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 this -- there was
   7     another visit subsequently to Birmingham by him and
   8     others, but not you?
   9   A. Yes.
  10   Q. You mentioned retraining. Who was going to be
  11     retrained?
  12   A. "Retraining" is a very difficult word. I use it because
  13     of ease and it is available for anyone who wishes to go
  14     and see how another unit is performing any particular
  15     task to see whether any of us can learn from seeing
  16     someone else's experience with a particular technique.
  17   Q. Who is going to learn from this visit?
  18   A. Anybody and everybody who was going there went with the
  19     intention of seeing whether there was anything to be
  20     learned.
  21   Q. Whose idea was it to go to Birmingham?
  22   A. It is my recollection that it was Mr Dhasmana's.
  23   Q. Did he discuss it with you? Did he say "Do you want to
  24     come to Birmingham next week, Sally?"
  25   A. I cannot recall now how it was decided that I would go

   1     with him.
   2   Q. Dr Monk, I think, has suggested to the Inquiry that
   3     it was his idea that there should be a visit made to
   4     Birmingham.
   5   A. As I say, I cannot recall. If Dr Monk has said that,
   6     then I would accept what Dr Monk has said, but I do not
   7     recall exactly how it was decided that I would go.
   8   Q. That is what I was going to ask you. Why was it you who
   9     went on this particular occasion? Was it because you
  10     volunteered? Did somebody ask you specifically? Was it
  11     your turn, or what?
  12   A. Again, my recollection is that I showed great interest
  13     in going and I do recall that in order for me to go,
  14     I did have to change my work for that day because I had
  15     to ask one of my colleagues to cover my operating list
  16     that day.
  17        So I think I showed a great desire to go, so it
  18     was arranged that I could go.
  19   Q. Mr Dhasmana, I think, saw an operation that was
  20     conducted by Mr Brawn?
  21   A. He did.
  22   Q. That was, I think, a neonatal switch operation?
  23   A. It was a neonatal switch.
  24   Q. Were you present in the operating theatre?
  25   A. I was present at the beginning, so I could witness the

   1     anaesthesia, the start of the anaesthetic and to speak
   2     to the anaesthetist who was involved with that
   3     anaesthetic. I did not stay for the whole procedure.
   4   Q. So and you Mr Dhasmana essentially went your separate
   5     ways once you got to Birmingham, he with the surgeon and
   6     you with the anaesthetist?
   7   A. I spent some time with the anaesthetist. I also spent
   8     some time looking at the Intensive Care Unit and
   9     speaking to an anaesthetic colleague, who I knew well,
  10     because we had been trainees together, who both
  11     anaesthetised children for heart surgery and was
  12     involved on the Intensive Care Unit in Birmingham.
  13   Q. You say in your statement -- we do not need to go to
  14     this -- WIT 270/4, that the visit to Birmingham led to
  15     minor changes in anaesthetic management.
  16        I think you gave a short explanation for what
  17     those were.
  18        What were you hoping to find, if anything, by
  19     going to Bristol?
  20   A. I went with very mixed emotions. Part of me wanted to
  21     go and find that there was something which was very
  22     different from what we as anaesthetists were doing, so
  23     that I could come back and say, "We should make this
  24     change and this may help with the programme". But the
  25     other side of me did not want to go and find that there

   1     was something completely different that we had not
   2     already appreciated was now accepted as part of normal
   3     anaesthetic management for these sorts of children.
   4        So with very mixed emotions, I was going.
   5   Q. Did you find that you had, if you like, missed
   6     a trick? Was there something glaring that the
   7     anaesthetists in Bristol had not been doing?
   8   A. No, I found that the general format of the anaesthetic
   9     was very similar to that that we were doing in Bristol.
  10   Q. Did that reassure you, or not reassure you? Did it
  11     leave you with the same feeling?
  12   A. It reassured one part of me that we were not doing
  13     things that were not now accepted practice, or not doing
  14     things that were now accepted practice.
  15   Q. On the other hand, perhaps you felt slightly uneasy that
  16     you had not found the answer, if you like?
  17   A. There was a small disappointment that I could not go
  18     back to my colleagues and say, "This is very different
  19     in Birmingham. If we do this, or shall we do this, can
  20     we discuss doing this, which might then help in the
  21     total management of these children".
  22   Q. You and Mr Dhasmana travelled to Birmingham together?
  23   A. Yes.
  24   Q. You travelled back together?
  25   A. We did.

   1   Q. And no doubt you discussed what you found?
   2   A. We did.
   3   Q. What was your impression of what he had found from
   4     the surgical side at Birmingham?
   5   A. He came back on the train and he was extremely
   6     enthusiastic about what he had seen and what he had been
   7     able to talk through with Mr Brawn, and felt very
   8     encouraged by what he had seen in relation to how he
   9     felt he would go forward with the neonatal switches that
  10     he was going to be operating on.
  11   Q. Was there a reporting back session, if you like, to
  12     your colleagues in Bristol on the meeting?
  13   A. I cannot recall a specific meeting that I convened to
  14     discuss the issues that I had discussed in Birmingham,
  15     but I did make sure that I discussed what I had seen in
  16     Birmingham with any of my colleagues who were going to
  17     deal with these children, so that if we did agree to
  18     take over the minor changes, that this was something
  19     done by consensus.
  20   Q. I asked you about what Mr Dhasmana had found, and you
  21     said he came back enthused.
  22        Was it your impression that Mr Brawn had explained
  23     something to Mr Dhasmana that Mr Dhasmana had not been
  24     doing before?
  25   A. It is difficult for me to say exactly what it was that

   1     Mr Dhasmana had seen, because they are surgical
   2     techniques and surgical ways of doing things about which
   3     I have relatively little knowledge, but it was just my
   4     impression, coming back on the train, that Mr Dhasmana
   5     had seen ways of doing things which were different --
   6     I do not know to what extent -- from how he was
   7     performing the operation, that Mr Dhasmana felt might
   8     make a difference to the management of these children.
   9   THE CHAIRMAN: May I just interrupt you for a moment,
  10     Mr Maclean? Did you circulate a note of what you had
  11     learned there to your colleagues?
  12   A. I cannot recall writing anything down, but I did discuss
  13     it with any of my colleagues who were involved with this
  14     work.
  15   Q. Did Dr Monk suggest a note being distributed before or
  16     afterwards?
  17   A. I cannot recall.
  18   THE CHAIRMAN: Thank you.
  19   MR MACLEAN: But it was your impression that the information
  20     you had gleaned was disseminated amongst the
  21     anaesthetists in Bristol?
  22   A. Yes.
  23   Q. You say you cannot recall a specific reporting back
  24     session, but was there a decision taken to recommence
  25     neonatal switches in Bristol?

   1   A. I do not know whether there was a specific decision to
   2     recommence doing neonatal switches. Transposition is
   3     not uncommon, but it is not that common a procedure and
   4     these children would come at intervals. Again, because
   5     the operation for neonatal switch procedure is done
   6     within the neonatal period, within the first 10 to 14
   7     days, then these operations are arranged at relatively
   8     short notice.
   9        So I do not know whether a decision was made to
  10     recommence or whether it was that a child with
  11     a suitable heart condition had not actually presented to
  12     the hospital in the intervening time.
  13   Q. When the next child did present and was operated on with
  14     the switch procedure, was that something that you, if
  15     you had known about it at the time (which you may have
  16     done), were comfortable with?
  17   A. Yes. I anaesthetised that child.
  18   Q. And were entirely content to do so?
  19   A. Yes.
  20   Q. And Mr Dhasmana was the surgeon?
  21   A. Yes.
  22   Q. We know that there was another visit by Mr Dhasmana to
  23     Birmingham about eight months later in July 1993?
  24   A. I know there was another meeting. I knew it was in 1993
  25     but I do not know the date.

   1   Q. The first one in 1992 had lasted how long?
   2   A. We had spent the whole day there.
   3   Q. You went up in the morning and came back --
   4   A. Yes.
   5   Q. Did you have any part in the 1993 visit to Birmingham?
   6   A. I did not go to Birmingham on that occasion.
   7   Q. Did any of your colleagues, as consultant anaesthetists,
   8     go?
   9   A. Dr Underwood went on that occasion.
  10   Q. Why she?
  11   A. I am sorry, could you repeat the question?
  12   Q. Why did she go? Why her? Why not one of the others?
  13   A. Again, I do not know the reason why it was Dr Underwood
  14     who specifically went.
  15   Q. Did you discuss it among yourselves, the anaesthetists,
  16     "Who is going to go this time?"
  17   A. I cannot recall such a discussion, but I imagine that we
  18     did.
  19   Q. Again, the focus of that visit was the arterial switch
  20     operation?
  21   A. Yes.
  22   Q. Because after, I think, a couple of good results, again
  23     sadly, some children died after that operation?
  24   A. I cannot now remember the specific --
  25   Q. I do not think you need to go into the specifics of it.

   1   A. Certainly the next two children who were operated on who
   2     had a neonatal switch following the visit in December
   3     1992 survived the procedure. I do remember that the
   4     next child did not, but I cannot remember how many more
   5     children were operated on after those three before
   6     Mr Dhasmana visited Birmingham again.
   7   Q. But the general picture was initial good results
   8     followed by again one or two or whatever poor outcomes
   9     in terms of death, hence another visit to Birmingham?
  10   A. That is my recollection.
  11   Q. By that time, had a pattern emerged of particular
  12     consultant anaesthetists working with Mr Dhasmana on
  13     this procedure?
  14   A. It is my recollection that at some stage we did have
  15     a discussion as to having a smaller number of
  16     anaesthetists involved, but again, I cannot remember the
  17     date when those discussions took place in relation to
  18     these particular procedures.
  19   Q. At the General Medical Council, Dr Bolsin was asked
  20     about which anaesthetist went to Birmingham when, and he
  21     accurately said that Sue Underwood and yourself went.
  22     Actually, he said it was Sue Underwood and yourself who
  23     went in July 1993, which was wrong, but certainly Sue
  24     Underwood went.
  25        He said:

   1        "It was those two because Ian [Dr Davies], myself
   2     and Chris [Dr Monk] had said that we did not want to
   3     undertake switch operations at the BRI or give the
   4     anaesthetic for them" -- I think he meant the latter and
   5     not the former.
   6        Is that your recollection, that by July 1993,
   7     Drs Davies, Bolsin and Monk had said they did not want
   8     to anaesthetise for switches?
   9   A. That is not my recollection.
  10   Q. Is it your recollection that at this time that result
  11     was achieved -- the result that Dr Bolsin referred to --
  12     by means of timetabling switches only for days when you
  13     or Dr Underwood were in theatre?
  14   A. At some stage during that time -- and again, I cannot
  15     say at what stage that was -- that timetabling was done,
  16     yes, so that Dr Underwood and I were the only ones doing
  17     switch procedures. I think that includes the older
  18     switches as well, so this might have been at a later
  19     stage after we had stopped doing neonatal switches.
  20     I cannot remember the time-scale.
  21   Q. We think that the neonatal switches ended in October
  22     1993. Is that your recollection?
  23   A. It is my recollection that the last child for a neonatal
  24     switch was operated on in October 1993.
  25   Q. Can you help us with this timetabling business any more,

   1     as to whether or not it was before or after that?
   2   A. I cannot. I am sorry, no.
   3   Q. Who would achieve this timetabling result? Who was in
   4     charge of saying "This case will be on [that day]",
   5     "This is Dr Masey's work"?
   6   A. I have for some considerable time, and including that
   7     time, been responsible for drawing up the rotas for the
   8     cardiac anaesthetists, for the theatre and for the
   9     on-call commitment. It is my recollection that if
  10     Mr Dhasmana wished to put a specific case on to have
  11     a specific anaesthetist anaesthetising that child, that
  12     he would look at that rota and timetable that particular
  13     child for a day when either myself or Dr Underwood, for
  14     instance, was there.
  15   Q. It is your recollection then, just to go back to this
  16     point, that at some stage there was a system whereby
  17     switches would be anaesthetised by you or Dr Underwood?
  18   A. It is my recollection that at some stage that decision
  19     was made.
  20   Q. And that system applied to neonatal switches and to
  21     non-neonatal switches?
  22   A. As I say, I cannot remember which that timetabling
  23     occurred. If it occurred after October 1993, then it
  24     would only have been for the non-neonatal switches, so
  25     I cannot help you on that.

   1   Q. That must follow, yes. The penultimate answer you gave
   2     about Mr Dhasmana slotting a patient into a day when you
   3     or Dr Underwood were working suggests that he was aware
   4     that the system was that you or Dr Underwood would
   5     anaesthetise for the switches?
   6   A. That certainly is the impression I have given, but --
   7   Q. In fact does it not go slightly further: that it was his
   8     choice? If he was coming along with a particular
   9     patient and he was the one who slotted it in for you or
  10     Dr Underwood, then he was specifically choosing one or
  11     other of you two?
  12   A. It would appear to be the case, yes.
  13   Q. Is it the case that at the time when this timetabling
  14     system emerged, the other anaesthetists had taken the
  15     view that they, for their part, did not want anything to
  16     do with anaesthetising switches?
  17   A. I think I would like to put it in a different way:
  18     I think there may have been some of my colleagues who
  19     would not want to be involved, but I also believe there
  20     were other colleagues who, rather than saying they did
  21     not want to be involved, had decided that it would be
  22     preferable to have a smaller number of anaesthetists who
  23     were involved.
  24        So rather than saying that they refused to
  25     anaesthetise these children, they had decided it would

   1     be better to have them being anaesthetised by a smaller
   2     number.
   3        So I think that is a difference in emphasis rather
   4     than saying they categorically refused, to saying,
   5     rather than refusing, that it would be preferable if
   6     a smaller number of anaesthetists were involved. They
   7     withdrew voluntarily rather than saying that they
   8     refused to do it.
   9   Q. But it was no accident that the smaller number comprised
  10     you and Dr Underwood as opposed to Dr Bolsin and
  11     Dr Davies, for example?
  12   A. I am sorry, I do not understand the question.
  13   Q. It is one thing to say there was to be a smaller number
  14     of anaesthetists, so you want to reduce the size of the
  15     available pool, but as it happens, when the pool was
  16     reduced, if that is what happened, the two that were
  17     left were you and Dr Underwood?
  18   A. Well, certainly the two who were left were myself and
  19     Dr Underwood.
  20   Q. I am suggesting it is perhaps not an accident that it
  21     was the two of you who were left for the switches,
  22     rather than, for example, Dr Bolsin and Dr Davies.
  23   A. I would agree that it was not an accident, but I would
  24     disagree as to whether it was due to an unwillingness on
  25     some of my colleagues to actually be involved with these

   1     procedures, as against a decision that it would be
   2     preferable if it was a smaller number.
   3   Q. I just want to press this a little bit. Were there some
   4     anaesthetists who were unwilling, so far as you were
   5     aware, to have anything to do with anaesthetising
   6     switches?
   7   A. It is my impression that some of my colleagues were less
   8     willing. I cannot recall a definitive decision for some
   9     of them to say they were definitely not willing, and
  10     I would have thought that it would be easier to ask
  11     those specific anaesthetists as to how they felt.
  12   Q. Which specific anaesthetists should we be asking?
  13   A. The ones I had the impression were less willing would be
  14     Dr Bolsin and Dr Davies.
  15   Q. That is from the anaesthetist's side. You explained in
  16     your earlier answer about Mr Dhasmana perhaps wanting to
  17     slot operations in for when you or Dr Underwood were
  18     available. Was it your impression that there were some
  19     of your anaesthetic colleagues with whom Mr Dhasmana was
  20     reluctant to work?
  21   A. It was my impression that he preferred working with
  22     myself and Dr Underwood.
  23   Q. Ahead of the others? You two were in a separate
  24     category, if you like?
  25   A. It was my impression that he preferred working with

   1     myself or Dr Underwood.
   2   MR MACLEAN: Dr Masey, may I just outline where I am going,
   3     and it may be that this is a convenient moment for
   4     a short break.
   5        I want to deal with some of the important meetings
   6     that took place throughout 1994 and 1995, and also with
   7     the question of the letter which was signed by the
   8     anaesthetists. We are going to come, and I hope
   9     reasonably swiftly after lunch, to the events of the
  10     early part of January 1995.
  11        I also want to show you very briefly some extracts
  12     from your log which you supplied to the Inquiry in
  13     respect of which you have made your first statement.
  14        Before we come to all of that, it may be
  15     appropriate now to have a short break.
  16   THE CHAIRMAN: Let us take lunch for half an hour,
  17     reconvening at 1.20.
  18   (12.50 pm)
  19            (Adjourned until 1.20 pm)
  20   (1.20 pm)
  21   MR MACLEAN: Now, Dr Masey, what I want to go to now is an
  22     extract from your logs. Your first statement, which we
  23     saw right at the very beginning this morning, which was
  24     WIT 270/1, dealt with the keeping of your logs.
  25   A. Yes.

   1   Q. And, as I understand it, you essentially logged in
   2     manually usually, as you say, on the day of surgery the
   3     paediatric cardiac cases that were done?
   4   A. All the cases that I anaesthetised, both paediatric and
   5     adult cardiac, and any other non-cardiac cases
   6     I anaesthetised.
   7   Q. Now I do not want to dwell on these logs for very long,
   8     but I just want to explore with you one or two changes
   9     in approach that are evident from them. Can we go first
  10     to WIT 270/18 on my screen only, first of all, please,
  11     and turn that round. I have checked this a couple of
  12     times. I think that is okay. Can we just highlight the
  13     bottom right-hand corner?
  14        What you have done here, this is the note at the
  15     end of the log, is it not?
  16   A. It is.
  17   Q. You write down all the cases that took place in the
  18     particular year and you write down the age of the child,
  19     which is the figure that is in brackets?
  20   A. Yes.
  21   Q. The procedure which was carried out on the child, for
  22     example switch, the fourth one from the bottom, and the
  23     initials of the surgeon carrying out the operation?
  24   A. Yes.
  25   Q. Then at the bottom of the page, this is from 1989, this

   1     one, so these operations would be for the calendar year
   2     1989, would they?
   3   A. They would be, yes.
   4   Q. You have written down:
   5        "Deaths: Paediatric: 12/49.
   6        Adult 8/109".
   7        First of all, why did you collate the number of
   8     deaths at the end of the log?
   9   A. For my own interest.
  10   Q. You do not divide them up in the summary there by
  11     procedure, but you would be able to see from looking at
  12     this summary page which procedures had led to death?
  13   A. I would, yes.
  14   Q. Now what I want to explore with you briefly, Dr Masey,
  15     if we go to WIT 270/20 on my screen only, first of all,
  16     and then can we go again to the bottom right-hand
  17     corner? This is for 1990, so the next year:
  18        "Cardiac cases: 140 bypasses -- adult 95
  19                       -- paediatric 45".
  20         So those would be all open heart operations
  21     requiring --
  22   A. If I have annotated as being bypasses, those would be
  23     classified as being open heart procedures, yes.
  24   Q. We see that, unlike the year before and I think any year
  25     before, you subdivided the paediatric cases into those

   1     under 1?
   2   A. Yes.
   3   Q. Why have you done that then?
   4   A. I do not know. I cannot recall why I decided -- you say
   5     this is 1990?
   6   Q. This is 1990, yes.
   7   A. I do not know why in 1990 I decided to start looking at
   8     the under 1s as a separate group.
   9   Q. If I showed you the top of the left-hand column, I could
  10     demonstrate that your writing says "Paediatrics 1990".
  11     Take it from me it is 1990. I was interested why you
  12     should adopt that particular subdivision at that
  13     particular time.
  14   A. I cannot recall.
  15   Q. You see below again, as you did the previous year, you
  16     have indicated the percentage of deaths. Again you
  17     subdivide the 13.3 per cent, which is total paediatric
  18     deaths under 1. It was 2 of 18, which is 11.1 per
  19     cent. You submitted these logs perfectly properly to
  20     the Inquiry. Had it ever struck you before that there
  21     was this change of approach between 1989 and 1990?
  22   A. It has only struck me very, very recently, when I was
  23     looking over information that I had sent to the Inquiry
  24     and I noticed myself that I had started to make this
  25     distinction.

   1   Q. I think we see the same distinction -- can we do the
   2     same procedure again, please -- at the bottom right-hand
   3     corner of WIT 270/22. This is 1991, the next year. It
   4     is the same set-up as the year before.
   5   A. Yes.
   6   Q. Again the subdivision "Paediatrics" and then those of
   7     under 1 year?
   8   A. Yes.
   9   Q. We touched on this a little earlier, you may remember,
  10     about why there should be a distinction of over 1 year
  11     and under 1 year. You will remember that Dr Bolsin's
  12     letter to Dr Roylance -- remember the one of July 1990
  13     -- in the penultimate paragraph specifically referred
  14     to under 1 year old children being, as he saw it, the
  15     problem?
  16   A. Yes.
  17   Q. Might there --
  18   A. I remember that letter.
  19   Q. Might there be a relationship between Dr Bolsin having
  20     highlighted under 1s in July 1990 and you in your logs
  21     for 1990 and 1991, but not for 10989, starting to draw
  22     the same distinction?
  23   A. That may well be the case, but I really cannot remember
  24     why I did it, and I was surprised when I looked at this
  25     data again very recently that I had done it. On looking

   1     at it, I could not recall the reason why I had chosen,
   2     as you say, for 1990 to separate the children. I really
   3     do not recall why I started to make this subdivision.
   4   Q. That was all I could think of. Maybe in due course
   5     subsequently you will have some call to recollect why
   6     you should have done this, in which case you will no
   7     doubt let the Inquiry know?
   8        Now there was one other slight change of approach
   9     in the log, and it is 1994. Can we go to WIT 270/24,
  10     please? This time if we could just highlight the first
  11     three or four lines on the left-hand side. This is just
  12     to highlight a point that recurs throughout this
  13     summary. The first case there, number 1, would appear
  14     to be a patient of 20 months?
  15   A. Yes.
  16   Q. Can you just read to me what the rest of the line says?
  17   A. The "2" with a little circle after it means "secundum".
  18     "ASD" is "atrioseptal defect". In brackets I have put
  19     "Down's", so the child had Down's Syndrome. I have
  20     also written "pulm hyper", which meant the child had
  21     pulmonary hypertension.
  22   Q. And then "JPD", Mr Dhasmana?
  23   A. Mr Dhasmana.
  24   Q. And, for example, the fourth one down, a child of -- it
  25     may be a child of six years?

   1   A. I think it is six, yes.
   2   Q. And again in brackets?
   3   A. It says "Down's Syndrome".
   4   Q. I will not weary you with the others, but there are
   5     other examples from the same summary of that year where
   6     you have written "Down's" again. I could not see in
   7     looking through these summaries you having done that for
   8     any previous year, particularly noting the Down's
   9     cases. You have been through the logs as well,
  10     I imagine?
  11   A. Yes. I have not got these logs as they are at the
  12     moment with the Inquiry. I had not noticed that. Again
  13     I cannot comment as to why I decided in 1994 to put that
  14     annotation in.
  15   Q. I am sure you will correct me if I turn out to be wrong
  16     and that you did, in fact, do that earlier, but it seems
  17     to the Inquiry at the moment at least that 1994 was the
  18     first time at which you did that?
  19   A. It was the first time.
  20   Q. Again if it occurs to you why, we would appreciate it if
  21     you would let us know.
  22        Can I look next at UBHT 61/91, please? Do you
  23     remember seeing this before? It is an extract from data
  24     put together by Dr Bolsin?
  25   A. I do not recall seeing this document before.

   1   Q. Can we go to page 98? What about this? This is related
   2     to VSDs.
   3   A. At some stage in 1993 I did see some preliminary data
   4     that I was shown quite by chance by Dr Black. I do not
   5     recall this as being the document, but I could not be
   6     certain --
   7   Q. The reason I show you --
   8   A. -- as to whether I have seen this document before.
   9   Q. I am sorry, Dr Masey. The reason I show you this one is
  10     that in your statement, as you may recall, WIT 270/14,
  11     you refer to seeing some figures by chance, as you put
  12     it, with Dr Black -- it is in the middle of the page.
  13   A. Yes.
  14   Q. Then it says in the middle of the screen:
  15        "Dr Black showed me ...", etc?
  16   A. Yes.
  17   Q. "There were also data on closure of ventricular septal
  18     defects but did I not study these closely"?
  19   A. That is what I recall from seeing the data.
  20   Q. That is why I showed you that page. Do you positively
  21     remember not seeing the data I just showed you or is it
  22     the case that it might have been what you saw and you
  23     simply now cannot recollect?
  24   A. It is my recollection that the format of the data that
  25     Dr Black showed me on that evening was not in that

   1     format, but that is my recollection. I would not like
   2     to say definitively whether it was that document or not.
   3   Q. You may by now know, Dr Masey, that some of the VSD data
   4     that Dr Bolsin produced turned out to be inaccurate?
   5   A. I do know that now, yes.
   6   Q. In that it recorded a significantly higher percentage of
   7     deaths than was, in fact, ultimately agreed to be the
   8     case?
   9   A. I do have that knowledge now.
  10   Q. And some of those who have given evidence to the enquiry
  11     who were shown VSD data by Dr Bolsin have told the
  12     Inquiry that they looked at it and essentially said to
  13     themselves: "This cannot be right". How did you react
  14     when you saw the VSD data, which, as you say in your
  15     statement, you did not study closely?
  16   A. I cannot recall what I thought specifically about the
  17     VSD data.
  18   Q. You are obviously aware now that Dr Bolsin produced
  19     a quantity of data about different procedures?
  20   A. Yes, I am aware of that.
  21   Q. Over a fairly lengthy period of time?
  22   A. I do not know over what length of time he was collecting
  23     the data.
  24   Q. To what extent -- I think the buzz word is "shared" --
  25     to what extent was this data shared with you?

   1   A. As I have said in my statement, which is now up on the
   2     screen, I believe it was the spring of 1993. It was
   3     some time in 1993. I was shown quite by chance some
   4     data by Dr Black.
   5   Q. Not by Dr Bolsin?
   6   A. Not by Dr Bolsin, by Dr Black, quite by chance. I was
   7     sitting in my office one late afternoon and he walked
   8     past the door and said: "Oh, I have these figures. You
   9     might be interested in them".
  10   Q. It was news to you at that stage that he had figures
  11     like that?
  12   A. It was complete news to me.
  13   Q. What was your attitude to discovering that these figures
  14     were in existence but had not hitherto been shared with
  15     you?
  16   A. I was surprised and disappointed that if Dr Bolsin felt
  17     that it was important to collect these figures, that he
  18     had not involved his cardiac anaesthetic colleagues in
  19     the collection of this data.
  20   Q. Was it your impression that somehow you were alone in
  21     being excluded from having this data shared with you as
  22     a Cardiac Consultant Anaesthetist or was it your
  23     impression that there were other Cardiac Consultant
  24     Anaesthetists who were similarly ignorant of the data?
  25   A. At that time none of my other Cardiac Anaesthetic

   1     Consultants had mentioned this to me, so either they
   2     were party to this knowledge and had not told me, or
   3     they were not party to that knowledge. I do not know
   4     which of the two it was.
   5   Q. Did you subsequently discover that Dr Underwood was
   6     similarly in the dark at this time?
   7   A. I cannot specifically recall that, but it was my
   8     impression at the time, certainly at the time of seeing
   9     this information, that none of my cardiac anaesthetic
  10     colleagues had intimated to me that this information was
  11     being collected.
  12   Q. When, if at all, was a collective discussion amongst
  13     anaesthetists themselves of the Bolsin data, if I can
  14     call it that, prior to these matters becoming public
  15     knowledge in the early part of 1995?
  16   A. As far as I am aware, Dr Bolsin never presented these to
  17     any meeting at which I was present.
  18   Q. What kind of meeting could he have done that at?
  19   A. He could have asked for a specific meeting to have been
  20     called amongst his cardiac anaesthetic colleagues if he
  21     wished to discuss it with us in the first instance. He
  22     could have asked it to be presented at an anaesthetic
  23     audit meeting, if he felt that was appropriate.
  24   Q. Those were the meetings that you told us earlier, the
  25     plenary sessions, that took place eight times a year; is

   1     that right?
   2   A. Yes.
   3   Q. Those are the ones you organised as audit co-ordinator?
   4   A. Yes.
   5   Q. Anything else?
   6   A. He could have approached the audit co-ordinator for
   7     cardiac surgery and asked him if he could have presented
   8     it at a cardiac surgery meeting.
   9   Q. Who was that? You said "the audit co-ordinator for
  10     cardiac surgery".
  11   A. I cannot remember at that time whether it was Mr Hutter
  12     or Mr Bryan.
  13   Q. It was one and then the other, was it?
  14   A. It was one and then the other. He could have asked to
  15     present this information at one of the more informal
  16     meetings that we held in people's homes in the evening.
  17   Q. Just to follow up on that last point, when I say it was
  18     one or the other, it was Mr Hutter and then Mr Bryan in
  19     that order, because Mr Bryan did not arrive until 1993.
  20   A. It was that order, yes.
  21   Q. So there were these various opportunities, as far as you
  22     can see, at which this data could have been shared with
  23     the other anaesthetists, none of which were taken?
  24   A. There were other opportunities which could have been
  25     taken which, as far as I am aware, Dr Bolsin did not

   1     take up the opportunity.
   2   Q. Why should that be, do you think?
   3   A. I do not know.
   4   Q. How would you have reacted if the data had been produced
   5     at, let us say, one of the anaesthetic audit meetings?
   6   A. I would have tried to ascertain the accuracy of the
   7     figures and I ascertained that the extent of the
   8     statistical analysis that he might have been presenting
   9     on them was robust.
  10   Q. And if there had come a time when you were satisfied
  11     about those matters, what do you think ought to have
  12     happened then?
  13   A. I think it would depend on which meeting Dr Bolsin had
  14     presented -- I mean, this is fairly hypothetical,
  15     because, as far as I am aware, he never did so.
  16   Q. But it may be important to ascertain your view as to
  17     where the appropriate channels, if you like, were. Let
  18     us assume that the anaesthetists had reached a stage
  19     where there was data presented that they were all fairly
  20     confident was "robust", whatever that means, such that
  21     they were all agreed that: "Yes, well, this looks as if
  22     this is a presentation of the picture". What do you
  23     think would have been the next stage?
  24   A. I would have felt the next stage would have been to have
  25     highlighted these concerns to our immediate managers,

   1     and/or the Clinical Director of Anaesthesia or the
   2     Clinical Director of Cardiac Services.
   3   Q. The former would have been Dr Monk at this time?
   4   A. In 1993?
   5   Q. 1993, or Dr Williams, whichever of the two it was at
   6     that time?
   7   A. I cannot remember. I think 1993 is Dr Monk.
   8   Q. Mr Langstaff tells me it was from January 1993. Now do
   9     you recall a meeting in the University Department of
  10     Cardiac Surgery seminar group in January 1994 attended
  11     by surgeons, cardiologists and anaesthetists?
  12   A. Not specifically.
  13   Q. Attended by Drs Davies, Pryn, Underwood, yourself,
  14     Bolsin, Mr Bishop, Mr Hutter and perhaps Drs Joffe and
  15     Martin?
  16   A. There were so many meetings throughout my time working
  17     at the BRI that I do not know to which meeting you are
  18     specifically referring.
  19   Q. This one may be more unusual than some of the others in
  20     that it has been suggested in particular yesterday
  21     I think by Dr Monk that the purpose of this meeting was
  22     to give an opportunity for the surgeons to present the
  23     paediatric data and an opportunity for Dr Bolsin to
  24     raise his data, so that afterwards the two groups or
  25     parties, as he put it, could get together and attempt to

   1     resolve their differences. So this was a meeting, so
   2     Dr Monk has it, which was specifically called for the
   3     purpose of information passing from surgeons to
   4     anaesthetists and vice versa.
   5   A. Can you tell me the date of that meeting?
   6   Q. 20th January 1994, Level 7 in the University Department
   7     of Cardiac Surgery?
   8   A. I do not have a specific recollection of the meeting.
   9   Q. Dr Monk's evidence was, I think, that Mr Wisheart
  10     presented data on either a blackboard or whiteboard -- a
  11     whiteboard, I think. Does that ring a bell?
  12   A. I attended many meetings throughout my time where
  13     results were produced, but I am sorry. I have no
  14     specific recollection of that particular meeting, those
  15     particular presentations of results.
  16   Q. Do you remember Dr Pryn ever presenting or attempting to
  17     present data on paediatric cardiac outcomes to a meeting
  18     of the anaesthetists and the surgeons?
  19   A. No, I do not.
  20   Q. You do not recall at this meeting that I am talking
  21     about and any others, Dr Bolsin presenting data to the
  22     assembled gathering of anaesthetists, surgeons,
  23     cardiologists?
  24   A. I do not recall Dr Bolsin ever presenting his data at
  25     such a meeting.

   1   Q. Is that because it is a long time ago and your memory
   2     may have faded, or are you clear in your recollection
   3     that there never was a meeting you were at where that
   4     was done by Dr Bolsin?
   5   A. I would say it is clear in my recollection that I did
   6     not ever attend a meeting where Dr Bolsin presented his
   7     data.
   8   Q. Can we have UBHT 61/7, please? You recognise this, do
   9     you?
  10   A. If I could read the letter, because there were a number
  11     of drafts. Yes, I do recognise the letter because all
  12     our signatures are on it.
  13   Q. This is a version of the so-called anaesthetists'
  14     letter. If we scan down the page, please, this one has
  15     five signatures on it.
  16   A. Yes.
  17   Q. Including yours?
  18   A. Yes.
  19   Q. So this is the one that you signed up to. Can we just
  20     examine it a little? Can we look at the text of the
  21     letter, please:
  22        "We wish to express our concern at the arterial
  23     switch programme currently being undertaken in this
  24     hospital."
  25        Pausing there, at that time there was only

   1     a non-neonatal switch programme being undertaken in the
   2     hospital, was there not?
   3   A. The last neonatal switch had been performed in October
   4     1993, so at this stage in June 1994 the only switches we
   5     had done since October 1993 had been in the non-neonatal
   6     age group.
   7   Q. As far as you are aware, had potentially neonatal
   8     switches been transferred elsewhere or whatever between
   9     October 1993 and June 1994?
  10   A. I do not know whether any children had been transferred
  11     anywhere else.
  12   Q. Was it your impression that there was a moratorium at
  13     this time on carrying out neonatal switches?
  14   A. I had never been aware of a definitive decision being
  15     made that no more neonatal switches would be performed.
  16   Q. What about a tentative decision?
  17   A. I do not think I was aware even of a tentative decision.
  18   Q. Were you aware of the issue being floated?
  19   A. All I was aware of -- and I became aware of that earlier
  20     than June 1994 -- was that it was some time since we had
  21     done any neonatal switch, but I did not know the reasons
  22     why we had not performed any.
  23   Q. Let us look at the next sentence:
  24        "The mortality for this operation is apparently
  25     high, particularly for those operations undertaken in

   1     the neonatal period, but the recent death of a 14 month
   2     old child following the arterial switch procedure must
   3     now lead to an open and thorough review of the results
   4     so far".
   5        When you signed this letter, did you agree with
   6     that sentence?
   7   A. I agreed with the sentence. This was the sentence that
   8     I had asked to be changed from the first draft. I had
   9     seen where the word "apparently" did not occur.
  10   Q. Perhaps we can split the screen and have a look at
  11     GMC 4/64. Just blow up the text. This version on the
  12     right-hand side referring to "increasing concern". Do
  13     you see that in the first line?
  14   A. Yes.
  15   Q. Did you ever see a letter before now -- I appreciate it
  16     is a long time ago -- that used the term "increasing
  17     concern" rather than just the term "concern"?
  18   A. I do not know. I know I did see a draft of a letter the
  19     wording of which I was unhappy with. I do not know if
  20     it is this draft or whether there is another draft where
  21     some words or some phrases had already been changed.
  22   Q. Look at the second line, please, Dr Masey, the sentence
  23     beginning:
  24        "The mortality for this operation is apparently
  25     unacceptably high".

   1        The version that you signed deletes the word
   2     "unacceptably"?
   3   A. Yes. I have not seen the letter on the left-hand side
   4     of the screen for some considerable time, but it would
   5     now appear, seeing the two letters side by side, it is
   6     not the word "apparently" that I wished to have added
   7     but the word "unacceptably" that I wished to have
   8     removed.
   9   Q. Having seen these letters now for the first time in
  10     a long time, you are pretty clear that is the change
  11     that you had made?
  12   A. To say I am clear it is the change I made, certainly
  13     from the point of view of what the second letter is
  14     saying, it would appear that it is the change that
  15     I asked to be made. It is the emphasis of the first
  16     letter that I was unable to sign.
  17   Q. Can we see all of the left-hand letter, please? Do you
  18     see that that version is only signed by Dr Davies. Now
  19     if we go to UBHT 61/6, this version is signed by four
  20     consultant anaesthetists, but not you or Dr Underwood.
  21     So would it appear to be the case that the two of you
  22     were the last two to sign the letter?
  23   A. Is there any change in the wording of this letter from
  24     the one --
  25   Q. No, there is not. This is the same version as the one

   1     I showed you with your signature on. The one I showed
   2     you with your signature on is signed by everybody except
   3     for Dr Baskett, and this one is signed by everybody
   4     apart from you and Dr Underwood.
   5        It may be that not much turns on all of this, but
   6     can we go back to 61/7, which is the one that you did
   7     sign? I read to you that second sentence and asked you
   8     if you agreed with it. Let us look at the next
   9     sentence:
  10        "It is our belief that this review should be
  11     confidential and take place between all the cardiac
  12     anaesthetists, all the cardiac surgeons, all the
  13     paediatric cardiologists and the Director of Cardiac
  14     Services. This responsible approach to our clinical
  15     practice would defuse many of the criticisms of the
  16     programme in this institution expressed privately and
  17     publicly".
  18        What criticisms were you aware of that had been
  19     expressed publicly at this time, June 1994?
  20   A. In June 1994 -- in 1992 there had been an article in
  21     "Private Eye", which had reported on the results of
  22     paediatric cardiac surgery, and so some figures about
  23     the results of paediatric cardiac surgery were in the
  24     public domain.
  25   Q. You in your statement refer to the "Private Eye"

   1     articles and you say the publication of those "Private
   2     Eye" articles, so far as you were aware, had a chilling
   3     effect on the willingness of the surgeons to share
   4     information?
   5   A. That was my impression.
   6   Q. Now that letter was sent to Dr Monk. It is addressed to
   7     Dr Monk; yes?
   8   A. Yes.
   9   Q. Who sent it or took it to Dr Monk? Do you know?
  10   A. I do not know who actually took it to Dr Monk.
  11   Q. It was not you?
  12   A. It was not me.
  13   Q. Were you ever aware of a suggestion that this letter or
  14     something very similar was going to be written to
  15     Dr Roylance rather than to Dr Monk?
  16   A. Having read some documents recently, it has reminded me
  17     that, yes, it was initially thought that this letter
  18     would be addressed to Dr Roylance.
  19   Q. And signed by Dr Monk in addition to the others?
  20   A. And signed by Dr Monk.
  21   Q. Why should that plan have changed? Why not simply write
  22     to the Chief Executive and be done with it?
  23   A. I do not know what the reasons were. I cannot remember
  24     what the reasons were why it was felt to be preferable
  25     to direct this letter through the Clinical Director of

   1     Anaesthesia.
   2   Q. Now the letter concerns only the arterial switch
   3     procedure?
   4   A. Yes.
   5   Q. Was there ever any suggestion that Dr Monk should be
   6     written to about any other procedure in addition?
   7   A. Not that I can recall.
   8   Q. What did you, for your part, expect Dr Monk to do with
   9     this letter when he got it? What was its purpose?
  10   A. Its purpose, as far as I was concerned, was -- as the
  11     last line says, talking about the criticisms of the
  12     programme -- to actually make this into a much more open
  13     and transparent mechanism for looking at any criticisms
  14     and trying to gain more information to see whether there
  15     was any basis in these criticisms.
  16   Q. What the letter is calling for is an open and thorough
  17     review?
  18   A. Yes.
  19   Q. That is what it wants to achieve?
  20   A. Yes.
  21   Q. Who was going, as far as you were concerned, to set up
  22     the review? Was Dr Monk going to do it, or was he going
  23     to have to have the assistance of others to set up the
  24     open and thorough review?
  25   A. I do not know how Dr Monk hoped to achieve having an

   1     open and thorough review.
   2   Q. Was it your impression that Dr Monk had it in his power
   3     to establish an open and thorough review involving
   4     anaesthetists, surgeons, cardiologists and the Director
   5     of Cardiac Services?
   6   A. I believe that anybody can call a meeting to discuss
   7     issues, and it is open to anybody who is asked to go to
   8     that meeting to choose whether he or she attends or not.
   9   Q. Calling a meeting is one thing; making it happen is
  10     another.
  11   A. Calling a meeting is one thing. Whether an individual
  12     attends is going to be up to that individual as to
  13     whether he or she chooses to go to the meeting or
  14     actually is able to go to the meeting.
  15   Q. Did you expect Dr Monk to take the letter to
  16     Dr Roylance, or send it to him?
  17   A. I would not have thought as a Clinical Director of
  18     Anaesthesia that that would have been his first line
  19     of --
  20   Q. What would his first line have been?
  21   A. If I had been Clinical Director of Anaesthesia and had
  22     been sent that letter, I would have taken the letter to
  23     the Director of Cardiac Services in the first instance,
  24     if I had been Clinical Director. I cannot answer as to
  25     what Dr Monk felt was the appropriate channel through

   1     which to take that letter.
   2   Q. If I remember my Dramatis Personae, that would be
   3     Professor Vann Jones?
   4   A. In June 1994 I cannot recall.
   5   Q. I think it was. A new Directorate of Cardiac Services
   6     had recently been established and he was the Clinical
   7     Director.
   8        Did you have any discussions with Dr Monk about
   9     this letter after it had, as far as you were concerned,
  10     gone to him?
  11   A. I cannot recall any specific discussions.
  12   Q. Did the open and thorough review take place in the wake
  13     of the letter?
  14   A. Not to my recollection. We did not review all the
  15     switch data until January 1995.
  16   Q. Was that because Dr Monk did not do anything about this
  17     letter, or was it because others did not play a role?
  18   A. I do not know the answer to that.
  19   Q. Did you ever chase up Dr Monk and say: "Look, here,
  20     Chris. What has happened to the open and thorough
  21     review we asked for?"
  22   A. I cannot recall specifically but that is the sort of
  23     conversation that could easily have taken place in
  24     a corridor or during an operating list. I cannot recall
  25     anything specific.

   1   Q. Did you ever discuss the letter or the concerns that
   2     underlie the letter specifically with Mr Dhasmana?
   3   A. I cannot recall discussing the letter specifically with
   4     Mr Dhasmana.
   5   Q. Or the concerns which underlay it?
   6   A. I cannot recall having a specific discussion with
   7     Mr Dhasmana about results, although we would have many
   8     conversations about results as cases were done.
   9   Q. On a case-by-case basis?
  10   A. Almost on a case-by-case basis, yes.
  11   Q. In terms of the joined-up thinking of seeing how things
  12     were going, do you remember any discussions with him
  13     about this time?
  14   A. In relation specifically to arterial switches?
  15   Q. In relation to arterial switches.
  16   A. No specific meetings, although certainly with the
  17     neonatal arterial switch programme again it was probably
  18     on a case-by-case basis, but I think all of us were
  19     aware on a case-by-case basis what the outcomes had
  20     been.
  21   Q. There would not be any discussion with neonatal switches
  22     at this time, because there were not any neonatal
  23     switches?
  24   A. Not at this time. I agree.
  25   Q. Now I think it is right -- tell me if you know to the

   1     contrary or tell me if you do not know -- that after
   2     this letter was written, but before the operation on
   3     Joshua Loveday in January 1995, Mr Dhasmana performed
   4     a non-neonatal switch operation?
   5   A. I cannot recall that specifically, but it would not be
   6     surprising in that timescale that he would operate on
   7     such a case.
   8   Q. Anaesthetised by Dr Underwood?
   9   A. I do not know.
  10   Q. If I suggested that there was a non-neonatal switch
  11     operation after this letter was written but before
  12     Joshua Loveday's operation, would it surprise you that
  13     Dr Underwood should have anaesthetised for that
  14     operation, she being a signatory of this letter?
  15   A. I cannot answer for Dr Underwood.
  16   Q. All right. If you had been programmed to be the
  17     anaesthetist for that non-neonatal switch operation
  18     after this letter but before Joshua Loveday, would you
  19     have done that?
  20   A. If there was no particular reason for that individual
  21     child not to, yes, I believe I would have anaesthetised
  22     the child.
  23   Q. Notwithstanding that in June 1994 it was your opinion
  24     that the time had come for an open and thorough review
  25     of the results so far?

   1   A. I was perfectly happy to sign this letter, because this
   2     was the first time that I felt that Dr Bolsin had asked
   3     us as a group of anaesthetists to act in concert with
   4     him to look at figures. I was not as concerned with the
   5     outcome from non-neonatal switches as it would appear
   6     Dr Bolsin was. My personal experience and my personal
   7     recollection of these operations was such that I did not
   8     hold the level of concern that Dr Bolsin appears to have
   9     done. I considered from my own experience and having
  10     been involved from 1988 with the non-neonatal switch
  11     procedure that the results of the non-neonatal switch
  12     procedures were acceptable, and therefore in that
  13     context I would have been happy, without having had this
  14     review, to have continued and anaesthetised the child.
  15   Q. So the review that you thought the results must now lead
  16     to was not a review which was such that it being carried
  17     out was a pre-condition to doing any more non-neonatal
  18     switches in the meantime?
  19   A. As far as I was personally concerned.
  20   Q. That was your position?
  21   A. That was my position.
  22   Q. And as far as you understood it, that would be
  23     Dr Underwood's position, otherwise would have been
  24     strange for her to have --
  25   A. You would have to ask Dr Underwood.

   1   Q. Do you recall the meeting at Dr Joffe's house in
   2     December 1994?
   3   A. I do.
   4   Q. On 8th December specifically?
   5   A. I do not know what the actual date was, but I do
   6     remember a meeting in December 1994 at Dr Joffe's house.
   7   Q. Do you remember that the attendees were Mr Bishop,
   8     Mr Dhasmana, Drs Joffe, Hayes, Martin, Pryn, yourself
   9     and perhaps Dr Underwood?
  10   A. I cannot remember the precise make-up of the people who
  11     were at the meeting.
  12   Q. And perhaps Dr Monk?
  13   A. I cannot recall whether Dr Monk was there or not.
  14   Q. Do you remember that Dr Bolsin was not there?
  15   A. I would not be able to say specifically. I would not be
  16     able to say definitively that Dr Bolsin was not there.
  17   Q. And I think it has been suggested that Dr Wilde was
  18     there?
  19   A. It has been suggested Dr Wilde was there.
  20   Q. Again you cannot specifically remember?
  21   A. I cannot specifically remember.
  22   Q. What was the subject of that meeting?
  23   A. I have very little recollection of the subject-matter of
  24     that meeting. All I can recall is more what I would
  25     describe as the tenor of the meeting.

   1   Q. Which was what?
   2   A. That there was a certain amount of unhappiness or even
   3     sadness at the amount of publicity that we appeared to
   4     be receiving, and it was my feeling that people at the
   5     meeting felt saddened and stressed by the situation we
   6     found ourselves to be in, being very much put into the
   7     public limelight.
   8   Q. Was it a discussion about a particular procedure or was
   9     it a general discussion about where the unit was?
  10   A. I cannot recollect the specific discussion at all.
  11   Q. Do you remember if at this time you were aware that
  12     Joshua Loveday -- maybe not specifically the name of the
  13     patient -- a patient was in the pipeline, if you like,
  14     for a non-neonatal switch?
  15   A. I was not aware at that stage that there was a child in
  16     the pipeline.
  17   Q. Do you remember if there was data produced at the
  18     meeting?
  19   A. I do not remember data produced at the meeting.
  20   Q. Now either at this meeting or generally you say there
  21     had been publicity and a feeling of sadness and so on.
  22     Was that relating at least in part to the switch series?
  23   A. I think all of us had hoped that we would be able to
  24     move forward in our paediatric cardiac practice by doing
  25     the neonatal switch procedure, and I was personally

   1     saddened when it became apparent that it was
   2     inappropriate for us at that time to continue with it,
   3     that we had not been able, as a team, to overcome
   4     problems with the neonatal switches.
   5   Q. What was Mr Dhasmana's attitude to his doing further
   6     switches, whether neonates or non-neonates, by November
   7     1994?
   8   A. I do not have any recollection of having discussions
   9     with Mr Dhasmana as to whether he felt he wished to
  10     carry on doing switches.
  11   Q. Mr Dhasmana said at the GMC that you and Dr Underwood
  12     were -- "quite certain" I think were his words -- that
  13     there were good results by that time in older switches.
  14   A. My recollection was that the results in the older
  15     switches were acceptable, yes, were within acceptable --
  16     were acceptable, yes.
  17   Q. In June 1994 you signed a letter saying:
  18        "The mortality for this operation is apparently
  19     high particularly for those operations undertaken in the
  20     neonatal period but ...", and so on, "... must now lead
  21     to an open and thorough review."
  22   A. Well, there is no doubt that for the operations
  23     undertaken in the neonatal period the mortality was very
  24     high indeed. I would not dispute that.
  25   Q. But it is the non-neonates that we are looking at at the

   1     moment?
   2   A. It is the non-neonates we are looking at.
   3   Q. This letter is concerned about those too?
   4   A. This letter is concerned about those too. As I have
   5     said, the reason that I signed this letter was to try to
   6     have a much more transparent discussion of perceived
   7     problems.
   8        As I have stated, I did not personally from my
   9     experience feel that we had a particular problem with
  10     the non-neonatal switches that should make us stop doing
  11     the non-neonatal switch programme, but I signed the
  12     letter because I felt that this was the first time that
  13     Dr Bolsin had asked us to do something as a group, which
  14     I had been asking him to do since the first letter he
  15     had written to Dr Roylance in 1990, and, secondly,
  16     I felt that if a review was undertaken, my perception in
  17     relation to the non-neonatal switches would be what
  18     would be found if the figures were looked at. That is
  19     why I would have been perfectly prepared to continue to
  20     anaesthetise children for non-neonatal switches.
  21   Q. I do not know whether you were aware of a dinner that
  22     took place between Drs Monk, Bolsin, Mr Wisheart and
  23     Professor Angelini in April 1994?
  24   A. Again, having read about it recently, it has reminded me
  25     that I probably did know about it around that time.

   1   Q. If we assume for the moment that you knew about it about
   2     that time and if we assume for the moment there was
   3     a meeting in January 1994 which was assembled for the
   4     purpose that Dr Monk outlined yesterday, namely for
   5     information to be passed from one side to the other, but
   6     that no data was produced by Dr Bolsin at such
   7     a meeting, would that not rather suggest that the time
   8     had rather gone past when an open and thorough review
   9     was capable of being carried out by those involved
  10     themselves rather than by some external force coming in
  11     to look at the review? Did it not appear as if the
  12     anaesthetists and the surgeons most centrally concerned
  13     would be incapable of talking to one another by the
  14     summer of 1994?
  15   A. I cannot answer that. I --
  16   Q. You see the point I am driving at?
  17   A. I think I see the point you are getting at.
  18   Q. There had been a meeting for one side to talk to the
  19     other, and on Dr Monk's version Dr Bolsin did not
  20     produce any data, and a dinner, which the Panel have
  21     heard evidence did not achieve its purpose. Yet, what
  22     is suggested even now is a review carried out
  23     internally, if you like. Maybe you cannot help us with
  24     that?
  25   A. I feel I cannot help you on that.

   1   Q. You discovered in due course that there was
   2     a non-neonatal switch programmed for January 1995, did
   3     you?
   4   A. Yes.
   5   Q. It turned out to be Joshua Loveday?
   6   A. Yes.
   7   Q. You attended a meeting the night before that operation
   8     took place?
   9   A. I did.
  10   Q. At whose instigation was that meeting held?
  11   A. I cannot recall at whose instigation that meeting was
  12     held.
  13   Q. What did you understand the powers of the meeting to
  14     be? What was its jurisdiction? Was it going to decide
  15     whether the operation took place or what was its role?
  16   A. Its role was to discuss as to whether it was appropriate
  17     for the operation to take place the following day.
  18   Q. Can we have a look, please -- this is one of the last
  19     documents we are going to look at -- at UBHT 54/11?
  20     This is Dr Monk's note of the meeting. There was
  21     another note of the meeting produced by Dr Martin. Did
  22     you ever see either note of the meeting about the time
  23     we are concerned with contemporaneously?
  24   A. I have seen copies of this document before, yes.
  25   Q. Can we go to the second page of this document, please?

   1     Do you see paragraph 4? Could you just read that to
   2     yourself? ( Pause.) Have you read that paragraph?
   3   A. I am having difficulty with the last sentence.
   4   Q. "A meeting was held by Mr Wisheart, Dr Bolsin and
   5     Dr Monk regarding the representation of the Trust by
   6     Dr Bolsin and the inappropriate channels of
   7     communication that the Department of Health were using".
   8        I do not want to focus on that for the moment. I
   9     am interested more in the earlier part of the paragraph,
  10     which would appear to suggest in the second line that
  11     the decision to carry out the operation was taken by
  12     three men: Mr Wisheart, Mr Dhasmana and Dr Monk in
  13     a side meeting off the main meeting?
  14   A. I was not at that side meeting, so I cannot comment on
  15     that.
  16   Q. No, I appreciate that. It may be what Dr Monk is
  17     getting at is that in the main meeting those three,
  18     Mr Dhasmana, Mr Wisheart and Dr Martin, were the ones
  19     who discussed the need for the operation and decided
  20     that the condition merited an immediate intervention.
  21     To what extent were the other people at the meeting
  22     having an input into the decision that the operation
  23     ought to be carried out in Bristol the next day?
  24   A. What I recall of the meeting is that the meeting started
  25     with a presentation of all the figures for non-neonatal

   1     switch procedures, both figures that Mr Dhasmana
   2     produced himself and figures that Dr Pryn had brought
   3     with him as well.
   4   Q. Can you just pause there and I will show them.
   5     GMC 16/38: there were some very minor amendments made
   6     to these figures but are these Dr Pryn's figures.
   7   A. This is the document I recall Dr Pryn bringing with him,
   8     yes.
   9   Q. If we scan down just a little, the second table is
  10     Dr Dhasmana's mortality for the switches, is it not?
  11   A. It does appear to be, yes.
  12   Q. Over 1 year, 13 per cent, middle column, between 1990
  13     and 1994, 1 out of 8, 13 per cent?
  14   A. Yes, 13 per cent.
  15   Q. So this is the data that was at the meeting?
  16   A. Yes.
  17   Q. Tell me then about the discussion around those figures.
  18   A. These figures were discussed and also compared to the
  19     most recent cardiac surgical register, and the figure is
  20     not there -- I do not believe the figure is there, so
  21     I cannot remember exactly what the figure was, but there
  22     was a unanimous agreement, having discussed these
  23     figures, that there was nothing in the figures to
  24     suggest that Mr Dhasmana should not go ahead and perform
  25     the operation the following day.

   1   Q. By the time that unanimous decision had been reached,
   2     had anyone left the meeting?
   3   A. Dr Pryn left the meeting at some stage. I do not know
   4     whether it was before or after that unanimous decision
   5     had been made.
   6   Q. Had anyone else left the meeting?
   7   A. Not that I can recall.
   8   Q. Was Dr Bolsin still there?
   9   A. Dr Bolsin was still there.
  10   Q. What was his attitude?
  11   A. Dr Bolsin -- I said it was unanimous -- agreed there was
  12     nothing in the figures that should preclude Mr Dhasmana
  13     going ahead with the operation the following day.
  14   Q. Did he suggest there was a qualification as to whether
  15     or not the operation should take place?
  16   A. He did express a qualification.
  17   Q. Which was what?
  18   A. Which was what could be termed a political
  19     qualification, that if the child was operated on the
  20     following day and the child died, that politically it
  21     would be an unwise move therefore to go ahead with the
  22     operation, which is known to be high risk.
  23   Q. Did he suggest a successful operation would not do much
  24     beneficially to the figures but an unsuccessful outcome
  25     would be likely to have significant repercussions?

   1   A. Looking purely at the figures, I do recall comments
   2     being made on how would the figures change, depending on
   3     whether the child survived or died. My recollection is
   4     that it would not make much difference to the figures
   5     either way, to the actual figures.
   6   Q. The other side of the coin that Dr Bolsin presented was,
   7     was it not, that an unsuccessful outcome would be likely
   8     to have significant repercussions?
   9   A. Yes.
  10   Q. There was an unsuccessful outcome?
  11   A. Yes.
  12   Q. There were significant repercussions?
  13   A. Yes.
  14   Q. Was the question that was asked at the meeting whether
  15     or not there was a clinical reason to defer the
  16     operation? Was that the essence of it?
  17   A. I find this question difficult, because with information
  18     that I now have, I do know that those conversations took
  19     place at this meeting, but I cannot remember whether it
  20     is my recollection from hearing it at the meetings or in
  21     subsequent conversations that I became aware that these
  22     conversations had taken place.
  23   Q. What was your understanding of the urgency of Joshua
  24     Loveday's condition?
  25   A. As I say, I find it difficult, because I now know that

   1     this was discussed at the meeting, but I am not clear in
   2     my own mind whether I had formed an impression at the
   3     meeting as to the urgency of the operation.
   4   Q. Were the questions these: what is the child's
   5     condition? What operation does this child need? When
   6     does he need it? Where can that operation best be
   7     performed?
   8   A. Subsequent to this meeting, I do now have those as part
   9     of my body of knowledge, but I do not recollect in
  10     detail those conversations at that meeting.
  11   Q. Do you remember what Dr Martin said about the urgency of
  12     the operation?
  13   A. Again I do not recall specifically what Dr Martin said.
  14     As I say, I do have a body of knowledge about that,
  15     which I do not know whether I received by taking it in
  16     at that meeting or by reading documents subsequently or
  17     discussing the case with my colleagues subsequently.
  18   Q. Do you remember whether the point came up as to whether
  19     or not Joshua Loveday could be moved to another hospital
  20     to have his operation?
  21   A. Again that is part of my body of knowledge now, but
  22     again I am not sure whether I specifically took that
  23     information in at that meeting or whether it became part
  24     of my knowledge on subsequent discussion with colleagues
  25     and reading the minutes of the meeting.

   1   Q. Dr Monk recalled yesterday that that point had come up.
   2     Have you any reason to take issue with that
   3     recollection?
   4   A. I have no reason to take issue with that at all.
   5   Q. In due course the operation took place. Did you have
   6     a discussion with Sister Herborn about who might be the
   7     anaesthetic nurse for the operation?
   8   A. I do not recall having a discussion with Sister Herborn
   9     about who would be the anaesthetic nurse.
  10   Q. Do you remember who the anaesthetic nurse was for the
  11     operation? I appreciate you did not anaesthetise the
  12     patient.
  13   A. No, I did not anaesthetise the patient. I do not know
  14     or cannot remember who the anaesthetic assistant was.
  15   Q. Do you remember whether you had a conversation with Kay
  16     Armstrong and Sister Herborn when they were reluctant --
  17     Sister Herborn was reluctant that Kay Armstrong should
  18     be the anaesthetic nurse, and you pointed out that
  19     Alison Reed was on a day off on the day of the operation
  20     and perhaps her shift could be changed so that she was
  21     the anaesthetic nurse?
  22   A. It was my recollection that Alison Reed was asked to
  23     come in to be the scrub nurse, not the anaesthetic
  24     assistant, but please correct me if I have remembered
  25     this incorrectly.

   1   Q. I think that may be right, Dr Masey. Yes, that is
   2     right. Kay Armstrong ultimately was the anaesthetic
   3     nurse for the operation.
   4   A. I do not know that, but if you tell me that is the case
   5      ...
   6   Q. Did you ever remark in Kay Armstrong's hearing that with
   7     two anaesthetists present, it was not actually necessary
   8     to have an anaesthetic assistant in the operation?
   9   A. I think it is extremely unlikely that I would have made
  10     such a comment, because it has always been recognised
  11     that an anaesthetic assistant is necessary. So I think
  12     it is unlikely that I would have suggested that we
  13     should proceed without an anaesthetic assistant.
  14   Q. It would be unusual to proceed without an anaesthetic
  15     assistant?
  16   A. At that stage it would be unheard of to proceed without
  17     an anaesthetic assistant.
  18   Q. It would be particularly unusual or odd to have no
  19     anaesthetic assistant in a situation where the operation
  20     was clearly very complex and had been the subject of
  21     such lengthy debate among consultants?
  22   A. By January 1995, as I say, it would be unheard of to
  23     proceed with any operation without an anaesthetic
  24     assistant.
  25   Q. So if it was suggested that you did make such a comment,

   1     you would find that very strange indeed?
   2   A. I would.
   3   Q. Now I just want to deal with a couple more points,
   4     Dr Masey. You have been very patient with me. I want
   5     to take you, please, somewhere else entirely, to WIT
   6     285/9. This is a statement from Mr Willis. Now
   7     I imagine that you will have seen this statement as part
   8     of the so-called rebuttal process?
   9   A. I have seen this statement.
  10   Q. What I want to do is to invite you, please, to read
  11     paragraph 20 and, when you have read it, scan down to
  12     21.
  13   A. Can I see the previous page? Does 20 start on the
  14     previous page?
  15   Q. Can we go back? Read as much of 20 as you like.
  16   A. If I could have the next page.
  17   Q. Yes.
  18   A. Thank you. Let me scan down so I can see 21, please.
  19     Thank you.
  20   Q. Now the point about 21 is -- I do not know whether you
  21     recall or not -- as it turns out, you were the
  22     anaesthetist. Do you remember that?
  23   A. Yes.
  24   Q. Do you know why it would seem at short notice you became
  25     the anaesthetist for that child and not Dr Underwood?

   1   A. I can say what I believe has happened here is a case of
   2     mistaken identity. Dr Underwood did not see the
   3     Willises on the night before the operation and
   4     Dr Underwood was never planned to be the anaesthetist
   5     for Daniel on that day and, in fact, Dr Underwood was on
   6     annual leave that week.
   7   Q. Who saw the Willises the night before the operation?
   8   A. Without looking at the anaesthetic record, to which I am
   9     not party, I cannot say for certain who saw the child
  10     pre-operatively. All I can say is I know I was at the
  11     hospital on the preceding day. It is my normal practice
  12     to see my patients pre-operatively. I cannot -- I think
  13     it is extremely unlikely that I did not go and see this
  14     child and one or other or both parents the night before
  15     the operation.
  16   Q. How many female Consultant Cardia Anaesthetists were
  17     there working in BRI at this time?
  18   A. There were two female Paediatric Cardiac Anaesthetists
  19     at this time.
  20   Q. You and Dr Underwood?
  21   A. Myself and Dr Underwood.
  22   Q. And she was away?
  23   A. She was away. Can I please add to that?
  24   Q. Do.
  25   A. We also do have trainee anaesthetists, and having looked

   1     back at my rotas for that time in May 1993, we did
   2     actually have two female trainee anaesthetists doing
   3     their cardiac surgery attachments at that time. Both of
   4     them had children and may have had children who were
   5     five months of age. All I can suggest, as I say,
   6     without looking at the anaesthetic chart, which might
   7     give me more information, is that what happened is one
   8     of the anaesthetic trainees also went to see the parents
   9     that night, because it was envisaged that she would be
  10     in the operating theatre with me the following day, and
  11     it is this anaesthetist that has been confused with
  12     Dr Underwood.
  13   Q. If you look up the page again, please, you see in the
  14     fourth line the reference to:
  15        "She apologised ...", and so on.
  16   A. Yes.
  17   Q. Do you recollect such an incident ever involving you?
  18   A. I could not ever say that I was hormonal because I had
  19     had a child, because I have no children.
  20   Q. That perhaps deals with that particular sentence.
  21        Dr Masey, there is only one more point before
  22     I finish my questions, and I said earlier I would come
  23     back to it and I am very happy to do so. Can I have on
  24     the screen, please, WIT 270/26? We saw earlier for
  25     other purposes of the Inquiry a letter from Dr Coates,

   1     who was a Clinical Director, to you; I am sure you
   2     recall. This is a letter a little later, about eighteen
   3     months later, slightly more, 7th November 1997, from
   4     Mr Pawade to Dr Coates. It says:
   5        "Dear David,
   6        Further to our telephone conversation, I should
   7     like" -- presumably the word "to" is missing --
   8     "reiterate that I have never accused Dr Sally Masey of
   9     clinical incompetence. I am perfectly happy for her to
  10     look after my adult congenital/acquired cases".
  11        By that time Mr Pawade would have established
  12     a relationship with his Paediatric Cardiac
  13     Anaesthetists, would he?
  14   A. He was working with the Paediatric Cardiac Anaesthetists
  15     at the Children's Hospital, yes.
  16   Q. And had been for two years by that time?
  17   A. Yes.
  18   Q. Then if we go over the page to page 27, a letter to you
  19     from Mr Ross, the Chief Executive. I do not know
  20     whether you want me to read that letter or whether you
  21     want to read it to yourself. Essentially he says:
  22        "Roger Baird tells me that he has now had the
  23     opportunity to talk to you at some length and to express
  24     his personal support".
  25        Roger Baird succeeded Mr Wisheart as the Medical

   1     Director, did he not?
   2   A. He did.
   3   Q. He would be the most senior person in the Trust?
   4   A. Well, he is the Medical Director.
   5   Q. "I felt that I should now write as Chief Executive of
   6     UBHT to reassure you that I have no reason to have any
   7     concern about your clinical competence, and that you
   8     have the personal support of Ian Stone ..."
   9        He was a Director of the Trust?
  10   A. A Director of Personnel.
  11   Q. " ... and myself in your continuing work in the Trust.
  12     I am only sorry that James Wisheart's personal situation
  13     meant that there was considerable delay before recent
  14     conversations and correspondence took place".
  15        Now, Dr Masey, I have asked you a number of
  16     questions, some of which I understand and realise and
  17     appreciate were upsetting, and I hope you understand
  18     that the Inquiry has got its job to do and sometimes it
  19     is necessary to explore those matters, and I hope we did
  20     that as sensitively as we could manage.
  21        Is there anything, having asked those questions,
  22     that you want to add now, anything that I have dealt
  23     with incompletely or badly, or anything else in general
  24     that you want to say to the Inquiry at this stage? I am
  25     sure the Chairman will remind you that you will have an

   1     opportunity to contribute further in writing at a later
   2     stage, if you so wish. Is there anything else you want
   3     to say now?
   4   A. No, there is nothing else I wish to say now.
   5   Q. I understand from Miss O'Rourke, who sits behind, that
   6     there is no re-examination. Does the Panel have any
   7     questions for Dr Masey?
   8   THE CHAIRMAN:  Mr Maclean, we have no questions from the
   9     Panel. May I, first of all, remind Dr Masey of what you
  10     already said, namely if there are matters that either
  11     you remember or come to your attention that you would
  12     like us to be aware of, please do let us have them to
  13     assist us, but beyond that, may I thank you very much
  14     indeed for coming today. You have helped us a great
  15     deal. Thank you.
  16   MR MACLEAN: If Dr Masey would just bear with me for a few
  17     seconds more, tomorrow, sir, at 9.30 we will be hearing
  18     from another Consultant Anaesthetist at the UBHT, Dr Sue
  19     Underwood.
  20   THE CHAIRMAN:  I heard from you 9 o'clock.
  21   MR MACLEAN: 9.30.
  22   THE CHAIRMAN:  My hearing again. Thank you very much
  23     indeed. Good afternoon, everyone.
  24   (3.30 pm)
  25              (Hearing adjourned)

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   8     DR SALLY MASEY:
   9         Examined by Mr MACLEAN .................. 2
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001