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 11th 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 Susan Underwood, Consultant Anaesthetist, BRI, since October 1991. She began by telling the Inquiry about her previous experience in paediatric cardiac anaesthesia prior to joining the BRI. She then discussed the standard and appropriateness of equipment used at the BRI and commented on protocols applied within the cardiac intensive care unit (CICU). She highlighted the establishment of intensivist sessions in the cardiac intensive care unit and her impression that, as a result, improvements in communication and management of care post-operatively occurred. Dr Underwood then discussed the raising and presentation of concerns and procedures for dealing with complaints. She then commented on the introduction of the surgical switch programme at the BRI. She went on to discuss operative issues such as by-pass times and undiagnosed abnormalities. Dr Underwood then gave her recollections of how concerns about paediatric cardiac surgery emerged, including the circulation of data, how the concerns were discussed within the directorates of anaesthesia and cardiac surgery and what action was taken in respect of the concerns. She concluded by commenting on her involvement in the operation performed on Joshua Loveday in January 1995 and her subsequent responsibility for paediatric cardiac anaesthesia at the BRI and the Bristol Children’s Hospital. Dr Michael Scallan, Consultant Anaesthetist, Royal Brompton Hospital, attended today’s hearing as a member of the Inquiry’s Expert Group.

FULL TRANSCRIPT

   1               Day 75, Thursday, 11th November 1999
   2   (9.30 am)
   3   THE CHAIRMAN:  Good morning, everyone. Good morning,
   4     Mr Langstaff. You will know that, it being
   5     11th November, we shall, of course, at 11 o'clock take
   6     two minutes' silence. I just put everyone on notice of
   7     that at this point.
   8   MR LANGSTAFF:  Sir, would it perhaps be convenient for the
   9     first session of the morning then to finish with the two
  10     minutes' silence immediately before the break, and if we
  11     were to postpone our usual morning break until 11.02?
  12   THE CHAIRMAN:  That would be very helpful. Thank you.
  13   MR LANGSTAFF:  Sir, before Miss Grey calls Miss Underwood
  14     to give her evidence, may I just say a few words about
  15     a matter of concern which has reached the ears of the
  16     secretariat and legal team, not least from Mr Lissack on
  17     behalf of the Heart Action Group. That is the concern
  18     that in the focus which is inevitable upon mortality,
  19     that morbidity should not be overlooked. If reassurance
  20     is necessary, I give it that throughout the Inquiry it
  21     has not been overlooked, nor will it be overlooked, and
  22     it is perhaps appropriate that I should say that those
  23     who have looked closely at the statistical report which
  24     was published last week will have seen that the Inquiry
  25     has done what it can to investigate such indications as

   1     there may be that may help you, the Panel, to resolve
   2     the questions that arise in respect of morbidity.
   3        For instance, it is apparent that there is
   4     a difference between Bristol, when compared with the
   5     rest of the country and other centres, on the basis of
   6     the hospital episode statistics as to the incidence of
   7     neurological problems and to an extent renal and
   8     respiratory problems following surgery. As we
   9     explained, it is difficult on the basis of those
  10     statistics alone to know whether those problems arose
  11     before, during or consequent upon the operation, or were
  12     indeed consequent upon the underlying condition, but the
  13     difference is there and, of course, remains in part to
  14     be explored. It will not have escaped, I hope, notice
  15     that the clinical case note review was divided as to 40
  16     cases of those who had sadly died and 40 who had
  17     thankfully survived, but of those who survived, it was
  18     expected that there may be some, and indeed there are
  19     some, who have complications of one or other sort, which
  20     may be described as morbidity. Inevitably some of those
  21     cases will be used in the weeks that come in the
  22     evidence of the clinicians involved in those cases to
  23     explore those issues that arise.
  24        But perhaps again more fundamentally if I may
  25     simply say that we have a lot of evidence, some of which

   1     will never be given orally by parents, because it has
   2     been put in writing, about their particular children,
   3     and that evidence is evidence to the Inquiry. It may
   4     not look like it, because the parents themselves have
   5     not come and given their evidence here, but I know and
   6     they should know that you have and will read again that
   7     evidence, and where it deals with a child who we are
   8     told appeared untroubled before surgery but was troubled
   9     afterwards by one or other complications, then you, the
  10     Panel, will not lose sight of the message that is
  11     contained in it.
  12        It is right that I should say, because it is
  13     obvious, because it seems to us to be accurate, and we
  14     should be grateful if anyone were to put us right if we
  15     are wrong on this, that inevitably mortality is sadly
  16     easy to identify and morbidity may not be. There are
  17     problems of definition, problems of degree that arise,
  18     and thankfully the incidence is not as obvious nor as
  19     great, it appears, as is mortality, but that does not
  20     mean to say that you cannot draw such conclusions as are
  21     available on the evidence and will expect to do so and
  22     will expect in due course to be addressed by those who
  23     have an interest in the report of this Inquiry as to
  24     what findings should be made in that respect.
  25        Sir, I have gone on at some length, in essence,

   1     I hope, to provide reassurance to those who may need it,
   2     because of the focus that this inquiry inevitably has,
   3     particularly on this day of all days, on death rather
   4     than on survival with complications.
   5   THE CHAIRMAN:  Mr Langstaff, I am very grateful to you and
   6     indeed to others who have raised the matter. We have
   7     never lost sight of that as an issue, but we recognise
   8     that it is an immensely complex issue. We shall
   9     continue to do what we can to unravel what can be
  10     unravelled as best we can. I give that assurance to
  11     everyone. I gave it at the outset and I repeat it
  12     here. Our obligation is to get to the bottom of
  13     things. We will seek to go as deeply as we can, but
  14     some matters are very, very complex, as you yourself
  15     indicated.
  16   MR LANGSTAFF:  Sir, yes. I hope, as I have said, that the
  17     investigation of those cases which are selected to put
  18     to the various clinicians which arise from the case note
  19     review may help to elucidate some of the problems that
  20     there are. I should perhaps say, and I shall say more
  21     about it on Monday, that when cases are selected --
  22     there will inevitably be a selection made to put to
  23     clinicians -- they will be essentially to explore and to
  24     illustrate the themes which have arisen thus far from
  25     both the statistical review and the case note review,

   1     and it is not intended that there will be the sort of
   2     exploration that there might be were the case one of
   3     seeking compensation or clinical negligence. It is not
   4     the purpose, as you have often said, for this Inquiry to
   5     hold a trial of individual cases, but rather to
   6     establish the adequacy of care as an overall view and
   7     come to conclusions which are truly across the board
   8     rather than deciding in any individual case why it was
   9     that a particular child died or, for that matter,
  10     survived.
  11   THE CHAIRMAN:  Yes. Just to add to that, which is very
  12     helpful, Mr Langstaff, to say that it is not just the
  13     statistical review and case review which serve as
  14     indicators of adequacy, but also the evidence we have
  15     gleaned from a variety of other sources, not least the
  16     evidence we have heard from parents, around certain
  17     themes which have begun to emerge, and it is those
  18     themes that we need to explore and explore and explore,
  19     and to the extent that we will be assisted in so doing
  20     by referring to any case, it is in that context and only
  21     in that context that we do, in fact, refer to it. So
  22     thank you.
  23        Miss Grey?
  24   MISS GREY:  Sir, this morning we shall be hearing from
  25     Dr Underwood. Dr Underwood is represented, as was

   1     Dr Masey, by Miss O'Rourke. We also have the benefit
   2     today of Dr Scallon's presence. Again he was of
   3     assistance to us earlier this week.
   4   THE CHAIRMAN:  Yes. Good morning.
   5   MISS GREY:  Dr Underwood, would you like to stand, please,
   6     to take the oath?
   7            DR SUE UNDERWOOD (SWORN):
   8             Examined by MISS GREY:
   9   Q. Thank you. Now, Dr Underwood, you have provided two
  10     statements to the Inquiry. If we could look at the
  11     first of those, please. This is WIT 318/1. That is
  12     a statement concerning your anaesthetic log; is that
  13     correct?
  14   A. Yes.
  15   Q. If we turn over the page, we should see your signature
  16     there. Is that your signature?
  17   A. It is, yes.
  18   Q. And are the contents of that statement true to the best
  19     of your knowledge and belief?
  20   A. They are.
  21   Q. Now if we could look, please, at the second statement
  22     you have provided, which starts at page 3, is that the
  23     first page of your second statement?
  24   A. Yes, it is.
  25   Q. If we look, please, at page 7 and scroll down a little,

   1     please -- can you go up just a little and look at
   2     paragraph G4 there? There are two corrections you want
   3     to make to that?
   4   A. There are please, yes. The Intensive Care sessions
   5     began when the intensivists arrived. There were
   6     initially three and later five mornings a week.
   7   Q. Going on, please, to page 12 of the statement, the copy
   8     we have has not been signed. With the two corrections
   9     you have just made, are you happy to adopt that as your
  10     evidence to the Inquiry?
  11   A. Yes, I am.
  12   Q. Are its contents true to the best of your knowledge and
  13     belief?
  14   A. They are.
  15   Q. Now if we could go, please, on to page 14 of the
  16     statement, you do, in fact, append a CV?
  17   A. Yes.
  18   Q. And you have told us in the statement that you took up
  19     post at the Royal Infirmary in October of 1991. If we
  20     scroll down the page, we can see your previous
  21     experience. In particular -- can we go down a little
  22     further, please -- we can see that from October 1987 to
  23     November 1988 you were an anaesthetic research fellow at
  24     the London Chest Hospital?
  25   A. I was.

   1   Q. Was your work there exclusively with adult patients?
   2   A. It was.
   3   Q. You then go on to act as a Senior Registrar in
   4     anaesthetics at the Royal London Hospital, and you say
   5     that you spent one year in paediatric anaesthesia based
   6     at the Great Ormond Street Hospital?
   7   A. Yes.
   8   Q. Were you involved there in paediatric cardiac
   9     anaesthesia?
  10   A. I was indeed, yes.
  11   Q. Can you tell us the extent of your experience there?
  12   A. Yes. I had a rotation around the hospital, which
  13     included a period in paediatric cardiac anaesthesia, and
  14     also, because I knew that my interest lay in cardiac
  15     anaesthesia, when there were options to go for extra
  16     days, I would go for extra days as well. So I spent
  17     a fair proportion of my time that year in the cardiac
  18     theatre and Intensive Care.
  19   Q. You may need to try to slow down your evidence a little
  20     bit for the sake of those on your right, who, as we all
  21     know, are perhaps the most vital members of our team.
  22     So if I ask you to pause occasionally, it will be
  23     because of that.
  24        You say quite a considerable proportion of your
  25     time. Can you just help us a little bit more as to what

   1     proportion that might be?
   2   A. It is a long time ago. It is very difficult to
   3     remember, but I would imagine it is in the area of three
   4     months out of the year.
   5   Q. Three months out of the year. When you went on to act
   6     as a lecturer under Professor Strunin, whom the Inquiry
   7     has already heard from, did you have any continuing
   8     exposure to paediatric cardiac anaesthesia there?
   9   A. Not at the London Hospital, no.
  10   Q. At Great Ormond Street were you active both in the
  11     theatre and in post-operative care?
  12   A. Yes.
  13   Q. What sort of a basis for comparison with other centres
  14     then or perhaps more accurately with Great Ormond Street
  15     did you think you had when you arrived in Bristol in
  16     October 1991?
  17   A. I had a recent experience in working in a large
  18     paediatric hospital. Although I have tried to summarise
  19     because you pressed me, for a number of months, my
  20     experience was spread over the year. It was not a block
  21     just on its own. I felt I had great recent experience
  22     of what was happening in another hospital in paediatric
  23     cardiac anaesthesia and in intensive care.
  24   Q. Now when you came to the Royal Infirmary, were you
  25     working -- we will just take the period for this moment

   1     up to May of 1995 --
   2   A. Yes.
   3   Q. -- so when the children were based exclusively at the
   4     Royal Infirmary for open heart operations --
   5   A. Yes.
   6   Q. -- did you work at the Children's Hospital to any
   7     extent?
   8   A. No. I was based solely at the Bristol Royal Infirmary.
   9     I did do some paediatric cases at the Dental Hospital
  10     during the general anaesthetic part of my week, but in
  11     terms of cardiac, it was all at the Bristol Royal
  12     Infirmary.
  13   Q. So you did not carry out any general paediatric
  14     anaesthesia up at the Children's Hospital?
  15   A. Not at the Children's Hospital, but one list a week at
  16     the Dental Hospital.
  17   Q. If we can go back, please, to your statement at page 4,
  18     page 2 of your second statement, and scroll down
  19     a little, please, to your treatment of issue B1e, you
  20     talk there about equipment and you mention, firstly,
  21     that the ventilators were not ideal for patients with
  22     difficult respiratory requirements. Did those include
  23     children on occasion?
  24   A. Yes, indeed.
  25   Q. And what sort of difficulties would that give rise to?

   1   A. We would more frequently than you would nowadays need to
   2     use the hand ventilation method.
   3   Q. Well, you say in the next sentence that all children
   4     were hand ventilated until preparation for theatre was
   5     complete until a ventilator was borrowed from the day
   6     surgery unit by the ODA?
   7   A. Yes.
   8   Q. When did that take place?
   9   A. The reason I did not write a date was I could not
  10     remember it. The ODA arrived about 1993, I think, so it
  11     would have been after that time.
  12   Q. What sort of difficulties, if any, did hand ventilation
  13     give?
  14   A. It would have been a problem if we had not had
  15     sufficient anaesthetists, but in practice the
  16     anaesthetic was provided by a consultant and always
  17     a senior anaesthetic trainee was present as well,
  18     obviously as part of their training, but they were well
  19     able to assist with the hand ventilation. So in
  20     practice there were enough pairs of hands in the room to
  21     provide the ventilation. It obviously became easier
  22     when equipment was available too but it was quite
  23     feasible with two anaesthetists to do it in that
  24     fashion.
  25   Q. How did that situation compare with your experience at

   1     Great Ormond Street?
   2   A. I cannot honestly remember if there was a ventilator in
   3     the room or not. It is quite common when setting up
   4     a child for complex surgery to have a period of hand
   5     ventilation. You are in complete touch with the
   6     patient. You can feel the stiffness of the lungs and so
   7     on. So it would not be unusual to use a hand
   8     ventilation method for some time. So it did not strike
   9     me as a major difference in a sense, but it was a sign
  10     perhaps that the theatre was coping with paediatric and
  11     adult cases and in that respect some of the equipment
  12     had to be suited to both, and it may have been chosen
  13     differently if it had been suited to one or the other
  14     group of patients.
  15   Q. (To Dr Scallon) Dr Scallon, could I ask you to come in
  16     on this? Do you find this description of the state of
  17     affairs until some time in 1993 or thereafter at all
  18     surprising?
  19   DR SCALLON: No. I think the comments that have been made
  20     are absolutely fair, that hand ventilation can be as
  21     good as mechanical ventilation in the anaesthetic room,
  22     and, as Dr Underwood said, there is a period during the
  23     setting up of the anaesthetic when even if there is
  24     a ventilator, there will be a period of hand
  25     ventilation.

   1        I think that the general comment that it is
   2     perhaps a symptom that the facilities were not geared
   3     towards paediatric anaesthesia is a fair one. It may
   4     also point to the criticisms that we have heard
   5     elsewhere of the lack of equipment and the lack of
   6     a ventilator may be another one. Whether it follows
   7     from this that the standard of care in the anaesthetic
   8     room was inferior is, I think, incorrect. A standard of
   9     care using hand ventilation in the anaesthetic room can
  10     be as good as that when using the ventilator.
  11   Q. So the staff may have to work a little harder perhaps on
  12     occasion, but the children in no way would suffer from
  13     that?
  14   A. That is right. The point is that with the second
  15     anaesthetist present, this is not a problem. A solo
  16     anaesthetist would clearly have problems.
  17   Q. (To Dr Underwood) You go on to say in the statement
  18     that the transfer of patients to ITU at the end of
  19     surgery was sometimes a long and difficult journey. We
  20     heard from Dr Pryn on Monday that there was a serious
  21     problem with back-up batteries for transport monitors.
  22     Can you help us on the nature of that problem, if indeed
  23     you perceived there to be one?
  24   DR UNDERWOOD:  Yes. Again, it is a long time ago and it is
  25     difficult to remember exactly what we had then, but

   1     there was certainly a period when we relied on
   2     a battery, which was a physically large piece of
   3     equipment in those days, hanging on the end of the bed
   4     or the cot to provide us with electricity for the
   5     journey. We needed the electricity to run the
   6     monitoring and equipment we were using on the journey.
   7     That equipment was essential to the child. So there was
   8     always a worry when you heard that someone else or
   9     somebody had been concerned that the battery might not
  10     last that that would be a feature of the journey.
  11        So the journey was stressful, because we were
  12     concerned that something may happen. I do not think it
  13     would be fair to say that I can remember an actual
  14     incident when that happened, but I do remember that
  15     patients who were needing a lot of support, you would be
  16     concerned when you set out for the journey, because you
  17     knew that there was a possibility -- the journey seemed
  18     long, because it included a lift journey. It was not
  19     physically very far.
  20   Q. So to the best of your recollection you can remember
  21     concerns that something might arise, but no incident in
  22     which actually problems did arise because of this
  23     particular problem?
  24   A. Exactly, yes. Yes.
  25   Q. Can you remember then any occasion in which the journey

   1     or length of the journey from theatre to ITU did, in
   2     fact, compromise the health or safety of any patient?
   3   A. No, I do not think so specifically. I think because we
   4     knew that the journey was long and potentially
   5     hazardous, we would not embark on it until the patient
   6     was quite stable, so that in moving a sick patient from
   7     the operating table to the cot or the bed, there may be
   8     some instability in a very sick patient, but then you
   9     would not move out of the theatre until you had overcome
  10     that period and then you would move to the Intensive
  11     Care Unit. There was never any pressure to press on
  12     with the next patient if the patient was not fit to make
  13     the journey, because everybody understood that you must
  14     not set out on the journey unless it was going to be
  15     made as safe as possible.
  16   Q. Did you move directly from theatre to the ITU or was the
  17     room immediately outside theatre where you would
  18     stabilise the patient after surgery?
  19   A. No, you would stabilise in the theatre and then move up
  20     to the Intensive Care as one journey.
  21   Q. If we look at UBHT 297/69, this is the list of equipment
  22     that was drawn up by Dr Pryn in December 1994, major
  23     equipment that is, required by cardiac services.
  24     Firstly, what was the system for review of equipment
  25     before Dr Pryn started his overhaul?

   1   A. The anaesthetic part of the equipment was dealt with by
   2     the Anaesthetic Department, who always had an equipment
   3     officer, one of the consultants nominated to do that
   4     job, in the department, and I was never that officer and
   5     never particularly involved in that sense with the
   6     equipment.
   7   Q. Now we have a record there of requirements of updating
   8     to Intensive Care ventilators. Can you describe the
   9     situation with ventilation before the replacements were
  10     purchased?
  11   A. We always had, to my memory, ventilators that were
  12     suitable for use on the children, but there used to be
  13     separate paediatric ventilators or adult ventilators up
  14     in Intensive Care. If I remember rightly, and as I say
  15     it was not my primary responsibility to do that, this
  16     was to introduce more modern ventilators. In fact, they
  17     would be useful for the adults or the children.
  18   Q. The particular concern set out there is there are no
  19     servicing or spare parts available, so if anything went
  20     wrong, it was difficult to do anything about it. Again
  21     can you remember any incident where this potential
  22     problem became an actual one?
  23   A. No, but I do remember that we only had a limited number
  24     of paediatric ventilators and we used to ask for them to
  25     be set up before we started the case or during the start

   1     of the case. So they would be prepared on Intensive
   2     Care before we arrived there and again I can picture in
   3     my mind the ones we had and they were ones I had been
   4     used to using in GOS. I knew the problem was they would
   5     not be sustainable. I think that is why Dr Pryn made
   6     a concerted effort to do that.
   7   Q. If there are only a limited number of paediatric
   8     ventilators, did that ever function as a limitation on
   9     the throughput of children through the ward, or were
  10     there other more critical issues, such as nursing or
  11     indeed availability of consultants to perform
  12     operations?
  13   A. I do not remember the ventilators themselves being
  14     a limiting factor in the throughput of children, but the
  15     beds on Intensive Care were to some extent labelled as
  16     paediatric and adult in that there was a maximum number
  17     of children that could be coped with on Intensive Care
  18     from the nursing and medical point of view. So that was
  19     really a much more limiting feature, and I do not
  20     remember the ventilators on any particular occasion
  21     being a limiting feature.
  22   Q. Can I ask you just to speak up a little as well?
  23   A. Yes.
  24   Q. From the point of view of factors limiting the number of
  25     children that could be operated upon, what were the most

   1     significant?
   2   A. There was a limited number of beds available for
   3     children in the Intensive Care, and at this stage
   4     I cannot remember if it was three or four, but we
   5     usually had two or three children on the Intensive Care,
   6     but I do not know exactly what it was that caused that
   7     to be the number. My understanding would have been that
   8     it was related to ability to provide a suitable
   9     paediatric experienced nursing staff in the Intensive
  10     Care, but also probably related to the requirement to do
  11     a certain amount of adult cardiac surgery through the
  12     same unit. So there would have had to be a balance and
  13     there was a limit on the number of beds in Intensive
  14     Care that could be filled with children at any time.
  15   Q. Going back to this page, if we scroll down, please, we
  16     can see there the reference to replacing the patient
  17     monitoring system, and Dr Pryn picked out in particular
  18     the problem of electrical interference with diathermy.
  19     Was that a problem that you recognised?
  20   A. Yes, indeed. That was the problem with older monitors
  21     particularly obviously in the operating theatre and
  22     during the use of diathermy which at some stages in the
  23     operation is quite continuous, it would be difficult to
  24     monitor the child or indeed the adult.
  25   Q. I think if we went to Dr Pryn's list of minor equipment

   1     or more minor equipment, which would be at UBHT 84/101,
   2     he picked out the necessity for new syringe pumps. What
   3     was your experience of syringe pumps' adequacy before
   4     they were replaced in this round of reviews?
   5   A. Again I think that things were developing gradually bit
   6     by bit and we were all becoming more aware of the fact
   7     that there were better syringe pumps than the ones we
   8     had. Some of the variation in the condition of patients
   9     we could ascribe to the pulsing nature of the syringe
  10     pumps. When the pumps became available that provided
  11     a smoother action, it was obviously sensible to try to
  12     obtain some, if we could.
  13   Q. So you had had experience of problems with pulsing of
  14     inotropes?
  15   A. Yes, I think we had. We had certainly seen variations
  16     in the patients' condition, some of which we put down to
  17     the possibility of that being a cause of it, so that you
  18     would think that if a better equipment became available,
  19     if it was possible to have it, that would reduce that
  20     aspect of variability at least.
  21   Q. Again, did that ever cause a serious compromise to any
  22     significant extent to the condition of a patient?
  23   A. I do not recall any specific incidents where the syringe
  24     pump was at fault, although I do know that it was
  25     considered in the unit that the syringe pumps had caused

   1     on occasions difficulty.
   2   Q. Generally, Dr Underwood, in looking at the availability
   3     or function of equipment, if the Inquiry is looking to
   4     explain outcomes at Bristol, to what extent do you think
   5     that equipment failure or deficiencies in equipment
   6     should be regarded as an actual or potential cause of
   7     any problems?
   8   A. I think it is very difficult to single out equipment
   9     from the rest of the procedure really. Obviously it is
  10     easier to do a procedure better with better equipment,
  11     but it is a balance between being able to do the
  12     procedure with the equipment you have or saying that you
  13     must have better equipment, and although this is
  14     a one-off document that you have picked out here, in
  15     fact, the procedure is a much more on-going, rolling
  16     programme. It does have occasional boosts ahead when it
  17     is possible to change syringe pumps or get a completely
  18     new set of ventilators, but in general it proceeds bit
  19     by bit. I think I would find difficult to pick out what
  20     part that plays in the whole picture, but I think it is
  21     fair to say that it does play a part in the whole
  22     picture.
  23   THE CHAIRMAN:  Can I just interrupt? It is very important
  24     we hear everything you say and capture everything you
  25     say, and sometimes you are going quite quickly, not for

   1     my ears, but for the fingers of the lady to your right.
   2   A. Sorry.
   3   THE CHAIRMAN:  So before we see blood emerging from her
   4     fingers, remember to slow down sometimes, because it is
   5     so important that we have a full transcript.
   6   A. I do apologise.
   7   THE CHAIRMAN:  No apology is called for.
   8   MISS GREY:  Dr Underwood, your answer suggests that
   9     equipment might have made some difference?
  10   A. Yes.
  11   Q. Can you help us a little bit more as to the nature of
  12     any difference that it might have made?
  13   A. I think if there is better equipment, everything is
  14     easier. Everything flows more smoothly. One piece of
  15     equipment which is not actually highlighted here but
  16     which made a big difference to my mind, and I think to
  17     my colleagues' too, is a difficultly in keeping
  18     particularly very small children warm during the
  19     procedure of setting up for an operation.
  20        Certainly I remember that when I first arrived
  21     there was no equipment to help us with that. We used to
  22     turn the temperature up in the anaesthetic room but it
  23     was very difficult to keep small babies warm. I did
  24     manage to procure an overhead warming device from the
  25     Maternity Hospital, in fact, which we borrowed for some

   1     time, and later tried to get some more equipment to keep
   2     babies warm.
   3        So there are things like that which are important
   4     and relevant in the care of the child, but I would not
   5     -- it would be hard to say exactly what part they play.
   6   Q. Not every hospital will necessarily have
   7     state-of-the-art equipment at any one time. In your
   8     judgment how did Bristol compare with your experience of
   9     what had been available to you at Great Ormond Street?
  10   A. The biggest differences I saw were in the heating
  11     arrangements for keeping children warm and in the
  12     monitoring, and I knew that there was effort to change
  13     the monitoring in theatre and in the Intensive Care, and
  14     I was pleased. I think it helped my practice when it
  15     did change.
  16   Q. Warming you have told us about, in preparing children
  17     for theatre?
  18   A. Yes.
  19   Q. Are you also talking about the situation in the ITU?
  20   A. In the Intensive Care there were some cots with heaters
  21     over the top, but they were operated by the nurses
  22     rather than the more modern servo-controlled. So again
  23     there were some -- less than the most modern at that
  24     time.
  25   Q. You have reminded us that the monitoring was changed.

   1     Can you date that?
   2   A. No. No more clearly than Dr Pryn.
   3   Q. It is something that arose out of Dr Pryn's review of
   4     equipment, is it?
   5   A. I believe that is what made it actually happen.
   6   Q. (To Dr Scallon) Dr Scallon, you came and helped us on
   7     Monday and indeed were sworn in on that occasion and so
   8     I should perhaps remind all for the sake of the wider
   9     audience that you remain on oath.
  10        Is there anything you would like to comment on on
  11     the general availability of state-of-the-art equipment
  12     or the most modern equipment within hospitals within the
  13     NHS across this period?
  14   DR SCALLON: It varies enormously from hospital to
  15     hospital. As Dr Underwood said, equipment is acquired
  16     as a continuous programme, but there are times when it
  17     can be extremely difficult to get money for equipment
  18     because the money is simply not available or because
  19     other people are competing for it.
  20        My own hospital was fortunate in that we moved to
  21     a new building about ten years ago and we were able to
  22     get, as part of the package, a whole new set of
  23     equipment, but that is unique in a new hospital. Old
  24     hospitals do not have that luxury.
  25   Q. Thank you.

   1   A. Can I just come in on another point, on the issue of
   2     heating in the anaesthetic room? It is correct to say
   3     that in general terms children and small babies need to
   4     have their heat conserved, because during exposure they
   5     can lose heat very quickly, but babies and children
   6     undergoing cardiac surgery will be cooled as part of the
   7     process of the operation. So I would say a modest
   8     amount of cooling in the anaesthetic room is not
   9     necessarily a disadvantage. Indeed, many people in the
  10     field deliberately leave the children exposed during
  11     that period as part of the cooling process. So one has
  12     to balance the degree of cooling. It is not necessarily
  13     in all situations a bad thing.
  14   Q. So it would follow from what you are saying that the
  15     lack of temperature controls or inadequate, limited
  16     systems to warm children in the pre-theatre room would
  17     not necessarily be a factor that concerned you?
  18   A. Provided it did not lead to excessive cooling, the
  19     answer to your question is yes.
  20   Q. (To Dr Underwood) Excessive cooling, Dr Underwood, was
  21     that a problem?
  22   DR UNDERWOOD: I think I would be in agreement with
  23     Dr Scallon on this that moderate cooling was fine. Our
  24     theatres were old and frequently very cold in the
  25     morning. I think we are actually talking about the same

   1     thing, about maintaining a reasonable temperature but
   2     not the normal body temperature. Now we are in a newer
   3     theatre, we have much less trouble controlling the
   4     ambient temperature and we see the difference.
   5   THE CHAIRMAN:  May I come in with a question that would
   6     help me? You referred back a little while ago to
   7     monitors, for example, being less than modern, as
   8     I think your words were. One has that impression of
   9     some of the other equipment. Do you think it is a cause
  10     for, let us say, concern, without putting any strong
  11     value on that word, that one is engaged in surgery which
  12     is extremely modern, at the leading edge of what is
  13     possible, and yet one's equipment is not at that same
  14     degree of development?
  15   A. I think it would be impossible to keep the monitoring
  16     always at the leading edge, and when we are looking at
  17     this time at the monitors that we had in theatre and the
  18     Intensive Care, we are looking at the end of their
  19     period ready for the start of the next monitor. So this
  20     is as bad as the monitor can ever get before it is
  21     replaced. Over a period of years that would not
  22     represent the average, if you like. So I think that is
  23     very difficult. We had to press to keep updating things
  24     as much as is feasible, but these monitors that we were
  25     replacing were at the end of their useful life from our

   1     point of view, and we were pressing to have them
   2     replaced. We were organising to have them replaced.
   3   THE CHAIRMAN:  But just for the sake of clarity, when you
   4     say "as bad as they get", do you mean, and I do not seek
   5     to put words into your mouth, within the cycle of them
   6     being serviceable to the need, they go from being very
   7     good at that to less good at that but remain
   8     serviceable, or do you mean they had ceased to be
   9     serviceable?
  10   A. I believe they were still serviceable. As a practising
  11     anaesthetist they provided me with the measures
  12     I needed. They were not as clear as the more modern
  13     ones were. You could not attach them to a central
  14     station, as you could with the newer ones and so on and
  15     so forth, but the monitoring that I needed minute by
  16     minute for the patient was available on the screen,
  17     though harder to discern from the screen perhaps than
  18     the more modern ones.
  19   MISS GREY:  Dr Underwood, if we could go back to your
  20     statement, please, 318/4, and scroll down a little
  21     further, please, you give us at B1(e), the second
  22     sentence of the paragraph there, the statement that:
  23        "In the Intensive Care Unit adults and children
  24     were nursed alongside each other".
  25        What significance do you think that fact had

   1     firstly from the point of view of parents of children?
   2   A. I should imagine it was very difficult, particularly as
   3     a parent. I think the children in Intensive Care
   4     generally were sedated and, even if they were not
   5     sedated, probably do not have a lot of recall for that
   6     period, although once they become high dependency
   7     patients rather than intensive care, that would be
   8     different. I would imagine that a parent in
   9     that setting would find it very difficult.
  10   Q. From the point of view of an anaesthetist concerned in
  11     the post-operative care, what were the disadvantages of
  12     this set-up?
  13   A. I think it can be quite difficult to be concentrating on
  14     one aspect of your work one minute and another aspect
  15     another minute, but they were all cardiac patients and
  16     my training was in cardiac anaesthesia for all age
  17     groups, so that I think the problem for me personally,
  18     when I first arrived, was probably less than it was for
  19     the parents and children themselves.
  20   Q. I asked you what the disadvantages were. Do you think
  21     they were significant?
  22   A. In terms of my anaesthetic input for the children
  23     I think probably maybe not, but I think in my part as an
  24     intensivist -- I am not a trained intensivist as folk
  25     are now, but I had training in Intensive Care and looked

   1     after the patients on Intensive Care. In that role
   2     I think it was difficult, because the back-up in other
   3     specialities for children was not physically present in
   4     the hospital.
   5   Q. We will come back to this in greater detail later. You
   6     have just said you draw a distinction between training
   7     as intensivist and your own training as anaesthetist
   8     involved in post-operative care.
   9   A. Indeed.
  10   Q. Can you help us a little more on the distinction you are
  11     drawing there? How would an intensivist be trained
  12     first?
  13   A. In these modern times it is set out quite clearly how an
  14     intensivist would train, but in the time when I was
  15     appointed, if I had been interested in an intensive care
  16     post, I would have had to show more training and
  17     experience in the Intensive Care field itself, but, as
  18     I spent a lot of training doing cardiac and thoracic
  19     anaesthesia, then that is where I spent my specialist
  20     experience, if you like, in that field, rather than in
  21     Intensive Care, but obviously anybody who is trained in
  22     anaesthesia for major operations has some training in
  23     post-operative care of those patients on the Intensive
  24     Care Unit.
  25   Q. If we can go over the page, please, and look at

   1     paragraph B6, you say you do not remember seeing any
   2     written protocols or guidelines before the arrival of
   3     the intensivists in 1993. We have heard from Dr Pryn
   4     about the protocols that he was instrumental in
   5     developing. If we could look, please, at WIT 341/60,
   6     these are Mr Wisheart's comments on Dr Pryn's
   7     statement. Can we scroll up again, please? Thank you.
   8     I am sorry. We should turn back, to give it the
   9     context, to page 59 first, where we can see that Dr Pryn
  10     had been commenting on the red book that he had seen
  11     called: "Guidelines for the Care of the Cardiac
  12     Surgical Patient", and he said a number of features were
  13     out of date.
  14        If we look over the page, page 60, we can see
  15     Mr Wisheart's comments on that. He says that the book
  16     had been written in 1988, or this edition had been
  17     produced in 1988 with a number of contributors helping
  18     him. He had started the book in 1976 in his first year
  19     in Bristol, and that it contained comprehensive
  20     guidelines. He said that he felt it was important that
  21     the authorship of these guidelines should pass to new
  22     hands, but that nobody took up this opportunity, and
  23     that when Drs Pryn and Davies were appointed as
  24     intensivists or with intensivist sessions it naturally
  25     fell to them to do so.

   1        Were you aware of the red book? Did you see it
   2     when you arrived in October 1991?
   3   A. When I wrote my statement, I had completely forgotten
   4     about the red book. When I saw mention of it in my
   5     reading in the last few days, I do recall there being
   6     a red book. I do not remember reading it myself.
   7     I remember that my understanding was that it had been
   8     written by the surgeons, and that it was generally aimed
   9     at the surgical SHOs who were working hour by hour on
  10     the Intensive Care Unit. I did know later on that some
  11     updating was needed, and I seem to remember that before
  12     Dr Pryn started writing protocols which he put in an
  13     orange book, that actually one or two even of the senior
  14     registrars in cardiac surgery had started to make some
  15     updates to the book.
  16   Q. So you were aware of it?
  17   A. Yes, I was.
  18   Q. Did you actually see a copy of it?
  19   A. I do not now recall that I saw a copy of it.
  20   Q. Can you remember when you became aware of it, roughly in
  21     relation to --
  22   A. No, except I do remember discussion standing around in
  23     the intensive care, discussion about updating it, and
  24     I do recall that a Senior Registrar was reported to be
  25     doing that updating. So I was obviously aware of it at

   1     that time, and that was before Dr Pryn wrote protocols,
   2     I believe.
   3   Q. Why not read it yourself and satisfy yourself that it
   4     was a proper and adequate guide?
   5   A. I think because I considered it to be part of the
   6     surgical arrangements on Intensive Care, and my vague
   7     memory of it is that it was something written by the
   8     surgical seniors for the surgical juniors. I would have
   9     been more concerned with teaching people on the ground,
  10     if you like, particularly the anaesthetic trainees in
  11     our aspects of Intensive Care, although obviously the
  12     surgical SHOs were frequently with us at the time.
  13   Q. So when Mr Wisheart says that he felt it important that
  14     the authorship of those guidelines should pass to new
  15     hands, but no-one took up this opportunity, was it ever
  16     suggested to you that that might be a useful way in
  17     which to spend your time?
  18   A. I do not remember it ever being suggested to me
  19     personally.
  20   Q. Going back then to your statement at page 5, please, and
  21     scrolling down to B7, you say:
  22        "In the ITU note-keeping was more difficult but
  23     started to improve with the arrival of the
  24     intensivists".
  25        Can you explain what it was like before they

   1     arrived?
   2   A. Of course it is only my perception, but before they
   3     arrived there would be more people passing in and out of
   4     the Intensive Care, and there was not a senior person
   5     allocated to the Intensive Care, so that, as decisions
   6     were made through the day, they may or may not have been
   7     written in the patients' notes. I think it is the
   8     nature of the Intensive Care and the changing of the
   9     plan as the day goes by that partly made it difficult to
  10     make a consistent record. That is made much easier if
  11     one person is in the Intensive Care for a prolonged
  12     period and can either summarise what has happened during
  13     the day or add to the records as the day goes by.
  14   Q. But surely even the trainees on the ward must have
  15     appreciated the importance of documenting changes in
  16     care or condition as the day went on?
  17   A. I think once the intensivists arrived, this was more
  18     strongly stressed, that it was left to the junior people
  19     to make a note in the notes, and if they did not do it,
  20     it probably was not checked. Certainly I did not check
  21     myself when making the evening ward rounds that
  22     something had been written in the notes.
  23   Q. So it would be your practice to make a ward round and
  24     discuss with the trainees on the ward at that time what
  25     changes in management needed to be made but not to

   1     document it yourself?
   2   A. That is right. We used to make an evening ward round
   3     after the theatre list with the people that were going
   4     to be available for the Intensive Care for the evening
   5     and night, and if there were instructions to nurses,
   6     they would be written on the charts at the head of the
   7     bed, so that they were visible all night for the nurse
   8     to follow.
   9   Q. They would be written by whom?
  10   A. I remember writing quite a lot myself. They may be
  11     written by someone else on the ward round. Actions that
  12     required carrying out that evening would be written down
  13     on the Intensive Care page rather than in the patients'
  14     notes. The arrival of the intensivist brought a new
  15     page to be filled in each day, which made it easier for
  16     the trainees to understand that that is where the
  17     information should go, and try to coordinate it, but
  18     I think even that was sporadically completed probably.
  19   Q. Well, Dr Pryn's evidence was that that was seen as
  20     being, as it were, something, if I may put it that way,
  21     owned by the intensivists rather than being something
  22     which necessarily concerned the surgical trainees. Is
  23     that evidence which you would agree with?
  24   A. I think it is, and I think that the reason that is now
  25     becoming quite clear is we have not addressed the issue

   1     of who was physically present in the Intensive Care.
   2     There was no intensivist or anaesthetist allocated to
   3     the Intensive Care for the day when I first arrived.
   4   Q. Until the arrival of Dr Pryn and Dr Davies?
   5   A. After the arrival of Dr Pryn and Dr Davies, who had
   6     between them three morning sessions on a consultants'
   7     basis, and then also managed to re-arrange the trainee
   8     rota so that an anaesthetist of a junior level was
   9     available in the Intensive Care during the day as well
  10     as being on-call for the night.
  11   Q. I will come back, if I may, to the question of who was
  12     present when, but looking down a little this page, still
  13     on the subject of note-keeping, we can see at B12d that
  14     you found communicating with other staff relatively
  15     easy, but it depends on conversations in theatre, office
  16     and Intensive Care with little written down. So it is
  17     informal discussions, is it, with colleagues?
  18   A. They could be described as informal, though often they
  19     were very useful and often they would be clinically
  20     relevant and clinically based. If I had a question to
  21     ask a surgeon about the patient, I would seek out the
  22     surgeon, because they would generally not be far away,
  23     discuss the question and then one or other of us would
  24     take the action that we had decided on. So they may
  25     have been about clinical issues and the running of

   1     actual patients' care and so on.
   2   Q. If you had had a discussion with another member of
   3     staff, a colleague, would you document the fact that
   4     this change had been made with the agreement of, say,
   5     Mr Wisheart and Mr Dhasmana, or would you simply record
   6     the change?
   7   A. I would more likely record the change itself, because it
   8     is very common in Intensive Care that a decision to
   9     change is made by a group of people rather than an
  10     individual.
  11   Q. If we look at the Clinical Case Review, the preliminary
  12     report from the Inquiry, which is INQ 16/23, we can see
  13     the overall comments on post-operative management issues
  14     at 5.11, where it says:
  15        "It was difficult to determine who took either
  16     medical or nursing responsibility for directing the
  17     management of patients on the ITU and particularly as
  18     applied to the management of paediatric patients".
  19        Were you clear who was taking medical
  20     responsibility for directing the management of patients?
  21   A. The patients were always under the care of the
  22     consultant surgeon under whom they were admitted, but
  23     their medical care would be a matter of discussion
  24     between the anaesthetists and the surgeons, and they may
  25     have a certain amount of input, depending on the nature

   1     of the problem being addressed. For example, a problem
   2     of ventilation, I would assume that my decision would be
   3     satisfactory to the surgeon, and if I was going to make
   4     a major change, I would probably speak to the surgeon
   5     about it, but I would expect that change would be
   6     satisfactory to them and indeed it generally was.
   7   Q. So what do you mean by "a patient was always under the
   8     care of the consultant surgeon"? Is that a question of
   9     ultimate authority or what?
  10   A. I do not think in the day-to-day life on Intensive Care,
  11     looking after the patients that we had, that that was
  12     something that came to my mind particularly. I was more
  13     concerned in dealing with the adjustments to medical
  14     care to try to improve the condition of patients and
  15     obviously to make them better and out of Intensive
  16     Care. So I was concerned with communicating with the
  17     surgeons in assisting the patients in progressing
  18     through the unit, and at that point I would not have
  19     said that either one or other of us was superior to the
  20     other. We would be having a discussion in the usual way
  21     of Intensive Care with how to proceed with a certain
  22     problem.
  23   Q. So if you were confident in your role in managing in
  24     particular the anaesthetic or ventilatory side of the
  25     patient care, what does the fact that the patient was in

   1     the care of the surgeon mean to you?
   2   A. Only that I think, because the patient is not actually
   3     separate units of ventilation and heart and kidney and
   4     so on, it is a whole patient, that something that I do
   5     to the ventilation may make a difference to the patient
   6     in general. So it would be unhelpful to wander into an
   7     intensive care and change the ventilation of the patient
   8     without due regard to the rest of the patient. So if
   9     I was making a major change in ventilation, for instance
  10     I was going to take a patient off the ventilator because
  11     they no longer required it, I would like to mention that
  12     to the surgeon some time in the next few hours, so they
  13     are aware of that situation with their patient, but
  14     I would still expect to be responsible for the
  15     ventilatory aspects of what I was doing.
  16   Q. But if the care in ITU is at any time in danger of being
  17     fragmented, disorganised, because of, say, the
  18     management or junior people on the ward, difficulties of
  19     communication with more senior people, to paint
  20     a hypothesis, for instance, who is responsible for
  21     sorting out that problem and ensuring that proper
  22     communication does take place?
  23   A. I would say that that was a reason that intensivist
  24     sessions were so helpful to us, and why we were so keen
  25     to have them, because it is more a coordinating role

   1     than a supervisory role, I would suggest, in getting the
   2     right information together and that somebody who has
   3     time allocated for that purpose is much more able to
   4     achieve that than people who have duties elsewhere.
   5   Q. But, with respect, that is to say that you can solve the
   6     problem by appointing someone to coordinate. If you
   7     cannot appoint someone to coordinate, because you do not
   8     have the resources to do it, say, or there is not
   9     agreement that it is necessary, who is responsible for
  10     controlling the problem or eradicating it at an earlier
  11     stage?
  12   A. Before the arrival of intensivists I would always work
  13     on the premise that it would be a team effort because
  14     anybody with something to add in that sphere for that
  15     patient, and I would consider that we would be working
  16     together to do that.
  17   Q. Are you saying then that if you observed difficulties in
  18     communication on the ward or problems of inadequate
  19     cover whilst very junior people were present, that you
  20     would think it would be an equal responsibility between
  21     yourself and the surgeons, the other consultants, to
  22     sort that problem out?
  23   A. Yes, I think you covered a lot in there. Some of it
  24     I could agree with. I personally did not find
  25     communication particularly difficult, because there were

   1     a smaller group of us in those days, which makes
   2     communication easier. It was easy to locate people you
   3     wanted to speak to, because they would be in the
   4     Intensive Care or in the theatre or perhaps in the
   5     office opposite, and so there was a lot of communication
   6     about the patients and what progress they were making
   7     and how they could be assisted to make more progress
   8     between the parties involved, and as an anaesthetist,
   9     I thought that that was an appropriate way to go about
  10     it before the arrival of intensivists, as you say.
  11   Q. Well, we may be at cross-purposes, because we are
  12     talking about two different things. If we remain on the
  13     subject of management, as it were, management of the
  14     ITU, if there are difficulties in communication, and
  15     I will put that as a hypothesis for the moment, that
  16     people are not talking to each other, there are problems
  17     with junior staff not being able to get a hold of more
  18     senior staff, for instance, when they need to make
  19     changes in management, this sort of problem, who is
  20     responsible for taking a look at the ITU and seeing
  21     whether or not those problems are real and, if they are,
  22     sorting them out?
  23   A. I do not know if I am qualified to answer that question,
  24     but I would say that because the Anaesthetic Department
  25     has a big input into Intensive Care, that the

   1     anaesthetists or perhaps the Director of the Anaesthetic
   2     Department had some responsibility in helping to resolve
   3     those kind of issues, but I do not know if I am the
   4     right person to answer the question, unless I have
   5     misunderstood your question.
   6   Q. Why not, with respect, because you were working on an
   7     ITU? You must have some idea of who to go to if there
   8     are difficulties in management of the ITU or whether it
   9     was something that you yourself would have
  10     responsibility for sorting out?
  11   A. I think some confusion may arise because in my mind
  12     it would depend a lot on the problem. If there was
  13     a problem with anaesthetic trainees having difficulty
  14     contacting anaesthetic consultants, then I would have
  15     a responsibility to try to investigate that and assist
  16     in resolving it. If it was a problem with a surgical
  17     trainee having the difficulty, then I would envisage
  18     that coming under the aegis of the surgical team. So
  19     I think it depends on the sort of problem. It is in
  20     Intensive Care where all these things meet together and
  21     it is quite difficult to unpick when it is run by
  22     a group of people.
  23   Q. Going back then to paragraph 5.1, the comment there is
  24     that it was difficult for the reviewers to determine who
  25     was taking -- and we will stay with medical --

   1     responsibility for directing the management of patients
   2     on the ITU. Do you think that is a fair comment? Is
   3     that a confusion you ever had?
   4   A. I think it is a fair comment for someone from outside to
   5     make. I do not remember it being a problem from
   6     personally looking after an individual patient on the
   7     Intensive Care, although I do think they are two
   8     separate questions.
   9   Q. Going on to the second sentence:
  10        "In general Intensive Care appeared to have been
  11     fragmented and insular in approach".
  12        Do you think that is a fair comment?
  13   A. Again in the day-to-day sense from my perspective
  14     I think it was a less fragmented than it would have
  15     appeared to an outsider trying to piece it together
  16     now. So I do think that is a fair comment made by an
  17     outsider, but my perspective at the time was starting
  18     from me and looking around myself, communication was
  19     quite easy, though very time-consuming, when nobody was
  20     based on the Intensive Care and I was not based on the
  21     Intensive Care myself.
  22   Q. You say very time-consuming. I think Dr Pryn identified
  23     one of the problems he was dealing with was simply one
  24     of delay. It was getting hold of the relevant people to
  25     discuss a change in management when they were busy

   1     people. I am talking in particular now of the
   2     Consultant Surgeons, who had responsibilities in
   3     theatre, who had perhaps administrative responsibilities
   4     as well. Was that something you would endorse?
   5   A. Yes, I think that is a fair comment. It might be quite
   6     easy to know where they were but if they were in the
   7     middle of doing a complex operation, that was not the
   8     time to discuss management of a patient on Intensive
   9     Care. So some delay could have arisen in that form,
  10     yes.
  11   Q. The next sentence points to delayed response to
  12     post-operative problems. Would that be a problem that
  13     you had encountered in practice?
  14   A. Yes. My involvement with Intensive Care was necessarily
  15     patchy during the daytime, because I was involved in the
  16     theatre. There were times of day in theatre when it was
  17     not possible for me to go to Intensive Care. Although
  18     somebody would go if there was a crisis and a trainee
  19     would go to help with practical procedures so long as
  20     they were able to do that, longer-term decisions could
  21     only be made when you had time to be on the Intensive
  22     Care and think them through. So I think it is fair to
  23     say that because we were -- well I , as an anaesthetist,
  24     was only physically present in the Intensive Care for
  25     part of the day, it could result in delays in responding

   1     to problems.
   2   Q. The first part of that sentence:
   3        "There was a failure to anticipate clinical
   4     problems ..."
   5        Is that again something you observed?
   6   A. I cannot remember any particular instances but I was
   7     very aware that it is stressful to be working in an
   8     operating theatre on one floor and to be anaesthetically
   9     responsible for patients two floors up.
  10   Q. The front-line care, if I may call it that, was provided
  11     by a Senior House Officer, who was a cardiac surgical
  12     trainee, and there was, I think, on-call cover from
  13     another cardiac surgeon trainee, this time a Special
  14     Registrar?
  15   A. Yes.
  16   Q. Would either of those two perhaps have had problems on
  17     occasion in anticipating clinical problems?
  18   A. The cardiac surgery SHO is naturally a relatively junior
  19     trainee, and I would not expect them to have any
  20     experience in anaesthesia or anaesthetic-related issues
  21     and unless they had worked on another Intensive Care,
  22     probably very little experience of ventilation. So that
  23     the anaesthetic aspects of Intensive Care, if I can call
  24     them that, were not covered by somebody physically
  25     present on the Intensive Care Unit in the first months

   1     and years after I arrived.
   2   Q. If we could go back then, please, to your statement at
   3     page 5 still, you say at the bottom that you believe
   4     that complaints were investigated with the involvement
   5     of the clinicians concerned. I think this is in
   6     response to a question of management of complaints from
   7     patients.
   8   A. Yes.
   9   Q. Can you recollect any instances where complaints were
  10     received about paediatric cardiac services?
  11   A. I do not think that I was involved in any personally.
  12   Q. Do you know of any complaints being made?
  13   A. Not specifically, no.
  14   Q. So when you say that you believe that complaints were
  15     investigated with the involvement of the clinicians
  16     concerned, on what experience is that evidence based?
  17   A. Well, that is based on my recollection of the
  18     arrangements within the Trust for such complaints to be
  19     dealt with.
  20   Q. Can you actually remember -- I think it is implicit that
  21     you cannot -- when complaints about the paediatric
  22     cardiac services were successfully brought through to
  23     any conclusion, an instance of that?
  24   A. No, I could not, no.
  25   Q. Turning over the page, please, you say at the top there

   1     that:
   2        "The fact that a person had to seek outside
   3     publicity to air a concern was seen as a failure of the
   4     system to resolve that problem early and completely."
   5        When you wrote that, did you have any example in
   6     mind?
   7   A. I was thinking of Dr Bolsin in particular.
   8   Q. Well, in relation to that, is that an accurate statement
   9     of the chronology of events? Would Dr Bolsin not say
  10     that he did not seek or attain any outside publicity
  11     until the matter had already broken in the media?
  12   A. I could not say obviously from his perspective, but from
  13     my perspective and my recollection I thought that we had
  14     failed in some way if any of this became so notable to
  15     the public because we had failed to note something or to
  16     change something or to look into something
  17     satisfactorily and to reach a good conclusion. So
  18     I would consider that it should not have been necessary
  19     for information to get into the public domain, because
  20     if there was something of concern, it should have been
  21     investigated and satisfactorily concluded amongst the
  22     people for whom it was a concern.
  23   Q. So we should read this sentence, should we, not as
  24     direct commentary, still less than attack on Dr Bolsin,
  25     but rather self-criticism directed at the organisation;

   1     is that right?
   2   A. I always thought, and still think, that it is very sad
   3     that problems could not be investigated more completely
   4     and to the satisfaction of everybody locally concerned,
   5     and that they had to come to a bigger audience for
   6     resolution.
   7   Q. Who in the Trust should have been responsible for
   8     achieving an earlier resolution of these difficulties?
   9   A. The concerns are expressed at the shop floor, if you
  10     like, and I think that, as they are expressed and people
  11     make responses to them, so I would hope that before they
  12     had gone through many cycles, they would be resolved,
  13     and I think that now our audit system provides some of
  14     that facility, but that was not in place in the time
  15     that we are talking about.
  16   Q. Well, can you be a little more specific? You have
  17     talked about the failure and sadness. Who failed?
  18   A. That is a more complex question than it sounds,
  19     I think. If somebody expresses a concern, then they, in
  20     my opinion, should provide suitable evidence for the
  21     concern to be considered properly by peers, and then by
  22     the next level of the seniority, and so on, until it is
  23     resolved. I think it would be possible that there are
  24     some concerns which would have to go right up the
  25     system, but there are some concerns which can be

   1     resolved at a more local level, but the concern must be
   2     aired in such a way that it can be understood by the
   3     other people and clearly identified, so that it can be
   4     addressed. So it could be said that there was a failure
   5     in a lot of areas, or it could be said that the concern
   6     was not clearly expressed. That is why I say to me it
   7     is a complex question, quite difficult.
   8   Q. If we stay at the level of the peer group, and we will
   9     come to that in more detail --
  10   A. Yes.
  11   Q. -- that is your first line of analysis, as it were?
  12     That is the first point at which concern should be
  13     aired?
  14   A. To my view, yes.
  15   Q. You have really identified two possible failures there:
  16     one, the way that the concern was aired and, two, and I
  17     am not sure about it, the response of the peer group.
  18     First of all, taking the first one, are you making any
  19     direct comment or criticism of the way in which
  20     a concern was expressed or ventilated by Dr Bolsin?
  21   A. I think it might be a bit clearer somewhere later in my
  22     statement too, but my recollection is that he voiced
  23     concern quite frequently to me, and therefore
  24     I understood that he had a concern, over the mortality
  25     in the paediatric cardiac surgery, to clarify, but that

   1     my recollection and my understanding at the time was
   2     that he was not producing for me any data which helped
   3     to substantiate that, and again my recollection is that
   4     on several occasions at meetings where I had hoped that
   5     data about the paediatric cardiac surgery outcomes may
   6     be presented it was not, and I found that difficult,
   7     because I then was unable to have a view on whether this
   8     concern was real or not. So I think that some of the
   9     difficulty arose quite near the beginning of the process
  10     in that respect, but I am only one anaesthetist and I do
  11     know he showed some things to some other people.
  12   Q. That is then the comment on how Dr Bolsin presented his
  13     data, at least to you. What then on the other side of
  14     the coin, the response of the group of Cardiac
  15     Anaesthetists? Do you, with the benefit of hindsight
  16     admittedly, now question the adequacy of that response,
  17     of the response to it?
  18   A. If exactly the same were to happen again, I think it
  19     would still be difficult to respond without clearer
  20     data, and one difficulty was that the surgeons had
  21     produced data and Dr Bolsin had apparently produced some
  22     data. So my understanding from talk among people, but
  23     not from any meeting, was that these were not always the
  24     same. I think that then the discussion became focused
  25     on how to compare these data, and which were correct,

   1     rather than on the issue which was whether there was
   2     a problem with the mortality in paediatric cardiac
   3     surgery, so that the focus was tending and the talk
   4     around the place was tending to be on whose data was
   5     correct and who had collected what, and that actually
   6     the issue was a different issue, and it was difficult to
   7     get to the issue itself, which should have been the main
   8     cause for debate.
   9   Q. You have described the response of the institution, at
  10     least at the level of the peer group, to Dr Bolsin's
  11     data and the audit prior to, if I may take this as
  12     a watershed, January 1995. What about the response of
  13     the UBHT as an organisation after that date? If we look
  14     at Dr Bolsin's statement, WIT 80/129, we can see -- can
  15     we scroll down, please -- his account of the changes in
  16     his anaesthetic sessions after this had all become
  17     public, and in particular a change in his work
  18     arrangements, cutting down his paediatric cardiac
  19     surgery sessions. Did you have any knowledge of that?
  20   A. In that I worked in the cardiac theatre and in the
  21     cardiac section of the Anaesthetic Department, I saw
  22     that that occurred, but I had no personal knowledge of
  23     the arrangements that had been made.
  24   Q. Did you have to change your theatre sessions in order to
  25     accommodate this change?

   1   A. Not to my recollection.
   2   Q. Can you help us on the working arrangements or
   3     atmosphere between Dr Bolsin and, firstly, Mr Wisheart
   4     after this had occurred, after January 1995?
   5   A. I would never have been present when the two of them
   6     were working together.
   7   Q. And the same arises with Dr Dhasmana?
   8   A. Indeed.
   9   Q. So in general can you help us on the manner in which the
  10     UBHT responded to Dr Bolsin's concerns and the events of
  11     January 1995? Was it proper? Was it adequate?
  12   A. I do not know that I can shed any light on that, because
  13     I was not part of those arrangements.
  14   Q. Going back to your statement then, and in particular you
  15     treat very briefly the fact that you were not, I think,
  16     particularly conscious or involved with the financial
  17     arrangements for children who were under 1s, if we look
  18     at UBHT 84/129, we can see there that it is a minute of
  19     a Cardiac Services Management Board which you attended,
  20     25th April 1994. If we scroll down a little, we should
  21     see that under the "Contract Report" there is a note
  22     there of you saying that the reduction in under 1s could
  23     be a cause for concern.
  24   A. Yes.
  25   Q. Can you remember what the concerns were at the time when

   1     designation for Supra Regional Services was removed?
   2   A. I had nothing to do with the fact that we were a Supra
   3     Regional Centre or not or whatever from that management
   4     point of view, if you like, but, as an anaesthetist,
   5     I was very concerned, particularly because my work was
   6     split between paediatric and adult anaesthesia, that in
   7     order to maintain my clinical skills, I would need to do
   8     a certain amount of each type of anaesthesia. I was
   9     concerned that the number of patients under 1 year of
  10     age was very small, and with the Anaesthetic Department
  11     gradually growing over the years, this may spread the
  12     cases to such a degree that none of us would feel
  13     skilled enough to do it, and certainly I would not have
  14     felt skilled enough to do it. So I was concerned that
  15     we should either do sufficient cases under 1 to make
  16     that a reasonable option or to say that we could not
  17     maintain skills if we did not do sufficient cases.
  18   Q. Well, it is fair to say that the link in the removal of
  19     Supra Regional Services' funding from the 1st April 1994
  20     is one that I have made rather than one that you have
  21     put, according to this minute, but more generally can
  22     you tell us: was there a perception at this time, as is
  23     suggested by this minute, that the number of under 1s
  24     was or could reduce in the future?
  25   A. I do not remember that. I do remember that I personally

   1     -- when I first arrived, I think I was probably doing
   2     at least as much paediatric anaesthesia as anybody else,
   3     or perhaps more in the first year, because of the nature
   4     of the days on which I worked, but I was concerned that
   5     I was doing only just enough to maintain my skills
   6     anyway, and I would have been very concerned to do much
   7     less than that.
   8   Q. What you are minuted as saying, accurately or
   9     inaccurately, is that you feel that the reduction in
  10     under 1s could be a cause for concern. It is minuted as
  11     a fact.
  12   A. I do not recall that fact. I presume it would refer to
  13     a reduction which had recently or was about to occur.
  14   Q. Can you help us as to what the expectation was for the
  15     service for under 1s from the 1st April 1994?
  16   A. No, I do not recall that at all.
  17   Q. In general, what was the perception, if you can
  18     recollect any, on the importance of funding for the
  19     under 1s from the Supra Regional Services?
  20   A. I do not remember ever being involved in or
  21     understanding the issue between the funding and the
  22     patients as such. Obviously in this kind of meeting the
  23     funding is mentioned and so on, and I realised that it
  24     is something that is important, but I would have been,
  25     and still am, because of the position that I work in,

   1     interested in the patients coming through from
   2     a clinical point of view and in what service we can
   3     provide for them and what is a feasible number of
   4     patients to provide this service for.
   5   Q. We will come back to it in greater detail later, but
   6     I think it is right that you were one of the two
   7     anaesthetists who did most of the anaesthetising for the
   8     switch operation?
   9   A. I think that is true, yes.
  10   Q. And, as such, you were involved in a considerable number
  11     of discussions with Dr Dhasmana and others on the
  12     continuation of the switch programme, both for neonates
  13     and non-neonates; is that right?
  14   A. Yes. Mr Dhasmana.
  15   Q. I appreciate the switch programme for non-neonates
  16     started before you arrived in Bristol.
  17   A. Yes. I think it started in 1988. I arrived in October
  18     1991.
  19   Q. The neonatal switch programme started in January 1992,
  20     so after your arrival; is that right?
  21   A. I think that is correct, yes.
  22   Q. So you must have been involved in general on discussions
  23     on both neonatal and non-neonatal switch programmes?
  24   A. Yes, in general.
  25   Q. If we go to Dr Bolsin's statement, please, WIT 80/1, we

   1     can see there that he says that during 1989 the unit
   2     commenced arterial switch operations, and he says he
   3     believed it was to maintain a favourable comparability
   4     with other supra-regional and non-designated paediatric
   5     cardiac surgical centres.
   6        I think, Dr Underwood, we have reached an
   7     appropriate moment for a break. We have mentioned
   8     already that we will be breaking to observe the two
   9     minutes' silence.
  10   THE CHAIRMAN:  We will save that question until after the
  11     break. May I ask you to rise with us and observe two
  12     minutes' silence in the memory of those who have fallen
  13     in war?
  14          (Two minutes' silence observed)
  15   MISS GREY:  Until 11.15, sir?
  16   THE CHAIRMAN:  Yes, until 11.15.
  17   (11.02 am)
  18               (Short break)
  19   (11.20 am)
  20   MISS GREY: Dr Underwood, I was asking you about discussions
  21     about switch procedures generally, and I think you
  22     answered that you had been involved in discussions.
  23     Does that need qualification in any way?
  24   A. It might do to confirm that as an anaesthetist doing the
  25     switch procedures, particularly with Mr Dhasmana,

   1     I would have multiple conversations with him and
   2     discussions about individual cases, but I was not
   3     involved in a management sense in planning a switch
   4     programme.
   5   Q. We will come back to that in later detail, but for the
   6     moment can you look at WIT 80/1 on the screen, where
   7     Dr Bolsin suggested that the unit commenced arterial
   8     switch operations, which he believed was to maintain
   9     a favourable comparability with other supra-regional and
  10     non-designated paediatric cardiac surgical centres.
  11        He dates that to 1989. You were not involved in
  12     any of those discussions?
  13   A. No, I arrived in 1991.
  14   Q. If we go on, he says at (b) that he believes that to
  15     have suspended the arterial switch operation or
  16     programme in the competitive environment would have cost
  17     the unit a considerable amount in top-sliced funding and
  18     that this put considerable pressure on the unit to
  19     continue to provide the arterial switch procedure,
  20     amongst others, he suggests, and he thinks may well have
  21     contributed to the excessive mortality in the operations
  22     undertaken.
  23        Leaving that last part of his evidence aside, the
  24     excess of mortality, are you aware of any discussions
  25     which linked continuation of the switch programme, after

   1     October 1991, after you arrived, to factors relating to
   2     funding?
   3   A. No, I am not aware of any discussion involving funding
   4     and the switch procedures.
   5   Q. If such a discussion had taken place you necessarily
   6     have been aware of it?
   7   A. No, I would not necessarily have been aware of it.
   8   Q. I have asked about discussions. At any time in your
   9     discussions with Mr Dhasmana on particular switch
  10     procedures, did you gain any impression that issues
  11     related to funding or the prestige of the centre might
  12     be important in continuing the arterial switch
  13     programme?
  14   A. My discussions with Mr Dhasmana would have been, were
  15     indeed, purely clinical. They were discussions that an
  16     anaesthetist has with a surgeon about many cases. But
  17     did not ever refer to funding.
  18   Q. What about issues of prestige or the importance of being
  19     able to do procedures that other centres were known to
  20     be doing? Was that ever a factor in discussion?
  21   A. I do not think that was a factor in discussion. The
  22     discussion was purely clinical and would be a discussion
  23     about a particular patient with what lessons we may have
  24     learned from such a patient and how we might proceed
  25     with the next individual patient.

   1   Q. Going back to your statement, then, please, at page 6,
   2     scrolling down, please, to issue C4, you talk about the
   3     difficulties of making comparisons when looking at small
   4     groups of patients in the paediatric cardiac surgery
   5     group, and you say that because they are small, it is
   6     difficult to make comparisons with the national
   7     register.
   8        If you just hold in your mind that part of your
   9     evidence, and then go on, please, to page 10, issue M6,
  10     you say there you vaguely recall on two occasions being
  11     shown, in the Anaesthetic Department, your paediatric
  12     cardiac surgery data alongside national data. This was
  13     not in a regular audit meeting.
  14        Were those the only occasions when you saw data
  15     for the paediatric cardiac service as a whole set
  16     against national data?
  17   A. I believe that they were, yes.
  18   Q. So if we turn back to issue C4, page 6, you make
  19     comments on the difficulty of these sorts of
  20     comparisons. Is it right that you saw an attempt to
  21     make them only on two occasions?
  22   A. I think that on two occasions I saw the annual return
  23     figures.
  24   Q. Were there any other attempts that you are aware of,
  25     prior to the arrival of Dr Hunter and Professor de Leval

   1     in January or February 1995, to collect figures for the
   2     unit as a whole and to make comparisons with national
   3     averages?
   4   A. I was aware that Dr Bolsin was collecting some data on
   5     paediatric cardiac patients.
   6   Q. But you did not see it, you say?
   7   A. I did not see it.
   8   Q. So attempts that you yourself were involved in are
   9     restricted to two that you have spoken of under issue
  10     M6; is that right?
  11   A. They were occasions when I saw the data from the unit,
  12     yes.
  13   Q. Before January 1995, you had been in the unit for
  14     something in the region of 3 and a half years?
  15   A. Yes.
  16   Q. Is that an adequate assessment or evaluation of outcomes
  17     to be involved in?
  18   A. I think I was not in any way in charge of audit. I did
  19     not have any responsibility to the unit as a whole in
  20     that sense, so that what I saw was only at an individual
  21     level, if you like.
  22        I used to attend the audit meetings and you will
  23     know from my statement they developed over the years,
  24     but --
  25   Q. The audit meetings for the Anaesthetic Department?

   1   A. I was going to say, they were at the same time as the
   2     Cardiac Department and in my first years I would attend
   3     the Anaesthetic Department audit meetings.
   4        There were no minutes that I received of the
   5     meetings that occurred in the Cardiac Unit.
   6   Q. In the first years; what about the later years?
   7   A. The much later years I attended the cardiac surgery audit.
   8   Q. What do you mean by "much later"?
   9   A. More recently, and I am trying to think whether that
  10     would be before 1995. I think maybe not.
  11   Q. Mr Bryan seems to recollect your attending such
  12     meetings, the cardiac surgical audit meetings, in 1994
  13     or thereabouts. Do you have any recollection of that?
  14   A. It is possible that I went to something because when
  15     there was audit afternoon set aside by the hospital for
  16     audit, I would always attend one or the other. I would
  17     try to find out what was to be discussed and make
  18     a judgment which would be the more useful for me to
  19     attend.
  20   Q. But going back to the previous answer, you said that on
  21     an individual level, you were aware of some outcome data
  22     for the unit as a whole being seen by you on two
  23     occasions?
  24   A. Yes.
  25   Q. You have made the point that you had no formal

   1     responsibility for audit. But you have told us earlier
   2     that you were aware that concerns were being expressed
   3     about outcomes in the unit?
   4   A. Yes.
   5   Q. Was seeing the data on those limited number of occasions
   6     adequate?
   7   A. I would have preferred it if we had had one database to
   8     collect all the data and indeed, that is what we have
   9     now, but it is an extremely time-consuming and difficult
  10     job to set that up, and not one which an individual
  11     anaesthetist at that time was probably able to do.
  12        I remember that when concerns were expressed,
  13     particularly by Dr Bolsin on one occasion, which
  14     I mention later in the statement, that the cardiac
  15     anaesthetist present, including myself, pressed him to
  16     bring some data for us to look at.
  17        Then when I later knew that he was collecting
  18     data, I kept assuming that he would present it in
  19     a forum where it was free for everybody to see, and
  20     I think that month by month I kept thinking that that
  21     would be soon appearing.
  22   Q. Going back to C4, you point out the difficulties in
  23     making comparisons when numbers of patients in each of
  24     the neonatal and paediatric groups was small?
  25   A. Yes.

   1   Q. When you saw data, on two occasions you say, leaving
   2     aside Dr Bolsin's audit, was the data broken into groups
   3     that were small? How was it broken down?
   4   A. My recollection is that it was broken down into the
   5     categories of -- possibly of the Cardiac Surgery
   6     Register, but there were few numbers in each group, yes.
   7   Q. So was the result that you could never tell whether the
   8     results were acceptable or not?
   9   A. I think it meant that we, or perhaps it is fairer to say
  10     "I" felt that Bristol would not have been the top
  11     performing centre in the country, but it was not clear
  12     from the data that I saw that it would be outwith the
  13     group, centres within the country.
  14   Q. Where did the data come from on those occasions? Was
  15     it from the surgeons?
  16   A. I do not recall who showed it to me on the first
  17     occasion, but I think on one occasion Dr Monk had some
  18     papers, including this particular piece that I have in
  19     mind, and that he showed me, and he sat down and looked
  20     down the columns at the operations to have a look at
  21     it.
  22        I think he probably brought it from the surgeons,
  23     but I do not know.
  24   Q. Can you help us on the date of that incident?
  25   A. No, I racked my brain when I was writing my statement to

   1     try to do that, but I cannot.
   2   Q. Does that apply to the other incident as well?
   3   A. I think the other incident was prior to it, but again,
   4     I cannot recall when it was.
   5   Q. The second incident you have told us was a discussion
   6     between yourself and Dr Monk?
   7   A. Yes.
   8   Q. Was there anyone else there?
   9   A. Not to my recollection, no. It was in the Anaesthetic
  10     Department.
  11   Q. And the other occasion, possibly earlier: who was there
  12     on that occasion?
  13   A. I do not recall who was there on that occasion.
  14   Q. So you remember data being seen by you?
  15   A. Yes.
  16   Q. Can you not remember whom you got it from on that
  17     occasion?
  18   A. No, I cannot.
  19   Q. You have pointed out the difficulties of data analysis.
  20     Can you remember any discussion on how the data you did
  21     see on those two occasions was presented and whether it
  22     could be examined in a more meaningful way?
  23   A. No. I think because it was presented in the way that
  24     the Cardiac Surgery Register apparently required it,
  25     that that was the only point, really, about the

   1     presentation of the data.
   2        The audit meetings that developed would have
   3     included discussion on morbidity and mortality of
   4     individual patients, but I do not remember it being
   5     until much later that statistics of the whole unit's
   6     performance were presented in an audit meeting.
   7   Q. You are saying in effect there that any data that you
   8     did see did not allow meaningful comparison; is that
   9     correct?
  10   A. It puts our data alongside such national data as was
  11     available at the time. In that respect, the fact that
  12     my memory was that in some categories our figures were
  13     worse and some better, in that sense it seemed
  14     a reasonable comparison at the time.
  15   Q. Was that a comparison which related to the results for
  16     one year only, or were the groups being aggregated over
  17     a longer period?
  18   A. My recollection is that on each occasion it was only the
  19     annual figures that I saw.
  20   Q. Was that enough, therefore, to allow adequate
  21     comparisons with the national register?
  22   A. In retrospect, and judging by the level of audit that
  23     I would now consider suitable, it would have been
  24     lacking in that.
  25   Q. At the time were you aware of those deficiencies?

   1   A. At the time I was pleased to see our figures set against
   2     some other figures, because prior to that I only had my
   3     diary record and the discussions with anaesthetists in
   4     coffee rooms and anaesthetic departments as to what was
   5     going on. So I was pleased that I had seen some results
   6     from my unit, set aside some other results which had
   7     some weight to them.
   8   Q. What conclusions did you draw from the comparisons?
   9   A. As I said, my recollection is that in some categories we
  10     were better, in we were some worse. Because the numbers
  11     were very small, it was difficult to know whether the
  12     areas in which our results were not as good were
  13     a matter of chance or a matter of concern.
  14   Q. But what I am seeking to press you on is, if the data,
  15     when aggregated for a year only, was not such as to
  16     enable you to draw comparisons, did you not say to
  17     yourself, "We need to see more data aggregated over
  18     a longer period of time in order to see whether more
  19     reliable conclusions or wider conclusions can be
  20     drawn"?
  21   A. I think if I had been in charge of audit, that would
  22     have been a reasonable question to ask and a reasonable
  23     line to pursue, but in fact, in my daily work as
  24     a cardiac anaesthetist, keeping my own record, I felt
  25     pleased that there were people in the department who

   1     were collecting fuller data. I was reassured by the
   2     fact that the surgeons were returning annually their
   3     data to the National Cardiac Surgical Register, and
   4     I took in audit as it developed in the unit.
   5   Q. But this is coming against a background in which, as you
   6     say later in your statement, Dr Bolsin expressed
   7     concerns about the performance of the Paediatric Cardiac
   8     Surgery Unit from the time you arrived in Bristol.
   9        In those circumstances, is it enough to say that
  10     others had the responsibility for audit and therefore it
  11     was enough to have seen these figures?
  12   A. I think it has to be set in the context of the whole
  13     department, perhaps, as well. If somebody makes
  14     a concern, then I would say that they have some duty to
  15     try and elucidate that, particularly to gain support,
  16     and to either confirm or deny the concern.
  17        I was involved in anaesthesia for a number of
  18     different procedures in different groups of patients,
  19     and I do not think it would be feasible for me to make
  20     an audit of all the children in the Dental Hospital and
  21     of the patients on my other lists and so on, so I was
  22     a supporter of the increasing interest in audit and
  23     always completed any audit data that was requested of me
  24     in order to try and assist the unit to do their audit
  25     procedures, but I was not instrumental myself in

   1     producing such an audit.
   2   Q. In relation to pre-operative care, turning to later
   3     issues in your statement, it was the case that meetings
   4     were held at the Children's Hospital to assess the
   5     management of children, if surgery would be appropriate
   6     and when.
   7        Were you able to, or did you ever attend those
   8     case conferences?
   9   A. No, I never attended those at the Children's Hospital.
  10   Q. Dr Scallon, can I turn to you on this? Would it be
  11     normal to have anaesthetic input into these sort of case
  12     conferences?
  13   DR SCALLON: From my experience, most units did not attend
  14     these sorts of case conferences.
  15   MISS GREY: If we look at UBHT 84/177, it gives us the
  16     reference: Cardiac Services Management Board meeting on
  17     Monday, 25th October 1993.
  18        Over the page, back again, please, we can see
  19     there that there is a discussion on throughput through
  20     the unit. You are minuted as saying you need to address
  21     efficiency issues throughout the whole system and
  22     improving entry to the system was important, but it
  23     would not work if it resulted in blocked beds in ITU due
  24     to case selection.
  25        What was the issue of case selection that you were

   1     discussing there?
   2   DR UNDERWOOD: I am just reading it. (Pause) If I remember
   3     rightly, this was the first or one of the first meetings
   4     of this group, so I think it was one of the first times
   5     that a cardiologist in the form of Dr Pitts-Crick had
   6     been present at these management meetings.
   7        My recollection is that we were discussing
   8     generally throughput through the intensive care and that
   9     it was helpful for me to point out that the cardiologist
  10     had some influence on the bed situation in intensive
  11     care in that if we did a run of emergency or urgent
  12     patients, they could be expected to be in intensive care
  13     a little longer than the routine patients, and this
  14     could result in a blockage in intensive care causing
  15     cancellation of other operations.
  16        I was keen to explain that, because I felt that
  17     the cardiologists may not have appreciated that there
  18     were blockages occurring further down the line, and
  19     I think it probably followed discussion about the
  20     cardiologist passing work to the surgeons and maybe
  21     about the balance of urgent and emergency patients and
  22     patients who had been waiting in hospital and so on.
  23   Q. Was there any concern over case selection in the sense
  24     that there was a feeling that cases were being selected
  25     for operation which should not have been because, for

   1     instance, the case was really too dire to be amenable to
   2     surgical correction?
   3   A. I think in general their decision about which case
   4     should be selected for operation is made between the
   5     cardiologists and the cardiac surgeon, and perhaps
   6     including the general practitioner, but not the
   7     anaesthetist.
   8   Q. I appreciate it is not a matter for the anaesthetist to
   9     select that, but nevertheless, in general discussions
  10     amongst colleagues, had that been an issue of concern in
  11     any way?
  12   A. I do not think that was a particular issue here.
  13   Q. Dr Pitts-Crick is an adult cardiologist?
  14   A. Yes.
  15   Q. Were there any issues or concerns that you can remember
  16     relating to case selections for children?
  17   A. No, I do not remember any discussion on children's case
  18     selection.
  19   Q. If we go back to page 7 of your statement, please, at
  20     issue F6 you talk there about your experience of
  21     operating as part of a team in theatre.
  22        You mention there that your experience had been of
  23     shorter operations in cardiopulmonary bypass times, and
  24     you were particularly concerned when circulatory arrest
  25     times exceeded 45 minutes.

   1        Why was that a point at which your concerns would
   2     be particularly raised?
   3   A. During my training it was emphasised that that could be
   4     associated with poorer outcome, and this was the figure
   5     that had stuck in my mind from my training time.
   6   Q. So it is a rough rule of thumb, is it?
   7   A. I would say that is fair, yes.
   8   MISS GREY: Dr Scallon, would you like to come in on that?
   9     Is there a point at which a concern would be
  10     particularly raised?
  11   DR SCALLON: I think circulatory arrest is essential in some
  12     operations, but it does carry a price. The short answer
  13     is that the less circulatory arrest you have, the
  14     better. What is considered to be a reasonable period of
  15     circulatory arrest? Well, 45 minutes is generally
  16     accepted as a reasonable period, but it by no means
  17     means that 44 minutes is okay and 46 minutes is
  18     unsatisfactory. The risk of damage to various organs
  19     increases with the longer duration of circulatory
  20     arrest, and the organ most of at risk of damage is the
  21     brain.
  22   Q. So 45 minutes might be a rough point at which concerns
  23     might be triggered as a rough rule of thumb, but it has
  24     no particular special magic?
  25   DR SCALLON: No special magic, no.

   1   Q. If we look at INQ 16/22 we can see at paragraph 5.8 that
   2     the reviewers saw relatively long cross-clamp times and
   3     circulatory arrest times. "Such times would be unusual
   4     in the current era but not necessarily so in the past."
   5        What was your perception of the comparison between
   6     Bristol and Great Ormond Street at the time?
   7   DR UNDERWOOD: I think it is hard -- well, it is impossible
   8     to answer without imposing some of the thoughts I had in
   9     intervening years, but my memory at the time is that
  10     I felt that the operations were longer and that the
  11     cross-clamp times tended to be longer than I had been
  12     used to at Great Ormond Street.
  13        I did discuss that with my colleagues as I have
  14     written, and I do understand that the operation must be
  15     completed technically very carefully and very well,
  16     otherwise obviously a disaster is likely, so that taking
  17     a cross-clamp time out of context may be unhelpful.
  18   Q. So when you say in your statement that you discussed
  19     this with your colleagues, both anaesthetic and
  20     surgical, on an informal basis, was that the response
  21     that you had firstly from the surgeons?
  22   A. Yes. A surgeon would discuss with us anything that we
  23     wished to ask about the operation, really, and in saying
  24     that I felt that cross-clamp times were a bit longer
  25     than I was used to, I do not remember specific

   1     conversation, but I recall general conversations in
   2     which we would discuss the fact that the technical
   3     completion of the operation is of paramount importance
   4     and that if that resulted in a slightly longer
   5     cross-clamp time, so long as the myocardium was properly
   6     protected, that could be a sensible way of proceeding
   7     with the operation.
   8   Q. Dr Pryn, in giving evidence, was drawing comparison
   9     between Mr Pawade and Mr Wisheart and Mr Dhasmana in
  10     terms of speed of surgery.
  11        Did you have an opportunity to observe Mr Pawade
  12     in the operating theatre?
  13   A. I did anaesthetise for Mr Pawade on a number of
  14     occasions, yes.
  15   Q. Did you find him to be a quicker surgeon?
  16   A. My general impression would have been that the
  17     operations he did were shorter, but I have not compared
  18     the types of operations that we were doing at that
  19     time. I worked with him only from June until December
  20     1995.
  21   Q. So you are saying you have not studied the case mix at
  22     the time?
  23   A. I have not studied the case mix.
  24   THE CHAIRMAN: Professor Jarman wishes to ask a question.
  25   PROFESSOR JARMAN: Relating to the cross-clamp times, you

   1     have said if the myocardium is protected, maybe it is
   2     not such a bad thing if they are too long. But what
   3     about the point that Dr Scallon has just raised with
   4     regard to the effect on the brain? Could a longer
   5     cross-clamp time affect the brain while not affecting
   6     the heart if it is properly protected?
   7   A. The cross-clamp time would not be related to the
   8     neurological outcome really, because the circulation
   9     would be maintained by the perfusionists to the body,
  10     all except for the myocardium.
  11   MISS GREY: Dr Scallon, would you like to comment on that?
  12   DR SCALLON: The cross-clamp time refers to the time when
  13     the heart is not being supplied with blood. It does not
  14     follow that the rest of the body is not being perfused
  15     at that time, so they are really separate issues.
  16   PROFESSOR JARMAN: So it is really only a question of the
  17     time of cardiac arrest we are dealing with, circulatory
  18     arrest?
  19   A. Yes.
  20   THE CHAIRMAN: Bypass time.
  21   DR SCALLON: The cross-clamp time refers to the period when
  22     the myocardium is not getting blood. The circulatory
  23     arrest time refers to the time when the whole body is
  24     not being perfused. The bypass time is when the heart
  25     is being perfused by the cardio pulmonary bypass

   1     machine.
   2   MISS GREY: So the concern about brain damage relates to the
   3     period of circulatory arrest, rather than the period of
   4     the time when the heart alone is not being perfused?
   5   DR SCALLON: They are independent, yes.
   6   MISS GREY: If we look back again at paragraph 5.8, the
   7     clinical case reviewers said that such time would be
   8     unusual in the current era, but not necessarily so in
   9     the past.
  10        Dr Scallon, you reviewed the notes as part of the
  11     exercise. Can you help us what the "past" meant,
  12     because here we are looking at a period from 1991
  13     onwards and the comparison is being made with Great
  14     Ormond Street. Are you able to help us as to whether or
  15     not it might have been felt by the team that by October
  16     1991 onwards, the cross-clamp times and bypass times
  17     were long in Bristol?
  18   DR SCALLON: I think the general impression was that the
  19     cross-clamp times and bypass times were much longer in
  20     Bristol than elsewhere.
  21        "Such times would be unusual in the current era,
  22     but not necessarily so in the past"? I am not sure
  23     I entirely agree with that. I think as surgery has got
  24     better, so it has become better, so operations tend to
  25     be faster, but I do not think there is a major

   1     difference.
   2   Q. Just coming back to your answer, what we have on the
   3     transcript was that you said "I think the general
   4     impression was that the cross-clamp times and bypass
   5     times were much longer in Bristol than elsewhere"; is
   6     that correct?
   7   DR SCALLON: Yes.
   8   MISS GREY: Dr Pryn in giving evidence -- I am looking at
   9     WIT 341/23, paragraph 11, please -- referred to the
  10     children needing higher amounts of inotropic support
  11     after cardiopulmonary bypass than he was accustomed to.
  12     Was that something that you were aware of?
  13   DR UNDERWOOD: I do not remember it striking me when
  14     I arrived in Bristol. I had seen some children on
  15     little support and others on a lot of support in my time
  16     at Great Ormond Street and I continued to see that in
  17     the BRI, some requiring a lot and some not, so it was
  18     not something that struck me in the same way that it
  19     appears to have struck Dr Pryn in that statement.
  20   Q. Did you ever have any conversations about such a subject
  21     with Dr Bolsin?
  22   A. I do not remember discussing inotropic support with
  23     Dr Bolsin particularly.
  24   Q. If we go back to the clinical case review, please, at
  25     INQ 16/12, and scroll to "Perfusion", we can see that

   1     one of the most frequent comments concerned acidosis,
   2     i.e. an unacceptable buildup of acid in the patient
   3     during the operation.
   4        Dr Scallon, can you help us on the significance of
   5     this observation?
   6   DR SCALLON: The development of acidosis suggests inadequate
   7     perfusion of the tissues and therefore abnormal
   8     metabolism. A degree of acidosis is almost inevitable
   9     during the course of cardiopulmonary bypass, and again,
  10     the longer the bypass, the more likely you are to get
  11     this acidosis. Bypass is physiologically an abnormal
  12     method of perfusion. Periods of circulatory arrest are
  13     inevitably associated with acidosis, as are periods of
  14     low flow, although in that situation the degree of
  15     acidosis may be less.
  16   Q. Does it follow that if the circulatory arrest times are
  17     long, the danger of an increased amount of acidosis is
  18     greater?
  19   A. That is correct.
  20   Q. So is there any link, then, between the observation of
  21     long bypass times and cross-clamp times and the
  22     observation that there was a greater degree of acidosis
  23     than might otherwise be expected?
  24   A. I think that is a reasonable conclusion.
  25   Q. What is the responsibility of the anaesthetist if

   1     acidosis has occurred?
   2   A. There are two things. One is to try and prevent its
   3     development and that is to try and maintain an adequate
   4     perfusion, the need for circulatory arrest, the need for
   5     low flow may prevent that at a particular time. The
   6     other thing is to correct the acidosis when it develops,
   7     to give appropriate medication to reverse the acidosis.
   8   Q. Dr Underwood, were you aware of perhaps higher instances
   9     of the build-up of acid in patients undergoing surgery
  10     at Bristol? By that I mean children.
  11   A. Yes -- I am sorry, I mean "yes" to the children part of
  12     the question. I do not remember it striking me when
  13     I arrived, but along with Dr Scallon, I agree that one
  14     of its main causes is low flow and so on, and sometimes
  15     that is necessary for surgery.
  16        I also found that in Bristol, perhaps slightly
  17     differently from my experience in Great Ormond Street --
  18     there again, it is a long time ago to be sure -- the
  19     perfusionists who were in charge of the bypass machine
  20     were, in the earlier days, reluctant to increase the
  21     blood flow on bypass machine because of the damage that
  22     that causes to the red cells and so on.
  23        Later, when new perfusionists arrived, they
  24     adopted what I considered to be the more modern approach
  25     of increasing the flow further on bypass, and I think

   1     that the problem was less common after that.
   2   DR SCALLON: That is absolutely fair. I think in the
   3     earlier days, when the perfusion machines were more
   4     traumatic to blood, there was a reluctance, as
   5     Dr Underwood said, to push the flows. The tendency now,
   6     it is accepted practice generally to try and maintain
   7     high flows during the course of the bypass.
   8   Q. Is this an issue, then, about the provision of
   9     machinery, or changes of technique amongst the
  10     perfusionists themselves?
  11   A. It is both, really. I think it is both.
  12   Q. If an unacceptable build-up of acid in the bloodstream
  13     of a patient had occurred during operation, would that
  14     have any lasting effect?
  15   A. Perhaps the acid in itself would not, but the
  16     implication that there has been inadequate perfusion and
  17     therefore low grade damage to the tissues may well have
  18     a lasting effect.
  19   THE CHAIRMAN: Mrs Howard has a question.
  20   MRS HOWARD: Dr Scallon, can I just take you back to the
  21     perfusionists? Do perfusionists work autonomously and
  22     independently in terms of decisions they make vis-a-vis
  23     the discussion we have just been having, or would you
  24     expect them to be working under the direct instruction
  25     of an anaesthetist?

   1   DR SCALLON: A lot of the work of perfusionists is dedicated
   2     to him, but he will work with the anaesthetist and will
   3     discuss difficulties such as acidosis and what to do
   4     about it. The ultimate responsibility must be with the
   5     anaesthetist and with the surgeon.
   6   MRS HOWARD: So if there were particular changes in the
   7     acidotic state of the patient during an operation, would
   8     the perfusionist be expected to make those decisions
   9     himself as to changing matters, or would he or she be
  10     waiting for a prompt from the anaesthetist?
  11   DR SCALLON: It would depend largely on the local
  12     arrangement. The perfusionist seeing that may well
  13     recognise that there is a problem and try to increase
  14     perfusion, but it may be in discussion with the
  15     anaesthetist.
  16        This all has to be taken in the context of the
  17     operation and what is required by the surgeon to enable
  18     him to do the operation. A higher flow will almost
  19     invariably mean more blood in the operative field and so
  20     may make the operation more difficult. So there is
  21     a balancing act.
  22   THE CHAIRMAN: I think Mrs Howard also has in mind that
  23     in Dr Underwood's statement -- perhaps I can address
  24     this to you, Dr Underwood. You talk in your statement
  25     of sometimes, during an operation, going to do a ward

   1     round and coming back. Maybe Miss Grey will refer to
   2     this later on. During that time, a trainee would be in
   3     charge, as it were.
   4        Could the sort of monitoring which Mrs Howard has
   5     just been referring to, and the exchange between the
   6     perfusionist and the anaesthetist, be less as it were
   7     successful on those occasions?
   8   A. Indeed, you raise a good point. In our department the
   9     perfusionists are fairly autonomous, although I agree
  10     with Dr Scallon they obviously work along with the
  11     anaesthetists in maintaining the perfusion of the
  12     patient during the operation.
  13        They also receive a lot of instruction from the
  14     surgeon who must have certain conditions in order to
  15     complete the operation, so that my perception is not
  16     that the perfusionist works for the anaesthetist in any
  17     sense, but would indeed work with the anaesthetist in
  18     many aspects.
  19        You also raised the question of the anaesthetist
  20     being absent during a period of bypass. This is not
  21     ideal and in the climate of the time, meant a choice on
  22     the part of the anaesthetist between those patients
  23     upstairs and downstairs. On occasion, the ward round
  24     did not get done because the patient in theatre needed
  25     the anaesthetist, but it was more common, as I wrote in

   1     my statement, to do the ward round at that time.
   2   MISS GREY: Dr Scallon, it might be an appropriate moment to
   3     ask you whether, in your experience, that choice was
   4     a common one for an anaesthetist, to have to choose
   5     between doing a ward round or seeing a patient who
   6     required attention in the ITU, and remaining in theatre,
   7     at that time.
   8   DR SCALLON: Yes, this dilemma did certainly arise. I have
   9     certainly experienced it myself. During the course of
  10     cardio pulmonary bypass it is undoubtedly a period
  11     when the demands on the anaesthetist are less, because
  12     a lot of the responsibility is dedicated to the
  13     perfusionist, and the anaesthetist does not leave the
  14     patient unattended; if the senior is not there, a junior
  15     anaesthetist would be present. But it is symbolic of
  16     some of the pressures of trying to run a service in the
  17     theatre and to run a service in the Intensive Care Unit.
  18   Q. We have touched upon this issue several times already
  19     this morning. Perhaps it is an appropriate moment to
  20     ask you for your comments on firstly the reasons why
  21     intensivist sessions were developed in the late 1980s or
  22     early 1990s? What was that a response to?
  23   A. I think a lot of the issues that were raised before the
  24     break by Dr Underwood outlining the difficulties of
  25     management of patients in Intensive Care Unit were by no

   1     means unique to Bristol. It was a recognition of these
   2     difficulties that undoubtedly played a large part in the
   3     push towards dedicated paediatric cardiac intensivists.
   4     As you rightly say, it is a relatively recent
   5     development, 10/15 years ago we did not have dedicated
   6     paediatric cardiac intensivists.
   7   Q. So one of the pressures it is responding to is the need
   8     to take either anaesthetists, but also perhaps surgeons
   9     as well, out of theatre to look at a patient who
  10     requires attention in ITU?
  11   A. Correct.
  12   Q. Dr Underwood, in theatre, was it a common experience to
  13     find that the surgeons were confronted with anatomy that
  14     they had not perhaps expected or visualised prior to the
  15     operation?
  16   DR UNDERWOOD: It would not be for me to comment exactly on
  17     what they were expecting, what they saw. That would
  18     have been more between them and the cardiologist, but it
  19     was my impression that on occasion they were surprised
  20     by some of the anatomy that they found.
  21   Q. On occasion? How often can you remember that happening?
  22   A. I would put it in the "from time to time" rather than
  23     "regularly".
  24   Q. When that happened, was it ever a response to call for
  25     the cardiologist to come over and have a look?

   1   A. That was rarer; partly the physical problem of coming
   2     from one hospital to another, but certainly,
   3     cardiologists did come to theatre on occasion.
   4   Q. So rarer but on occasion?
   5   A. Yes.
   6   Q. Can you help us as to how often it occurred within the
   7     context of --
   8   A. In my recollection of the cases that I was personally
   9     involved in, which would really be the only time I would
  10     know if the cardiologists had been physically present,
  11     probably a single figure number of times.
  12   Q. And that obviously relates to the occasions when you
  13     were anaesthetising?
  14   A. Exactly. I would not necessarily know if the
  15     cardiologist had come when someone else was
  16     anaesthetising.
  17   Q. You spoke about the split site. Were you aware of the
  18     practical difficulties that might be imposed on
  19     a cardiologist in coming over to theatre?
  20   A. The whole issue of the practicality of the split site
  21     was a major feature of the discussion I had with members
  22     of the department before I took a job in Bristol, and
  23     they were asking if I had any ideas of how to make two
  24     hospitals into one even before I arrived. Obviously as
  25     a Senior Registrar, I could not solve the problem, but

   1     it was already seen as a difficulty in a very practical
   2     sense.
   3   Q. Who raised it as a difficulty? Did you, or did they?
   4   A. I think everybody knew that it was physically two
   5     hospitals, and it was a topic around which there was
   6     much discussion for a new member thinking of joining the
   7     department.
   8   Q. So when you discussed it you mean with anaesthetic
   9     colleagues; is that right?
  10   A. Particularly with anaesthetic colleagues.
  11   Q. What was it suggested its effect was on patient care?
  12   A. I think at that stage it was in a pre-interview
  13     discussion and people were asking me what I would think,
  14     whether there were potential difficulties, and those
  15     would be of a very practical nature of not being
  16     surrounded in a hospital by people with paediatric
  17     interests who could assist in backing up if things
  18     became difficult.
  19        The expertise for cardiac surgery and cardiac
  20     anaesthesia was at the BRI, but the other aspects of
  21     paediatric care, general paediatric physicians, as well
  22     as cardiologists and other paediatric facilities, were
  23     based in a different hospital.
  24   Q. You gave that answer, then, when you were applying for
  25     a job. You could foresee it was a potential problem?

   1   A. Yes.
   2   Q. After you had been in post for a few years, again always
   3     looking prior to January 1995, what was your perception
   4     of it as an actual problem?
   5   A. I think it was an actual problem. But it was my
   6     impression that before I arrived, and certainly from the
   7     time I arrived, all debate was on trying to unify the
   8     service in one site. In fact, in the period round about
   9     the time of my appointment and until 1992, the
  10     discussion revolved around the possible appointment of
  11     a further paediatric surgeon.
  12   Q. Those are, if I may say, the responses to the problem.
  13     Can you help us on identifying the nature of the
  14     problem?
  15   A. I beg your pardon, yes. From my perspective, the
  16     problem came particularly in intensive care. If
  17     a patient became a long-term patient with multiple
  18     problems, then the back-up that you would like was not
  19     easily available. It was available by telephoning or by
  20     asking colleagues up at the Children's Hospital, but to
  21     explain that a bit further, if an adult patient had some
  22     difficulty in intensive care and I would like some more
  23     information, some more help with that, I can call on
  24     a selection of adult physicians who can come readily
  25     between their clinics or after their lists to assist me

   1     in intensive care and can pop in and out frequently in
   2     the following few days.
   3        That service is much more difficult for people who
   4     are working in a hospital up the hill.
   5   Q. One of the things we have heard during the course of the
   6     Inquiry is that crises or changes in the condition of
   7     children in particular can happen very quickly.
   8        Were there occasions on which these sorts of
   9     changes were happening and your ability to get hold of
  10     a relevant specialist was compromised?
  11   A. I think the very acute things that occur in intensive
  12     care, the biggest problem was the lack of a senior
  13     physician with knowledge of cardiac surgery patients on
  14     the spot. So that sometimes, as we said earlier, there
  15     would be delay in getting the consultant anaesthetist
  16     from theatre, he would not be able to come until they
  17     had finished doing their next acute thing in theatre, so
  18     that aspect I think is also relevant.
  19   Q. If we go back to your statement, please, at page 7, you
  20     describe there the introduction of the intensivists, and
  21     at G5 you say that better co-ordination and improvement
  22     in communication were enabled by the institution of the
  23     intensive care sessions?
  24   A. Yes.
  25   Q. As it stands, then, the statement begs the question of

   1     what it was like before those sessions were introduced.
   2        We have touched on it already, but can you
   3     describe it to us?
   4   A. I think that I have already described quite a lot of
   5     what I am meaning here: the fact that it would be
   6     individuals contacting each other about individual
   7     patients and so on, there was not a senior person
   8     available on intensive care whom everybody else could
   9     speak through, and not only could speak through but who
  10     also had expertise in intensive care and the ability to
  11     carry out manoeuvres and procedures and so on as they
  12     required it pretty much instantly.
  13   Q. When the intensivist is not there for one of his
  14     sessions, you carried out a ward round later in the day
  15     once a patient was safely established on bypass. What
  16     about the surgeons? When did they carry out their
  17     wards?
  18   A. There was a business round first thing in the morning,
  19     which I think the trainee surgeons went on, and
  20     I believe that Mr Dhasmana and Mr Wisheart would go to
  21     intensive care on arrival at hospital and see their own
  22     patients. So when they came to theatre -- I think
  23     I mentioned as well that I would go to the intensive
  24     care before going to the theatre, because obviously
  25     there was no point in leaving something in intensive

   1     care to start a reasonably lengthy period in theatre,
   2     not knowing what was happening in intensive care.
   3        So I would have looked in intensive care and on
   4     occasion I was delayed starting in theatre by being on
   5     intensive care.
   6        So I would go to intensive care and then down to
   7     the theatre, and by the time the consultant surgeon
   8     came, we may be in a position to discuss any
   9     particularly burning issues related to patients of that
  10     day.
  11        Then, during the bypass period, I would go back up
  12     to the intensive care again and proceed from there.
  13   Q. If I may stop you, you say "when the consultant surgeon
  14     came"; do you mean on the morning round prior to going
  15     into theatre?
  16   A. Yes, when he arrived in theatre, I would speak to him.
  17   Q. So at that stage, when you are about to start
  18     a procedure on another patient, you can use that as
  19     an opportunity, you say, to discuss any issues arising
  20     on ITU?
  21   A. That might be a time when the two of you were passing.
  22     He would have up-to-date information from the intensive
  23     care. You would be shortly going to go there, so that
  24     was a point where you could discuss things that needed
  25     to be done or changes that were being made.

   1   Q. When Dr Pryn gave evidence, he described, and again,
   2     I am paraphrasing it in broad terms, difficulties of
   3     communication with changes in management made without
   4     necessarily being consulted on every occasion that he
   5     thought he should have been, as an intensivist or
   6     a consultant anaesthetist.
   7        What was your experience of that problem?
   8   A. Can you clarify: you mean changes made by surgeons that
   9     I may or may not have had communication with?
  10   Q. Changes made either by cardiac surgeons or alternatively
  11     by the cardiac surgical trainees on the ITU, changes in
  12     the management of a patient, that you felt were within
  13     your province and you should have been consulted about?
  14   A. I am sure that did occur on occasion, because of the
  15     nature of being in two places at once, but in general,
  16     I felt that I saw them so frequently during the day that
  17     we would exchange information.
  18   Q. Who do you mean by "them"?
  19   A. I am particularly thinking of the consultant cardiac
  20     surgeons. The trainees were on the ward round. They
  21     were less likely to make major changes without some
  22     senior input.
  23   Q. If we look at Mr Wisheart's comments on Dr Pryn's
  24     statement, WIT 341/62, please, we can see, if we go down
  25     to the last part, where he says that Dr Pryn mentions

   1     unilateral actions by surgeons and he says:
   2        "We did not discuss every decision as in addition
   3     to each having a good understanding of the way the other
   4     would work, we also had some ideas of our own spheres of
   5     responsibility and what therefore needed discussion and
   6     what did not."
   7        He says:
   8        "It is possible that our ideas or expectations in
   9     this area may not have been identical."
  10        Do you think that your ideas and expectations of
  11     what required consultation and discussion and what did
  12     not were similar or identical to those of the consult
  13     cardiac surgeons?
  14   A. Because the system ran by a lot of individuals,
  15     attempting to work together, although not physically
  16     present always at the same time, I think that I had
  17     a tendency to communicate more rather than less and try
  18     to keep the surgeon informed of what I was doing in my
  19     sphere of responsibility, and so on.
  20        I therefore felt that I generally understood what
  21     they were doing in their sphere.
  22        I think some of the responsibility of the
  23     anaesthetist and the surgeon are clear to us on
  24     intensive care , so I myself or the
  25     surgeon may make a decision and take some actions that

   1     I would not necessarily expect to be told about because
   2     they would be in the routine way of things and rather
   3     under the surgical "umbrella". So I would not feel that
   4     I had to have been told of everything.
   5        I do not think that I would particularly say that
   6     I was excluded from any communications or that I was
   7     without the knowledge of what the surgeons were planning
   8     or thinking with respect to the patients.
   9   Q. Are you saying, Dr Underwood, if I can attempt to
  10     summarise it, that you had a relatively good
  11     understanding of what changes required consultation and
  12     which did not, perhaps built out of experience with
  13     working with Mr Wisheart and Mr Dhasmana from 1991
  14     onwards?
  15   A. I felt that I got on with them well enough to know what
  16     they were likely to do and what they expected of me in
  17     terms of communication, and although the practicality of
  18     it was sometimes difficult in terms of having to run up
  19     and down stairs or find people in offices, I felt that
  20     my communication with them was, in general, very good.
  21   Q. Was the arrival of the two new intensivists, therefore,
  22     to some extent an unsettling change, even if it was one
  23     that resulted in positive change in the long-term?
  24   A. The addition of extra members to the team, I think, is
  25     always potentially unsettling. The way the system

   1     worked before involved a lot of person-to-person contact
   2     which was obviously much easier with a smaller number,
   3     but the great advantage of having expertise, senior on
   4     the spot, far outweighed, to my mind, any difficulty in
   5     getting that settled into a new system.
   6        The most difficult thing about it was the fact
   7     that it was not consistent throughout the week, so that
   8     we would have a plan of arrangements for the middle of
   9     the week which was not sustainable on the Monday and
  10     Friday. I think that was quite difficult.
  11        But as an Anaesthetic Department and as part of
  12     the anaesthetic team, I was fully supportive of trying
  13     to get the intensive care sessions, although they were
  14     only three, because I felt that this was three towards
  15     five and who knows, maybe one day towards 10, but none
  16     was none, and we could have stuck on none if we had not
  17     grasped an opportunity when we found it.
  18   Q. Do you think that the system did settle in, then, before
  19     you got five rather than three?
  20   A. I think it developed as time went by, and the
  21     responsibilities of everybody in the team became clearer
  22     to everybody else in the team.
  23        As you rightly allude to, a lot of the team
  24     arrangement before the intensivists came relied on
  25     experience of working together, and so as the new people

   1     arrived, their experience of working together with
   2     everybody else obviously gradually developed. Then,
   3     when we went to five, it simplified matters.
   4        The complications and the simplifications are more
   5     relevant for the trainees perhaps than they are for the
   6     consultants, who are there for long enough to understand
   7     how they have developed and where they are going.
   8   THE CHAIRMAN: That was a question I was going to ask of
   9     you: that this development of working patterns, of
  10     understanding, might operate at the consultants' level,
  11     but for a large period of time, does one understand
  12     trainees were operating?
  13        How is it that they were able to understand what
  14     was for whom?
  15   A. Initially the surgical trainees were the only people on
  16     the intensive care all day, so that they would undertake
  17     tasks appropriate to their training. They would be
  18     doing some more simple practical tasks. My
  19     understanding was that they might be writing in the
  20     notes, although we have heard there were some
  21     difficulties with that.
  22        Then the anaesthetists came, and because they were
  23     all in one room, and the anaesthetists tend to be more
  24     senior than the surgical SHOs, they would work together
  25     and the surgical SHO might ask for advice on matters

   1     more related to intensive care or anaesthetic.
   2        He would not tend to make decisions of a major
   3     type on surgery, but he would know where to find
   4     somebody more senior to assist if necessary.
   5        So the surgical SHO did not take a big
   6     responsibility in larger planning decision-making
   7     processes in the long-term patients, but more in the
   8     administration of the more routine patients.
   9   Q. Is it always the case that a trainee or someone who was
  10     not a consultant would recognise the difference between
  11     a major decision and some decision which was not major?
  12     In its implications or consequences, as well as --
  13   A. That could be, but all this is set against the
  14     background of the nursing staff who are one-to-one with
  15     the patient and many of whom have much more senior
  16     experience, and I think their input is vital in that
  17     respect.
  18   MISS GREY: If we look at Dr Hunter and Professor de Leval's
  19     report, UBHT 61/356, and go to the bottom of the page,
  20     please, we can see that the opinion they formed was
  21     that:357
  22        "Overall post-operative management at the Royal
  23     Infirmary appears to be highly disorganised with
  24     conflicting decisions between the surgical Senior
  25     Registrar and the SHO who do the rounds at 8.00 am, the

   1     anaesthetists who see the patients at 9.00 am and the
   2     intensivists who work three days a week."
   3        Is that a fair comment?
   4   A. I would not have phrased it like that myself. I think
   5     there are some aspects of that which are not quite
   6     fair. Anaesthetists do work all week, though, in
   7     intensive care three mornings a week.
   8   Q. But the substance of the point is that there are
   9     a number of rounds being undertaken with a potential for
  10     conflict between them?
  11   A. The number of people working in intensive care, offering
  12     input in intensive care, is always a problem and how to
  13     organise the rounds is always difficult when people have
  14     other commitments as well.
  15        The biggest confusion arises between the medical
  16     staff and the nursing staff, and when the intensivists
  17     came and really pressed on trying to document things
  18     more clearly, this helped focus the mind and improve the
  19     prescriptions to which I referred before on the charts
  20     at the ends of the beds, so that if decisions were
  21     changed for good reason, it would be clear to the
  22     nursing staff who were trying to implement them which
  23     decision was current.
  24        So I think that like many things in intensive
  25     care, this was an evolving process and at one point it

   1     is true that the rounds took place at different times.
   2        In fact, before this, there would be the junior
   3     surgical round first thing in the morning and then the
   4     anaesthetist popping in before theatre, and then the
   5     consultant surgeon arriving individually and then the
   6     anaesthetist coming on bypass and so on.
   7        So I think over the years, it has gradually
   8     improved, although, until recently, it has not been
   9     really completely co-ordinated, because it has been
  10     evolving from a situation where people were years ago
  11     popping in and out to do their best, into a team led by
  12     an intensivist now.
  13   Q. Why do you say that the greatest potential for
  14     misunderstanding is between the medical staff and the
  15     nursing staff?
  16   A. Perhaps I stray on to their territory and they would be
  17     better able to answer it, but I would imagine that the
  18     difficulty comes -- a lot of these decisions would be
  19     a correct decision, but they maybe could not occur
  20     concurrently, so if somebody felt that ventilation
  21     should be reduced to wean a patient off a ventilator and
  22     somebody else felt no, we should do some more work on
  23     the inotropes before we do that, in different
  24     circumstances it is possible that two plans would be
  25     suitable. Obviously it only works for the patient if we

   1     follow one plan.
   2        For a nurse who meets the junior folk first who
   3     says one thing and then a senior comes and says
   4     something different and another senior says something
   5     different again, all addressing the same problem, that
   6     can be difficult and sometimes it is a difficulty in
   7     describing the reasoning and the choice of plan, rather
   8     than the choice of plan.
   9        But all those things are clearer if they are
  10     written down at the end of the discussions and the
  11     current decision is clearly marked for the patient so
  12     that everybody knows this is the plan that we are doing
  13     at the moment because it has been decided amongst us
  14     that at the present time, that is the best answer.
  15   Q. But you are saying that did not always occur?
  16   A. I think, yes, that is true, that there would on occasion
  17     have been times when that did not occur. My impression
  18     and my memory is that as the years went by, this
  19     occurred more and more --
  20   Q. Less and less --
  21   A. I know myself as the years go by I write down more and
  22     more on the chart at the end of the bed to help clarify
  23     that process.
  24   Q. So the problem occurred less and less, I think is what
  25     you are saying?

   1   A. I believe that is the case, yes.
   2   Q. If we go back to your statement, please, at page 8, you
   3     start to talk there about study leave, K1. You say you
   4     have an entitlement of 30 days study leave and you use
   5     this to keep abreast?
   6   A. Yes.
   7   Q. Were you able to use your full study leave?
   8   A. Yes, I think I have, yes.
   9   Q. If we go on, please, to K6b, you say that it is your
  10     responsibility to ensure that you have the necessary
  11     anaesthetic skills to cover a new surgical procedure.
  12        What consideration was given to whether any new
  13     anaesthetic skills would be demanded when the switch
  14     programme for neonates was introduced?
  15   A. I arrived in October 1991. I believe the first neonatal
  16     switch I saw was in the spring time of 1992 -- in fact
  17     my diary can confirm, but some time after.
  18        My training, the switch operation, only a few as
  19     I recall had been done at Great Ormond Street but they
  20     were part of the normal work. When I saw such a case on
  21     my list, I assumed it was part of the normal work.
  22        I knew that there were older switches being done
  23     at the BRI; I knew that we had operated on neonates at
  24     the BRI and I did not have any input in the discussion
  25     on the switch programme, as such, so that it did not

   1     seem to me particularly surprising that such a child
   2     should appear on my routine list.
   3   Q. If we look at UBHT 54/81, we can see that the first
   4     neonatal switch operation took place at the end of
   5     January 1992?
   6   A. Yes, I think that is the case to which I refer.
   7   Q. So you anaesthetised the first neonatal switch; is that
   8     correct?
   9   A. I believe that is correct.
  10   Q. Is it implicit in your answer that there was no formal
  11     discussion amongst the anaesthetists as to whether or
  12     not new skills might be required, or any further
  13     training required, or thought required, before the
  14     neonatal switches were first undertaken?
  15   A. I think that it is fair to say that I did not anticipate
  16     any skills outside the ones I have already developed,
  17     for the reason that I said: the size of the child was
  18     within the normal range of my usual practice and the
  19     operation was within the range of the normal practice,
  20     and something which I had seen in my training.
  21   Q. You ultimately went to Birmingham in July 1993 to watch
  22     a switch operation being performed by Mr Brawn there?
  23   A. Yes.
  24   Q. You went as part of a team which included of course
  25     Mr Dhasmana and others.

   1        What, if anything, did you learn about anaesthetic
   2     technique on that visit to Birmingham?
   3   A. I went to observe, to see if there was anything
   4     different in a major way between our anaesthetic routine
   5     and theirs. I do not remember seeing anything that was
   6     really different from what we were doing. Dr Masey had
   7     been the year before and I had spoken with her obviously
   8     about the visit. I did know from that time that some of
   9     the combinations of inotropes that they chose in the
  10     post-operative period were slightly different from the
  11     ones we had used, and in fact, my recollection is that
  12     after or about that time, we did tend to change over to
  13     their version of the combination of inotropes.
  14        So when I went in the middle of 1993, it was to
  15     observe them doing that same thing which Dr Masey had
  16     described to me, and I do not remember adding anything
  17     different or extra after that particular visit.
  18   Q. You also, I think, went to Melbourne in 1995 to observe
  19     Mr Pawade at work. You went, I think, with Dr Pryn.
  20     Did you see anything there that caused you to change
  21     anaesthetic techniques at Bristol in any way?
  22   A. In fact I went with Dr Masey, at the beginning, I think
  23     it was, of 1995. We went to observe the anaesthetics
  24     and the intensive care post-operative management there,
  25     and also to see Ash Pawade at work, so we were better

   1     prepared for things that were to come in Bristol.
   2     By that time we already well knew he would be coming to
   3     join us.
   4        I do not remember anything particularly
   5     anaesthetically new. I do remember that they had the
   6     availability and in fact were using from time to time
   7     nitric oxide in their Intensive Care Unit. Other than
   8     that, I do not remember any specific anaesthetic changes
   9     that we made.
  10   Q. In the post-operative care, though: anything there?
  11   A. The nitric oxide pertains to the post-operative care.
  12   Q. That was it: no other changes in organisation or
  13     management that you brought back to Bristol?
  14   A. Not from the anaesthetic point of view.
  15   Q. More generally?
  16   A. I think seeing paediatric cardiac surgery in
  17     a children's hospital, it showed us just the difference
  18     between a children's hospital and an adult hospital,
  19     which we had seen here in our training obviously on
  20     different sites.
  21        So I do not think that there was anything else to
  22     add, except that we had both been keen from the start
  23     and remained extremely keen that the children should
  24     move to the Children's Hospital.
  25   Q. You must have watched Mr Pawade at work in the theatre.

   1     There again, did you see anything that led you to make
   2     any comparison between him and the practices at Bristol?
   3   A. I think it is difficult as an anaesthetist to comment
   4     too much on the surgery itself, because I am not there
   5     with the same view as the surgeon. He has a very
   6     routine way of going about things, from my perspective.
   7   Q. What do you mean by "routine"?
   8   A. My recollection is that he worked with the same small
   9     group of people and that they were used to his routine
  10     way of doing things. Obviously they did a lot more
  11     cases than we were used to doing, so that you might
  12     anticipate that when a case of a certain type came up,
  13     they had done another one more recently than we would
  14     have done, and so on.
  15        In that sense, I think routine is part of the
  16     greater bulk of work that they were able to do there
  17     because they were a dedicated unit in a children's
  18     hospital.
  19   Q. So there was an impression of familiarity in the cases,
  20     the procedures, the steps that would be needed to get
  21     through it that you were not so aware of at Bristol.
  22   A. I think the setting of the Children's Hospital gives
  23     a very different background than the setting of
  24     a hospital dealing with a lot of different things,
  25     particularly perhaps the more so in intensive care.

   1   Q. One of the difficulties sometimes is in the labelling of
   2     training and retraining. Do you call this "retraining",
   3     your visit to Melbourne?
   4   A. I do not know if I would call it "retraining" or not.
   5     It is part of keeping up to date and observing others.
   6     If you are a trainee anaesthetist, you would call it
   7     "training". Perhaps "further training" rather than
   8     "retraining", since it covered the same aspects that
   9     you cover in your training as a Registrar.
  10   Q. If we go back to your statement, please, page 9, you
  11     talk there, at K22, about defining an acceptable
  12     learning curve "prospectively by clear definition,
  13     minimum acceptable mortality (sic)".
  14        Was that done in the case of the switch operation
  15     at Bristol?
  16   A. I think the operations on the neonates, to have the
  17     switch operations came in amongst the other operations,
  18     as I said, in an age group with which we were dealing
  19     anyway, and an operation which we had done anyway, so
  20     I think it is quite hard to fit it into this category in
  21     a sense.
  22   Q. Was there any attempt to define what would be acceptable
  23     mortality rates for the procedure?
  24   A. I am not aware that any such figures were defined
  25     beforehand, nor that they were for any other procedures

   1     within a unit.
   2   Q. Do you think that this clear prospective definition was
   3     something which was common, or common practice, at the
   4     time?
   5   A. My recollection is that the concept of the learning
   6     curve was quite new at that time. It was certainly new
   7     to me, but I am not sure that that was because I was
   8     turning from a trainee into a consultant or because it
   9     was new to everybody. But I am aware of the things that
  10     Professor de Leval had written, or was writing after
  11     that.
  12        So to fit our cases into the scenario of
  13     a learning curve, I find difficult because at the time
  14     I did not perceive of them being in a category where
  15     that would be appropriate, as we started to do them.
  16   Q. If we go down, please, to K25b, you are saying there
  17     that the patients with most to gain and least to lose
  18     will opt for the new procedure and this may cause bias
  19     in the group having the newer treatment.
  20        Is that a theoretical comment, or is that
  21     a comment based on looking at the switch procedure in
  22     Bristol? Are you saying, in other words, that the case
  23     mix at Bristol should be regarded as being more risky or
  24     effected by the bias you talk about in this paragraph?
  25   A. If I remember correctly, this group of questions was

   1     about the learning curve itself, so this is my
   2     theoretical answer and my view in theoretical terms
   3     about a learning curve itself. As I have already said,
   4     I was not convinced at the time that our data was of
   5     that type.
   6   Q. But it is not a comment, then, on your experience at
   7     Bristol, or the case selection for the patients
   8     undergoing the arterial switch; it is a theoretical
   9     discussion of the issue of the learning curve; is that
  10     correct?
  11   A. This was my opinion on the discussion of the learning
  12     curve itself and not related to particular cases.
  13   Q. If we can turn over the page, please, you go on to
  14     discuss the issue of audit in the Anaesthetic
  15     Department.
  16        Can you just help us, please, at UBHT 81/201,
  17     there is a reference there, if we scroll down the page,
  18     please, to the PATS computer system improving
  19     dramatically with "Sue" and I think that is you, "and
  20     John Hutter's weekly audits".
  21        Can you help us as to what those are?
  22   A. There are more Sues there, but I think it is me.
  23        I do not know how often we met -- an occasional
  24     meeting of a group of people interested in trying to
  25     improve their efficiency in theatre.

   1        We had had periods -- this might refer to the
   2     other Sue. I will finish saying what I was going to say
   3     and then I will explain.
   4        We had periods where we were waiting a long time
   5     for trainee surgeons to arrive in theatre. In order to
   6     try and focus their minds on turning up, we recorded
   7     their arrival times and so on, and they did improve.
   8     This refers to Sue, John Hutter's secretary, and Sue and
   9     he may have looked at the PATS data.
  10   Q. So you were not involved in any audit of the PATS data,
  11     as you can recollect?
  12   A. No, but Mr Hutter does have a secretary called "Sue".
  13     I do not know if that refers to her.
  14   Q. I was looking at the list of attendees. You are the
  15     only "Sue" recorded as attending?
  16   A. I am recorded as not attending.
  17   Q. Yes, I apologise. If we go on to UBHT 84/140, and
  18     scroll down, please --
  19   A. I am sorry, I missed the date at the top -- 27th June,
  20     yes, thank you.
  21   Q. If we go down, and turn over the page -- I will have to
  22     come back to that reference.
  23   A. I can say something about that, if you like.
  24   Q. Yes, please.
  25   A. I was the rota co-ordinator for the Anaesthetic

   1     Department trainees at that time and I think this
   2     referred to having extra theatre sessions. I would have
   3     been able to make some comment on the availability of
   4     anaesthetists to cover extra sessions.
   5   Q. If we could just go back to your statement at page 10,
   6     you talk there, at M6 and M7, about being shown data on
   7     two occasions -- we have explored this already -- but
   8     that data was not freely circulated or easily available.
   9        What do you mean by it not being freely
  10     circulated?
  11   A. I do not remember any minutes of cardiac audit
  12     meetings. With my responsibility in the Anaesthetic
  13     Department -- I had quite a big responsibility in the
  14     rota which actually is part and parcel of the training
  15     of anaesthetic trainees, so I was drawn to the
  16     Anaesthetic Department audit meetings in those years
  17     which were, to my mind, more relevant to me at that
  18     point, and more clearly organised.
  19   Q. Can you help us with what you mean by "in those years"?
  20   A. Now the reason I go to the cardiac surgery ones is that
  21     we have the single database with the support that that
  22     requires, and we get from that, at the audit meetings,
  23     an ongoing picture of the mortality and morbidity in the
  24     different areas of cardiac surgery. That is obviously
  25     very useful in the practice of cardiac anaesthesia, and

   1     very important for us to watch, but it --
   2   Q. If I can stop you there, you are painting a picture of
   3     a contrast between the situation before you had the
   4     database and after. Before the database: what is the
   5     date on that?
   6   A. I think the complete database -- and Mr Bryan will be
   7     much better to answer this question than myself, but the
   8     complete records are at least three years of complete
   9     records, and the PATS before that offered some data for
  10     another two or three years before that. But my
  11     recollection was that at cardiac surgery meetings, the
  12     discussion was of morbidity and mortality, rather than
  13     an overview of all the figures either for a particular
  14     procedure or a particular period of time.
  15        In fact, in the Anaesthetic Department the same
  16     pertained at that time. The bigger database and the
  17     better availability of data came when we were able to
  18     get more support to help with it. I think I have
  19     mentioned later that I believe now it is one of the
  20     best.
  21   MISS GREY: Sir, perhaps that might be a convenient moment
  22     to break for lunch?
  23   THE CHAIRMAN: Yes, Miss Grey, thank you. Shall we break
  24     until 1.30?
  25   (12.50 pm)

   1               (A short break)
   2   (1.35 pm)
   3   MISS GREY: Dr Underwood, before we go back to the subject
   4     of audit, which we had touched upon, I would like to
   5     take you back, if I may, to the visit to Melbourne and
   6     ask Dr Scallon to comment on the reputation that
   7     Melbourne enjoyed in January or thereabouts of 1995, in
   8     post-operative care in particular for children.
   9   DR SCALLON: The Melbourne unit was I think one of the
  10     leaders in the development of post-operative intensive
  11     care for children who had heart surgery. They were in
  12     a sense well ahead of the rest of the world and there is
  13     no doubt that a lot of what they developed there and the
  14     ideas they developed there have had an influence in this
  15     country. They showed that well-organised intensive care
  16     is of enormous value in the post-operative management of
  17     children who have had heart surgery.
  18   Q. Were you aware that Melbourne enjoyed this reputation at
  19     the time you went there?
  20   DR UNDERWOOD: I was certainly aware that the Melbourne
  21     cardiac surgery had a very good reputation in the world,
  22     yes.
  23   Q. That is cardiac surgery?
  24   A. Including the whole cardiac surgery business, the
  25     post-operative care as well.

   1   Q. With the introduction that Dr Scallon has given, are you
   2     able to help us any further on whether you noticed any
   3     aspects of the care at Melbourne that struck you as
   4     being interesting or highly developed compared to your
   5     previous experience?
   6   A. I mentioned the slight difference in drug usage in ITU.
   7     The other thing I did not highlight there was the
   8     dedicated intensive care sessions that were filled by
   9     anaesthetists there to provide a very good
  10     post-operative service in the Intensive Care Unit.
  11   Q. How many dedicated sessions were they able to supply
  12     there?
  13   A. I would not like to say with certainty, but I would
  14     remember that it was a full-time cover and I believe it
  15     included night cover as well and probably a 24-hour
  16     cover on the Intensive Care Unit with quite senior
  17     anaesthetists.
  18   Q. So if we went to the subject on the arrival of Mr Pawade
  19     in Bristol, was post-operative intensive care something
  20     that he was keen to alter or change in any way?
  21   A. I do not know what his view would have been on that in
  22     particular, but certainly the moving of the children to
  23     the Children's Hospital, which was due to take place
  24     round about the same time as his arrival, was all part
  25     and parcel of a big improvement we hoped would come, his

   1     arrival and a closer facility with the intensive care in
   2     the setting of the Children's Hospital, and in due
   3     course, with more intensive care sessions to look after
   4     them, too, so part of a planned move to move really
   5     right up to date and ahead on the whole care of the
   6     cardiac surgical child.
   7   Q. In the period just up to October 1995, before the
   8     children ultimately, that is, moved across to the BCH
   9     for open-heart surgery, did Mr Pawade put a high level
  10     of support or personal involvement into post-operative
  11     care?
  12   A. Do you refer to the period where he operated at the
  13     BRI?
  14   Q. Yes, prior to October 1995.
  15   A. Yes, indeed, he was frequently on the intensive care in
  16     the evening, and we would discuss the patients and so
  17     on.
  18   Q. Can you help us as to the sorts of hours he was putting
  19     in at that time?
  20   A. I do not think I could comment on that. But I know when
  21     I was on call I frequently met with him and spoke with
  22     him on intensive care.
  23   Q. At what sort of hours of the day or night was that,
  24     then?
  25   A. On call, my on-call commitment in particular, that would

   1     be during the evening and into the late evening or into
   2     the night if the child was sick.
   3   Q. If we can go back, then, please, to your statement,
   4     issue M, you were talking about the availability of data
   5     and the difficulties of data collection prior to
   6     computerisation of the system.
   7        You say you did not feel you were prevented from
   8     seeing it at any stage. Leaving aside Dr Bolsin, whom
   9     we will come to in a moment, did you ever ask anyone to
  10     supply you with data?
  11   A. I do not remember asking anyone specifically for data on
  12     any particular issue, no.
  13   Q. That answer would include, then, the cardiac surgeons,
  14     Mr Wisheart and Mr Dhasmana?
  15   A. I do not remember ever asking them specifically to see
  16     their data.
  17   Q. You mentioned "Private Eye" at N8. What was the effect
  18     of the articles being published in Private Eye in May
  19     and July 1992?
  20   A. My impression was that it was causing people to feel
  21     maybe even a little irritated, to be suspicious that
  22     there were people in the unit who were giving
  23     information to such a magazine, and that made them
  24     cautious in discussing outcomes and the process of audit
  25     because they were afraid that snippets of information

   1     would appears published outside the hospital and that
   2     that would not represent what was going on in the
   3     hospital.
   4   Q. You say "such a magazine". How was Private Eye
   5     regarded?
   6   A. I think it was regarded as an entertaining magazine
   7     rather than a paper of fact.
   8   Q. When you say "people", who do you mean?
   9   A. I refer to conversations that I had with colleagues,
  10     particularly anaesthetic but also cardiac surgical
  11     colleagues, chatty conversations in coffee rooms about
  12     it, really, because I think everybody knew that to
  13     improve the audit system was important, but this was
  14     something outside of that.
  15   Q. You say "cardiac surgical colleagues". Can you give us
  16     names, please, of any people you discussed this with?
  17   A. I do remember speaking about the Private Eye articles to
  18     Mr Wisheart, or with Mr Wisheart, I should say. I do
  19     not remember who started the conversation.
  20   Q. Do you have any recollection of a discussion with
  21     Mr Dhasmana on that?
  22   A. Not specifically, but I would not be at all surprised if
  23     I had spoken with him about it.
  24   Q. If we go back to the previous page, please, and look to
  25     the bottom, M10, you say that when Dr Bolsin approached

   1     the surgeon with some data on VSD, the discussion
   2     centred around the inaccuracies of his data.
   3        You are suggesting there I think, that there were
   4     problems on the data collection or the figures that he
   5     prepared on the VSD procedures in particular?
   6   A. I did not see his data on VSD procedures. My memory now
   7     is that at some point he had some such data and that
   8     I had heard, and I do not know how, that he had shown it
   9     to some surgeons and I come back to a previous point
  10     that discussion was around inaccuracies of the data
  11     rather than about whether there was a problem in the
  12     patients with the VSD repair.
  13   Q. You had heard he had shown it to some surgeons. From
  14     whom had you heard that?
  15   A. I do not remember whom I had heard it from or who he had
  16     reported it to or spoken to about it. The reason
  17     I remember it, I believe, is because in trying to think
  18     of the issues, what I knew at the time, it highlights to
  19     me that discussion was around the difficulty of
  20     collecting data rather than about the issues that needed
  21     to be discussed.
  22   Q. You say you had heard he may have shown it to some
  23     surgeon. Which surgeons did you understand it had been
  24     shown to?
  25   A. I do not remember anything more specific than what

   1     I have written there.
   2   Q. Because Mr Wisheart has produced comments on your
   3     statement and if we look, please, at WIT 318/20 and
   4     scroll down, please, he makes the point that during the
   5     period under review, data was collected by the surgeons
   6     and was available to the clinicians.
   7        I think you have already said that you never
   8     specifically asked for any data, so you would not be in
   9     a position to comment on its availability. Is that
  10     right?
  11   A. I am sorry, I was reading, could you repeat the
  12     question?
  13   Q. I have looked at the first sentence of Mr Wisheart's
  14     comment, and you have made the point already that you
  15     never specifically asked for any data. Does it follow
  16     that you would not be in a position to comment about the
  17     availability of data to clinicians?
  18   A. I never felt that I was excluded from asking for data
  19     from the surgeons.
  20   Q. So when Mr Wisheart says that it was available to the
  21     clinicians, you have no reason to disbelieve that?
  22   A. I have no reason to disbelieve it. It is possible that
  23     that is correct.
  24   Q. He says he does not recall any question or concern about
  25     reliability of data at any time. Can you comment on

   1     that?
   2   A. I think that there was some difficulty with the
   3     perceived accuracy of the data that Dr Bolsin produced
   4     at some time, perhaps for his audit with Dr Black, or
   5     perhaps other data; I am not clear in my mind. I am
   6     clear that I was aware of some discussion about
   7     reliability of data in that setting.
   8   Q. I think Mr Wisheart's point is that he did not know
   9     anything about that issue over the accuracy of data.
  10     Are you able to help us on that perception or evidence
  11     from Mr Wisheart?
  12   A. No, I think I am not able to help on that.
  13   Q. He makes the point that he did not see Dr Bolsin's
  14     figures for VSDs until May or June 1995 and the detail
  15     on those figures until later in 1995. Again, can you
  16     comment on that?
  17   A. I think that fits with my recollection. I suspect that
  18     my vague memory, the things I was able to write down, do
  19     refer to this period where there were errors in
  20     Dr Bolsin's VSD data, according to Mr Wisheart's data.
  21   THE CHAIRMAN: Miss Grey, may I ask one question, which is
  22     to explore a little further, when you said earlier that
  23     the discussion about Dr Bolsin and his data was about
  24     the accuracy of the data rather than whether there was
  25     any problem; I think that is more or less what you said.

   1        What do you say to someone who says that there is
   2     no difference between those two propositions because
   3     whether there is any problem depends upon whether there
   4     is any good data; or are they severable in your mind?
   5   A. I think a concern having been raised, the next question
   6     was to collect sufficient reliable data to answer that
   7     concern.
   8        I do remember a meeting where Dr Bolsin raised
   9     a concern and the anaesthetists requested him, he must be
  10     concerned for some reason, could he bring some data to
  11     assist in that process.
  12        I think that it was in waiting for that data to
  13     come that I heard things around the place, but never in
  14     an audit meeting, that there were some figures for this,
  15     or maybe somebody had something for that, but it never
  16     quite added up and it never was a complete picture of
  17     the whole situation at the time.
  18   Q. Perhaps we should follow that up by turning to page 11
  19     of your statement, please, where you turn to Issue N,
  20     concerns in general, and arising out of the Chairman's
  21     question, you said, N4a, that you recall an evening
  22     meeting in winter, possibly 1993, when you think all the
  23     cardiac anaesthetists were present.
  24        Can you help us further on that meeting? What
  25     sort of a meeting was it?

   1   A. It is a meeting to which I referred in the last answer.
   2     It was a meeting of consultant anaesthetists in the
   3     cardiac section of the department at somebody's home,
   4     and my recollection is that part of the discussion that
   5     Steve Bolsin brought up was this concern over the
   6     paediatric cardiac surgery mortality and it was at that
   7     meeting that I remember -- and I would not know if
   8     I personally made the comment or somebody else did, but
   9     the group of us asked him to bring some data because we
  10     would like to see that and to be involved in taking that
  11     forward.
  12   Q. So you think it was a meeting that took place in
  13     someone's home?
  14   A. Yes.
  15   Q. Were there regular meetings of the cardiac anaesthetists
  16     at each other's homes?
  17   A. We have had over the years meetings at people's homes in
  18     order for everybody to be present.
  19   Q. Would they be called for a particular reason, or did
  20     they just take place at periodic intervals?
  21   A. They were periodic, in order for everybody to be up to
  22     date with what everybody else was doing.
  23   Q. If Dr Bolsin had been asked to present data to
  24     a meeting, what sort of a meeting was he being asked to
  25     return to?

   1   A. On this occasion, he was being asked to bring data to
   2     this relatively informal meeting, for a decision where
   3     that should go. Because it would be impossible for the
   4     group of cardiac anaesthetists to make a suggestion to
   5     the surgeons about a further investigation or audit
   6     without some more basis to a concern.
   7   Q. So he is being asked to come back to the same event as
   8     it were, the next time around?
   9   A. That is my recollection.
  10   Q. When was that scheduled to take place?
  11   A. I do not remember. It would have been usual for it to
  12     occur in a few months time.
  13   Q. Would it have been scheduled to take place at that
  14     particular meeting, or would it have been organised at
  15     a later date?
  16   A. It could have been either. The general principle was to
  17     make it on a day when as many of us could attend as
  18     possible and that is why they were convened outside
  19     their normal working hours.
  20   Q. How many tended to take place over a year?
  21   A. My recollection is that there would be somewhere between
  22     four and six in a year.
  23   Q. So between every two to three months or so?
  24   A. That is my recollection.
  25   Q. So Dr Bolsin was being asked to return to another

   1     meeting that would take place probably in two or three
   2     months time?
   3   A. That is my recollection, yes.
   4   Q. If he had data which concerned outcomes in paediatric
   5     cardiac surgery and put it in terms of patient safety
   6     and welfare, was that a sufficiently quick response to
   7     his data?
   8   A. It takes time to collect accurate data. I think that if
   9     he was able to come in two months time with that data,
  10     that would be helpful. There was nothing to stop him.
  11     Any one of us could convene such a meeting, and he or
  12     anyone else could have requested a meeting sooner if the
  13     data was available sooner.
  14   Q. Did any meetings ever take place in his house?
  15   A. I am not aware of any taking place in his house, and
  16     I did not attend any in his house.
  17   Q. Can you remember the next meeting after this one?
  18   A. I do not have any recollection of which would be the
  19     meeting after this, because I do not have a recollection
  20     of him presenting any data to that type of meeting.
  21   Q. Can you be confident that you attended the next meeting?
  22   A. It is possible that I would have missed it if I had been
  23     on leave, but if I had been in town, I would have gone
  24     to it. It is possible that I missed the next meeting,
  25     yes.

   1   Q. So how are you able to say whether or not he came back
   2     to another meeting with data to present?
   3   A. I think it likely that I would have known from my
   4     colleagues. These meetings are very well attended
   5     because they are for a small group of people
   6     specifically designed on days to be at times when
   7     everybody can get to them, and I think my working
   8     relationships with my colleagues was such that if he had
   9     arrived with some data, they would have passed that
  10     message on to me and I would have been involved.
  11   Q. And you clearly never got that message?
  12   A. I did not.
  13   Q. It sounds like a relatively informal meeting. Is it
  14     possible for anyone to raise any concern that he or she
  15     may have?
  16   A. I believe so. They are meetings among colleagues that
  17     are held outside the hospital, as I said, for practical
  18     reasons, but perhaps that makes it even easier for
  19     people to raise concerns that they have.
  20   Q. So you would not need to wait to be invited by say
  21     Dr Monk to present any issue of concern to such
  22     a meeting?
  23   A. At these meetings there are a group of peers talking to
  24     each other about concerns, about arrangements, about
  25     future plans for this group of doctors, and I would have

   1     thought that anybody would feel able to bring things up
   2     in that forum.
   3   Q. To clarify, these were specifically for the cardiac
   4     anaesthetists?
   5   A. These were solely cardiac anaesthetists.
   6   Q. If we go to Dr Bolsin's calendar of events, UBHT 61/49,
   7     he describes two meetings of the cardiac anaesthetists
   8     in 1991. Do you have any recollection of the first
   9     meeting?
  10   A. I do not remember going to any meeting including
  11     Dr Baskett, so I think not.
  12   Q. And the second meeting?
  13   A. From that description, I cannot recall.
  14   Q. Can you remember a meeting, just generally in 1991,
  15     where Dr Bolsin is voicing concerns and those are
  16     presumably discussed amongst the group without a way
  17     forward being suggested?
  18   A. My recollection is that the reason I knew of his
  19     concerns was from personal conversation with him in the
  20     general course of my work, rather than from a particular
  21     meeting.
  22   Q. We have mentioned already that the neonatal switch
  23     programme started in January 1992. After each
  24     procedure -- sticking with the neonatal switch for the
  25     moment -- in 1991 and 1992, would there be discussion as

   1     to the outcome?
   2   A. Indeed, I would discuss with the surgeon the outcome of
   3     any case, particularly if there had been a complication,
   4     and I certainly remember having discussions with
   5     Mr Dhasmana in the theatre environment, in the theatre
   6     suite, but often just the two of us, about what had
   7     occurred in any particular case and what lesson we might
   8     learn for another case.
   9   Q. Does that assume that there will be another case, or was
  10     there any discussion of whether or not the programme
  11     should continue?
  12   A. I was involved only in discussion on a case-by-case
  13     basis as an anaesthetist working in the theatre, not on
  14     an overall discussion of the programme itself in so far
  15     as that is a separate issue, but with Mr Dhasmana,
  16     I would discuss what had occurred on each occasion and
  17     I think if we had decided that we thought it not
  18     feasible to repeat a procedure, then we would have been
  19     able to make that decision.
  20   Q. If June 1992, if we look at UBHT 61/165, there was
  21     a meeting which you were not present at, at the BCH,
  22     I think, in which Dr Dhasmana presented, if we go down,
  23     the results of the arterial switch operations.
  24        Were you aware that this meeting and this
  25     discussion had taken place?

   1   A. I was not aware of this meeting. I was aware that there
   2     were meetings occurring at the Children's Hospital which
   3     surgeons and cardiologists, and I presumed others,
   4     attended.
   5   Q. If we go back to UBHT 54/81, we can see there the first
   6     five neonatal switches, taking you down to September
   7     1992. Can you recollect any particular discussion about
   8     what should happen after this run of deaths?
   9   A. I think it might be some time about then that it was
  10     decided that some more experience from elsewhere or
  11     drawing on some more experience from elsewhere would be
  12     helpful.
  13        We would have had discussion after each case, and
  14     sometimes a case we would consider had had more
  15     complications than we would anticipate, or more complex
  16     procedure than we would anticipate the next time. I do
  17     remember, for example, that the first patient had
  18     a coarctation as well as other problems, and this was
  19     not something we would anticipate meeting on the next
  20     occasion, so that it seemed reasonable to proceed with
  21     another operation. But I think after several deaths in
  22     the switch patients, that was when we decided to try and
  23     get some more outside information. Certainly it is
  24     around about that time, I believe, that Dr Masey went to
  25     the Birmingham Children's Hospital.

   1   Q. That took place, I think, in December 1992.
   2   A. Yes.
   3   Q. When Mr Dhasmana gave evidence to the GMC, I think he
   4     suggested that after the fifth neonatal switch, he
   5     discussed the case with you on the day and with yourself
   6     and Dr Masey the following day, and it was decided that
   7     the neonatal cases would stop for a while; that he would
   8     consult his colleagues at the next EPA meeting in
   9     Birmingham, and that after that, the decision was taken
  10     that Dr Masey would go with others, including
  11     Mr Dhasmana, to Birmingham.
  12        Can you recollect that taking place as
  13     a discussion?
  14   A. I do not remember that discussion specifically, but
  15     a discussion along those lines would have been quite in
  16     keeping with the way that we were discussing after each
  17     case, and as we went along, how we should proceed with
  18     the neonatal switch operations.
  19   Q. Let us take that off the screen, then.
  20        After Dr Masey had gone to Birmingham with
  21     Mr Dhasmana, can you remember a discussion between
  22     cardiac surgeons, cardiologists and yourself and
  23     Dr Masey about a resumption of the programme?
  24   A. I do not remember any specific meeting with those
  25     parties present.

   1   Q. Again, the suggestion is that it was an informal meeting
   2     of what might be called the "paediatric cardiac club",
   3     at Dr Jordan's house. Does that ring any bells with
   4     you?
   5   A. Do you have a date for it?
   6   Q. It would have taken place shortly after the visit to
   7     Birmingham in December.
   8   A. It is quite likely that I was on maternity leave then.
   9     At Dr Jordan's house? I do not remember going to any
  10     meeting at Dr Jordan's house, no.
  11   Q. The suggestion is that this meeting considered and
  12     agreed the resumption of the neonatal switch programme.
  13     Does that raise any recollection with you?
  14   A. It does not, but I was expecting, when I returned from
  15     leave, to continue doing the neonatal switch procedures,
  16     and I had discussed with Dr Masey what she had seen in
  17     Birmingham.
  18   Q. Can you remember when you came back from leave?
  19   A. Yes, April, Easter, 1993.
  20   Q. When you came back, the neonatal switch programme had
  21     been resumed and non-neonatal switch operations were
  22     also carrying on; is that right?
  23   A. That is my recollection, yes.
  24   Q. If we could look at a particular incident in May 1993,
  25     could we look at WIT 285/1, first? This is the

   1     statement of Mr Willis. If we turn on, please, it is
   2     a statement which relates to his son, Daniel. If we go
   3     on to page 8, we can see towards the bottom of the
   4     page --
   5   A. I think I have seen the statement and my name appears
   6     further on.
   7   Q. It is here. If we can turn back to page 8, at the
   8     bottom there, it starts at the beginning "Later on that
   9     evening, as we were sat by ...." And then scroll over
  10     the page, there is an account of a visit apparently from
  11     yourself, Dr Underwood?
  12   A. Yes.
  13   Q. Can you explain to us whether you think that you were
  14     involved in this incident?
  15   A. Yes, I am sure that was not me. I did not remember
  16     Daniel Willis in particular, so I checked back in my
  17     diary. I was not the anaesthetist, and in fact, I was
  18     on annual leave that week and some parts of the week
  19     before and after, so I am sure it was not me on that
  20     occasion.
  21   Q. So you think it is a case of mistaken identity?
  22   A. I believe it is, yes.
  23   Q. Can you help us as to who might have been the
  24     anaesthetist who visited the Willis family at that
  25     point?

   1   A. I understand that the anaesthetist for the operation was
   2     Dr Masey, and I think it is quite likely that she and
   3     a senior trainee anaesthetist would have been involved
   4     in the anaesthetic, and quite possibly, one or both of
   5     them with the pre-operative visit. Certainly one of
   6     them, most likely Dr Masey, would have done the
   7     pre-operative visit, but it was most unusual for the
   8     anaesthetist not to make a pre-operative visit to the child.
   9   Q. Is it possible that the trainee anaesthetist, since we
  10     have heard from Dr Masey that she did not think she was
  11     involved in this incident either, might have said
  12     something about having a child?
  13   A. We have had a succession of folk coming back to work who
  14     had children and the rotas from that period suggest
  15     there were one or two people who could have fitted that
  16     description.
  17   Q. You had just had a child at that point?
  18   A. I had a child in the year before.
  19   Q. The statement made in the statement was that whoever was
  20     involved in this incident had underlined worries or
  21     concerns about the procedure that was about to take
  22     place.
  23        In April/May 1993, when you were back in the
  24     hospital, did you have any such concerns about the
  25     paediatric cardiac operations that were taking place, in

   1     general?
   2   A. I was still bothered by the fact that the questions
   3     raised by Dr Bolsin had not been properly answered; that
   4     we did not have printed out whole sets of data for every
   5     operation and so on in the type of audit we would have
   6     nowadays, but in a day-to-day sense, I did not have
   7     a concern.
   8   Q. Did that apply to the switch procedures as well?
   9   A. Indeed, because I met with her specifically to discuss
  10     the point before I came back to work, I understood from
  11     Dr Masey that her visit to Birmingham had been helpful,
  12     confirming that the anaesthetic technique was similar
  13     and so on, and she reported to me that Mr Dhasmana had
  14     been pleased with his visit and was going to do some
  15     technical aspects of the operation, I think in
  16     a different order or a slightly different way and we
  17     were optimistic that this would improve our results.
  18   Q. Is there any possibility that you might have been
  19     genuinely concerned for a family such as the Willis
  20     family at this time, because of the difficulties that
  21     the surgeons were experiencing in the switch procedure?
  22   A. I think one is always sympathetic with a family of
  23     a child who has to undergo such a major procedure. It
  24     is impossible not to be, yes.
  25   Q. The implication in the statement, though, is that there

   1     were specific difficulties in managing this programme
   2     successfully. Did you hold any such concerns at that
   3     time?
   4   A. I felt that we were now in a position, with more
   5     information from outside, from Birmingham in particular,
   6     and that proceeding to do another case of a neonatal
   7     switch operation was a reasonable solution.
   8        As I said to you before, from the anaesthetic
   9     point of view we had been dealing with children in the
  10     neonatal age range and we had been anaesthetising for
  11     children having the switch operation, so that it was
  12     not, from my point of view, embarking on something
  13     completely new.
  14   Q. In any event, in July 1993, you also went on a visit to
  15     Birmingham, and we have discussed that already.
  16        What was that prompted by?
  17   A. I was working with Mr Dhasmana in theatre the day
  18     before, and he said he would be going to Birmingham to
  19     see some more switch procedures on the Friday. I felt
  20     it very important that we should work as a team; that if
  21     our results were going to be really good, then we must
  22     all understand each other better, and although I was not
  23     really expecting to see anything surprisingly different
  24     on the anaesthetic front, having had Dr Masey's report,
  25     I felt I would like to go with him and to focus on the

   1     anaesthetic side of things so that I could be sure that
   2     there was nothing I was missing.
   3        So I asked Dr Monk if I could be released from my
   4     other duties in the Anaesthetic Department on the
   5     Friday, in order to accompany Mr Dhasmana on the visit
   6     on that Friday.
   7   Q. Was that visit not prompted by concerns that too many
   8     children died during or shortly after switch operations?
   9   A. I think it was a continuation of the same reason that
  10     people had gone in December, to try and find from other
  11     institutions if there was a major difference between
  12     what they were doing and what we were doing.
  13   Q. But that comparison would only be relevant if you were
  14     worried about what you were doing?
  15   A. I do not think I felt particularly worried about what
  16     I was doing from the anaesthetic point of view per se,
  17     but I am always acutely aware that in the operating
  18     theatre the surgeons and anaesthetists rely wholly on
  19     one another and therefore to visit another place with an
  20     excellent reputation might be helpful to improving our
  21     own.
  22   Q. Shortly after the visit, the second visit to Birmingham
  23     in October 1993, the neonatal switch programme in fact
  24     ceased, in that the last procedure took place.
  25        Were you aware of that at the time?

   1   A. From my perspective, it was not a cessation of
   2     a programme, but I was aware, increasingly as the months
   3     went by, that no further neonatal switches had appeared
   4     on the operating list.
   5   Q. If you think that the word "programme" for neonatal
   6     switch procedures is inappropriate, can you tell us how
   7     you characterised, at the time, the distinction between
   8     carrying out neonatal and non-neonatal switches?
   9   A. I am not quite sure I follow your question.
  10   Q. I suggested to you that a neonatal switch programme had
  11     ceased and I think you quarreled with that in suggesting
  12     that there was no formal programme as such. But equally
  13     well, neonatal switch procedures had started later than
  14     non-neonatal ones.
  15        How did you see the distinction, if there was one,
  16     between carrying out neonatal and non-neonatal switch
  17     procedures, at the time?
  18   A. I was used to thinking of my anaesthetic practice as
  19     neonatal and non-neonatal because of the technical
  20     differences, for one thing, between the tiny children
  21     and the older ones, so that in my mind, there tends to
  22     be a separation between neonatal procedures and children
  23     slightly older.
  24        I quarrelled with the use of the word "programme"
  25     because to me the neonatal switch operation was another

   1     operation in the range of things that we were doing and
   2     was part of the cardiac surgery workload. It was not
   3     like the Anaesthetic Department taking on a whole new
   4     specialty that is something completely new, but for us
   5     this was encompassed within the usual range of cardiac
   6     surgery.
   7   Q. When did you first become aware of the fact that there
   8     were no other neonatal switch procedures taking place at
   9     the BRI?
  10   A. I do not remember that for sure, but I think it is
  11     likely that after two or three months I would have
  12     noticed a difference, because until then, we would have
  13     seen them appearing on the list from time to time, so
  14     that after two or three months, we might have been
  15     saying to ourselves, "That is interesting, that no
  16     neonatal switches have come on the list".
  17        What I did not know was whether that was because
  18     no patients with transposition had appeared at the
  19     Children's Hospital, or whether there had been
  20     a decision further back in the pipeline that they should
  21     not come to us for surgery.
  22   Q. It is apparent that you were not involved in any formal
  23     discussion, indeed, any discussion, with the cardiac
  24     surgeons as to whether neonatal switches should
  25     continue. Do you find that surprising?

   1   A. No, I think it is appropriate that the surgeon should
   2     decide what he is able to do well and I think that in
   3     terms of children requiring operation, it is appropriate
   4     that cardiologists and cardiac surgeons decide which is
   5     the right operation.
   6   THE CHAIRMAN: May I clarify something for myself which
   7     Miss Grey was pursuing a moment ago? You were asked
   8     whether you were aware that there was a formal cessation
   9     of the switch programme and the conversation then was
  10     around the word "programme", but for me, the import of
  11     the question is as much whether you were aware that
  12     there was a formal cessation rather than them simply not
  13     happening. I think that is what Miss Grey is seeking
  14     perhaps to elucidate in subsequent questions. I hope
  15     that helps. Maybe you will be able to speak on that to
  16     Miss Grey now.
  17   A. I was not aware of any firm decision or written
  18     statement to the fact that the neonatal switch operation
  19     should be ceased.
  20   MISS GREY: What do you mean by the word "firm"?
  21   A. I do not remember any meeting or debate resulting in
  22     a decision to stop doing the neonatal switches at that
  23     time, although I do allude in my statement to something
  24     a bit later on.
  25   Q. When you say you do not remember any firm decision,

   1     would it be more accurate to say you do not remember any
   2     decision being made?
   3   A. I think it would be fair to say I do not remember any
   4     decision on that point, yes, at that time.
   5   Q. When you say "at that time", are you referring onwards
   6     to the question of the letter sent by the anaesthetist
   7     for discussion at that stage, or to what are you
   8     referring?
   9   A. I was particularly referring to a meeting which I might
  10     have to see to refresh the date. I think it might have
  11     been at the end of 1994.
  12   Q. If we look at page 12 of your statement, is that what
  13     you are referring to?
  14   A. Yes. That is the paragraph I am referring to.
  15   Q. So December 1994, you decide not to perform any further
  16     neonatal switch procedures, but in fact there had not
  17     been any since October 1993?
  18   A. Indeed. My recollection of that meeting was the
  19     discussion, as I describe, and an agreement between
  20     those present that continuing with neonatal switch
  21     procedures would be unwise, but in fact there had been
  22     none for some time before that.
  23        But I think that was the first time that I heard
  24     any debate and result from a debate stating that.
  25   Q. So the first, as it were, formalised discussion amongst

   1     a peer group of colleagues about whether or not switch
   2     procedures should or should not be carried out?
   3   A. As far as I remember, yes.
   4   Q. Can we go back, please, to page 11 of your statement?
   5     You say that by the winter of 1993 there was growing
   6     concern amongst the cardiologists, cardiac surgeons,
   7     anaesthetists, over the mortality of the neonatal switch
   8     operations.
   9        We have just agreed that none had been scheduled
  10     for operation since October?
  11   A. Yes.
  12   Q. Why the growing concern by this time?
  13   A. I think there were different concerns by those that were
  14     more involved than those who were less involved,
  15     probably. Because I was involved with a lot of the
  16     patients, a lot of the cases, I knew after every case
  17     I discussed with Mr Dhasmana, and more importantly, he
  18     had discussed with me, so that I understood some of the
  19     reasons why people had run into complications, but the
  20     anaesthetists outside that small group would not
  21     necessarily be aware of those kind of discussions and
  22     they would be hearing that the outcomes from the
  23     neonatal switch were poor but their mortality rate was
  24     high, and they would be expressing concern that they
  25     would want to know more information.

   1   Q. Does it follow from what you are saying that you would
   2     have been happy to continue anaesthetising neonatal
   3     switch patients had any been scheduled for operation
   4     after October 1993?
   5   A. I think that if Mr Dhasmana had felt that was a suitable
   6     operation and that he felt able to perform it, then
   7     I would have supported that. The difficulty with the
   8     early switch operations that I remembered was coming
   9     across more complex anatomy than he had anticipated on
  10     occasion, so I can imagine that it would be possible
  11     that if a neonatal switch operation was posted for
  12     a date after October 1993, I could have been happy to
  13     anaesthetise, yes.
  14   Q. Why would you have been sufficiently confident that the
  15     problems had been ironed out?
  16   A. I knew that he was in constant touch with cardiologists,
  17     and everybody knew when we had come across different
  18     anatomies, those were patients more difficult for us
  19     with our limited experience, but I also knew Mr Dhasmana
  20     had done a number of switch operations with older
  21     children very successfully and that he operated on some
  22     neonates very successfully, so it did not seem
  23     unreasonable to me that it would be possible for
  24     a neonate operation to be a suitable option.
  25   Q. Does it come down to this: if Mr Dhasmana was confident

   1     about his ability to undergo an operation, you would be
   2     happy to support him in that?
   3   A. I think in general terms that could be the case,
   4     although there may be circumstances when an anaesthetist
   5     would feel it necessary to say something, or not to say
   6     something. But in general terms, I think that would be
   7     fair.
   8   Q. What sort of circumstances would have caused you to
   9     enter a caveat or to raise with a surgeon a concern
  10     about his or her competence to perform the procedure?
  11   A. I understood that Mr Dhasmana had worries about complex
  12     cases, and therefore I took it that he would consider
  13     the surgical aspects of the case and from the
  14     anaesthetic point of view, I would consider particularly
  15     those aspects of the case and then, obviously, we would
  16     work together and with other colleagues in the intensive
  17     care.
  18        So I was more focused on the anaesthetic aspect of
  19     whether a case was feasible and he on the surgical
  20     aspect.
  21   Q. So in effect, he was responsible for ensuring that he
  22     was surgically competent and if he was satisfied and you
  23     were satisfied with the sphere of your responsibility in
  24     anaesthetic procedures, then that was adequate and
  25     sufficient?

   1   A. I think my responsibility lies with my skills and my
   2     ability to do something, and I should only embark on
   3     things which I am trained in and able to perform.
   4   Q. N7 suggests that the concern was linked to the mortality
   5     of the neonatal switch patients in particular. Were
   6     there not more generalised concerns about the
   7     performance of the unit across other procedures?
   8   A. I think the generalised concerns were the ones we
   9     referred to earlier, and I still had no sight of audits
  10     which I believed were ongoing by Dr Bolsin and Dr Black.
  11   Q. Dr Bolsin had come to you since your arrival, raising
  12     questions, if I can put it like that, about the
  13     performance of the unit. Did others not come to you
  14     about that as well? More specifically, what about the
  15     nurses?
  16   A. I knew that the nurses spoke to Dr Bolsin about concerns
  17     over mortality. I had, on occasion, been asked the odd
  18     question about specifics, but I was not asked about
  19     overviews or whether I had any data on the overall
  20     picture.
  21   Q. So to what extent were you hearing, as it were, a buzz
  22     in the corridors amongst staff generally -- I put that
  23     deliberately broadly -- about the performance of the
  24     unit?
  25   A. My impression and my understanding was that Bristol was

   1     not the top cardiac centre in the UK, but that a lot of
   2     people were making efforts to improve that; that those
   3     that had management roles were attempting to unify their
   4     cardiac surgery or their paediatric cardiac surgery with
   5     the general paediatrics or in the Children's Hospital;
   6     that where people had come across difficulties they had
   7     gone elsewhere to try to learn more. Everyone was
   8     working to improve the service.
   9   Q. If we can look at a particular procedure on a particular
  10     child, this is the case of Danyele Rudge. We have
  11     a witness statement from his parents, if we look first
  12     at 340/1. We can see this is the statement of
  13     Mrs Rudge. She is talking about Danyele's case. He was
  14     born on 11th November 1992.
  15        If we go on to page 10 we can see that generally
  16     the statement concerns the position of Danyele who had
  17     a condition of transposition of the great arteries and
  18     a Sennings repair was recommended.
  19        If we scroll down, please, we can see that in that
  20     page Mrs Rudge is talking about the fact she was told in
  21     1999 that further procedures would need to take place.
  22        We can see she says at the bottom that she feels
  23     "cheated by the way we have been treated by the
  24     hospital".
  25        If we turn over the page, can I invite you to read

   1     that, please?
   2        If we go, please, to part of the medical record in
   3     the case of Danyele, and look at medical record
   4     3428/148, if we could take off the address, please,
   5     before it comes on the screen, we can see there that on
   6     the discharge summary, very briefly, there is the
   7     condition set out for Danyele: transposition of the
   8     great arteries, and secondly that a Senning operation
   9     took place in November 1993.
  10        So that would have been when Danyele was just
  11     under 1 year old, so a non-neonatal Senning procedure.
  12        The suggestion we have seen in Mrs Rudge's
  13     statement is that Mr Dhasmana would not have been
  14     confident to carry out a switch repair at that time so
  15     a Senning repair was chosen as the procedure of choice
  16     for the child.
  17        Are you able to help us on the state of
  18     Mr Dhasmana's confidence at that time and whether or not
  19     that might have been a factor influencing Danyele's
  20     care?
  21   A. I do not think I can help, because the discussion would
  22     be between cardiology and cardiac surgery and would
  23     involve a lot of information about the anatomy and the
  24     child's condition, both in the neonatal period and
  25     later.

   1   Q. Just for the sake, then, of completion, we should look,
   2     perhaps, at page 159 of the medical records. Again,
   3     please, can we take out the address? We can see there
   4     that as early as May 1993, Danyele is being accepted for
   5     Sennings repair. If we go back, please, to yet another
   6     record at page 164, we see there again a reference to
   7     him being suitable for Sennings operation, and again,
   8     the date is at the bottom of that page. Do you have
   9     that?
  10   A. Yes.
  11   Q. "17th May 1993". So does it follow that any decisions
  12     on Danyele's care as to the suitability of the Senning
  13     or switch were taken back in May 1993, from what you
  14     have seen in the records?
  15   A. I could not comment on which cardiologist or cardiac
  16     surgeon made those decisions, but obviously a neonatal
  17     switch operation was to be done as early as possible.
  18   Q. Putting the question on the basis that it was in May
  19     1993 that the decision was taken that Danyele was
  20     suitable for a Senning rather than a switch, are you
  21     able to help us on the degree of confidence being felt
  22     in the non-neonatal switch procedure at that time?
  23   A. The non-neonatal switch operations were proceeding as
  24     routine cardiac surgery operations.
  25   Q. So from what you know, would it be fair to suggest that

   1     a choice might have been made to deliberately prefer
   2     a Sennings rather than a switch, because Mr Dhasmana was
   3     concerned about his results or his abilities in the
   4     switch procedure?
   5   A. I do not have the expertise in deciding which is the
   6     better operation for a baby when it is just born and
   7     which route to go down. I think that would be more in
   8     the realms of the cardiology experience, as discussed
   9     later.
  10   Q. I appreciate that. What I am seeking to ask you is
  11     about the perception of the non-neonatal switch
  12     procedure in around May 1993, the degree of confidence
  13     felt in the programme at the time. If you cannot
  14     recollect, please say so, but I think the question is
  15     addressed to your expertise and involvement in the
  16     procedure, and not about matters of cardiological
  17     expertise.
  18   A. I think that the confidence of a surgeon to do an
  19     operation is a point for the surgeon. I could not say
  20     on his behalf.
  21   Q. Just remaining, then, with Mrs Rudge's statement,
  22     please, if we go back, please, to page 9, WIT 340/9, and
  23     look at paragraph 23, this is concerned with Danyele's
  24     condition after the operation and, indeed, in the
  25     long-term.

   1        What is being said there is that "although Danyele
   2     has learned to talk, he cannot clearly speak and my
   3     husband has been told at one of the appointments that
   4     this is because Danyele's vocal cords were damaged when
   5     he was on the ventilator.
   6        Can I come in and ask you, Dr Scallon, is this
   7     a possible consequence of requiring ventilatory
   8     support?
   9   DR SCALLON: It is most unusual. Patients, children,
  10     adults, are intubated for quite long periods of time and
  11     it is remarkable how rapidly the vocal cords do recover
  12     and the voice function recovers after the tube has been
  13     removed.
  14   Q. So does it follow that it is a possible but not a very
  15     common consequence of requiring ventilatory assistance,
  16     intubation?
  17   A. It is extremely rare. I cannot recall a case, myself.
  18     But it is a possibility.
  19   Q. Dr Underwood, are you able to help us any further as to
  20     whether or not, in Danyele's case, this might have been
  21     a consequence of the procedures at Bristol?
  22   DR UNDERWOOD: No more than Dr Scallon. I do not think
  23     I have seen, actually, a long-term vocal cord problem
  24     after intubation.
  25   Q. I should perhaps have made it clear these questions were

   1     addressed to you as the anaesthetist concerned at this
   2     particular operation. Do you have any awareness of this
   3     being spotted as a complication at the time?
   4   A. I would need to look at the notes to confirm that. I do
   5     not recall anything, but I would need to look at the
   6     notes. I do not know at what point Danyele was
   7     extubated, from memory.
   8   Q. If we can go back, then, please, to your statement,
   9     page 11, you mention there the fact that you knew that
  10     Dr Bolsin was undertaking an audit of the paediatric
  11     cardiac surgical work.
  12   A. Yes.
  13   Q. Can you remember when you became aware of that?
  14   A. I cannot remember but it was during the collecting of
  15     the data because I remember he and Dr Black and
  16     Dr Black's daughter looking for information,
  17     particularly Dr Black's daughter looking for information
  18     around the department.
  19   Q. What exactly did he tell you about it?
  20   A. I believe he referred to collecting data on paediatric
  21     cardiac surgery, which of course I was quite pleased
  22     about in a sense, because I felt that a full collection
  23     of data would be helpful.
  24   Q. If Dr Bolsin were to suggest that you saw data that he
  25     had produced on firstly the provisional switch

   1     mortality, can you recollect that?
   2   A. I do not recollect his data on switch mortality. I do
   3     remember looking at switch mortality myself with
   4     Drs Pryn and Masey a little later.
   5   Q. That would be in preparation or immediately prior to the
   6     meeting about Joshua Loveday's case; is that right?
   7   A. It was in early 1995, yes.
   8   Q. So nothing from Dr Bolsin, you think?
   9   A. I think not.
  10   Q. What about the data that he produced on the AV canal and
  11     summary tables of the results of his audit?
  12   A. I do not remember seeing any results from the audit he
  13     was undertaking and in fact it is not until reading more
  14     recently that I understood when his audit was
  15     completed. I did not understand at the time when he had
  16     completed his audit.
  17   Q. So if he were to suggest that you saw papers which laid
  18     out the results of his audit, you think he was
  19     mistaken?
  20   A. I do not recall seeing any papers.
  21   Q. Why not get a copy from him?
  22   A. I was not aware that he had finished and presented the
  23     data in any form that could be got. I knew that he had
  24     been trying to collect data, particularly Dr Black's
  25     daughter was collecting the information which I assumed

   1     would then go back to Steve Bolsin to be prepared as
   2     a more formal presentation of audit, but I was never
   3     aware that that was completed.
   4   Q. Were you happy, then, with the level of information that
   5     you had about outcomes or results in paediatric cardiac
   6     surgery?
   7   A. I was waiting for his data to come into an open forum
   8     and to be presented in front of an appropriate group of
   9     people, the whole team of cardiac surgery.
  10   Q. Why was the initiative to rest with Dr Bolsin? If these
  11     were concerns, issues about the performance of the unit,
  12     why not ask the surgeons to provide further
  13     information?
  14   A. Because at that time I attended the anaesthetic audit
  15     meetings, I was not at the cardiac surgery audit
  16     meetings. And I think it is in that forum that people
  17     would have presented results such as they had as they
  18     went along. As I say, no minutes that I received came
  19     from those meetings.
  20        I think it is not long after this, or it may be
  21     about this time, that we started to collect the data on
  22     the PATS system, and I saw that as a much better way of
  23     collecting data and trying to follow outcome as we went
  24     along, and put my energies into trying to be diligent
  25     over my part in collecting that data.

   1   Q. From a number of people we have heard talk of a meeting
   2     in a seminar room in the University, on level 7, I think
   3     in around January 1994.
   4        It seemed clear that that meeting involved both
   5     people from the cardiac surgery side and also the
   6     cardiac anaesthetists, and that Mr Wisheart presented,
   7     on a blackboard or whiteboard, figures relating to the
   8     performance of the unit in the previous year.
   9        Do you have any recollection of being at such
  10     a meeting?
  11   A. I do not have a recollection of being at such a meeting,
  12     and I am sure that if I had known of it and been in the
  13     hospital, and been at all able to go, I would have gone
  14     to it. So I think that I may have been away and there
  15     was a week again in my diary in January that I was away,
  16     or I may have been elsewhere, occupied on emergencies
  17     and been unable to go, but I do not think I was there.
  18   Q. Travelling over the evidence to the GMC, I think, was
  19     Dr Bolsin's suggestion to the GMC you were there.
  20     Dr Martin thought you were there and Mr Wisheart, when
  21     it was put to him that you were there, replied that it
  22     was very probable that you were there.
  23        Are they all mistaken?
  24   A. I think that if I could have been there, I would have,
  25     so I think it is very probable I would have been there

   1     if possible. Do you have a date for it?
   2   Q. The 20th.
   3   A. I was away that week. I was back on the 24th according
   4     to my personal diary.
   5   Q. You were away --
   6   A. Until Friday the 21st, yes.
   7   Q. Dr Monk's witness statement, WIT 105/23, paragraph 12,
   8     speaks about "in concert with Drs Pryn and Davies",
   9     withdrawing his support from the programme in late
  10     spring 1994.
  11        If we could just remember that but also turn,
  12     please, to page 25, paragraph 16, we can see there that
  13     he also talks of a policy being adopted to concentrate
  14     the paediatric work on three consultants, the third
  15     being Dr Pryn.
  16        In relation to the switch procedure, what did you
  17     understand had taken place? Had the other
  18     anaesthetists, apart from yourself and Dr Masey,
  19     withdrawn support from the switch programme?
  20   A. My perception was more that as a group of anaesthetists
  21     we felt that with limited case numbers in the category
  22     of paediatric surgery and particularly in neonatal
  23     paediatric surgery, we should focus our expertise to
  24     a fewer number of people, and I was very concerned that
  25     as the years went by, my experience in neonatal cases

   1     was low. The number of cases we did per year was quite
   2     low, and I was quite pleased that we should focus it on
   3     two or three of us, because in that way we could
   4     maintain the number of cases each.
   5        As the Cardiac Anaesthetic Department grew with
   6     Dr Pryn and Dr Davies arriving, there was obviously
   7     a danger that experience would be spread thinner, and
   8     I felt that was a worry to maintaining my personal
   9     anaesthetic skills, and I was pleased to focus on to the
  10     two or three of us to do the smaller children.
  11   Q. Did anyone amongst other cardiac anaesthetists ever
  12     express to you the thought that they had withdrawn or
  13     would cease to provide anaesthetic cover for the switch
  14     programme because of concerns about its success?
  15   A. I think that the general concern was such that the
  16     expertise should be limited to a smaller group of
  17     people. I would rather put it that way round.
  18   Q. If we look, please, at UBHT 61/7, we can see there
  19     a letter to Dr Monk, 21st June, expressing concern at
  20     the arterial switch programme. It says the mortality
  21     for this operation is apparently high.
  22        It is signed by you. Why were you happy to sign
  23     that letter -- or, why did you sign that letter I should
  24     say?
  25   A. I was happy to sign that letter. Dr Bolsin brought it

   1     to my home because I was sick and asked me, would I be
   2     prepared to sign it after reading it, so I read it
   3     carefully and I said I was because I was very keen that
   4     the anaesthetists should act as a group. I felt that if
   5     as a group we expressed a concern, if Dr Bolsin had some
   6     evidence of a concern, then to approach the unit, in
   7     particular the surgeons, with such a concern, would get
   8     a good response and we would be able to move forward and
   9     improve the service, or adjust the service as required.
  10        So I was happy to support it because I thought it
  11     was the first time Dr Bolsin had come to his peer
  12     cardiac anaesthetists to try and move the issue
  13     forward. I believed that the mortality for the
  14     operation of neonatal switch was apparently high, but
  15     not from my experience and my diaries in the older
  16     switch cases, but in order to get the group working as
  17     a team, to have an open review, I felt that this was
  18     a suitable letter to sign. We did refer to a thorough
  19     and open review of the results so far, and I felt that
  20     that was the key issue in this letter.
  21   Q. If we look at GMC 4/64, there is a slightly different
  22     version of this letter here, signed by Dr Davies, and
  23     Dr Davies alone. It talks, for instance, of increasing
  24     concern and the mortality being apparently unacceptably
  25     high.

   1   A. Yes.
   2   Q. Did you ever see this version of the letter?
   3   A. No, I do not think so.
   4   Q. So you saw the version you have just looked at and
   5     signed that?
   6   A. I believe I saw the other version and I believe that
   7     Dr Bolsin said that he had made some changes after
   8     discussion with colleagues, I think, along those lines
   9     but I was happy it was highlighting a concern and
  10     requesting an open and thorough review.
  11   Q. The letter you see was addressed to Dr Monk, as indeed
  12     is this one. Are you aware of any suggestion that it
  13     should ever have gone to any other recipient, or
  14     potential recipient?
  15   A. I was aware only that we were sending it initially to
  16     Dr Monk, with the understanding that he would then be
  17     able to use it.
  18   Q. What result do you understand this letter had?
  19   A. I do not think that it led to an open and thorough
  20     review of the results. In that sense, it was
  21     disappointing.
  22   Q. Did you ever discuss it with Mr Dhasmana?
  23   A. Did I discuss the letter with Mr Dhasmana?
  24   Q. Yes.
  25   A. I do not remember doing so.

   1   Q. Or why no open or thorough review had been taking place
   2     in response to it?
   3   A. No. I do not think I did.
   4   Q. The letter is dated 21st June.
   5   A. Yes.
   6   Q. I think it is right that you went on to anaesthetise in
   7     a non-neonatal switch operation on 30th June, only some
   8     nine days after. Why, when you want to have an open and
   9     thorough review, go on to do that?
  10   A. The case you refer to, I believe, is an older child
  11     having a switch operation. It was on the routine
  12     cardiac surgery list for which I routinely
  13     anaesthetised, so it was part of my ordinary everyday
  14     work to do that. I did not think this letter prevented
  15     me from continuing with that routine work, and indeed,
  16     my experience from my own records was that the cases of
  17     older children having switches, which I had done with
  18     Mr Dhasmana, had generally survived. In fact, looking
  19     back through my records, I think it is fair to say that
  20     from the time of my arrival until the case before the
  21     one to which you allude, all the patients had survived,
  22     so it seemed to me quite reasonable to proceed with my
  23     routine list in the routine fashion.
  24   Q. So a review had to take place, but the operations could
  25     continue whilst that was taking place?

   1   A. I understood concern with the arterial switch programme
   2     to refer particularly to the neonates. I do appreciate
   3     it does not say that in the letter, but my concern was
   4     particularly with the neonates, who, as we heard, were
   5     not being operated on in this period anyway, and
   6     I thought that if any pressure by the anaesthetists led
   7     to a more open and thorough audit, that would be
   8     helpful. But I did not think that this would mean that
   9     we should not do an operation in the next week.
  10   Q. As a matter of history, I think it is right that there
  11     were no further switch operations carried out until
  12     Joshua Loveday's case in January. What did you
  13     understand to be the status of the programme at the
  14     time?
  15   A. Again, at the time the operation was scheduled on the
  16     routine list and I was the anaesthetist for that day in
  17     that theatre. We were now narrowed down to fewer
  18     anaesthetists doing paediatrics, so it was quite usual
  19     for me to be doing a paediatric list. The results that
  20     I had in my personal diary from experience suggested
  21     that it was feasible to go ahead.
  22        However, I did know that there was more discussion
  23     in corridors and more concern, because some people were
  24     grouping all the switches together and people not
  25     acutely involved had not even realised that we were not

   1     doing neonatal switches any more, I think, and just
   2     thought that the general switch operation had poor
   3     results. So when I knew that Joshua Loveday was on the
   4     list, I embarked in the days before that in going
   5     through my own statistics, my own diaries, and then, in
   6     conjunction with Dr Masey and Dr Pryn, through the
   7     theatre records to try to resolve that question.
   8   Q. I will come back to your data if I may, in a moment, but
   9     I think between the date of this letter and, let us say,
  10     the December 1994 meeting which we have already referred
  11     to, was there not confusion in the department as to what
  12     was happening with the switch procedure?
  13   A. To my mind, I would not have expected to see any more
  14     neonatal switches on my list after a long period of not
  15     seeing any -- from October 1993 I gradually assumed
  16     I would not see any more and the meeting later in 1994
  17     confirmed that. But I was fully expecting to see all
  18     other forms of paediatric cardiac surgery on the list in
  19     the usual way.
  20   Q. Turning back to your statement, please, WIT 315/12, here
  21     is the evening meeting. I think it took place at
  22     Dr Joffe's house; is that right?
  23   A. It is, yes.
  24   Q. Can you remember why it was set up? Was it a normal
  25     meeting or did it have any specific purpose?

   1   A. I do not remember it having a specific purpose. There
   2     was a series of such meetings where cardiologists,
   3     cardiac surgeons and anaesthetists could go, would go,
   4     and all with paediatric interest. I think you referred
   5     earlier to the Paediatric Interest Group or some such
   6     name. I do not remember it having a particular title,
   7     but it was one in that series of meetings.
   8   Q. It was not then set up in order to consider the question
   9     of whether arterial switches should be allowed or should
  10     carry on, resume?
  11   A. My recollection is not that it was set up for that
  12     particular purpose, although others may have made it
  13     known that they wanted to bring that up in discussion.
  14   Q. Was there anything else discussed at that meeting?
  15   A. I believe the discussion ranged across all the complex
  16     neonatal cases, if my memory serves me right.
  17   Q. Relating to switch procedures, or the complex
  18     procedures?
  19   A. That would include the switch procedures.
  20   Q. Can you remember whether there was any specific
  21     consideration of Joshua Loveday's case? Was his name
  22     mentioned?
  23   A. I do not remember if it was at that point. From my
  24     point of view, as an anaesthetist, the first time I see
  25     the actual theatre list is the day before surgery, but

   1     there is a forward planning list on which some names
   2     appear up to three or four weeks beforehand, so it may
   3     be --
   4   Q. Is that a "yes" or a "no" to the question whether it
   5     was discussed at this meeting?
   6   A. I do not remember whether it was discussed and I may not
   7     even have known at that point that his name was coming
   8     up on the list.
   9   Q. Can you remember if any figures relating to the results
  10     of the procedure were presented to the meeting?
  11   A. I do not remember any figures written on pieces of
  12     paper, no.
  13   Q. Pieces of paper were not circulated, then, is that what
  14     you mean?
  15   A. I do not remember having any data before or during the
  16     meeting --
  17   Q. In written form, or generally?
  18   A. Generally -- but the neonatal cases of switch were small
  19     in number and there was some discussion about the
  20     neonatal switch procedures, so that the people present
  21     probably did remember all of the cases of the neonatal
  22     switches that we had done.
  23   Q. So if it was suggested that Mr Dhasmana in particular
  24     presented in a sense of talking his way through the
  25     details of each of the neonatal cases, would that accord

   1     with your recollection?
   2   A. I do not remember it specifically, but it would fit with
   3     my recollection of the meeting as a whole.
   4   Q. What about the older switches? Any discussion of
   5     those?
   6   A. I do not remember a discussion of older children at that
   7     meeting.
   8   Q. Was there any comparative data tabled at that meeting
   9     that might help you to put the results in Bristol in
  10     context?
  11   A. I do not recall that there was.
  12   Q. How easy or difficult was it to reach the conclusion
  13     that no further neonatal switch procedures should be
  14     carried out?
  15   A. I do not remember there being any dissent from that at
  16     the end of discussion. But it did entail some
  17     discussion because after considering each case, you
  18     would think that some of those cases you would be happy
  19     to repeat. So there was some discussion as to whether
  20     we should continue or not, but I do not remember there
  21     being any dissent from the fact that it would be better
  22     not to continue at the present time.
  23   Q. What about the question of the non-neonatal switches?
  24     What discussion was there of the suitability of
  25     continuing that programme?

   1   A. They could have been discussed at that meeting, but I do
   2     not have a recollection of a discussion of the children
   3     over 1 month of age at that particular meeting.
   4   Q. In general, what is the state of your recollection of
   5     that meeting?
   6   A. I can remember the venue quite well, and it was very
   7     cold. I remember there were a lot of people there and
   8     cardiac surgeons, cardiologists, anaesthetists, and
   9     I remember having a discussion about neonatal switch
  10     procedures and feeling sad that we had failed to improve
  11     our results sufficiently to proceed with the programme.
  12     But thinking that it was a reasonable summary to think
  13     that we should not continue at that point.
  14   Q. But you are not mentioning there any discussion of the
  15     non-neonatal switch procedures, or any concrete decision
  16     to continue with that particular series of cases?
  17   A. Yes. Whether it is because my memory focused so much on
  18     the neonates that I do not remember that happening or
  19     whether it did not happen, I could not say.
  20   Q. If others suggested that there had been a difficult and
  21     anxious consideration of the non-neonatal programme but
  22     that it had been decided, with your support, that that
  23     programme should continue, how do you react to that?
  24   A. I do not recall that at all, but I do know that I looked
  25     at my figures at the beginning of January and then at

   1     the figures for the rest of the unit, specifically
   2     myself going to look for the data on the non-neonatal
   3     switches, and it could well be that, with that
   4     discussion in mind, I felt it important to have
   5     information before proceeding with another non-neonatal
   6     switch, rather than just proceeding without that
   7     information.
   8   Q. So when did you start to look at the figures for the
   9     switch after the December 1994 meeting?
  10   A. I think that I looked at them in the beginning of 1995,
  11     in the first week or two in January.
  12   Q. Was that before or after you had been told or realised
  13     that a further non-neonatal switch case was scheduled to
  14     continue to take place?
  15   A. I could not say for sure because I do not know when
  16     I knew about the case on the list, but it would be round
  17     about the same time and certainly it became essential to
  18     complete the collection of the data before that, I felt.
  19   Q. Can you help us as to how far in advance of the
  20     operation on 12th January you found out that it was
  21     scheduled to take place?
  22   A. No, I cannot be sure because the forward list would give
  23     more notice than the theatre list. It would be
  24     certainly on the theatre list of the day before.
  25   Q. Was it the list that drew this to your attention, or was

   1     it because other colleagues mentioned it to you?
   2   A. I could not say.
   3   Q. Did anyone discuss the procedure with you before the
   4     meeting which we know took place on 11th January, and
   5     raise any issues or concerns about it taking place?
   6   A. It was already a point of discussion because I was
   7     summarising the data from my diary and I do not know at
   8     what point I spoke to Dr Masey, but she added hers and
   9     we spoke to Dr Pryn, because we knew he would have done
  10     some too, and then the three of us, in the few days
  11     before the operation, were looking in the theatre book
  12     and on the hospital activity to try to get a better
  13     picture or fact of what had happened in the non-neonatal
  14     switches to clarify, because there was a range of
  15     opinion as to what the results had been in that group session.
  16   Q. Did Dr Bolsin speak to you about this operation taking
  17     place?
  18   A. I do not remember him speaking to me specifically about
  19     this operation.
  20   Q. What about Dr Sheila Willetts? Did she speak to you
  21     about it?
  22   A. I do not remember her speaking to me about it.
  23   Q. Nurse Armstrong, for her part, recollects that she asked
  24     you why this could not wait for Mr Pawade. Do you
  25     remember that conversation taking place?

   1   A. I remember her speaking to me at the beginning of the
   2     day when I went to the anaesthetic room to prepare for
   3     the operation, and she was there preparing for the
   4     operation -- she was the anaesthetic nurse on that
   5     occasion -- and she asked me why we were doing this
   6     case. Obviously I could only explain from my
   7     perspective, but I explained that the results that we
   8     had in Bristol for the non-neonatal switches, the older
   9     children, were quite good, and that I therefore felt it
  10     was reasonable that we proceed with this case.
  11   Q. Had you had any dealings with Nurse Armstrong before
  12     that conversation?
  13   A. If you mean had I worked with her before, I have worked
  14     with her on a number of occasions.
  15   Q. I am sorry, in relation to this particular operation and
  16     arrangements for it?
  17   A. I do not recall anything particularly.
  18   Q. I ask you that because she gave evidence about the
  19     unwillingness of some nurses to scrub up or participate
  20     in the operation. She was asked whether there was any
  21     pressure put on her to be the anaesthetic nurse, which
  22     is the post I think she ended up fulfilling. She said,
  23     a comment was made but I cannot remember exactly by
  24     whom, therefore it was insinuated, I do not think
  25     seriously, that with two anaesthetists present, did they

   1     actually need an anaesthetic assistant? But I do not
   2     know if it was a serious comment and I cannot remember
   3     who made it. But the thought that they might carry on
   4     without an anaesthetic assistant in my view, the child
   5     was better off with me acting as an anaesthetic nurse on
   6     that day.
   7        Then the question was asked:
   8        "That type of suggestion would be likely to have
   9     come from an anaesthetist, would it not?"
  10        Answer: Yes.
  11        Question: A consultant anaesthetist?
  12        Answer: I really do not remember who made that
  13     comment."
  14        Did you have any discussion with her?
  15   A. No, I would never have contemplated giving an
  16     anaesthetic without an anaesthetic nurse or operating
  17     department assistant, particularly not a complex child
  18     cardiac case. I would never have contemplated that, and
  19     I cannot think that I would ever have said that.
  20   Q. Even if supported by whoever it was who was supporting
  21     you, would it be a Registrar?
  22   A. Yes, but he is a trainee, and an anaesthetic nurse or an
  23     ODA has a completely different experience from a trainee
  24     anaesthetist, and complements the anaesthetist in the
  25     skills that they have, and I would not contemplate it in

   1     general, as I say, let alone in a case with complex
   2     monitoring, to embark on a case, and with two
   3     anaesthetists and no anaesthetic nurse.
   4   Q. You have spoken about data collection. If we look,
   5     please, at GMC 16/106, did you have any input into the
   6     preparation of this data?
   7   A. Yes. This is the data that we were collecting in the
   8     few days before the meeting.
   9   Q. So you collected that together with Dr Masey and
  10     Dr Pryn?
  11   A. Indeed, yes.
  12   Q. If we go, please, to UBHT 54/11, this is, I think,
  13     Dr Monk's minute of the meeting that was held on Joshua
  14     Loveday's case on the evening of 11th January?
  15   A. Yes.
  16   Q. Were you present at the meeting?
  17   A. I was not present at the meeting, no.
  18   Q. Or for any part of it?
  19   A. No, I did not attend the meeting at all. I was invited
  20     to attend it. I do not know when it was originally
  21     arranged, but I was invited to attend it at short notice
  22     and I already had a prior commitment. I did know that
  23     it was going to take place, and I obviously realised
  24     that it would be important for me to know its outcome
  25     before I embarked on anaesthesia the next day, so

   1     I arranged with Dr Monk that he would ring me in the
   2     evening and summarise the meeting for me, so I would be
   3     aware of the facts before I proceeded.
   4   Q. We will come back to that conversation, if we may, but
   5     if it was suggested that you attended for the
   6     presentation of the figures we have just seen, and their
   7     agreement, but left after that, that would be wrong,
   8     would it?
   9   A. I am sure that I did not attend any part of the meeting.
  10   Q. It is obviously fair to note -- this was the purpose of
  11     showing you the minute -- that you are not listed as an
  12     attendee on that record of attendance.
  13   A. In fact, it is interesting, I only realised yesterday it
  14     was held at the BCH. I had always assumed it was held
  15     at the BRI, but I did not go to it.
  16   Q. For the sake of completing the picture, if we turned up
  17     Dr Martin's minute, again the record of attendees would
  18     not include you.
  19        You spoke then to Dr Monk after the meeting had
  20     taken place. What did he tell you?
  21   A. I cannot remember his words verbatim, but he described
  22     to me that the meeting was in an agreement that we
  23     proceed with the case the next day that there had been
  24     some discussion, but that the consensus was at the end
  25     of the meeting that we should proceed and therefore he

   1     was quite happy that I proceed to give the anaesthetic
   2     the next day.
   3        I spoke to him rather than the others because he
   4     was the Director of the Anaesthetic Department at the
   5     time.
   6   Q. Had you any knowledge of Dr Martin's cardiological
   7     assessment of Joshua Loveday?
   8   A. It is very difficult for me to remember what I knew
   9     then, and what I have picked up since, because obviously
  10     I have read a lot and heard a lot since then. My
  11     recollection was that this was a relatively urgent
  12     operation.
  13   Q. Did you know any details of when Dr Martin had last seen
  14     Joshua?
  15   A. I would have seen that in the notes when I went to my
  16     pre-operative assessments.
  17   Q. If you had seen that then, would you have known at the
  18     time, therefore, that Joshua had last been seen by
  19     Dr Martin in November 1994?
  20   A. I could have known that, then. I would certainly have
  21     read the notes in the ward before I visited the patient.
  22   Q. So if it was apparent in the notes, you would have known
  23     it at the time?
  24   A. I hope so. I would certainly have read the notes
  25     carefully before I saw the patient.

   1   Q. If he had not seen Joshua since November 1994, and we
   2     will assume that to be the case for the moment, what
   3     conclusion would you have drawn from that?
   4   A. I think the decision on when to do surgery is again made
   5     at the other end of the spectrum from me, between
   6     cardiology and cardiac surgery, and my involvement comes
   7     when I see the patient listed for an operation, and I am
   8     looking much more in the notes for the condition of the
   9     patient, the anatomy, the blood flows and so on, the
  10     technical information that is in the notes, and then
  11     I am assessing whether there are any anaesthetic
  12     implications, what they are, how I am going to deal with
  13     them and so on, and I am focusing much more on whether
  14     there are any other reasons from an anaesthetic point of
  15     view, such an intercurrent disease, coughs, colds and so
  16     on, whether I should proceed or not.
  17   Q. How do you get adequate information on that?
  18   A. That is what I assess, in my pre-operative assessment,
  19     in the case of children by meeting their parents.
  20   Q. So it is a judgment you can form from your own knowledge
  21     on the basis of the visit you yourself make; is that
  22     right?
  23   A. I think the main reasons for an anaesthetist to proceed
  24     or cancel operations, yes.
  25   Q. Can you remember, when you made a pre-operative visit to

   1     Joshua and possibly his parents, did it take place
   2     before or after the meeting we have just discussed?
   3   A. It would have taken place before the meeting.
   4   Q. Can you remember if you saw his parents?
   5   A. I am pretty sure I did.
   6   Q. Would you have felt it necessary to say anything about
   7     the nature of the procedure or its timing to them?
   8   A. I do not think that would have been within my remit.
   9   Q. Why not?
  10   A. Because, as I say, the timing of the procedure is much
  11     more related to the cardiology and cardiac surgery
  12     aspects of it than it is to anaesthesia. I would know
  13     more if I could see the anaesthetic chart, because
  14     I always relied on the anaesthetic chart.
  15   Q. We can bring up Joshua's notes, if that helps,
  16     certainly. First of all, if we turn first to MR 164/15,
  17     that is just to show you there, we have the record
  18     there, a brief note, "seen by anaesthetist", so there is
  19     a short record of a pre-operative visit. We have, if we
  20     turn to page 8 -- do you want to look through that,
  21     first of all, Dr Underwood?
  22   THE CHAIRMAN: It is not on the screen, yet.
  23   MISS GREY: It should be on the screen now. Do you need to
  24     look through any of that?
  25   A. The words down the side are actually from the

   1     page behind, it is a folded document. (Pause). That is
   2     my writing, and that suggests to me that I did make the
   3     pre-operative assessment. I had a senior trainee
   4     working with me that day.
   5   Q. That is Dr Berry, is it?
   6   A. Indeed, yes, but it was me who made the pre-operative
   7     visit. He may also have done, but I obviously did
   8     myself.
   9   Q. Looking at that, then, was there anything you felt
  10     necessary to draw either to the surgeon's or to the
  11     parents' attention?
  12   A. Not particularly. I would have described the
  13     anaesthetic activities and some of the intensive care
  14     features to the parents.
  15   Q. You made a note under "General health", I think,
  16     "Cyanosed"?
  17   A. Yes.
  18   Q. How did you form that judgment?
  19   A. That would have been either from the notes or more
  20     likely, from looking at Joshua himself.
  21   Q. Was there any measure of oxygen saturations being taken?
  22   A. I do not recall, and I do not think it was our practice
  23     at that time to do routine pre-operative saturations at
  24     that time.
  25   Q. When this operation took place, finally, it took place

   1     some six months approximately since Mr Dhasmana had last
   2     performed a switch procedure. Did you think that placed
   3     or had any implications for the appropriateness of
   4     carrying out the procedure?
   5   A. No. I think because of the wide range of operations
   6     required in paediatric cardiac surgery, it would not be
   7     unusual for the same operation to only crop up after
   8     a six-month period, and at another time, it may crop up
   9     twice in two weeks, the nature of the variability of the
  10     operations required would result in that.
  11   Q. When Dr Monk spoke to you after the meeting, and indeed,
  12     from any other source such as discussions with other
  13     colleagues about this, did you have a sense that there
  14     might be any, as it were, political pressure on
  15     Mr Dhasmana that this would be a tense operation because
  16     there were concerns about whether or not it should take
  17     place?
  18   A. I did not have those concerns so much the night before
  19     the operation, because my understanding was that the
  20     result of the meeting was a consensus, and that
  21     therefore I perhaps naively supposed that people would
  22     support this in general, as you say from a political
  23     point of view. I was already convinced that from
  24     a medical point of view, it was a reasonable decision.
  25     But on the morning of the operation, then I think it

   1     became more clear to me because I also felt some
   2     pressure that the fact of the operation having been
   3     discussed in an extraordinary meeting the night before,
   4     did add a little to the stress of the day.
   5   Q. How did that manifest itself, that pressure, on you?
   6   A. I think because you were dealing with sick people, sick
   7     patients, a lot of the time, they are used to dealing
   8     with a certain amount of stress, and I hoped that it did
   9     not make any difference in the actions that I took, or
  10     my judgments, once I was concentrating on preparing the
  11     anaesthetic and giving the anaesthetic, that was fine.
  12     But I --
  13   Q. If I could just stop you there, I think the question was
  14     directed at, and it was badly phrased, I apologise, who
  15     made you feel that you were under pressure and why?
  16   A. That was what I was going to say. I think that I just
  17     realised when I walked into the theatre the next
  18     morning, that there were more political implications to
  19     this than I had previously appreciated.
  20   Q. Why did you realise that?
  21   A. Perhaps because Kay, for instance, asked me, "Are you
  22     sure this is the right operation? Are you sure that it
  23     is sensible that we are doing this operation?" and so
  24     on, so you realise there is more talk about this
  25     operation than about others.

   1   Q. What was the atmosphere like in the theatre whilst the
   2     operation was proceeding?
   3   A. I think everyone concentrates on the job in hand and the
   4     politics has to be kept outside the theatre, which is
   5     why I remember sensing it as I arrived in the theatre,
   6     but I do not remember after that sensing it during the
   7     day.
   8   Q. We know that it was a very long operation. I think the
   9     operation note records that the cardiopulmonary bypass
  10     time was just under 8 hours and that sadly at the end,
  11     Joshua died.
  12        Sister Armstrong recalls after this had happened
  13     a conversation with you in which you said, apparently,
  14     that "There will be no more".
  15        Firstly, can you remember saying that?
  16   A. I have read that in her statement, and I am not certain
  17     that I recall it exactly, but I do have a general
  18     recollection of some conversation along those lines, and
  19     my recollection is that I said that there would not be
  20     any more such operations because I knew that Mr Pawade
  21     was coming in the not too distant future, a few months
  22     after this; I knew that there had been an extra
  23     discussion about proceeding with this particular case,
  24     so I could not foresee any further switch operations
  25     occurring before Mr Pawade arrived.

   1   MISS GREY: Sir, I am conscious of the time. I think that
   2     there are very few questions left for Dr Underwood, but
   3     what we do need is to have a break for perhaps a maximum
   4     of five minutes to allow the stenographers to change.
   5     I wonder if I might suggest that that be appropriate?
   6   THE CHAIRMAN: Yes, indeed, thank you for reminding me.
   7     At 3.25 we reconvene.
   8   (3.20 pm)
   9               (A short break)
  10   (3.25 pm)
  11   MISS GREY:  Thank you. Passing on then to events after
  12     this operation had taken place, can I ask you to look,
  13     please, at UBHT 61/390? This is a protocol concerning
  14     operations after the Joshua Loveday case had occurred
  15     and events afterwards, and it concerns, firstly, the
  16     period up to 1st May 1995, when Mr Pawade arrives and
  17     then, secondly, if we scroll down a little, further
  18     treatment from 1st May 1995?
  19   A. Yes.
  20   Q. Can I ask you first what knowledge did you have of this
  21     protocol at the time, that is from January to May 1995?
  22   A. I had no knowledge of this written document.
  23   Q. So when did you first see this written document?
  24   A. Yesterday.
  25   Q. You had no knowledge of this written document. Were you

   1     aware of any policy regarding which operation should
   2     take place at the BRI and which should not during this
   3     time?
   4   A. Please refresh me on the dates.
   5   Q. Well, this policy was developed after the visit of
   6     Dr Hunter and Professor de Leval and concerned events up
   7     to 1st May and thereafter the transition of work.
   8   A. I was just trying to get it into perspective. I was
   9     aware there had been some discussion at some level and
  10     that there would be some operations we would not see for
  11     a while, but since it is the surgeons who put the
  12     operations on their theatre lists, I am not surprised
  13     that I did not see this actual document at that time.
  14   Q. Have you no role or responsibility in looking at which
  15     cases are suitable for surgical operations then?
  16   A. I do not think I do have a role in choosing which cases
  17     have surgery, no.
  18   Q. Do you have any knowledge of to whom this document was
  19     circulated then?
  20   A. No. Because I have not seen the document, I do not know
  21     who did see it.
  22   Q. Was there any general conversation as to how operations
  23     would be managed during this period that you can
  24     recollect?
  25   A. I do recollect that there were some operations we were

   1     not going to do until the arrival of a new surgeon, and
   2     that my memory does coincide with what is written here,
   3     the switch in particular and the AV canal.
   4   Q. Questions have been raised about an operation on one
   5     child, and if we look, please, at the medical record
   6     572, page 372 and take out the address, please --
   7   THE CHAIRMAN:  I think we may have the wrong reference.
   8   MISS GREY:  It is medical record 0572/0372.
   9   THE CHAIRMAN:  I am receiving signals that that is not
  10     showing up as a medical record.
  11   MISS GREY:  It is on my copy, but perhaps I can do this
  12     without the necessity of looking at the medical
  13     records.
  14        A child who was born in November of 1993 and was
  15     operated upon by Mr Wisheart on 1st May 1995, that child
  16     had a coarctation of the aorta and by the time this
  17     third procedure took place, two previous operations for
  18     the repair of the coarctation had already taken place
  19     performed by Mr Wisheart. You were the anaesthetist for
  20     that operation. Do you have any recollection of that?
  21   A. Some, yes.
  22   Q. How do you feel that operation fits within the terms of
  23     this protocol that we are looking at here?
  24   A. Which has gone, but the age of the child was over 1
  25     year; it was a procedure about which there had not been

   1     any particular concern; and it was a patient who already
   2     had been operated on by Mr Wisheart in the past. Those
   3     things I did know at the time of the surgery, and so
   4     I was not surprised to see the child on my routine
   5     operating list.
   6   Q. If you had been surprised, if you thought that it was
   7     not within what you had understood about which
   8     procedures were to be carried out, what would you have
   9     done?
  10   A. I could go and see Mr Wisheart the day before and speak
  11     to him about it. Certainly if I came across things on
  12     the list, patients who were not optimised for surgery or
  13     who had coughs or colds or anything like that, where
  14     I had a concern that I should take some action
  15     pre-operatively, then I would seek out the appropriate
  16     consultant surgeon and discuss that with them, and
  17     explain that I could not give an anaesthetic because of
  18     this or that reason. So I was quite used to going to
  19     find them to discuss problems of a clinical nature with
  20     them.
  21   Q. So would you have done so, if you had thought this
  22     operation should not have taken place, because it was
  23     the sort of surgery you were not seeing at the time?
  24   A. Could you clarify "surgery"?
  25   Q. Would you have gone to see Mr Wisheart if you had

   1     thought this surgery was of a type that it had been
   2     agreed would not be carried on at the UBHT pending
   3     Mr Pawade's arrival?
   4   A. Yes, I could have gone to speak to him.
   5   Q. If it is up on the screen again, we can see the protocol
   6     says, firstly:
   7        "Mr Wisheart will continue to operate on children
   8     over 1 year of age for all conditions excluding the AV
   9     canal".
  10        Is that the category in which you think this child
  11     fitted?
  12   A. No, he would not have fitted into that category by
  13     virtue of his age or the condition requiring operation.
  14   Q. You mean, in other words, the operation could continue
  15     with Mr Wisheart on children for that sort of procedure
  16     or what? Why did he not fit into that category?
  17   A. He was over 1 year of age and did not have an AV canal
  18     defect.
  19   Q. In other words, he was one of those cases on which
  20     Mr Wisheart could continue to operate?
  21   A. Indeed, yes.
  22   Q. However, the operation did take place on 1st May.
  23     That was the day on which Mr Pawade arrived at the UBHT;
  24     is that right?
  25   A. Yes, I believe that is the case.

   1   Q. What we see from 1st May is we see there will be
   2     discussion of Mr Wisheart's outstanding waiting list and
   3     the transfer of patients will be agreed. Mr Wisheart
   4     will continue to operate on a few children in the couple
   5     of months following the 1st May where the parents,
   6     children and cardiologists wish?
   7   A. Yes.
   8   Q. What did you know about that policy at the time?
   9   A. I did not know anything about this written document
  10     here. I did know Mr Pawade was coming at the beginning
  11     of May. I do not recall when he set foot in the
  12     hospital on 1st or 2nd May or indeed what date he
  13     started to operate. It would be usual practice for
  14     a new consultant to spend a few days getting used to the
  15     hospital and making sure that the scene was set for
  16     their routines and so on. So that on 1st May, when
  17     a routine case arrived on Mr Wisheart's list, the
  18     description that you made to me, then that seemed
  19     appropriate to me and did not suggest that I should take
  20     any further action.
  21   Q. What duty do you think there was on the referring
  22     cardiologists and surgeons to advise about the arrival
  23     of Mr Pawade and the possibility that another surgeon
  24     might be able to take the case on?
  25   A. I do not think I could comment on what the cardiologist

   1     thought about that. The case to which you refer was
   2     a coarctation of the aorta, requiring a re-repair, and
   3     I do not think there was any question as to the results
   4     in that category of operation at the BRI.
   5   Q. Looking at this procedure on 1st May, do you say this
   6     falls into the first or second limb of this particular
   7     policy, within 1.3 or 2.1?
   8   A. I am not sure it is for me to say since I did not read
   9     or write the policy and I do not put the patients on the
  10     list for surgery but it seemed to me quite reasonable
  11     that a child of that type should appear on the operating
  12     list and that we should continue with this usual
  13     treatment.
  14   Q. Just a few further matters then. When Mr Pawade
  15     arrived, what was it envisaged your role would be as
  16     a paediatric anaesthetist, paediatric cardiac
  17     anaesthetist?
  18   A. There was much discussion before he arrived on how we
  19     should organise ourselves to provide a good anaesthetic
  20     service, and the plan that was chosen after much
  21     discussion and many debates was that a limited number of
  22     us, and by this time it was obvious that that should be
  23     Dr Masey, Dr Pryn and myself, would be involved in
  24     anaesthetising for him, and that when he moved to the
  25     Children's Hospital later in the year, we would provide

   1     some of the anaesthetic and on-call cover for the
   2     cardiac patients in that venue until new arrangements
   3     were made.
   4   Q. Have you anaesthetised for him as anticipated while he
   5     was still at the BRI before October?
   6   A. Yes, I did anaesthetise his lists on occasion at the
   7     BRI.
   8   Q. On occasion; as you had envisaged?
   9   A. As in the usual turn of things, as the days came up,
  10     yes.
  11   Q. What about after he went to the BCH? What happened
  12     then?
  13   A. The limiting factor deciding the number of anaesthetists
  14     required to be involved in the cardiac theatre up there
  15     was really the on-call commitment to Intensive Care and
  16     so on, so that the bottom line of that was that Dr Masey
  17     and I shared a one-day list between us, so that we would
  18     go on alternate weeks on a Monday, and, in fact, with
  19     bank holidays and so on arriving on the Monday, it soon
  20     became clear to me that that was a very limited
  21     experience and now the number of paediatric cases that
  22     I was doing in a week, in a month was declining
  23     dramatically and I was very concerned about maintaining
  24     my skill and by the end of 1995 I no longer worked up
  25     there.

   1   Q. You decided in other words you were not getting enough
   2     paediatric exposure to maintain your expertise in that
   3     area; is that right?
   4   A. I felt nervous that would soon come upon me. I could
   5     see that coming. I also saw that the provision for
   6     Intensive Care and ability for the Intensive Care people
   7     up there, the medics, to expand and start to take over
   8     those sessions and run their on-call and so on was
   9     growing much faster than we had envisaged prior to the
  10     arrival of Mr Pawade. I think as that developed so
  11     quickly, it was not necessary for the system to run for
  12     me to work up there. I really had to choose between
  13     moving all my work to the Children's Hospital so as to
  14     be involved up there or all my work to the BRI to be
  15     involved there and I went to the BRI.
  16   Q. You took the latter decision?
  17   A. I did.
  18   Q. Was that a decision you took or was it forced upon you?
  19   A. After discussion with colleagues I would say that I made
  20     that choice myself.
  21   Q. Just two further points. Firstly, Dr Underwood, so that
  22     we can understand the context of your replies about
  23     concerns and knowledge of concerns, is it right that
  24     from October 1992 to April of 1993 you were away from
  25     the BRI on maternity leave?

   1   A. No, December 1992 until April 1993.
   2   Q. Thank you. After you came back in April 1993, did you
   3     then take annual leave?
   4   A. Yes. I was on annual leave -- I cannot remember off the
   5     top of my head -- for another couple of weeks around
   6     about that time. It would have been some time in May,
   7     I believe.
   8   Q. Going back to the incidents that Mr and Mrs Willis
   9     remember about the involvement of an anaesthetist or
  10     potential trainee anaesthetist, can you tell us if at
  11     the time, May 1993, any other trainee anaesthetist had
  12     a child, a baby?
  13   A. I believe that they did, and looking back on the rotas,
  14     there are certainly names on the rotas of that month of
  15     female anaesthetists who I know had had babies.
  16   Q. Of about the same age as yours?
  17   A. Quite possibly. I could tell you who made the
  18     pre-operative assessment by looking at the anaesthetic
  19     chart.
  20   Q. We do not have available at this moment that record.
  21   A. I was certainly away.
  22   MISS GREY: We can come back to you perhaps and perhaps we
  23     could ask for your assistance after today's hearing on
  24     that point. Thank you. Those are all the questions
  25     I have.

   1   THE CHAIRMAN:  The Panel have no questions.
   2     Miss O'Rourke?
   3   MISS O'ROURKE: No, sir, thank you.
   4   THE CHAIRMAN:  I am grateful to you.
   5        Miss Grey, I do not know whether you have any
   6     other matters to put to Dr Scallon or whether I should
   7     thank both of them now and move on to Mr Langstaff?
   8   MISS GREY:  It remains only to thank Dr Scallon and
   9     Dr Underwood for their help.
  10   THE CHAIRMAN:  Dr Underwood, thank you very much for being
  11     with us today. It has been very helpful to hear from
  12     you. One matter did remain unclarified or needing
  13     clarification and we were not able to help you by not
  14     being able to bring up the relevant record. So if in
  15     conversation that can be done later, Miss O'Rourke I am
  16     sure will advise you about that and then we can dot that
  17     i and cross that t, but in addition if there are any
  18     other matters that you think would help us and which we
  19     have not explored today, of course, we are always
  20     grateful to hear from you. But for the moment, thank
  21     you very much indeed. Perhaps Caroline will be able to
  22     show you out.
  23        Also thank you, Dr Scallon. As ever, you have
  24     been very helpful to us. We have not appeared to call
  25     on you a great deal, but I know you have given a great

   1     deal of advice, as it were, behind the scenes to all,
   2     and we, as ever, are very much in your debt. Thank
   3     you.
   4        Mr Langstaff?
   5          MR LANGSTAFF re proposed timetable:
   6   MR LANGSTAFF:  Sir, today, being the last day of this week,
   7     it is perhaps appropriate to look ahead at the end of
   8     this part of the Inquiry on 16th December of this year,
   9     and to announce the winter schedule, as has been
  10     arranged. What I am going to do is to identify those
  11     witnesses whom we have programmed to come and the dates
  12     upon which it is expected that they will give their
  13     evidence. I should emphasise that these are those
  14     witnesses who have either clinical commitments which
  15     require a date to be identified some time in advance or
  16     those who are likely to be attending the Inquiry over
  17     more than one day, and therefore it is important to
  18     programme at this stage, and it will be obvious that the
  19     programme does not includes a number of others who will,
  20     in fact, give evidence.
  21        We anticipate that there will be parents, further
  22     witnesses and I bear in mind that you have not yet ruled
  23     and resolved an outstanding application for recall of
  24     witnesses. All of that may also have to be programmed.
  25     So what essentially I am doing is outlining the backbone

   1     of the material which we will put before you in open
   2     session.
   3        Next week at 10.30 in the morning we will hear
   4     from Mr Robert McKinlay, who was the Chairman of the
   5     Trust from 1994 until 1996, and therefore in his term of
   6     office spanning some of the rather more interesting
   7     events that we have heard about in the last few days.
   8     He will be followed by Dr Robin Martin, consultant
   9     cardiologist at the UBHT. I regret that we do not have
  10     a statement from Dr Martin, but nonetheless invite those
  11     who have questions or material which they would wish me
  12     to put to him when he comes to do so as best they can in
  13     the absence of a formal statement to us. He will give
  14     his evidence both on Monday after Mr McKinlay and on
  15     Tuesday of next week, beginning at 9.30 in the morning.
  16        Wednesday, 17th and thus 18th, both days starting
  17     at 9.30, we expect to hear from Dr Stephen Jordan,
  18     Emeritus Consultant Cardiologist of UBHT, now retired.
  19        The following week, beginning 22nd, beginning at
  20     10.30 on the Monday, 9.30 on other days, we will hear
  21     from Dr Stephen Bolsin, the Director of Anaesthesia at
  22     the Geelong Hospital, Victoria, Australia, who is coming
  23     here, as I have indicated before, in order to give his
  24     evidence.
  25        In the week beginning 29th November, 10.30 on

   1     Monday and 9.30 on other days, as is the case for each
   2     of the weeks, we will hear from Mr Dhasmana.
   3        The week beginning 6th December, on the Monday and
   4     the Tuesday we will hear from Dr John Roylance, the
   5     second time that he will have given evidence, and on the
   6     Tuesday from Dr Norman Halliday, who has been recalled
   7     to give evidence in the particular circumstances that
   8     have since arisen surrounding his evidence.
   9        On 8th and 9th we will hear from Dr Hyam Joffe,
  10     Consultant Paediatric Cardiologist at the Bristol
  11     Children's Hospital.
  12        The last week before Christmas, that is Monday
  13     13th December -- the last week we sit before Christmas
  14     -- we will hear from Mr James Wisheart, the former
  15     Medical Director and Consultant Surgeon at the Trust.
  16        Sir, as I have indicated, those are the -- if
  17     I say principal witnesses, I hope I shall not be accused
  18     of undervaluing the evidence of the parents and others
  19     whose evidence will be shorter, but those are the longer
  20     witnesses and witnesses who, because of their
  21     commitments, we need to accommodate at this stage, who
  22     we shall be calling and when.
  23        It is thought appropriate to indicate that
  24     publicly now, with a view to aiding the preparation of
  25     others who may have an interest to put questions and

   1     past material to us, as they have done in the past, and
   2     to whom yet again I pay tribute.
   3   THE CHAIRMAN:  Thank you, Mr Langstaff. It is important
   4     that you refer to the fact that there will be
   5     opportunities to hear from witnesses in addition to
   6     these, but this is the core, if you like, of the witness
   7     programme for those who need notice, and it will, as you
   8     rightly say, take us up to the close of Phase I of this
   9     Public Inquiry, which will be on December 16th.
  10        But until Monday when we hear, therefore, from
  11     Mr McKinlay and others, thank you very much and good
  12     afternoon to everyone and good afternoon to you.
  13     (Adjourned until 10.30 am on Monday, 15th November 1999)
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   4     DR SUE UNDERWOOD (Sworn)
   5        Examined by MISS GREY ....................... 6
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   7     MR LANGSTAFF re proposed timetable ................ 183
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Published by the Bristol Royal Infirmary Inquiry, July 2001
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