Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts     Hearing summary 10th 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.   Today’s 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 Children’s’ 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 Children’s 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.

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

   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.

   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

   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?

   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?

   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

   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?

   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

   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

   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

   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

   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

   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?

   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

   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?

   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

   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

   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

   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:

   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?

   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

   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

   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

   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.

   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

   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

   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.

   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

   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?

   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".

   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

   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

   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?

   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:

   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

   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

   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.

   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".

   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

   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

   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?

   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

   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.

   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

   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

   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

   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

   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

   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?

   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.

   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.

   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.

   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.

   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

   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

   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.

   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?

   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

   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?

   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

   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?

   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

   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

   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

   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,

   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)

   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

   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

   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

   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

   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.

   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

   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

   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

   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?

   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

   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:

   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.

   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

   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.

   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

   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

   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?

   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

   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

   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.

   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

   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