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 difficul