement on behalf of the anaesthetists in the 15 post-operative management of the cardiac patients on the 16 Intensive Care Unit, apart from Dr Burton, who was 17 heavily involved in looking after the children with whom 18 he had been involved. 19 This was not what I would have wished to have had 20 as my job, if I had proceeded with my application, but 21 in discussion with the two cardiac surgeons who were 22 then there at the Bristol Royal Infirmary, Mr Wisheart 23 and Mr Keen, I gained the impression from them that they 24 would be very pleased for an increased anaesthetic input 25 on to the Intensive Care Unit, and because I had that 0044 1 impression from the surgeons, I proceeded with my 2 application for the job. 3 During my initial years my contractual obligations 4 did not include specific sessions for the Cardiac 5 Intensive Care Unit, although the Consultant contract in 6 1984 did include a contractual element for pre-operative 7 and post-operative visiting. Over the time that I was 8 there in the 1980s I felt that it would be advantageous 9 to have personnel who had within their contracts actual 10 time set aside for Intensive Care. 11 Q. Eventually Intensivists or Consultant Anaesthetists with 12 such time built into their contracts were appointed? 13 A. Yes. 14 Q. Can we have a look at UBHT 84/49? I will just finish 15 off this little point and then it may be time for a 16 short break. This is 6th June 1995, so we are getting 17 on towards the end of the Inquiry period. Cardiac 18 Surgery Associate Directorate meeting. We see you are 19 one of the attendees, fourth from the bottom of the 20 list. 21 If we go to page 50, paragraph 7: 22 "Management of Patients in ITU. 23 The issue of the management of the patient on ITU 24 was debated and it was agreed that this would also be 25 debated by a group consisting of 0045 1 surgeon-anaesthetist/nurse manager; an Intensivist five 2 days per week may be the best way forward". 3 Do you remember that discussion? 4 A. I do not remember this specific discussion at this 5 meeting, but I do know these discussions were taking 6 place at that time. 7 Q. Just a little later, UBHT 48/88, the same meeting, the 8 same type of meeting, now 4th September 1995. If we go 9 to page 89, the top of the page, it would appear -- you 10 see the first two paragraphs: 11 "Dr Pryn proposed that cover be increased by two 12 sessions per week". 13 A session is half a day, is it not, three and 14 a half hours; is that right? 15 A. A session is half a day. 16 Q. " ... that cover be increased by two sessions per week 17 to bring the cover to five mornings per week". 18 So by 1995 the position was that there was an 19 Intensivist three mornings per week and here is the 20 suggestion that that should be increased to five? 21 A. Yes. 22 Q. Was that done? Was that proposal carried through? 23 A. It was done, yes. 24 Q. Then just before we finish on this point, to what extent 25 in your experience of caring with children for 0046 1 paediatric cardiac surgery who went to the Intensive 2 Care Unit at the BRI did one see the paediatric 3 cardiologists post-operative in the Intensive Care Unit? 4 A. I tended to see the paediatric cardiologists on two 5 different sorts of occasions. They did come sometimes 6 routinely to see how children were doing, and they would 7 also attend if we had a difficulty and we wished to have 8 their specific specialist input into the management of 9 a child. 10 Q. What was the paediatric cardiological presence in the 11 Intensive Care Unit other than those specific visits 12 from the consultants as part of a round to check up or 13 to deal with an emergency? Were there some residents 14 for paediatric cardiology? 15 A. No, there was no resident paediatric cardiologist. Are 16 you suggesting at trainee level? 17 Q. At whatever level? 18 A. There were no resident paediatric cardiology contacts. 19 Q. Dr Masey, it may be that the Panel think this is 20 a convenient moment for a short break for ten minutes or 21 thereabouts. 22 THE CHAIRMAN: Yes. Thank you. I just wanted to explore 23 one matter for my own satisfaction before we do take 24 a break, which was concerned with your discomfort with 25 the concept of leadership, as I recall it, within the 0047 1 Intensive Care Unit. You said that you would see 2 yourself as taking the lead as regards respiratory care, 3 for example? 4 A. For example, because I felt that I had greater expertise 5 in this area than the surgeons and I would hope that any 6 questions relating to something like respiratory care 7 would be directed to me rather than to the surgeons. 8 Q. What might happen if a surgeon took a different view as 9 to the management of respiratory care? How would that 10 come to be resolved? 11 A. We would discuss the issue and we would agree -- come to 12 a consensus. 13 Q. It is quite hard to get a consensus if one person thinks 14 one thing and the other person thinks the other. How is 15 that resolved? 16 A. I -- 17 Q. Because, to concretise it, we did hear examples from, 18 I think, Dr Pryn about a view as to how to manage 19 extubation, with one view taken by him and one view 20 taken by Mr Wisheart. I will be corrected if I am 21 wrong, but I recall that as an example. 22 A. I think there can be difficulties when different points 23 of view are raised. One would hope through discussion 24 -- and many clinical decisions are made through 25 discussion and consensus. That is how decisions are 0048 1 quite often made. As to a disagreement where consensus 2 could not be reached over something which would be felt 3 to be more within the anaesthetist's domain than the 4 surgeon's domain -- 5 Q. At least by the anaesthetist? 6 A. At least by the anaesthetist, I would have felt that I, 7 as the anaesthetist, would have taken precedence in that 8 decision, but I cannot say that would always be the 9 case. It may be that I would allow myself to be 10 persuaded and reach consensus in that way. 11 THE CHAIRMAN: Thank you very much. Why do we not take 12 a break for ten minutes then and reconvene at 11.00? 13 Is that convenient? 14 MR MACLEAN: Yes. 15 (10.50 am) 16 (Short break) 17 (11.00 am) 18 MR MACLEAN: Dr Masey, I want to move away from the topic we 19 were dealing with just before the break and on to 20 something else, the question of the split site of the 21 Children's Hospital on the one hand and the Bristol 22 Royal Infirmary on the other. 23 Throughout the period you were anaesthetising for 24 paediatric cardiac operations, to what extent did you 25 work in both those hospitals? 0049 1 A. I only worked in the Children's Hospital following the 2 move of paediatric cardiac surgery to the Children's 3 Hospital, which I remember as being October 1995. 4 Q. The very end of the Inquiry's period? 5 A. Yes. 6 Q. Before that, the anaesthetists whom we see in the cases 7 we are concerned with, the paediatric cardiac 8 anaesthetists, would they all have the same pattern as 9 you, namely working only at the BRI not at the 10 Children's Hospital? 11 A. Those who were involved in anaesthetising for open-heart 12 surgery, yes. 13 Q. To what extent did the anaesthetists who worked at the 14 Children's Hospital also work at the BRI? 15 A. Some of the anaesthetists who worked at the Children's 16 Hospital did have other sessions at the Bristol Royal 17 Infirmary. 18 Q. Was that connected with cardiac work, or other work? 19 A. Mostly connected with other work, although, when I first 20 came to the BRI, the paediatric cardiac catheters were 21 being performed at the Bristol Royal Infirmary. 22 Q. But that situation ended in 1987 or 1988 when the new 23 cath' lab at the BCH was opened? 24 A. A new cath' lab was opened at the BCH, but I cannot 25 remember the date. 0050 1 Q. Neither can I precisely. It was either 1987 or 1988. 2 After that, that reason for the anaesthetists at the BCH 3 to go the BRI would have been removed? 4 A. For those coming down to anaesthetise children for 5 cardiac catheters, that would have been removed, but 6 there were still some other sessions that some of them 7 were doing at the BRI. 8 Q. What was left in terms of cardiac work to bring those 9 anaesthetists down to the BRI after the cath' lab was 10 opened at the Children's Hospital? 11 A. There was no cardiac work that was done at the BRI that 12 was being performed by anaesthetists based at the 13 Children's Hospital, as far as I can recollect -- no, 14 I am sorry, there is one type of work that was still 15 being done at the BRI, which was sometimes performed by 16 the Children's Hospital's anaesthetists and sometimes by 17 BRI anaesthetists, and that was children who needed 18 electrophysiological studies, which were done in a cath' 19 lab at the Bristol Royal Infirmary. 20 Q. The split site: to what extent did those clinicians who 21 worked in the paediatric cardiac field feel happy or 22 unhappy about the existence of the split site? 23 A. Do you mean those working at the BRI or those working at 24 the Children's Hospital? 25 Q. Both. 0051 1 A. I cannot speak for my colleagues. If the system had 2 been in place, I would have preferred to have had the 3 children at the Children's Hospital. 4 Q. Do you remember taking part in the cardiac services 5 Working Party in about 1990, which looked at the 6 question of the split site? 7 A. I do. 8 Q. Can we have a look at JDW 1/293? This is 1st November 9 1990, as we see, and that is the joint Working Party, is 10 it not? We see that you are a member of it. The 11 paediatric cardiologists, the surgeons, anaesthetists, 12 and others? 13 A. I do not know if that was the whole panel, but those 14 would appear to be the people who were present at that 15 particular meeting. 16 Q. If we go to page 294, option 2, paragraph 4.3: 17 "Total transfer of children's service to BCH 18 option - agreed. BRI implications: freed space would 19 allow adult work to increase to 830 cases per year." 20 If we scan down more, the implications for the 21 Children's Hospital are set out. 22 Over the page -- 23 A. May I just read that, please? 24 Q. You tell me when you are happy to move on. (Pause). 25 A. I am happy, thank you. 0052 1 Q. Over the page, if we look at 2.3 and 2.4, some of the 2 options were being worked up including the option of the 3 complete transfer of the children to the BCH? 4 A. I do remember there being a variety of options. I do 5 not know if they are mentioned previously in this paper, 6 but there were a number of options. I cannot remember 7 the details of those, but we were looking at a variety 8 of options. 9 Q. We know that in fact paediatric cardiac surgery did not 10 move to the BCH for another five years. 11 First of all, to what extent were the members of 12 the Working Party, so far as you are aware, of the view 13 that it was desirable that the move to the Children's 14 Hospital should take place? 15 A. It was my impression that, as long as various criteria 16 were fulfilled to make sure that the children were 17 getting the appropriate level of care at the Children's 18 Hospital, the Panel was in agreement that the children 19 should move to the Children's Hospital. 20 Q. What were those caveats and conditions? 21 A. One caveat that I can recall was that there would now 22 be a split in the surgical presence at a more junior 23 level and there was a concern that there may not be 24 adequate provision of junior surgical staff to cover 25 both sites. 0053 1 Q. So that would be something that the surgeons in 2 particular would be concerned about? 3 A. I recall that Mr Wisheart was concerned about that. 4 That is my recollection. 5 Q. Only Mr Wisheart, or Mr Dhasmana as well? 6 A. It is my recollection that Mr Wisheart was particularly 7 concerned about that issue. 8 Q. To what extent did Mr Dhasmana appear to be an 9 enthusiast for the ending of the split site? 10 A. I cannot recall specifically what his enthusiasm was. 11 Q. We know that, to the extent that that option of moving 12 to the Children's Hospital at that stage was advanced 13 and found important, it was not taken up at that time. 14 Why was that? Was that because of the non-fulfilment of 15 the condition, or was it for some other reason? What 16 was your impression? 17 A. My recollection of the events was following a meeting at 18 the end of that year, where plans were quite far 19 advanced, another meeting was planned for early the 20 following year, some time in January of the following 21 year. 22 Q. That would be 1991? 23 A. If that was 1990 -- 24 Q. It was. 25 A. -- I must assume it was January 1991. A date was set 0054 1 for that meeting and close to the time of that meeting, 2 the meeting was cancelled. I recollect that no other 3 date was suggested and as the days and weeks passed, 4 I enquired -- I cannot remember of whom -- as to whether 5 I had missed paperwork and another date had been 6 convened, and was informed by this person that another 7 date had not been convened because the plans had been 8 put on hold. 9 The reason I was given was that the hospital was 10 moving towards attempting to be in the first wave to 11 gain Trust status, and if it achieved this, then it was 12 felt there would be no money for capital expansion for 13 at least two years after that date. Therefore, there 14 was no point in continuing with these plans as there 15 would not be the finance to support it. 16 Q. So ultimately there was not going to be any money for 17 the foreseeable future, two years at least? 18 A. That was my impression. 19 Q. That was linked to the fact that the Trust was in the 20 pipeline, if you like? 21 A. That was the reason that I was given, but I am sorry, 22 I cannot remember who it was I spoke to. I had 23 a telephone conversation with a woman and I do not know 24 who it was. It would be the person who had been 25 organising the secretarial side of the Trust, and 0055 1 I believe it is this person who gave me that reason. 2 But I am not certain. 3 Q. Why should the institution of Trust status make 4 a difference to the availability of capital funding? 5 A. I do not know. 6 Q. But that is what you understood to be the reason? 7 A. That is what I understood to be the reason. 8 Q. We know that the split site was ended in 1995 and that 9 decisions about that were taken in 1994. What had 10 changed between this period, 1990/91 when the option was 11 not taken up, for the reasons as you believe you just 12 outlined, and 1994/95 when the same option was taken up? 13 A. I do not know of the financial side. I have no 14 knowledge of what there was on the financial side that 15 then made it possible for this move to occur. As you 16 can see, it was a move that people had wanted for a long 17 time, so I do not know what it was that then made it 18 possible for this to occur in 1995. 19 Q. In the early part of 1995, you would have known that an 20 advertisement had been placed for a new paediatric 21 cardiac surgeon, and that interviews had taken place -- 22 A. Yes. 23 Q. -- in September 1994, I think it was, and that Mr Pawade 24 had been appointed? 25 A. I knew that Mr Pawade had been appointed. 0056 1 Q. He was not going to take up his post for some months? 2 A. That is correct. If I remember rightly, it was May 1995 3 he was due to take up his appointment. 4 Q. 1st May. And he did take up his post then? 5 A. He did. 6 Q. When the decision was taken to end the split site and to 7 appoint Mr Pawade, what was the plan for you in terms of 8 paediatric cardiac anaesthesia? 9 A. The plan for me was to spend, at that time probably one 10 day a fortnight at the Children's Hospital. I was going 11 to share one day a week, which was going to be the 12 Monday, with my colleague Dr Underwood. 13 Q. She had also been working as a paediatric cardiac 14 anaesthetist at the BRI up until this point? 15 A. Yes. 16 Q. And you and she, I think it is fair to say, had taken 17 the lion's share of the paediatric cardiac anaesthesia 18 at least in some respects. For example, the switch 19 operation tended to be either you or Dr Underwood? 20 A. Towards the end of the time at the Bristol Royal 21 Infirmary, yes, Dr Underwood and I had taken more of the 22 paediatric cardiac work than our colleagues. 23 Q. So that would cover, between you, the Mondays? 24 A. Yes. 25 Q. Was Mr Pawade only going to operate on Mondays? 0057 1 A. No. 2 Q. So he would need other anaesthetists? 3 A. Yes. 4 Q. Where would they come from? 5 A. They were anaesthetists who were based at the Children's 6 Hospital. 7 Q. They were already in post there? 8 A. I am not sure when they took up their posts. 9 Q. But they were appointed at about the same time as 10 Mr Pawade? 11 A. At about the same time or a little bit afterwards. 12 Q. But they had not been, if you will pardon the 13 expression, long-standing members of staff in the way 14 you and Dr Underwood were at Bristol? 15 A. That is correct. 16 Q. How many sessions were they going to work with 17 Mr Pawade, between them? 18 A. As far as I can recollect, each of them was to do one 19 day a week with Mr Pawade. 20 Q. So that would be a total of three days a week for 21 Mr Pawade? 22 A. That would be a total of three days a week. 23 Q. Where did these other anaesthetists come from? 24 A. One, Dr Wolfe, was at that time a consultant in 25 Glasgow,. The other, Dr Murphy, came from a Senior 0058 1 Registrar post. I cannot remember where he was Senior 2 Registrar, although he had been at some stage a trainee 3 within Bristol. 4 Q. So far as you are aware, had either of them worked with 5 Mr Pawade before? 6 A. Yes, Dr Wolfe had worked with Mr Pawade. 7 Q. Where? 8 A. In Melbourne, Australia. 9 Q. So he was known to Mr Pawade? 10 A. He was. 11 Q. What about Mr Murphy? 12 A. So far as I know, Mr Murphy had not worked with 13 Dr Pawade. 14 Q. You and Dr Underwood went to Melbourne in February 1995? 15 A. We did. 16 Q. Why? 17 A. We felt that having had Mr Pawade appointed, in order to 18 make his transition to working in Bristol as smooth as 19 we could, it would be advantageous for those of us who 20 had not worked with him before to go and see him working 21 within an environment where he was used to working, so 22 we could see if there was anything that he was doing 23 that we might be able to do to help make his transition 24 smooth. 25 Q. What did you learn on that trip? 0059 1 A. It was my impression that, apart from one mode of 2 treatment on the Intensive Care Unit which was also to 3 be used in the operating theatre, there was nothing in 4 the anaesthetic management of the children that was 5 particularly different from what we were already doing 6 at the Bristol Royal Infirmary. 7 Q. What was that exception? 8 A. The use of inhaled nitric oxide. 9 Q. The implications of that would be what? 10 A. Inhaled nitric oxide is one treatment which is used for 11 the treatment of pulmonary hypertension. 12 Q. And how did you get on with Mr Pawade, you and 13 Dr Underwood, when you went to Melbourne? 14 A. It was my impression that I found Mr Pawade very 15 pleasant and very friendly, and I felt that I had 16 already started to build a relationship with him which 17 could be developed when he came to Bristol. 18 Q. Was that relationship developed when he came to Bristol? 19 A. I did not feel the relationship developed in the way 20 that I would have chosen. 21 Q. What was your feeling as to why that was? 22 A. It would appear that Mr Pawade had spoken to other 23 people and had gained the impression that I would not be 24 easy to work with. 25 Q. You say "it would appear that Mr Pawade had spoken to 0060 1 other people". Do you take it from that that he himself 2 never expressed those feelings to you? 3 A. He did express some of those feelings to me, yes. 4 Q. What was your reaction to that expression of his 5 feeling? 6 A. I was very disappointed because I wished to develop 7 a working relationship with him because I think it is 8 important if you are going to work as a team to have 9 a good working relationship. I was also disappointed in 10 the fact that he had asked other people what it was like 11 working with me and other people had been less than 12 complimentary. 13 Q. Do you know who else he had spoken to, who these other 14 people were? 15 A. He was always very reluctant to give specific names, but 16 he did say that he had spoken to all the cardiac 17 surgeons at the BRI. He had been given the impression 18 from people with whom he was working in Melbourne that 19 it would be difficult to work with me. 20 Q. Those were people who worked in Melbourne with whom he 21 had previously worked? 22 A. I only visited for two weeks, so I was there as 23 a visitor; I would not say that I worked with him. 24 Q. There was no-one in Melbourne, when you got there, with 25 whom you had worked previously elsewhere? 0061 1 A. No. 2 Q. So any impression they had formed in Melbourne of you 3 could only have been formed in those two weeks? 4 A. No. They could have been formed -- Dr Wolfe who had 5 been working in Melbourne had worked in Bristol as 6 a trainee. 7 Q. And he was coming to work at the Children's Hospital 8 with Mr Pawade? 9 A. In the February of that year, when we were in Melbourne, 10 I knew that Dr Wolfe had expressed an interest in 11 applying for the post that had been advertised at the 12 Children's Hospital. 13 Q. In fact, in 1996 you stopped anaesthetising for 14 paediatric cardiac work? 15 A. I did. 16 Q. Did Dr Underwood who previously worked at the BRI 17 continue with paediatric cardiac anaesthesia with 18 Mr Pawade at the Children's Hospital? 19 A. She continued for a short time. She stopped working at 20 the Children's Hospital before I did. I cannot remember 21 exactly the date, but my impression was, she stopped 22 working there at the end of 1995. 23 Q. Did you have an impression of any knowledge as to why 24 she stopped working at that time? 25 A. My impression from discussions with Dr Underwood was 0062 1 that she did not find it a happy experience working at 2 the Children's Hospital. 3 Q. What was she unhappy about? 4 A. I think it would be easier to ask Dr Underwood about her 5 particular unhappiness. 6 Q. What did Dr Underwood tell you about her unhappiness? 7 A. She told me she did not feel that she was becoming an 8 integrated member of the team. 9 Q. She felt excluded, did she? 10 A. She told me she felt excluded. 11 Q. Did you in fact do any paediatric cardiac anaesthesia 12 with Mr Pawade at the Children's Hospital? 13 A. I did. 14 Q. How much? 15 A. In the time from October to December 1995, I would share 16 the Mondays with Dr Underwood, so at that stage I was 17 doing alternate Mondays. When Dr Underwood, as I say, 18 I think at the end of 1995 withdrew, I was then 19 anaesthetising for Mr Pawade every Monday. 20 Q. At the end of 1995, the Clinical Director of the 21 Directorate of Anaesthesia changed? 22 A. Yes. 23 Q. And Dr Monk was replaced by Dr Coates? 24 A. Yes. 25 Q. You and Dr Underwood were obviously both unhappy at the 0063 1 beginning of 1996 about the way things had panned out in 2 the Children's Hospital? 3 A. I was certainly not as happy as I would have hoped to 4 have been. 5 Q. It is obvious, is it not, that the plan, the notion that 6 was behind you and Dr Underwood going to Melbourne, was 7 that you would work with Mr Pawade? 8 A. We would work with Mr Pawade and also we thought we 9 would still be working with Mr Dhasmana as well. 10 Q. Was Mr Pawade still working with the same paediatric 11 cardiologists as had previously worked with Mr Dhasmana, 12 Mr Wisheart, when the surgery was at the BRI? 13 A. I do not know what the organisation was in relation to 14 which cardiologists he worked with at the Children's 15 Hospital. 16 Q. I do not want to press this too much further, but I do 17 want to show you one letter, UBHT 38/95, a letter from 18 Dr Coates to you. It is dated April 1996. If we scan 19 down the page, you are familiar with that letter? 20 A. I am. 21 Q. I am not going to read it out, but you see the first 22 paragraph: is that an accurate description of your 23 feelings at this time? 24 A. I think it is an accurate description, yes. 25 Q. There have been discussions with Mr Ross. You were 0064 1 aware of those? 2 A. I was aware of them. 3 Q. He was the new Chief Executive? 4 A. Yes. 5 Q. If we go over the page, in the second line there is 6 a reference to you considering what had happened to be 7 less than fair? 8 A. I am sorry, can I read the ... is it in the top 9 paragraph or the second? 10 Q. Yes, the first paragraph. There is a lot in that 11 paragraph and the importance of it for the Inquiry is 12 that in this paragraph one perhaps has an indication of 13 the working out of what happened with the ending of the 14 split site and the introduction of the new surgeon. 15 Do you see the passage at the end of the 16 paragraph: 17 "It was this role that you were never going to be 18 allowed to achieve." 19 We see Dr Coates has referred to the "integrated, 20 flexible, collaborative and effective team of paediatric 21 cardiac anaesthetists, all of whom have day-to-day 22 involvement with paediatric intensive care at the 23 Children's Hospital." 24 I assume, Dr Masey, that you would welcome and 25 would be in favour of an integrated, flexible, 0065 1 collaborative and effective team of paediatric cardiac 2 anaesthetists? 3 A. Yes, of course I would. 4 Q. And wanted to be a member of such a team? 5 A. I did. 6 Q. The last sentence of the paragraph suggests that you 7 were, if you like, blocked or prevented from taking your 8 place in that team, does it not? As a matter of English 9 that is what the sentence suggests? 10 A. Yes. 11 Q. Is that an accurate reflection, in your opinion, of the 12 situation? 13 A. I think it is an accurate description, yes. 14 Q. Why should that situation have come about? 15 A. From the time of starting to work at the Children's 16 Hospital in October 1995, it became apparent that there 17 was no willingness for me to be integrated, by my 18 colleagues at the Children's Hospital. 19 Q. So in fact the situation, as far as anaesthesia was 20 concerned, was that very quickly after the ending of the 21 split site, there was a completely new team, was there? 22 A. After April -- could I please have a break? 23 MR MACLEAN: Yes, of course. 24 THE CHAIRMAN: Shall we have a break for five minutes? 25 (11.35 am) 0066 1 (A short break) 2 (11.58 am) 3 MR MACLEAN: Dr Masey, I am going to move on to something 4 else. Just before I do, we are going to refer later to 5 some other correspondence dealing with the matter we 6 have just been dealing with. I will come back to it 7 then, but I should make clear that it is not my 8 suggestion to you that there are any grounds for 9 questioning your clinical competence during the period 10 that the Inquiry is concerned with, or at any other 11 period for that matter. And the wider audience may want 12 to know what we will, I think, be seeing later that 13 there is some correspondence where any suggestions, if 14 there were suggestions of that nature, were as 15 I understand it unequivocally withdrawn and not 16 proceeded with. Perhaps we will see the details of that 17 later, but it is perhaps important that I make that 18 clear now. 19 DR MASEY: Thank you. 20 MR MACLEAN: Can we go to UBHT 52/290? We are going back in 21 time now to August 1990. This is a letter, if we scan 22 down the page, from Dr Bolsin to Dr Roylance, copied to 23 the three people you see at the bottom of the page, one 24 of whom was the Chairman of the Division of Anaesthesia. 25 You tell us in your statement -- we do not have to 0067 1 go to it, I think; it is WIT 270/13 -- that you were 2 aware of this letter more or less about the time it was 3 written; is that right? 4 A. I was aware of this letter at some stage soon after it 5 was sent to Dr Roylance. 6 Q. The paragraph, of course, as you acknowledge in your 7 statement, that we are concerned with somebody (but not 8 the Inquiry) has marked here on the screen: 9 "The unfortunate position of the South West 10 Regional Cardiac Centre's mortality for open heart 11 surgery on patients under 1 year of age. This, as you 12 may or may not know, is one of the highest in the 13 country and the problem should be addressed." 14 Perhaps we should go to your statement briefly, 15 WIT 270/13, towards the bottom of the page. 16 You say, three lines from the bottom: 17 "I asked Dr Bolsin why he had sent this letter 18 without discussing it with his other cardiac anaesthetic 19 colleagues." 20 He had not discussed it with you before sending 21 it? 22 A. He had not discussed it with me. 23 Q. Did you know or believe he had not discussed it with any 24 other consultant anaesthetist either? 25 A. I do not know whether he had discussed it with any of 0068 1 his other colleagues, but it was my impression at the 2 time that he had not. 3 Q. And you explain that you do not recall Dr Bolsin 4 explaining to you the reason why he had not discussed it 5 with you, or with others? 6 A. I cannot recall him giving me a reason. 7 Q. Leaving aside for the moment with whom he discussed the 8 matter before writing the letter to Dr Roylance, did you 9 agree with the sentiments he expressed in that 10 paragraph that we looked at? 11 A. Could I look at the paragraph again, please? 12 Q. Yes, it is UBHT 52/290. He refers to the "unfortunate 13 position" of mortality for open-heart surgery quite 14 specifically on patients under 1 year of age, as being 15 "one of the highest in the country". 16 A. I did know that our results in this age group were not 17 as good as I would have liked, but I cannot recall 18 knowing or even believing that they were one of the 19 highest in the country. 20 Q. You remember earlier on, when we were discussing the 21 good results, "very favourable", I think, was your 22 expression for the Sennings operation? 23 A. Yes. 24 Q. I asked you, how did you know that it was very 25 favourable compared to everywhere else, and you said the 0069 1 Register; do you remember? 2 A. Yes. 3 Q. Would you have the same ability to draw comparisons as 4 between Bristol's overall under 1 performance and the 5 performance of the rest of the country in so far as that 6 is reflected by the Register? 7 A. One would be able to know from the Cardiac Register, 8 which is why I can say I had an impression that our 9 results were not as good as I would have liked, but 10 because the Cardiac Register is presented as total 11 figures and is not presented by unit, I believe it would 12 be impossible to tell from the Cardiac Register as to 13 whether the figures were the worst in the country. All 14 one could say is whether there were average, above 15 average or below average. 16 Q. And obviously, the more markedly one was above average, 17 the more likely that centre was going to be one of the 18 highest in the country, but you could not be more 19 specific? 20 A. I would believe one could not be more specific. 21 Q. At this stage in 1990, had Dr Bolsin shared any of these 22 concerns with you? Apart from not showing the letter or 23 discussing the letter, had he shared his general 24 concerns with you at all? 25 A. The only time I can specifically remember him voicing 0070 1 a concern, again, I have mentioned it in my statement, 2 is an occasion on the Intensive Care Unit where he 3 commented that he felt that the standard of care was not 4 as good as it could be. 5 Q. That was not at a meeting, a formal meeting; that was 6 during a ward round? 7 A. That was during a ward round. 8 Q. You had not, at this stage -- this is summer 1990 -- 9 seen any data or audit from Dr Bolsin of paediatric 10 cardiac surgery? 11 A. As far as I can recollect, I had seen no information 12 generated by Dr Bolsin at that stage. 13 Q. You tell me if there is anything that I ought to focus 14 on between this date in 1990 and July 1991, but what 15 I want to move on to, unless you stop me, is a meeting 16 which took place in July 1991 at Mr Wisheart's house. 17 Do you remember that meeting? 18 A. There were many meetings at different consultants' homes 19 during my time when I was there, so I cannot say 20 I specifically remember the meeting to which you are 21 alluding. 22 Q. Let me try and see if this helps: UBHT 61/146. This is 23 described as a meeting of the paediatric cardiac 24 surgical and anaesthetic group at Mr Wisheart's house on 25 a Wednesday evening. 0071 1 It would appear that there were no cardiologists 2 at this meeting? 3 A. I cannot recall. 4 Q. These minutes were discussed at the GMC hearings and 5 I think it is right they were drawn up by Dr Bolsin. Do 6 you remember seeing these minutes and approving them in 7 any formal or informal way? 8 A. Having seen these documents recently, they do look 9 familiar. 10 Q. So you had seen them before? 11 A. It is my impression that I have seen them before, yes. 12 Q. But do you remember whether this was an agreed note of 13 the meeting in the sense that Dr Bolsin did his note of 14 the meeting and sent it around and said "Here is my note 15 of the meeting, do you agree with this?" 16 A. I cannot remember that it was an agreed minute. 17 Q. We see that this meeting looked at, amongst other 18 things, management of pulmonary hypertension, and 19 secondly, two specifically named operations, tetralogy 20 of Fallot and AVSD, and then the words "etc". 21 There is no mention, take it from me for the 22 moment, in this document of the arterial switch 23 procedure. This is July 1991. 24 Do you have any comment to make about the absence 25 of any reference to the arterial switch, given that 0072 1 date? 2 A. No, I have no comment to make on that. 3 Q. That would be before the neonatal switch, for example, 4 had begun in Bristol? 5 A. It was before the neonatal switch programme, yes. 6 Q. Do you remember seeing this type of minute, if that is 7 the right word, or note, of any other of these meetings? 8 A. I do not remember whether I did or did not see any 9 further minutes of meetings. 10 Q. If I suggested to you that Dr Bolsin has said that he 11 was asked not to produce any more of these notes, what 12 would you say? 13 A. I would have no comment to make on that. I do not 14 recall myself asking him not to do this. 15 Q. Do you recall asking him to do it or not to do it? 16 A. I do not recall either of those. 17 Q. If we go to the very bottom of the document, 18 UBHT 61/150, the bottom of the page, you see that there 19 is a plan for another meeting on 18th September at 20 Mr Dhasmana's house. 21 Does one take it from that that these meetings 22 took place roughly about every six weeks or couple of 23 months, something like that? 24 A. I do not recall there being a specific timetable for 25 these meetings. They occurred from time to time, but 0073 1 I do not remember specifically a decision being made 2 that they should occur at two-monthly or three-monthly 3 intervals. 4 Q. It would seem from reading the note of this that this is 5 a pretty serious discussion about some of the perceived, 6 if I use the word "problems" I am not using that 7 pejoratively, some of the issues current then: a pretty 8 serious discussion forum? 9 A. Having read it recently, without reading it again, 10 I think that these were important issues that we were 11 addressing that evening. 12 Q. Why should a serious meeting like this take place in 13 a forum and a structure which is completely, on the face 14 of it, removed from the Trust setup? It takes place in 15 a consultant's house in the evening; it is not minuted; 16 it does not report to anyone. You see the point? 17 A. Yes, I do see the point. These meetings were intended 18 to be moderately informal, although discussing important 19 issues, so that they were meetings where anybody could 20 come and express any concerns and these concerns could 21 be discussed. 22 They tended to be held in the evening in people's 23 homes because during the working day it is always very 24 difficult to get a group of clinicians together to 25 discuss issues because of clinical commitments. So it 0074 1 was easier and in order to get a larger number of people 2 being able to attend these meetings, it was felt it was 3 easier, and more pleasant, to hold them in people's 4 homes. 5 Q. How did one learn about a meeting taking place? 6 Obviously if one is at this meeting, presumably at the 7 end of the meeting everybody agreed "We will meet again 8 in X weeks time at Y's house"; but was there anything 9 sent out, if somebody missed one, to tell them about the 10 next one? 11 A. I cannot remember the mechanism whereby I would learn 12 of these meetings. 13 Q. Who ran them? Were they chaired by a surgeon? By an 14 anaesthetist? Did they have an agenda? How did it 15 work? 16 A. It varied from meeting to meeting. It would quite often 17 be chaired by the person in whose home the meeting was 18 being held. 19 Q. In the ranking of interaction between surgeons and 20 anaesthetists -- let us take those two specialties first 21 of all -- how important was this as a forum for 22 discussion between those two specialties, compared to 23 other fora that there might be? In other words, was 24 this the best chance for discussing issues of the day 25 between the two specialties? 0075 1 A. I felt it was a very good opportunity to talk to people 2 because the environment was moderately informal, and as 3 I have said before, there were also meetings where more 4 people were usually able to attend because they were out 5 of the normal working day. 6 Q. This meeting discussed two particular procedures: Fallot 7 and AVSD. We will see that in a minute from the body of 8 the note, but we saw it from the beginning of the note. 9 Do you know why those two were chosen? 10 A. I can certainly recall why the discussion of tetralogy 11 of Fallot took place. When the results for the year 12 1990 were reviewed, it was found that the mortality for 13 children having the operation for tetralogy of Fallot in 14 1990 was unexpectedly and unusually, in relation to 15 results from previous years, high. 16 Q. So the comparator was Bristol's own previous results? 17 A. The comparator was Bristol's own previous results, but 18 also, the 1990 figures, those figures that year, were 19 compared with the Cardiac Register of 1988, which would 20 have been the last register available for comparison. 21 Q. Because it takes the register a while to catch up? 22 A. I do not know how long it takes the Register, but it 23 always did seem to be that the figures we could compare 24 with would be from about two years previously. 25 Q. There is obviously going to be some lag because you 0076 1 cannot put in the figures for 1990 until after 1990 has 2 finished. They have to be collated? 3 A. Yes. 4 Q. Can we go to 149, please, under the discussion of the 5 Fallot operation. Can we go to the second 6 paragraph under that heading? 7 "Mr Dhasmana said he had reviewed specific deaths 8 with the paediatric cardiologists and had found in some 9 cases the information provided was just not good enough 10 with the specific reference to the pulmonary artery 11 anatomy." 12 Pausing there, do we take it that there was 13 a particular individual who was the paediatric 14 cardiologist? 15 A. When was this meeting, 1991? 16 Q. Yes, it was, on 28th July. 17 A. There were a number of paediatric cardiologists at the 18 Children's Hospital. I cannot remember with the more 19 recently appointed ones when they were appointed, but 20 there were a number of paediatric cardiologists. 21 Q. And obviously, any of them may have had a Fallot's case 22 coming through the door on any particular date? 23 A. Yes. 24 Q. Then if we go down to the next paragraph, we see the 25 paragraph beginning: 0077 1 "Dr Bolsin disagreed ..." 2 If we go about 10 lines down, there is a sentence 3 at the beginning of the line beginning "He also went on 4 to say ..." 5 Do you see that? 6 A. Yes. 7 Q. "He" is Mr Wisheart, I think, if you read the previous 8 sentence: 9 "He also went on to say in his experience deaths 10 associated with low cardiac output, renal failure and 11 pulmonary insufficiency, probably related to coronary 12 artery anatomy, not being well demonstrated. He also 13 went on to discuss the evolution of congenital heart 14 disease and the probable importance of early operation 15 in these children. He suggested that the surgeon should 16 approach the cardiologist about more detailed 17 demonstration of coronary anatomy in tetralogy of Fallot 18 and also the pulmonary artery anatomy. They should also 19 consider whether these patients should be operated on 20 early when the left ventricle was capable of taking the 21 systemic workload." 22 There is a reason given at the end for the early 23 operation. Does that reasoning make sense to you as 24 a clinician? 25 A. In its format, yes, it does make sense. 0078 1 Q. It is unfortunate that this note does not set out who 2 attended this meeting, but it does not appear, so far as 3 I was able to work out, to refer to cardiologists making 4 any contribution. It is plain, is it not, that this 5 discussion, we have seen in this paragraph, this 6 comment, was referring to discussion which needs to take 7 place between surgeon and cardiologist primarily? 8 A. It does seem to give that impression, yes. 9 Q. Can you help us with the extent to which the discussion 10 that Mr Wisheart was suggesting ought to take place with 11 the cardiologist about early operation and demonstrating 12 the coronary anatomy in Fallot's cases actually did take 13 place? 14 A. I cannot help there. I do not know what form those 15 discussions took. 16 Q. Was it just bad luck, as it were, that there were no 17 cardiologists at this meeting? Were cardiologists 18 typically at this type of meeting? 19 A. There would be cardiologists typically at this type of 20 meeting, so I do not know why at this particular meeting 21 there were none present. 22 Q. Is the problem with pulmonary hypertension -- this is 23 something that I think Dr Sumner mentioned yesterday -- 24 that patients with pulmonary hypertension, if they are 25 left too long before operating, end up with irreversible 0079 1 changes to the lungs? 2 A. With irreversible changes? 3 Q. With irreversible changes to the lung? 4 A. That is correct. 5 Q. That may make an operative procedure impossible in the 6 extreme? 7 A. That might make an operative procedure impossible, yes, 8 or unsuccessful. 9 Q. He referred to Great Ormond Street and the Boston 10 Children's Hospital and other hospitals having a policy 11 of operating on patients at the very earliest 12 opportunity? 13 A. Can I ask which particular sort of patients you are 14 alluding to? 15 Q. I can give you the reference. He was discussing -- it 16 was page 100 yesterday -- patients with pulmonary 17 hypertension in particular. 18 A. That is important, because we have moved from tetralogy 19 of Fallot and in tetralogy of Fallot, it is extremely 20 unusual because of the anatomy to have problems of 21 pulmonary hypertension. So I think it is important to 22 show we have moved on to a different sort of case. 23 Q. The third type of case discussed at this meeting was 24 AVSD? 25 A. AVSD. 0080 1 Q. Can we go to page 150? You see the top of the 2 page before it disappears. 3 "Mr Wisheart said in view of the Melbourne and 4 recent Great Ormond Street experience, these patients 5 should be operated on at a younger age." 6 Does that ring a bell, "the Melbourne and recent 7 Great Ormond Street experience"? 8 A. That does not specifically ring a bell, but it is 9 certainly part of my body of knowledge. I cannot recall 10 when it became part of my body of knowledge, that it was 11 preferable to operate on any child with pulmonary 12 hypertension at an early stage, and children with AVSD 13 would have pulmonary hypertension. 14 Q. So this would link into the pulmonary hypertension point 15 Dr Sumner was making yesterday? 16 A. It would, yes. 17 Q. That point about earlier operation, that was dependent, 18 was it, on development of bypass procedures and 19 intensive care improvement, so that the children would 20 be capable of being operated on earlier? 21 A. Throughout the whole period of this time, there were 22 gradual changes to many forms of management that might 23 mean that it was safer to operate on children at 24 a younger age, but I cannot say that there was anything 25 specific that happened at any specific time that would 0081 1 make the quantum leap to saying that it was safer to 2 operate on younger children. 3 Q. So far we have seen, back in 1987, you remember the 4 discussion about the transposition cases being operated 5 on earlier. We have seen the AVSD, Mr Wisheart drawing 6 on the Melbourne and Great Ormond Street experience, and 7 we have seen the reference on the previous page to 8 tetralogy of Fallot and Mr Wisheart saying that the 9 surgeons should have a discussion with the cardiologists 10 and it might be important to get them earlier as well, 11 through to operation. 12 In your witness statement at WIT 270/6, at E8 you 13 say: 14 "Surgery for correction of TAPVD (total anomalous 15 pulmonary venous drainage) was often not performed", and 16 you are referring to Bristol, "at a time that I had been 17 taught, as a trainee, was optimal. As a trainee at the 18 Brompton Hospital, I had been accustomed to these 19 operations being performed as emergencies." 20 So that is another example of a procedure, where 21 from your perspective at least, the children were 22 operated on later than you might have expected? 23 A. Certainly from my perspective, yes. 24 Q. If one puts together -- these are straws in the wind at 25 different times, but if one puts together the 0082 1 transposition method we have seen, the discussion of the 2 AVSD and Fallot in 1991 and your recollection here which 3 refers to which time period, you had arrived in Bristol 4 in 1984 and you noticed when you got here that the TAPVD 5 patients were not operated on as emergencies? 6 A. Yes, TAPVD is an uncommon cardiac anomaly. So I cannot 7 remember when I first noted this, because they occur 8 uncommonly, but it is my recollection that when we had 9 a child with TAPVD, that whereas before as a trainee 10 I was used to these being operated on as an emergency, 11 in Bristol these children might wait for a number of 12 days. 13 Q. Did you ever notice any change in that perception at 14 Bristol? Did there come a time when they were operated 15 on as emergencies? 16 A. The TAPVDs? 17 Q. Yes. 18 A. I did not ever see a particular change in that aspect of 19 management. 20 Q. To the extent that one derives from the discussion of 21 these various procedures that we have had so far today, 22 to what extent would it appear to you that there was 23 a consistency among different operations of children 24 being operated on in Bristol rather later than they 25 might be elsewhere? 0083 1 A. For some procedures it was my impression that the 2 children were operated on later in Bristol, but during 3 my time being involved with paediatric cardiac surgery, 4 it was my impression there was a continual move, as 5 I believe there was throughout the country, to try and 6 operate on all children at an earlier age; this was 7 something that was nationwide and Bristol was trying to 8 do this as well. 9 Q. To the extent that Bristol would be operating on 10 children later than elsewhere, does that suggest that 11 Bristol was slightly behind the day, if you like, in the 12 development towards earlier operation? 13 A. I think it is difficult to answer that. Even though one 14 does visit other hospitals and you talk to colleagues, 15 it is sometimes quite difficult to get, at that time, an 16 actual idea as to what the position is in other 17 hospitals, as to actually what they are doing. But 18 certainly, it was my impression for the AVSDs that we 19 were operating on them later in Bristol than in other 20 hospitals. 21 Q. If that was the position, if we accept for the moment 22 the hypothesis that you have just outlined, that Bristol 23 was doing that particular operation later than others, 24 and assuming, looking at the comment Mr Wisheart made at 25 that meeting, that it might be wise, desirable, to 0084 1 operate on those children earlier, if a centre wanted to 2 achieve that result, who would have to change their 3 behaviour? 4 A. It is my impression that the decision on the timing of 5 surgery was a joint decision between the cardiologists 6 and the surgeons. 7 Q. That would be made at the type of meeting that we 8 discussed, do you remember earlier, the planning type 9 meeting, would it? 10 A. It would be discussed at those sorts of meetings. 11 Q. Would it have been discussed perhaps earlier than that? 12 A. If a child came in as an emergency, then it would be 13 more likely discussed on a one-to-one basis without 14 going to those meetings. 15 Q. One could see that would be different, but elective 16 cases -- I am going to use the word "standard" case, but 17 you know what I mean, the elective case which is not in 18 any particular hurry for an operation tomorrow morning 19 or tomorrow afternoon -- that type of decision would be 20 made by the cardiologist together with the surgeon? 21 A. It is my impression from the time when I was going to 22 those meetings that the decisions were made jointly 23 between the cardiologists and the surgeons. 24 Q. To what extent, just to complete the loop here, having 25 looked at that meeting in Mr Wisheart's house which was 0085 1 attended, so it would seem, by anaesthetists and 2 surgeons, but not by cardiologists, what role would 3 anaesthetists have in advancing the time period within 4 which a child with, let us say, AVSD was operated on? 5 A. I would feel I had no role at all in advancing the time 6 when a child was operated on. 7 Q. Would it be your impression that that view of yours, 8 personally, would be one that would be shared with your 9 anaesthetic colleagues? 10 A. You would have to ask my anaesthetic colleagues. 11 Q. You would be surprised if any of them took a different 12 view? 13 A. I would not wish to be surprised, but from my point of 14 view, as an anaesthetist, I would not feel that I could 15 alter, under those circumstances, the timing of 16 operations. 17 Q. Let us go to something else. In December 1992 you went 18 to Birmingham with Mr Dhasmana? 19 A. I did. 20 Q. And I think you may have been accompanied by 21 a perfusionist as well? 22 A. I cannot recall that. Certainly Mr Dhasmana and 23 I travelled together by train and I do not recall 24 a perfusionist being with us. That does not mean he or 25 she did not travel by a different form of transport. 0086 1 Q. The reason for going to Birmingham was, in essence, 2 what? 3 A. A programme to perform neonatal switch procedures had 4 started in 1992 and the results had been uniformly poor, 5 so it was felt that some form of retraining was required 6 in order to see whether we could proceed with this 7 particular procedure. 8 Q. Who precisely was being retrained? Two or maybe three 9 people went to Birmingham, Mr Dhasmana, you and perhaps 10 a perfusionist? 11 A. On that occasion, yes. 12 Q. On that occasion. Let us only look at that occasion for 13 a moment. It was only envisaged at that time that there 14 would be one visit to Birmingham; is that right? There 15 was no reason to think there would be a need for 16 another? 17 A. It was my impression that if Mr Dhasmana wished to go 18 again, that he was free to do so. That is the 19 impression that I gained from Mr Dhasmana through him 20 talking to Mr Brawn. 21 Q. That is a slightly different point. There was no reason 22 to think that there was going to be a series of visits 23 to Birmingham, was there? 24 A. I am trying to recall carefully, because when I went in 25 December 1992, it was decided that an anaesthetist 0087 1 should go with Mr Dhasmana and it was decided that 2 I would go. I have a recollection that it was felt that 3 if Mr Dhasmana did go again, another anaesthetist would 4 go, so I have a recollection that it was not necessarily 5 a one-off visit. 6 Q. We know in fact -- we will come to this -- there was 7 another visit subsequently to Birmingham by him and 8 others, but not you? 9 A. Yes. 10 Q. You mentioned retraining. Who was going to be 11 retrained? 12 A. "Retraining" is a very difficult word. I use it because 13 of ease and it is available for anyone who wishes to go 14 and see how another unit is performing any particular 15 task to see whether any of us can learn from seeing 16 someone else's experience with a particular technique. 17 Q. Who is going to learn from this visit? 18 A. Anybody and everybody who was going there went with the 19 intention of seeing whether there was anything to be 20 learned. 21 Q. Whose idea was it to go to Birmingham? 22 A. It is my recollection that it was Mr Dhasmana's. 23 Q. Did he discuss it with you? Did he say "Do you want to 24 come to Birmingham next week, Sally?" 25 A. I cannot recall now how it was decided that I would go 0088 1 with him. 2 Q. Dr Monk, I think, has suggested to the Inquiry that 3 it was his idea that there should be a visit made to 4 Birmingham. 5 A. As I say, I cannot recall. If Dr Monk has said that, 6 then I would accept what Dr Monk has said, but I do not 7 recall exactly how it was decided that I would go. 8 Q. That is what I was going to ask you. Why was it you who 9 went on this particular occasion? Was it because you 10 volunteered? Did somebody ask you specifically? Was it 11 your turn, or what? 12 A. Again, my recollection is that I showed great interest 13 in going and I do recall that in order for me to go, 14 I did have to change my work for that day because I had 15 to ask one of my colleagues to cover my operating list 16 that day. 17 So I think I showed a great desire to go, so it 18 was arranged that I could go. 19 Q. Mr Dhasmana, I think, saw an operation that was 20 conducted by Mr Brawn? 21 A. He did. 22 Q. That was, I think, a neonatal switch operation? 23 A. It was a neonatal switch. 24 Q. Were you present in the operating theatre? 25 A. I was present at the beginning, so I could witness the 0089 1 anaesthesia, the start of the anaesthetic and to speak 2 to the anaesthetist who was involved with that 3 anaesthetic. I did not stay for the whole procedure. 4 Q. So and you Mr Dhasmana essentially went your separate 5 ways once you got to Birmingham, he with the surgeon and 6 you with the anaesthetist? 7 A. I spent some time with the anaesthetist. I also spent 8 some time looking at the Intensive Care Unit and 9 speaking to an anaesthetic colleague, who I knew well, 10 because we had been trainees together, who both 11 anaesthetised children for heart surgery and was 12 involved on the Intensive Care Unit in Birmingham. 13 Q. You say in your statement -- we do not need to go to 14 this -- WIT 270/4, that the visit to Birmingham led to 15 minor changes in anaesthetic management. 16 I think you gave a short explanation for what 17 those were. 18 What were you hoping to find, if anything, by 19 going to Bristol? 20 A. I went with very mixed emotions. Part of me wanted to 21 go and find that there was something which was very 22 different from what we as anaesthetists were doing, so 23 that I could come back and say, "We should make this 24 change and this may help with the programme". But the 25 other side of me did not want to go and find that there 0090 1 was something completely different that we had not 2 already appreciated was now accepted as part of normal 3 anaesthetic management for these sorts of children. 4 So with very mixed emotions, I was going. 5 Q. Did you find that you had, if you like, missed 6 a trick? Was there something glaring that the 7 anaesthetists in Bristol had not been doing? 8 A. No, I found that the general format of the anaesthetic 9 was very similar to that that we were doing in Bristol. 10 Q. Did that reassure you, or not reassure you? Did it 11 leave you with the same feeling? 12 A. It reassured one part of me that we were not doing 13 things that were not now accepted practice, or not doing 14 things that were now accepted practice. 15 Q. On the other hand, perhaps you felt slightly uneasy that 16 you had not found the answer, if you like? 17 A. There was a small disappointment that I could not go 18 back to my colleagues and say, "This is very different 19 in Birmingham. If we do this, or shall we do this, can 20 we discuss doing this, which might then help in the 21 total management of these children". 22 Q. You and Mr Dhasmana travelled to Birmingham together? 23 A. Yes. 24 Q. You travelled back together? 25 A. We did. 0091 1 Q. And no doubt you discussed what you found? 2 A. We did. 3 Q. What was your impression of what he had found from 4 the surgical side at Birmingham? 5 A. He came back on the train and he was extremely 6 enthusiastic about what he had seen and what he had been 7 able to talk through with Mr Brawn, and felt very 8 encouraged by what he had seen in relation to how he 9 felt he would go forward with the neonatal switches that 10 he was going to be operating on. 11 Q. Was there a reporting back session, if you like, to 12 your colleagues in Bristol on the meeting? 13 A. I cannot recall a specific meeting that I convened to 14 discuss the issues that I had discussed in Birmingham, 15 but I did make sure that I discussed what I had seen in 16 Birmingham with any of my colleagues who were going to 17 deal with these children, so that if we did agree to 18 take over the minor changes, that this was something 19 done by consensus. 20 Q. I asked you about what Mr Dhasmana had found, and you 21 said he came back enthused. 22 Was it your impression that Mr Brawn had explained 23 something to Mr Dhasmana that Mr Dhasmana had not been 24 doing before? 25 A. It is difficult for me to say exactly what it was that 0092 1 Mr Dhasmana had seen, because they are surgical 2 techniques and surgical ways of doing things about which 3 I have relatively little knowledge, but it was just my 4 impression, coming back on the train, that Mr Dhasmana 5 had seen ways of doing things which were different -- 6 I do not know to what extent -- from how he was 7 performing the operation, that Mr Dhasmana felt might 8 make a difference to the management of these children. 9 THE CHAIRMAN: May I just interrupt you for a moment, 10 Mr Maclean? Did you circulate a note of what you had 11 learned there to your colleagues? 12 A. I cannot recall writing anything down, but I did discuss 13 it with any of my colleagues who were involved with this 14 work. 15 Q. Did Dr Monk suggest a note being distributed before or 16 afterwards? 17 A. I cannot recall. 18 THE CHAIRMAN: Thank you. 19 MR MACLEAN: But it was your impression that the information 20 you had gleaned was disseminated amongst the 21 anaesthetists in Bristol? 22 A. Yes. 23 Q. You say you cannot recall a specific reporting back 24 session, but was there a decision taken to recommence 25 neonatal switches in Bristol? 0093 1 A. I do not know whether there was a specific decision to 2 recommence doing neonatal switches. Transposition is 3 not uncommon, but it is not that common a procedure and 4 these children would come at intervals. Again, because 5 the operation for neonatal switch procedure is done 6 within the neonatal period, within the first 10 to 14 7 days, then these operations are arranged at relatively 8 short notice. 9 So I do not know whether a decision was made to 10 recommence or whether it was that a child with 11 a suitable heart condition had not actually presented to 12 the hospital in the intervening time. 13 Q. When the next child did present and was operated on with 14 the switch procedure, was that something that you, if 15 you had known about it at the time (which you may have 16 done), were comfortable with? 17 A. Yes. I anaesthetised that child. 18 Q. And were entirely content to do so? 19 A. Yes. 20 Q. And Mr Dhasmana was the surgeon? 21 A. Yes. 22 Q. We know that there was another visit by Mr Dhasmana to 23 Birmingham about eight months later in July 1993? 24 A. I know there was another meeting. I knew it was in 1993 25 but I do not know the date. 0094 1 Q. The first one in 1992 had lasted how long? 2 A. We had spent the whole day there. 3 Q. You went up in the morning and came back -- 4 A. Yes. 5 Q. Did you have any part in the 1993 visit to Birmingham? 6 A. I did not go to Birmingham on that occasion. 7 Q. Did any of your colleagues, as consultant anaesthetists, 8 go? 9 A. Dr Underwood went on that occasion. 10 Q. Why she? 11 A. I am sorry, could you repeat the question? 12 Q. Why did she go? Why her? Why not one of the others? 13 A. Again, I do not know the reason why it was Dr Underwood 14 who specifically went. 15 Q. Did you discuss it among yourselves, the anaesthetists, 16 "Who is going to go this time?" 17 A. I cannot recall such a discussion, but I imagine that we 18 did. 19 Q. Again, the focus of that visit was the arterial switch 20 operation? 21 A. Yes. 22 Q. Because after, I think, a couple of good results, again 23 sadly, some children died after that operation? 24 A. I cannot now remember the specific -- 25 Q. I do not think you need to go into the specifics of it. 0095 1 A. Certainly the next two children who were operated on who 2 had a neonatal switch following the visit in December 3 1992 survived the procedure. I do remember that the 4 next child did not, but I cannot remember how many more 5 children were operated on after those three before 6 Mr Dhasmana visited Birmingham again. 7 Q. But the general picture was initial good results 8 followed by again one or two or whatever poor outcomes 9 in terms of death, hence another visit to Birmingham? 10 A. That is my recollection. 11 Q. By that time, had a pattern emerged of particular 12 consultant anaesthetists working with Mr Dhasmana on 13 this procedure? 14 A. It is my recollection that at some stage we did have 15 a discussion as to having a smaller number of 16 anaesthetists involved, but again, I cannot remember the 17 date when those discussions took place in relation to 18 these particular procedures. 19 Q. At the General Medical Council, Dr Bolsin was asked 20 about which anaesthetist went to Birmingham when, and he 21 accurately said that Sue Underwood and yourself went. 22 Actually, he said it was Sue Underwood and yourself who 23 went in July 1993, which was wrong, but certainly Sue 24 Underwood went. 25 He said: 0096 1 "It was those two because Ian [Dr Davies], myself 2 and Chris [Dr Monk] had said that we did not want to 3 undertake switch operations at the BRI or give the 4 anaesthetic for them" -- I think he meant the latter and 5 not the former. 6 Is that your recollection, that by July 1993, 7 Drs Davies, Bolsin and Monk had said they did not want 8 to anaesthetise for switches? 9 A. That is not my recollection. 10 Q. Is it your recollection that at this time that result 11 was achieved -- the result that Dr Bolsin referred to -- 12 by means of timetabling switches only for days when you 13 or Dr Underwood were in theatre? 14 A. At some stage during that time -- and again, I cannot 15 say at what stage that was -- that timetabling was done, 16 yes, so that Dr Underwood and I were the only ones doing 17 switch procedures. I think that includes the older 18 switches as well, so this might have been at a later 19 stage after we had stopped doing neonatal switches. 20 I cannot remember the time-scale. 21 Q. We think that the neonatal switches ended in October 22 1993. Is that your recollection? 23 A. It is my recollection that the last child for a neonatal 24 switch was operated on in October 1993. 25 Q. Can you help us with this timetabling business any more, 0097 1 as to whether or not it was before or after that? 2 A. I cannot. I am sorry, no. 3 Q. Who would achieve this timetabling result? Who was in 4 charge of saying "This case will be on [that day]", 5 "This is Dr Masey's work"? 6 A. I have for some considerable time, and including that 7 time, been responsible for drawing up the rotas for the 8 cardiac anaesthetists, for the theatre and for the 9 on-call commitment. It is my recollection that if 10 Mr Dhasmana wished to put a specific case on to have 11 a specific anaesthetist anaesthetising that child, that 12 he would look at that rota and timetable that particular 13 child for a day when either myself or Dr Underwood, for 14 instance, was there. 15 Q. It is your recollection then, just to go back to this 16 point, that at some stage there was a system whereby 17 switches would be anaesthetised by you or Dr Underwood? 18 A. It is my recollection that at some stage that decision 19 was made. 20 Q. And that system applied to neonatal switches and to 21 non-neonatal switches? 22 A. As I say, I cannot remember which that timetabling 23 occurred. If it occurred after October 1993, then it 24 would only have been for the non-neonatal switches, so 25 I cannot help you on that. 0098 1 Q. That must follow, yes. The penultimate answer you gave 2 about Mr Dhasmana slotting a patient into a day when you 3 or Dr Underwood were working suggests that he was aware 4 that the system was that you or Dr Underwood would 5 anaesthetise for the switches? 6 A. That certainly is the impression I have given, but -- 7 Q. In fact does it not go slightly further: that it was his 8 choice? If he was coming along with a particular 9 patient and he was the one who slotted it in for you or 10 Dr Underwood, then he was specifically choosing one or 11 other of you two? 12 A. It would appear to be the case, yes. 13 Q. Is it the case that at the time when this timetabling 14 system emerged, the other anaesthetists had taken the 15 view that they, for their part, did not want anything to 16 do with anaesthetising switches? 17 A. I think I would like to put it in a different way: 18 I think there may have been some of my colleagues who 19 would not want to be involved, but I also believe there 20 were other colleagues who, rather than saying they did 21 not want to be involved, had decided that it would be 22 preferable to have a smaller number of anaesthetists who 23 were involved. 24 So rather than saying that they refused to 25 anaesthetise these children, they had decided it would 0099 1 be better to have them being anaesthetised by a smaller 2 number. 3 So I think that is a difference in emphasis rather 4 than saying they categorically refused, to saying, 5 rather than refusing, that it would be preferable if 6 a smaller number of anaesthetists were involved. They 7 withdrew voluntarily rather than saying that they 8 refused to do it. 9 Q. But it was no accident that the smaller number comprised 10 you and Dr Underwood as opposed to Dr Bolsin and 11 Dr Davies, for example? 12 A. I am sorry, I do not understand the question. 13 Q. It is one thing to say there was to be a smaller number 14 of anaesthetists, so you want to reduce the size of the 15 available pool, but as it happens, when the pool was 16 reduced, if that is what happened, the two that were 17 left were you and Dr Underwood? 18 A. Well, certainly the two who were left were myself and 19 Dr Underwood. 20 Q. I am suggesting it is perhaps not an accident that it 21 was the two of you who were left for the switches, 22 rather than, for example, Dr Bolsin and Dr Davies. 23 A. I would agree that it was not an accident, but I would 24 disagree as to whether it was due to an unwillingness on 25 some of my colleagues to actually be involved with these 0100 1 procedures, as against a decision that it would be 2 preferable if it was a smaller number. 3 Q. I just want to press this a little bit. Were there some 4 anaesthetists who were unwilling, so far as you were 5 aware, to have anything to do with anaesthetising 6 switches? 7 A. It is my impression that some of my colleagues were less 8 willing. I cannot recall a definitive decision for some 9 of them to say they were definitely not willing, and 10 I would have thought that it would be easier to ask 11 those specific anaesthetists as to how they felt. 12 Q. Which specific anaesthetists should we be asking? 13 A. The ones I had the impression were less willing would be 14 Dr Bolsin and Dr Davies. 15 Q. That is from the anaesthetist's side. You explained in 16 your earlier answer about Mr Dhasmana perhaps wanting to 17 slot operations in for when you or Dr Underwood were 18 available. Was it your impression that there were some 19 of your anaesthetic colleagues with whom Mr Dhasmana was 20 reluctant to work? 21 A. It was my impression that he preferred working with 22 myself and Dr Underwood. 23 Q. Ahead of the others? You two were in a separate 24 category, if you like? 25 A. It was my impression that he preferred working with 0101 1 myself or Dr Underwood. 2 MR MACLEAN: Dr Masey, may I just outline where I am going, 3 and it may be that this is a convenient moment for 4 a short break. 5 I want to deal with some of the important meetings 6 that took place throughout 1994 and 1995, and also with 7 the question of the letter which was signed by the 8 anaesthetists. We are going to come, and I hope 9 reasonably swiftly after lunch, to the events of the 10 early part of January 1995. 11 I also want to show you very briefly some extracts 12 from your log which you supplied to the Inquiry in 13 respect of which you have made your first statement. 14 Before we come to all of that, it may be 15 appropriate now to have a short break. 16 THE CHAIRMAN: Let us take lunch for half an hour, 17 reconvening at 1.20. 18 (12.50 pm) 19 (Adjourned until 1.20 pm) 20 (1.20 pm) 21 MR MACLEAN: Now, Dr Masey, what I want to go to now is an 22 extract from your logs. Your first statement, which we 23 saw right at the very beginning this morning, which was 24 WIT 270/1, dealt with the keeping of your logs. 25 A. Yes. 0102 1 Q. And, as I understand it, you essentially logged in 2 manually usually, as you say, on the day of surgery the 3 paediatric cardiac cases that were done? 4 A. All the cases that I anaesthetised, both paediatric and 5 adult cardiac, and any other non-cardiac cases 6 I anaesthetised. 7 Q. Now I do not want to dwell on these logs for very long, 8 but I just want to explore with you one or two changes 9 in approach that are evident from them. Can we go first 10 to WIT 270/18 on my screen only, first of all, please, 11 and turn that round. I have checked this a couple of 12 times. I think that is okay. Can we just highlight the 13 bottom right-hand corner? 14 What you have done here, this is the note at the 15 end of the log, is it not? 16 A. It is. 17 Q. You write down all the cases that took place in the 18 particular year and you write down the age of the child, 19 which is the figure that is in brackets? 20 A. Yes. 21 Q. The procedure which was carried out on the child, for 22 example switch, the fourth one from the bottom, and the 23 initials of the surgeon carrying out the operation? 24 A. Yes. 25 Q. Then at the bottom of the page, this is from 1989, this 0103 1 one, so these operations would be for the calendar year 2 1989, would they? 3 A. They would be, yes. 4 Q. You have written down: 5 "Deaths: Paediatric: 12/49. 6 Adult 8/109". 7 First of all, why did you collate the number of 8 deaths at the end of the log? 9 A. For my own interest. 10 Q. You do not divide them up in the summary there by 11 procedure, but you would be able to see from looking at 12 this summary page which procedures had led to death? 13 A. I would, yes. 14 Q. Now what I want to explore with you briefly, Dr Masey, 15 if we go to WIT 270/20 on my screen only, first of all, 16 and then can we go again to the bottom right-hand 17 corner? This is for 1990, so the next year: 18 "Cardiac cases: 140 bypasses -- adult 95 19 -- paediatric 45". 20 So those would be all open heart operations 21 requiring -- 22 A. If I have annotated as being bypasses, those would be 23 classified as being open heart procedures, yes. 24 Q. We see that, unlike the year before and I think any year 25 before, you subdivided the paediatric cases into those 0104 1 under 1? 2 A. Yes. 3 Q. Why have you done that then? 4 A. I do not know. I cannot recall why I decided -- you say 5 this is 1990? 6 Q. This is 1990, yes. 7 A. I do not know why in 1990 I decided to start looking at 8 the under 1s as a separate group. 9 Q. If I showed you the top of the left-hand column, I could 10 demonstrate that your writing says "Paediatrics 1990". 11 Take it from me it is 1990. I was interested why you 12 should adopt that particular subdivision at that 13 particular time. 14 A. I cannot recall. 15 Q. You see below again, as you did the previous year, you 16 have indicated the percentage of deaths. Again you 17 subdivide the 13.3 per cent, which is total paediatric 18 deaths under 1. It was 2 of 18, which is 11.1 per 19 cent. You submitted these logs perfectly properly to 20 the Inquiry. Had it ever struck you before that there 21 was this change of approach between 1989 and 1990? 22 A. It has only struck me very, very recently, when I was 23 looking over information that I had sent to the Inquiry 24 and I noticed myself that I had started to make this 25 distinction. 0105 1 Q. I think we see the same distinction -- can we do the 2 same procedure again, please -- at the bottom right-hand 3 corner of WIT 270/22. This is 1991, the next year. It 4 is the same set-up as the year before. 5 A. Yes. 6 Q. Again the subdivision "Paediatrics" and then those of 7 under 1 year? 8 A. Yes. 9 Q. We touched on this a little earlier, you may remember, 10 about why there should be a distinction of over 1 year 11 and under 1 year. You will remember that Dr Bolsin's 12 letter to Dr Roylance -- remember the one of July 1990 13 -- in the penultimate paragraph specifically referred 14 to under 1 year old children being, as he saw it, the 15 problem? 16 A. Yes. 17 Q. Might there -- 18 A. I remember that letter. 19 Q. Might there be a relationship between Dr Bolsin having 20 highlighted under 1s in July 1990 and you in your logs 21 for 1990 and 1991, but not for 10989, starting to draw 22 the same distinction? 23 A. That may well be the case, but I really cannot remember 24 why I did it, and I was surprised when I looked at this 25 data again very recently that I had done it. On looking 0106 1 at it, I could not recall the reason why I had chosen, 2 as you say, for 1990 to separate the children. I really 3 do not recall why I started to make this subdivision. 4 Q. That was all I could think of. Maybe in due course 5 subsequently you will have some call to recollect why 6 you should have done this, in which case you will no 7 doubt let the Inquiry know? 8 Now there was one other slight change of approach 9 in the log, and it is 1994. Can we go to WIT 270/24, 10 please? This time if we could just highlight the first 11 three or four lines on the left-hand side. This is just 12 to highlight a point that recurs throughout this 13 summary. The first case there, number 1, would appear 14 to be a patient of 20 months? 15 A. Yes. 16 Q. Can you just read to me what the rest of the line says? 17 A. The "2" with a little circle after it means "secundum". 18 "ASD" is "atrioseptal defect". In brackets I have put 19 "Down's", so the child had Down's Syndrome. I have 20 also written "pulm hyper", which meant the child had 21 pulmonary hypertension. 22 Q. And then "JPD", Mr Dhasmana? 23 A. Mr Dhasmana. 24 Q. And, for example, the fourth one down, a child of -- it 25 may be a child of six years? 0107 1 A. I think it is six, yes. 2 Q. And again in brackets? 3 A. It says "Down's Syndrome". 4 Q. I will not weary you with the others, but there are 5 other examples from the same summary of that year where 6 you have written "Down's" again. I could not see in 7 looking through these summaries you having done that for 8 any previous year, particularly noting the Down's 9 cases. You have been through the logs as well, 10 I imagine? 11 A. Yes. I have not got these logs as they are at the 12 moment with the Inquiry. I had not noticed that. Again 13 I cannot comment as to why I decided in 1994 to put that 14 annotation in. 15 Q. I am sure you will correct me if I turn out to be wrong 16 and that you did, in fact, do that earlier, but it seems 17 to the Inquiry at the moment at least that 1994 was the 18 first time at which you did that? 19 A. It was the first time. 20 Q. Again if it occurs to you why, we would appreciate it if 21 you would let us know. 22 Can I look next at UBHT 61/91, please? Do you 23 remember seeing this before? It is an extract from data 24 put together by Dr Bolsin? 25 A. I do not recall seeing this document before. 0108 1 Q. Can we go to page 98? What about this? This is related 2 to VSDs. 3 A. At some stage in 1993 I did see some preliminary data 4 that I was shown quite by chance by Dr Black. I do not 5 recall this as being the document, but I could not be 6 certain -- 7 Q. The reason I show you -- 8 A. -- as to whether I have seen this document before. 9 Q. I am sorry, Dr Masey. The reason I show you this one is 10 that in your statement, as you may recall, WIT 270/14, 11 you refer to seeing some figures by chance, as you put 12 it, with Dr Black -- it is in the middle of the page. 13 A. Yes. 14 Q. Then it says in the middle of the screen: 15 "Dr Black showed me ...", etc? 16 A. Yes. 17 Q. "There were also data on closure of ventricular septal 18 defects but did I not study these closely"? 19 A. That is what I recall from seeing the data. 20 Q. That is why I showed you that page. Do you positively 21 remember not seeing the data I just showed you or is it 22 the case that it might have been what you saw and you 23 simply now cannot recollect? 24 A. It is my recollection that the format of the data that 25 Dr Black showed me on that evening was not in that 0109 1 format, but that is my recollection. I would not like 2 to say definitively whether it was that document or not. 3 Q. You may by now know, Dr Masey, that some of the VSD data 4 that Dr Bolsin produced turned out to be inaccurate? 5 A. I do know that now, yes. 6 Q. In that it recorded a significantly higher percentage of 7 deaths than was, in fact, ultimately agreed to be the 8 case? 9 A. I do have that knowledge now. 10 Q. And some of those who have given evidence to the enquiry 11 who were shown VSD data by Dr Bolsin have told the 12 Inquiry that they looked at it and essentially said to 13 themselves: "This cannot be right". How did you react 14 when you saw the VSD data, which, as you say in your 15 statement, you did not study closely? 16 A. I cannot recall what I thought specifically about the 17 VSD data. 18 Q. You are obviously aware now that Dr Bolsin produced 19 a quantity of data about different procedures? 20 A. Yes, I am aware of that. 21 Q. Over a fairly lengthy period of time? 22 A. I do not know over what length of time he was collecting 23 the data. 24 Q. To what extent -- I think the buzz word is "shared" -- 25 to what extent was this data shared with you? 0110 1 A. As I have said in my statement, which is now up on the 2 screen, I believe it was the spring of 1993. It was 3 some time in 1993. I was shown quite by chance some 4 data by Dr Black. 5 Q. Not by Dr Bolsin? 6 A. Not by Dr Bolsin, by Dr Black, quite by chance. I was 7 sitting in my office one late afternoon and he walked 8 past the door and said: "Oh, I have these figures. You 9 might be interested in them". 10 Q. It was news to you at that stage that he had figures 11 like that? 12 A. It was complete news to me. 13 Q. What was your attitude to discovering that these figures 14 were in existence but had not hitherto been shared with 15 you? 16 A. I was surprised and disappointed that if Dr Bolsin felt 17 that it was important to collect these figures, that he 18 had not involved his cardiac anaesthetic colleagues in 19 the collection of this data. 20 Q. Was it your impression that somehow you were alone in 21 being excluded from having this data shared with you as 22 a Cardiac Consultant Anaesthetist or was it your 23 impression that there were other Cardiac Consultant 24 Anaesthetists who were similarly ignorant of the data? 25 A. At that time none of my other Cardiac Anaesthetic 0111 1 Consultants had mentioned this to me, so either they 2 were party to this knowledge and had not told me, or 3 they were not party to that knowledge. I do not know 4 which of the two it was. 5 Q. Did you subsequently discover that Dr Underwood was 6 similarly in the dark at this time? 7 A. I cannot specifically recall that, but it was my 8 impression at the time, certainly at the time of seeing 9 this information, that none of my cardiac anaesthetic 10 colleagues had intimated to me that this information was 11 being collected. 12 Q. When, if at all, was a collective discussion amongst 13 anaesthetists themselves of the Bolsin data, if I can 14 call it that, prior to these matters becoming public 15 knowledge in the early part of 1995? 16 A. As far as I am aware, Dr Bolsin never presented these to 17 any meeting at which I was present. 18 Q. What kind of meeting could he have done that at? 19 A. He could have asked for a specific meeting to have been 20 called amongst his cardiac anaesthetic colleagues if he 21 wished to discuss it with us in the first instance. He 22 could have asked it to be presented at an anaesthetic 23 audit meeting, if he felt that was appropriate. 24 Q. Those were the meetings that you told us earlier, the 25 plenary sessions, that took place eight times a year; is 0112 1 that right? 2 A. Yes. 3 Q. Those are the ones you organised as audit co-ordinator? 4 A. Yes. 5 Q. Anything else? 6 A. He could have approached the audit co-ordinator for 7 cardiac surgery and asked him if he could have presented 8 it at a cardiac surgery meeting. 9 Q. Who was that? You said "the audit co-ordinator for 10 cardiac surgery". 11 A. I cannot remember at that time whether it was Mr Hutter 12 or Mr Bryan. 13 Q. It was one and then the other, was it? 14 A. It was one and then the other. He could have asked to 15 present this information at one of the more informal 16 meetings that we held in people's homes in the evening. 17 Q. Just to follow up on that last point, when I say it was 18 one or the other, it was Mr Hutter and then Mr Bryan in 19 that order, because Mr Bryan did not arrive until 1993. 20 A. It was that order, yes. 21 Q. So there were these various opportunities, as far as you 22 can see, at which this data could have been shared with 23 the other anaesthetists, none of which were taken? 24 A. There were other opportunities which could have been 25 taken which, as far as I am aware, Dr Bolsin did not 0113 1 take up the opportunity. 2 Q. Why should that be, do you think? 3 A. I do not know. 4 Q. How would you have reacted if the data had been produced 5 at, let us say, one of the anaesthetic audit meetings? 6 A. I would have tried to ascertain the accuracy of the 7 figures and I ascertained that the extent of the 8 statistical analysis that he might have been presenting 9 on them was robust. 10 Q. And if there had come a time when you were satisfied 11 about those matters, what do you think ought to have 12 happened then? 13 A. I think it would depend on which meeting Dr Bolsin had 14 presented -- I mean, this is fairly hypothetical, 15 because, as far as I am aware, he never did so. 16 Q. But it may be important to ascertain your view as to 17 where the appropriate channels, if you like, were. Let 18 us assume that the anaesthetists had reached a stage 19 where there was data presented that they were all fairly 20 confident was "robust", whatever that means, such that 21 they were all agreed that: "Yes, well, this looks as if 22 this is a presentation of the picture". What do you 23 think would have been the next stage? 24 A. I would have felt the next stage would have been to have 25 highlighted these concerns to our immediate managers, 0114 1 and/or the Clinical Director of Anaesthesia or the 2 Clinical Director of Cardiac Services. 3 Q. The former would have been Dr Monk at this time? 4 A. In 1993? 5 Q. 1993, or Dr Williams, whichever of the two it was at 6 that time? 7 A. I cannot remember. I think 1993 is Dr Monk. 8 Q. Mr Langstaff tells me it was from January 1993. Now do 9 you recall a meeting in the University Department of 10 Cardiac Surgery seminar group in January 1994 attended 11 by surgeons, cardiologists and anaesthetists? 12 A. Not specifically. 13 Q. Attended by Drs Davies, Pryn, Underwood, yourself, 14 Bolsin, Mr Bishop, Mr Hutter and perhaps Drs Joffe and 15 Martin? 16 A. There were so many meetings throughout my time working 17 at the BRI that I do not know to which meeting you are 18 specifically referring. 19 Q. This one may be more unusual than some of the others in 20 that it has been suggested in particular yesterday 21 I think by Dr Monk that the purpose of this meeting was 22 to give an opportunity for the surgeons to present the 23 paediatric data and an opportunity for Dr Bolsin to 24 raise his data, so that afterwards the two groups or 25 parties, as he put it, could get together and attempt to 0115 1 resolve their differences. So this was a meeting, so 2 Dr Monk has it, which was specifically called for the 3 purpose of information passing from surgeons to 4 anaesthetists and vice versa. 5 A. Can you tell me the date of that meeting? 6 Q. 20th January 1994, Level 7 in the University Department 7 of Cardiac Surgery? 8 A. I do not have a specific recollection of the meeting. 9 Q. Dr Monk's evidence was, I think, that Mr Wisheart 10 presented data on either a blackboard or whiteboard -- a 11 whiteboard, I think. Does that ring a bell? 12 A. I attended many meetings throughout my time where 13 results were produced, but I am sorry. I have no 14 specific recollection of that particular meeting, those 15 particular presentations of results. 16 Q. Do you remember Dr Pryn ever presenting or attempting to 17 present data on paediatric cardiac outcomes to a meeting 18 of the anaesthetists and the surgeons? 19 A. No, I do not. 20 Q. You do not recall at this meeting that I am talking 21 about and any others, Dr Bolsin presenting data to the 22 assembled gathering of anaesthetists, surgeons, 23 cardiologists? 24 A. I do not recall Dr Bolsin ever presenting his data at 25 such a meeting. 0116 1 Q. Is that because it is a long time ago and your memory 2 may have faded, or are you clear in your recollection 3 that there never was a meeting you were at where that 4 was done by Dr Bolsin? 5 A. I would say it is clear in my recollection that I did 6 not ever attend a meeting where Dr Bolsin presented his 7 data. 8 Q. Can we have UBHT 61/7, please? You recognise this, do 9 you? 10 A. If I could read the letter, because there were a number 11 of drafts. Yes, I do recognise the letter because all 12 our signatures are on it. 13 Q. This is a version of the so-called anaesthetists' 14 letter. If we scan down the page, please, this one has 15 five signatures on it. 16 A. Yes. 17 Q. Including yours? 18 A. Yes. 19 Q. So this is the one that you signed up to. Can we just 20 examine it a little? Can we look at the text of the 21 letter, please: 22 "We wish to express our concern at the arterial 23 switch programme currently being undertaken in this 24 hospital." 25 Pausing there, at that time there was only 0117 1 a non-neonatal switch programme being undertaken in the 2 hospital, was there not? 3 A. The last neonatal switch had been performed in October 4 1993, so at this stage in June 1994 the only switches we 5 had done since October 1993 had been in the non-neonatal 6 age group. 7 Q. As far as you are aware, had potentially neonatal 8 switches been transferred elsewhere or whatever between 9 October 1993 and June 1994? 10 A. I do not know whether any children had been transferred 11 anywhere else. 12 Q. Was it your impression that there was a moratorium at 13 this time on carrying out neonatal switches? 14 A. I had never been aware of a definitive decision being 15 made that no more neonatal switches would be performed. 16 Q. What about a tentative decision? 17 A. I do not think I was aware even of a tentative decision. 18 Q. Were you aware of the issue being floated? 19 A. All I was aware of -- and I became aware of that earlier 20 than June 1994 -- was that it was some time since we had 21 done any neonatal switch, but I did not know the reasons 22 why we had not performed any. 23 Q. Let us look at the next sentence: 24 "The mortality for this operation is apparently 25 high, particularly for those operations undertaken in 0118 1 the neonatal period, but the recent death of a 14 month 2 old child following the arterial switch procedure must 3 now lead to an open and thorough review of the results 4 so far". 5 When you signed this letter, did you agree with 6 that sentence? 7 A. I agreed with the sentence. This was the sentence that 8 I had asked to be changed from the first draft. I had 9 seen where the word "apparently" did not occur. 10 Q. Perhaps we can split the screen and have a look at 11 GMC 4/64. Just blow up the text. This version on the 12 right-hand side referring to "increasing concern". Do 13 you see that in the first line? 14 A. Yes. 15 Q. Did you ever see a letter before now -- I appreciate it 16 is a long time ago -- that used the term "increasing 17 concern" rather than just the term "concern"? 18 A. I do not know. I know I did see a draft of a letter the 19 wording of which I was unhappy with. I do not know if 20 it is this draft or whether there is another draft where 21 some words or some phrases had already been changed. 22 Q. Look at the second line, please, Dr Masey, the sentence 23 beginning: 24 "The mortality for this operation is apparently 25 unacceptably high". 0119 1 The version that you signed deletes the word 2 "unacceptably"? 3 A. Yes. I have not seen the letter on the left-hand side 4 of the screen for some considerable time, but it would 5 now appear, seeing the two letters side by side, it is 6 not the word "apparently" that I wished to have added 7 but the word "unacceptably" that I wished to have 8 removed. 9 Q. Having seen these letters now for the first time in 10 a long time, you are pretty clear that is the change 11 that you had made? 12 A. To say I am clear it is the change I made, certainly 13 from the point of view of what the second letter is 14 saying, it would appear that it is the change that 15 I asked to be made. It is the emphasis of the first 16 letter that I was unable to sign. 17 Q. Can we see all of the left-hand letter, please? Do you 18 see that that version is only signed by Dr Davies. Now 19 if we go to UBHT 61/6, this version is signed by four 20 consultant anaesthetists, but not you or Dr Underwood. 21 So would it appear to be the case that the two of you 22 were the last two to sign the letter? 23 A. Is there any change in the wording of this letter from 24 the one -- 25 Q. No, there is not. This is the same version as the one 0120 1 I showed you with your signature on. The one I showed 2 you with your signature on is signed by everybody except 3 for Dr Baskett, and this one is signed by everybody 4 apart from you and Dr Underwood. 5 It may be that not much turns on all of this, but 6 can we go back to 61/7, which is the one that you did 7 sign? I read to you that second sentence and asked you 8 if you agreed with it. Let us look at the next 9 sentence: 10 "It is our belief that this review should be 11 confidential and take place between all the cardiac 12 anaesthetists, all the cardiac surgeons, all the 13 paediatric cardiologists and the Director of Cardiac 14 Services. This responsible approach to our clinical 15 practice would defuse many of the criticisms of the 16 programme in this institution expressed privately and 17 publicly". 18 What criticisms were you aware of that had been 19 expressed publicly at this time, June 1994? 20 A. In June 1994 -- in 1992 there had been an article in 21 "Private Eye", which had reported on the results of 22 paediatric cardiac surgery, and so some figures about 23 the results of paediatric cardiac surgery were in the 24 public domain. 25 Q. You in your statement refer to the "Private Eye" 0121 1 articles and you say the publication of those "Private 2 Eye" articles, so far as you were aware, had a chilling 3 effect on the willingness of the surgeons to share 4 information? 5 A. That was my impression. 6 Q. Now that letter was sent to Dr Monk. It is addressed to 7 Dr Monk; yes? 8 A. Yes. 9 Q. Who sent it or took it to Dr Monk? Do you know? 10 A. I do not know who actually took it to Dr Monk. 11 Q. It was not you? 12 A. It was not me. 13 Q. Were you ever aware of a suggestion that this letter or 14 something very similar was going to be written to 15 Dr Roylance rather than to Dr Monk? 16 A. Having read some documents recently, it has reminded me 17 that, yes, it was initially thought that this letter 18 would be addressed to Dr Roylance. 19 Q. And signed by Dr Monk in addition to the others? 20 A. And signed by Dr Monk. 21 Q. Why should that plan have changed? Why not simply write 22 to the Chief Executive and be done with it? 23 A. I do not know what the reasons were. I cannot remember 24 what the reasons were why it was felt to be preferable 25 to direct this letter through the Clinical Director of 0122 1 Anaesthesia. 2 Q. Now the letter concerns only the arterial switch 3 procedure? 4 A. Yes. 5 Q. Was there ever any suggestion that Dr Monk should be 6 written to about any other procedure in addition? 7 A. Not that I can recall. 8 Q. What did you, for your part, expect Dr Monk to do with 9 this letter when he got it? What was its purpose? 10 A. Its purpose, as far as I was concerned, was -- as the 11 last line says, talking about the criticisms of the 12 programme -- to actually make this into a much more open 13 and transparent mechanism for looking at any criticisms 14 and trying to gain more information to see whether there 15 was any basis in these criticisms. 16 Q. What the letter is calling for is an open and thorough 17 review? 18 A. Yes. 19 Q. That is what it wants to achieve? 20 A. Yes. 21 Q. Who was going, as far as you were concerned, to set up 22 the review? Was Dr Monk going to do it, or was he going 23 to have to have the assistance of others to set up the 24 open and thorough review? 25 A. I do not know how Dr Monk hoped to achieve having an 0123 1 open and thorough review. 2 Q. Was it your impression that Dr Monk had it in his power 3 to establish an open and thorough review involving 4 anaesthetists, surgeons, cardiologists and the Director 5 of Cardiac Services? 6 A. I believe that anybody can call a meeting to discuss 7 issues, and it is open to anybody who is asked to go to 8 that meeting to choose whether he or she attends or not. 9 Q. Calling a meeting is one thing; making it happen is 10 another. 11 A. Calling a meeting is one thing. Whether an individual 12 attends is going to be up to that individual as to 13 whether he or she chooses to go to the meeting or 14 actually is able to go to the meeting. 15 Q. Did you expect Dr Monk to take the letter to 16 Dr Roylance, or send it to him? 17 A. I would not have thought as a Clinical Director of 18 Anaesthesia that that would have been his first line 19 of -- 20 Q. What would his first line have been? 21 A. If I had been Clinical Director of Anaesthesia and had 22 been sent that letter, I would have taken the letter to 23 the Director of Cardiac Services in the first instance, 24 if I had been Clinical Director. I cannot answer as to 25 what Dr Monk felt was the appropriate channel through 0124 1 which to take that letter. 2 Q. If I remember my Dramatis Personae, that would be 3 Professor Vann Jones? 4 A. In June 1994 I cannot recall. 5 Q. I think it was. A new Directorate of Cardiac Services 6 had recently been established and he was the Clinical 7 Director. 8 Did you have any discussions with Dr Monk about 9 this letter after it had, as far as you were concerned, 10 gone to him? 11 A. I cannot recall any specific discussions. 12 Q. Did the open and thorough review take place in the wake 13 of the letter? 14 A. Not to my recollection. We did not review all the 15 switch data until January 1995. 16 Q. Was that because Dr Monk did not do anything about this 17 letter, or was it because others did not play a role? 18 A. I do not know the answer to that. 19 Q. Did you ever chase up Dr Monk and say: "Look, here, 20 Chris. What has happened to the open and thorough 21 review we asked for?" 22 A. I cannot recall specifically but that is the sort of 23 conversation that could easily have taken place in 24 a corridor or during an operating list. I cannot recall 25 anything specific. 0125 1 Q. Did you ever discuss the letter or the concerns that 2 underlie the letter specifically with Mr Dhasmana? 3 A. I cannot recall discussing the letter specifically with 4 Mr Dhasmana. 5 Q. Or the concerns which underlay it? 6 A. I cannot recall having a specific discussion with 7 Mr Dhasmana about results, although we would have many 8 conversations about results as cases were done. 9 Q. On a case-by-case basis? 10 A. Almost on a case-by-case basis, yes. 11 Q. In terms of the joined-up thinking of seeing how things 12 were going, do you remember any discussions with him 13 about this time? 14 A. In relation specifically to arterial switches? 15 Q. In relation to arterial switches. 16 A. No specific meetings, although certainly with the 17 neonatal arterial switch programme again it was probably 18 on a case-by-case basis, but I think all of us were 19 aware on a case-by-case basis what the outcomes had 20 been. 21 Q. There would not be any discussion with neonatal switches 22 at this time, because there were not any neonatal 23 switches? 24 A. Not at this time. I agree. 25 Q. Now I think it is right -- tell me if you know to the 0126 1 contrary or tell me if you do not know -- that after 2 this letter was written, but before the operation on 3 Joshua Loveday in January 1995, Mr Dhasmana performed 4 a non-neonatal switch operation? 5 A. I cannot recall that specifically, but it would not be 6 surprising in that timescale that he would operate on 7 such a case. 8 Q. Anaesthetised by Dr Underwood? 9 A. I do not know. 10 Q. If I suggested that there was a non-neonatal switch 11 operation after this letter was written but before 12 Joshua Loveday's operation, would it surprise you that 13 Dr Underwood should have anaesthetised for that 14 operation, she being a signatory of this letter? 15 A. I cannot answer for Dr Underwood. 16 Q. All right. If you had been programmed to be the 17 anaesthetist for that non-neonatal switch operation 18 after this letter but before Joshua Loveday, would you 19 have done that? 20 A. If there was no particular reason for that individual 21 child not to, yes, I believe I would have anaesthetised 22 the child. 23 Q. Notwithstanding that in June 1994 it was your opinion 24 that the time had come for an open and thorough review 25 of the results so far? 0127 1 A. I was perfectly happy to sign this letter, because this 2 was the first time that I felt that Dr Bolsin had asked 3 us as a group of anaesthetists to act in concert with 4 him to look at figures. I was not as concerned with the 5 outcome from non-neonatal switches as it would appear 6 Dr Bolsin was. My personal experience and my personal 7 recollection of these operations was such that I did not 8 hold the level of concern that Dr Bolsin appears to have 9 done. I considered from my own experience and having 10 been involved from 1988 with the non-neonatal switch 11 procedure that the results of the non-neonatal switch 12 procedures were acceptable, and therefore in that 13 context I would have been happy, without having had this 14 review, to have continued and anaesthetised the child. 15 Q. So the review that you thought the results must now lead 16 to was not a review which was such that it being carried 17 out was a pre-condition to doing any more non-neonatal 18 switches in the meantime? 19 A. As far as I was personally concerned. 20 Q. That was your position? 21 A. That was my position. 22 Q. And as far as you understood it, that would be 23 Dr Underwood's position, otherwise would have been 24 strange for her to have -- 25 A. You would have to ask Dr Underwood. 0128 1 Q. Do you recall the meeting at Dr Joffe's house in 2 December 1994? 3 A. I do. 4 Q. On 8th December specifically? 5 A. I do not know what the actual date was, but I do 6 remember a meeting in December 1994 at Dr Joffe's house. 7 Q. Do you remember that the attendees were Mr Bishop, 8 Mr Dhasmana, Drs Joffe, Hayes, Martin, Pryn, yourself 9 and perhaps Dr Underwood? 10 A. I cannot remember the precise make-up of the people who 11 were at the meeting. 12 Q. And perhaps Dr Monk? 13 A. I cannot recall whether Dr Monk was there or not. 14 Q. Do you remember that Dr Bolsin was not there? 15 A. I would not be able to say specifically. I would not be 16 able to say definitively that Dr Bolsin was not there. 17 Q. And I think it has been suggested that Dr Wilde was 18 there? 19 A. It has been suggested Dr Wilde was there. 20 Q. Again you cannot specifically remember? 21 A. I cannot specifically remember. 22 Q. What was the subject of that meeting? 23 A. I have very little recollection of the subject-matter of 24 that meeting. All I can recall is more what I would 25 describe as the tenor of the meeting. 0129 1 Q. Which was what? 2 A. That there was a certain amount of unhappiness or even 3 sadness at the amount of publicity that we appeared to 4 be receiving, and it was my feeling that people at the 5 meeting felt saddened and stressed by the situation we 6 found ourselves to be in, being very much put into the 7 public limelight. 8 Q. Was it a discussion about a particular procedure or was 9 it a general discussion about where the unit was? 10 A. I cannot recollect the specific discussion at all. 11 Q. Do you remember if at this time you were aware that 12 Joshua Loveday -- maybe not specifically the name of the 13 patient -- a patient was in the pipeline, if you like, 14 for a non-neonatal switch? 15 A. I was not aware at that stage that there was a child in 16 the pipeline. 17 Q. Do you remember if there was data produced at the 18 meeting? 19 A. I do not remember data produced at the meeting. 20 Q. Now either at this meeting or generally you say there 21 had been publicity and a feeling of sadness and so on. 22 Was that relating at least in part to the switch series? 23 A. I think all of us had hoped that we would be able to 24 move forward in our paediatric cardiac practice by doing 25 the neonatal switch procedure, and I was personally 0130 1 saddened when it became apparent that it was 2 inappropriate for us at that time to continue with it, 3 that we had not been able, as a team, to overcome 4 problems with the neonatal switches. 5 Q. What was Mr Dhasmana's attitude to his doing further 6 switches, whether neonates or non-neonates, by November 7 1994? 8 A. I do not have any recollection of having discussions 9 with Mr Dhasmana as to whether he felt he wished to 10 carry on doing switches. 11 Q. Mr Dhasmana said at the GMC that you and Dr Underwood 12 were -- "quite certain" I think were his words -- that 13 there were good results by that time in older switches. 14 A. My recollection was that the results in the older 15 switches were acceptable, yes, were within acceptable -- 16 were acceptable, yes. 17 Q. In June 1994 you signed a letter saying: 18 "The mortality for this operation is apparently 19 high particularly for those operations undertaken in the 20 neonatal period but ...", and so on, "... must now lead 21 to an open and thorough review." 22 A. Well, there is no doubt that for the operations 23 undertaken in the neonatal period the mortality was very 24 high indeed. I would not dispute that. 25 Q. But it is the non-neonates that we are looking at at the 0131 1 moment? 2 A. It is the non-neonates we are looking at. 3 Q. This letter is concerned about those too? 4 A. This letter is concerned about those too. As I have 5 said, the reason that I signed this letter was to try to 6 have a much more transparent discussion of perceived 7 problems. 8 As I have stated, I did not personally from my 9 experience feel that we had a particular problem with 10 the non-neonatal switches that should make us stop doing 11 the non-neonatal switch programme, but I signed the 12 letter because I felt that this was the first time that 13 Dr Bolsin had asked us to do something as a group, which 14 I had been asking him to do since the first letter he 15 had written to Dr Roylance in 1990, and, secondly, 16 I felt that if a review was undertaken, my perception in 17 relation to the non-neonatal switches would be what 18 would be found if the figures were looked at. That is 19 why I would have been perfectly prepared to continue to 20 anaesthetise children for non-neonatal switches. 21 Q. I do not know whether you were aware of a dinner that 22 took place between Drs Monk, Bolsin, Mr Wisheart and 23 Professor Angelini in April 1994? 24 A. Again, having read about it recently, it has reminded me 25 that I probably did know about it around that time. 0132 1 Q. If we assume for the moment that you knew about it about 2 that time and if we assume for the moment there was 3 a meeting in January 1994 which was assembled for the 4 purpose that Dr Monk outlined yesterday, namely for 5 information to be passed from one side to the other, but 6 that no data was produced by Dr Bolsin at such 7 a meeting, would that not rather suggest that the time 8 had rather gone past when an open and thorough review 9 was capable of being carried out by those involved 10 themselves rather than by some external force coming in 11 to look at the review? Did it not appear as if the 12 anaesthetists and the surgeons most centrally concerned 13 would be incapable of talking to one another by the 14 summer of 1994? 15 A. I cannot answer that. I -- 16 Q. You see the point I am driving at? 17 A. I think I see the point you are getting at. 18 Q. There had been a meeting for one side to talk to the 19 other, and on Dr Monk's version Dr Bolsin did not 20 produce any data, and a dinner, which the Panel have 21 heard evidence did not achieve its purpose. Yet, what 22 is suggested even now is a review carried out 23 internally, if you like. Maybe you cannot help us with 24 that? 25 A. I feel I cannot help you on that. 0133 1 Q. You discovered in due course that there was 2 a non-neonatal switch programmed for January 1995, did 3 you? 4 A. Yes. 5 Q. It turned out to be Joshua Loveday? 6 A. Yes. 7 Q. You attended a meeting the night before that operation 8 took place? 9 A. I did. 10 Q. At whose instigation was that meeting held? 11 A. I cannot recall at whose instigation that meeting was 12 held. 13 Q. What did you understand the powers of the meeting to 14 be? What was its jurisdiction? Was it going to decide 15 whether the operation took place or what was its role? 16 A. Its role was to discuss as to whether it was appropriate 17 for the operation to take place the following day. 18 Q. Can we have a look, please -- this is one of the last 19 documents we are going to look at -- at UBHT 54/11? 20 This is Dr Monk's note of the meeting. There was 21 another note of the meeting produced by Dr Martin. Did 22 you ever see either note of the meeting about the time 23 we are concerned with contemporaneously? 24 A. I have seen copies of this document before, yes. 25 Q. Can we go to the second page of this document, please? 0134 1 Do you see paragraph 4? Could you just read that to 2 yourself? ( Pause.) Have you read that paragraph? 3 A. I am having difficulty with the last sentence. 4 Q. "A meeting was held by Mr Wisheart, Dr Bolsin and 5 Dr Monk regarding the representation of the Trust by 6 Dr Bolsin and the inappropriate channels of 7 communication that the Department of Health were using". 8 I do not want to focus on that for the moment. I 9 am interested more in the earlier part of the paragraph, 10 which would appear to suggest in the second line that 11 the decision to carry out the operation was taken by 12 three men: Mr Wisheart, Mr Dhasmana and Dr Monk in 13 a side meeting off the main meeting? 14 A. I was not at that side meeting, so I cannot comment on 15 that. 16 Q. No, I appreciate that. It may be what Dr Monk is 17 getting at is that in the main meeting those three, 18 Mr Dhasmana, Mr Wisheart and Dr Martin, were the ones 19 who discussed the need for the operation and decided 20 that the condition merited an immediate intervention. 21 To what extent were the other people at the meeting 22 having an input into the decision that the operation 23 ought to be carried out in Bristol the next day? 24 A. What I recall of the meeting is that the meeting started 25 with a presentation of all the figures for non-neonatal 0135 1 switch procedures, both figures that Mr Dhasmana 2 produced himself and figures that Dr Pryn had brought 3 with him as well. 4 Q. Can you just pause there and I will show them. 5 GMC 16/38: there were some very minor amendments made 6 to these figures but are these Dr Pryn's figures. 7 A. This is the document I recall Dr Pryn bringing with him, 8 yes. 9 Q. If we scan down just a little, the second table is 10 Dr Dhasmana's mortality for the switches, is it not? 11 A. It does appear to be, yes. 12 Q. Over 1 year, 13 per cent, middle column, between 1990 13 and 1994, 1 out of 8, 13 per cent? 14 A. Yes, 13 per cent. 15 Q. So this is the data that was at the meeting? 16 A. Yes. 17 Q. Tell me then about the discussion around those figures. 18 A. These figures were discussed and also compared to the 19 most recent cardiac surgical register, and the figure is 20 not there -- I do not believe the figure is there, so 21 I cannot remember exactly what the figure was, but there 22 was a unanimous agreement, having discussed these 23 figures, that there was nothing in the figures to 24 suggest that Mr Dhasmana should not go ahead and perform 25 the operation the following day. 0136 1 Q. By the time that unanimous decision had been reached, 2 had anyone left the meeting? 3 A. Dr Pryn left the meeting at some stage. I do not know 4 whether it was before or after that unanimous decision 5 had been made. 6 Q. Had anyone else left the meeting? 7 A. Not that I can recall. 8 Q. Was Dr Bolsin still there? 9 A. Dr Bolsin was still there. 10 Q. What was his attitude? 11 A. Dr Bolsin -- I said it was unanimous -- agreed there was 12 nothing in the figures that should preclude Mr Dhasmana 13 going ahead with the operation the following day. 14 Q. Did he suggest there was a qualification as to whether 15 or not the operation should take place? 16 A. He did express a qualification. 17 Q. Which was what? 18 A. Which was what could be termed a political 19 qualification, that if the child was operated on the 20 following day and the child died, that politically it 21 would be an unwise move therefore to go ahead with the 22 operation, which is known to be high risk. 23 Q. Did he suggest a successful operation would not do much 24 beneficially to the figures but an unsuccessful outcome 25 would be likely to have significant repercussions? 0137 1 A. Looking purely at the figures, I do recall comments 2 being made on how would the figures change, depending on 3 whether the child survived or died. My recollection is 4 that it would not make much difference to the figures 5 either way, to the actual figures. 6 Q. The other side of the coin that Dr Bolsin presented was, 7 was it not, that an unsuccessful outcome would be likely 8 to have significant repercussions? 9 A. Yes. 10 Q. There was an unsuccessful outcome? 11 A. Yes. 12 Q. There were significant repercussions? 13 A. Yes. 14 Q. Was the question that was asked at the meeting whether 15 or not there was a clinical reason to defer the 16 operation? Was that the essence of it? 17 A. I find this question difficult, because with information 18 that I now have, I do know that those conversations took 19 place at this meeting, but I cannot remember whether it 20 is my recollection from hearing it at the meetings or in 21 subsequent conversations that I became aware that these 22 conversations had taken place. 23 Q. What was your understanding of the urgency of Joshua 24 Loveday's condition? 25 A. As I say, I find it difficult, because I now know that 0138 1 this was discussed at the meeting, but I am not clear in 2 my own mind whether I had formed an impression at the 3 meeting as to the urgency of the operation. 4 Q. Were the questions these: what is the child's 5 condition? What operation does this child need? When 6 does he need it? Where can that operation best be 7 performed? 8 A. Subsequent to this meeting, I do now have those as part 9 of my body of knowledge, but I do not recollect in 10 detail those conversations at that meeting. 11 Q. Do you remember what Dr Martin said about the urgency of 12 the operation? 13 A. Again I do not recall specifically what Dr Martin said. 14 As I say, I do have a body of knowledge about that, 15 which I do not know whether I received by taking it in 16 at that meeting or by reading documents subsequently or 17 discussing the case with my colleagues subsequently. 18 Q. Do you remember whether the point came up as to whether 19 or not Joshua Loveday could be moved to another hospital 20 to have his operation? 21 A. Again that is part of my body of knowledge now, but 22 again I am not sure whether I specifically took that 23 information in at that meeting or whether it became part 24 of my knowledge on subsequent discussion with colleagues 25 and reading the minutes of the meeting. 0139 1 Q. Dr Monk recalled yesterday that that point had come up. 2 Have you any reason to take issue with that 3 recollection? 4 A. I have no reason to take issue with that at all. 5 Q. In due course the operation took place. Did you have 6 a discussion with Sister Herborn about who might be the 7 anaesthetic nurse for the operation? 8 A. I do not recall having a discussion with Sister Herborn 9 about who would be the anaesthetic nurse. 10 Q. Do you remember who the anaesthetic nurse was for the 11 operation? I appreciate you did not anaesthetise the 12 patient. 13 A. No, I did not anaesthetise the patient. I do not know 14 or cannot remember who the anaesthetic assistant was. 15 Q. Do you remember whether you had a conversation with Kay 16 Armstrong and Sister Herborn when they were reluctant -- 17 Sister Herborn was reluctant that Kay Armstrong should 18 be the anaesthetic nurse, and you pointed out that 19 Alison Reed was on a day off on the day of the operation 20 and perhaps her shift could be changed so that she was 21 the anaesthetic nurse? 22 A. It was my recollection that Alison Reed was asked to 23 come in to be the scrub nurse, not the anaesthetic 24 assistant, but please correct me if I have remembered 25 this incorrectly. 0140 1 Q. I think that may be right, Dr Masey. Yes, that is 2 right. Kay Armstrong ultimately was the anaesthetic 3 nurse for the operation. 4 A. I do not know that, but if you tell me that is the case 5 ... 6 Q. Did you ever remark in Kay Armstrong's hearing that with 7 two anaesthetists present, it was not actually necessary 8 to have an anaesthetic assistant in the operation? 9 A. I think it is extremely unlikely that I would have made 10 such a comment, because it has always been recognised 11 that an anaesthetic assistant is necessary. So I think 12 it is unlikely that I would have suggested that we 13 should proceed without an anaesthetic assistant. 14 Q. It would be unusual to proceed without an anaesthetic 15 assistant? 16 A. At that stage it would be unheard of to proceed without 17 an anaesthetic assistant. 18 Q. It would be particularly unusual or odd to have no 19 anaesthetic assistant in a situation where the operation 20 was clearly very complex and had been the subject of 21 such lengthy debate among consultants? 22 A. By January 1995, as I say, it would be unheard of to 23 proceed with any operation without an anaesthetic 24 assistant. 25 Q. So if it was suggested that you did make such a comment, 0141 1 you would find that very strange indeed? 2 A. I would. 3 Q. Now I just want to deal with a couple more points, 4 Dr Masey. You have been very patient with me. I want 5 to take you, please, somewhere else entirely, to WIT 6 285/9. This is a statement from Mr Willis. Now 7 I imagine that you will have seen this statement as part 8 of the so-called rebuttal process? 9 A. I have seen this statement. 10 Q. What I want to do is to invite you, please, to read 11 paragraph 20 and, when you have read it, scan down to 12 21. 13 A. Can I see the previous page? Does 20 start on the 14 previous page? 15 Q. Can we go back? Read as much of 20 as you like. 16 A. If I could have the next page. 17 Q. Yes. 18 A. Thank you. Let me scan down so I can see 21, please. 19 Thank you. 20 Q. Now the point about 21 is -- I do not know whether you 21 recall or not -- as it turns out, you were the 22 anaesthetist. Do you remember that? 23 A. Yes. 24 Q. Do you know why it would seem at short notice you became 25 the anaesthetist for that child and not Dr Underwood? 0142 1 A. I can say what I believe has happened here is a case of 2 mistaken identity. Dr Underwood did not see the 3 Willises on the night before the operation and 4 Dr Underwood was never planned to be the anaesthetist 5 for Daniel on that day and, in fact, Dr Underwood was on 6 annual leave that week. 7 Q. Who saw the Willises the night before the operation? 8 A. Without looking at the anaesthetic record, to which I am 9 not party, I cannot say for certain who saw the child 10 pre-operatively. All I can say is I know I was at the 11 hospital on the preceding day. It is my normal practice 12 to see my patients pre-operatively. I cannot -- I think 13 it is extremely unlikely that I did not go and see this 14 child and one or other or both parents the night before 15 the operation. 16 Q. How many female Consultant Cardia Anaesthetists were 17 there working in BRI at this time? 18 A. There were two female Paediatric Cardiac Anaesthetists 19 at this time. 20 Q. You and Dr Underwood? 21 A. Myself and Dr Underwood. 22 Q. And she was away? 23 A. She was away. Can I please add to that? 24 Q. Do. 25 A. We also do have trainee anaesthetists, and having looked 0143 1 back at my rotas for that time in May 1993, we did 2 actually have two female trainee anaesthetists doing 3 their cardiac surgery attachments at that time. Both of 4 them had children and may have had children who were 5 five months of age. All I can suggest, as I say, 6 without looking at the anaesthetic chart, which might 7 give me more information, is that what happened is one 8 of the anaesthetic trainees also went to see the parents 9 that night, because it was envisaged that she would be 10 in the operating theatre with me the following day, and 11 it is this anaesthetist that has been confused with 12 Dr Underwood. 13 Q. If you look up the page again, please, you see in the 14 fourth line the reference to: 15 "She apologised ...", and so on. 16 A. Yes. 17 Q. Do you recollect such an incident ever involving you? 18 A. I could not ever say that I was hormonal because I had 19 had a child, because I have no children. 20 Q. That perhaps deals with that particular sentence. 21 Dr Masey, there is only one more point before 22 I finish my questions, and I said earlier I would come 23 back to it and I am very happy to do so. Can I have on 24 the screen, please, WIT 270/26? We saw earlier for 25 other purposes of the Inquiry a letter from Dr Coates, 0144 1 who was a Clinical Director, to you; I am sure you 2 recall. This is a letter a little later, about eighteen 3 months later, slightly more, 7th November 1997, from 4 Mr Pawade to Dr Coates. It says: 5 "Dear David, 6 Further to our telephone conversation, I should 7 like" -- presumably the word "to" is missing -- 8 "reiterate that I have never accused Dr Sally Masey of 9 clinical incompetence. I am perfectly happy for her to 10 look after my adult congenital/acquired cases". 11 By that time Mr Pawade would have established 12 a relationship with his Paediatric Cardiac 13 Anaesthetists, would he? 14 A. He was working with the Paediatric Cardiac Anaesthetists 15 at the Children's Hospital, yes. 16 Q. And had been for two years by that time? 17 A. Yes. 18 Q. Then if we go over the page to page 27, a letter to you 19 from Mr Ross, the Chief Executive. I do not know 20 whether you want me to read that letter or whether you 21 want to read it to yourself. Essentially he says: 22 "Roger Baird tells me that he has now had the 23 opportunity to talk to you at some length and to express 24 his personal support". 25 Roger Baird succeeded Mr Wisheart as the Medical 0145 1 Director, did he not? 2 A. He did. 3 Q. He would be the most senior person in the Trust? 4 A. Well, he is the Medical Director. 5 Q. "I felt that I should now write as Chief Executive of 6 UBHT to reassure you that I have no reason to have any 7 concern about your clinical competence, and that you 8 have the personal support of Ian Stone ..." 9 He was a Director of the Trust? 10 A. A Director of Personnel. 11 Q. " ... and myself in your continuing work in the Trust. 12 I am only sorry that James Wisheart's personal situation 13 meant that there was considerable delay before recent 14 conversations and correspondence took place". 15 Now, Dr Masey, I have asked you a number of 16 questions, some of which I understand and realise and 17 appreciate were upsetting, and I hope you understand 18 that the Inquiry has got its job to do and sometimes it 19 is necessary to explore those matters, and I hope we did 20 that as sensitively as we could manage. 21 Is there anything, having asked those questions, 22 that you want to add now, anything that I have dealt 23 with incompletely or badly, or anything else in general 24 that you want to say to the Inquiry at this stage? I am 25 sure the Chairman will remind you that you will have an 0146 1 opportunity to contribute further in writing at a later 2 stage, if you so wish. Is there anything else you want 3 to say now? 4 A. No, there is nothing else I wish to say now. 5 Q. I understand from Miss O'Rourke, who sits behind, that 6 there is no re-examination. Does the Panel have any 7 questions for Dr Masey? 8 THE CHAIRMAN: Mr Maclean, we have no questions from the 9 Panel. May I, first of all, remind Dr Masey of what you 10 already said, namely if there are matters that either 11 you remember or come to your attention that you would 12 like us to be aware of, please do let us have them to 13 assist us, but beyond that, may I thank you very much 14 indeed for coming today. You have helped us a great 15 deal. Thank you. 16 MR MACLEAN: If Dr Masey would just bear with me for a few 17 seconds more, tomorrow, sir, at 9.30 we will be hearing 18 from another Consultant Anaesthetist at the UBHT, Dr Sue 19 Underwood. 20 THE CHAIRMAN: I heard from you 9 o'clock. 21 MR MACLEAN: 9.30. 22 THE CHAIRMAN: My hearing again. Thank you very much 23 indeed. Good afternoon, everyone. 24 (3.30 pm) 25 (Hearing adjourned) 0147 1 2 3 4 5 I N D E X 6 7 8 DR SALLY MASEY: 9 Examined by Mr MACLEAN .................. 2 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0148