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 16th November 1999 The Bristol Royal Infirmary Inquiry oral hearings this week focus on the Directorate of Cardiology, United Bristol Healthcare NHS Trust (UBHT). Today we continued to hear evidence from Dr Robin Martin, Consultant Cardiologist, UBHT. He began by describing the auditing and discussion of audit data within the cardiac unit in Bristol and commented on the scope for comparison against other centres providing infant and neo-natal cardiac surgery. He recalled the discussion which took place regarding the unification of paediatric cardiac surgery on one site and the proposed appointment of a dedicated paediatric surgeon. He continued to discuss the problems of providing a service between two sites, and confirmed his responsibility as a cardiologist being primarily one of assessment pre-operatively. Dr Martin then gave the Inquiry examples of his weekly timetable, including visits made to outpatient clinics in hospitals away from Bristol and commented on the junior support and the standard of diagnostic equipment within the cardiac unit. He then commented on the working relationships within the cardiac services directorate. Dr Martin then turned his attention to the case of one of his patients, Joshua Loveday, who died following surgery performed by Mr Janardan Dhasmana, Consultant Cardiothoracic Surgeon, and told the Inquiry about his assessment of Joshua’s condition. He concluded his evidence by commenting on written evidence included in statements from parents of children who underwent surgery in Bristol and reports on cases reviewed by independent experts in the Inquiry’s Clinical Case Note Review. Eric Silove, Consultant Paediatric Cardiologist, Birmingham Children’s Hospital and Mr Philip Deverall, retired Consultant Paediatric Surgeon, attended today’s hearing as members of the Inquiry’s Expert Group.

FULL TRANSCRIPT

   1                Day 77, Tuesday, 16th November 1999
   2   (9.35 am)
   3   THE CHAIRMAN: Good morning, everyone.
   4   MR LANGSTAFF: Good morning, sir.
   5            DR ROBIN MARTIN (recalled)
   6         Examined by MR LANGSTAFF (continued)
   7   Q. Dr Martin, we were talking yesterday evening about audit
   8     and about the reaction to the Private Eye Articles.
   9     During the 1990s, after Trust status the contractual
  10     responsibility was placed, was it not, upon every
  11     consultant in his contract to take part in medical audit
  12     as it then was?
  13   A. (Witness nodding).
  14   Q. Tell me, what formally as opposed to informally took
  15     place after July 1992 when, as you were able to tell us
  16     yesterday, it seems that the audit meetings that had
  17     been conducted fell into disuse?
  18   A. The mortality meetings, the pathology meetings continued
  19     on a regular basis throughout 1993/1994. So each case
  20     would be discussed specifically, cases that had died
  21     surgically, cases that had been referred in for
  22     assessment to the pathologists would be discussed,
  23     foetal cases that had died either by therapeutic
  24     termination, they would all be discussed.
  25        We carried on auditing figures and results for

   1     certain parts of our speciality, certainly the foetal
   2     part of the speciality I was responsible for, we audited
   3     those results. We audited the results of cardiac
   4     catheter interventions and our cardiac catheter
   5     complications. I think it is true to say that after the
   6     Private Eye article there was a reluctance on the part
   7     of the surgeons I would say to produce surgical figures
   8     for open discussion in the previous format that we had
   9     discussed, but we did have discussion of general
  10     surgical policies and surgical issues as part of
  11     consultant meetings which tend to be held in the
  12     evening, perhaps two, three, four times a year.
  13   Q. Let us have a look at UBHT 55/127. It is an example of
  14     a series, it is of open corrections 1992 over 1 year of
  15     age.
  16        Let us have a look at the next page, 55/128.
  17     These show comparative figures between 1992, surgical
  18     figures, and the UK Cardiac Register for 1990.
  19        I cannot trace having any record of these figures
  20     or figures like this being produced in anything like
  21     this form for 1993; did it happen?
  22   A. I do not remember myself seeing these figures, though
  23     they may have been presented at one of the evening
  24     meetings, it is possible. With regard to 1993, I
  25     believe some time in early 1994 Mr Wisheart certainly

   1     presented some of those results at a joint meeting.
   2     I am not sure about 1993 itself, but early in 1994
   3     I think he presented the results up to that period.
   4   Q. If we have a look at UBHT 61/378, this is a report in
   5     its amended form by Messrs Hunter and de Leval following
   6     the Joshua Loveday incident which we will come to. This
   7     is the start of it, it is page 382.
   8        Can we go down. Number 2: "The surgeons'
   9     reticence to produce and analyse their own results ..."
  10        That is the description which Messrs Hunter and
  11     de Leval were giving in the amended report. What they
  12     are reflecting is obviously a reluctance on the part of
  13     the surgeons which I think is very much in line with
  14     what you have been saying; is that do you think a fair
  15     description of the position that had pertained since the
  16     Private Eye article?
  17   A. I did not get the impression that they were reluctant to
  18     reveal their figures, certainly not to myself, but
  19     I think they felt that that previous open format, they
  20     were worried about that following the Private Eye
  21     article.
  22   Q. Is it right or is it wrong for Messrs Hunter and
  23     de Leval to describe the picture as being one of
  24     reticence by the surgeons to produce and analyse their
  25     results?

   1   A. I think you would have to ask them that.
   2   Q. From your perception?
   3   A. My perception was that the surgeons were analysing
   4     their own results.
   5   Q. Were they reticent?
   6   A. They were not reticent.
   7   Q. About sharing the product of that analysis?
   8   A. As I say, there was reticence about the forum of sharing
   9     it, if you like, rather than the actual sharing it.
  10   Q. What am I to understand by that? The form of sharing
  11     it, how did that differ; are you saying it was put in
  12     writing before the end of --
  13   THE CHAIRMAN: I think the witness said "forum", rather than
  14     "form"; I may be wrong.
  15   A. Sorry.
  16   THE CHAIRMAN: You said "forum of sharing".
  17   MR LANGSTAFF: I beg your pardon, it is my mishearing, I am
  18     grateful.
  19        It was not shared in the forum of the meeting, how
  20     was it shared?
  21   A. I think, as I have said, we did have discussions at the
  22     evening meetings which happened a few times a year at
  23     individual consultants' houses.
  24   Q. Would those meetings include the anaesthetists?
  25   A. Quite often.

   1   Q. Would it include cardiologists?
   2   A. Yes.
   3   Q. Would it include others concerned about cardiac
   4     services?
   5   A. It would certainly include surgeons, it would usually
   6     include a cardiac radiologist, Dr Peter Wilde quite
   7     often came to those meetings.
   8   Q. Were figures circulated on paper?
   9   A. I do not recall.
  10   Q. Do you not recall it or did not it happen?
  11   A. I do not recall documents being produced at any
  12     meeting. That does not mean to say they were not there
  13     presented.
  14   Q. Sorry to press you a little bit further: not recalling
  15     is the same as not remembering; it might have happened,
  16     it might not have happened. Is what you are saying that
  17     you do not think it happened or that it might have
  18     happened but you simply cannot remember?
  19   A. I am saying I do not recall it happening.
  20   Q. If it had happened then the chances are, are they, that
  21     someone attending the meeting would have filed away the
  22     piece of paper with the figures on it?
  23   A. It is possible, but not invariable. Personally I very
  24     rarely keep pieces of paper, so there were relatively
  25     few -- I am not a great keeper of minutes and so forth

   1     of meetings et cetera. So my documentary record on
   2     these things is poor on a personal level. It would be
   3     unlikely I would keep any piece of paper if they were
   4     handed out. I cannot speak for others whether they
   5     might have done.
   6   Q. Let me ask you about other sources of collections of
   7     information. Did you at any stage take part in the
   8     collection of data for the South West and Congenital
   9     Heart Register?
  10   A. Not directly collecting data. That was organised, the
  11     setup for that was originally set up by Dr Jordan. So
  12     he arranged for -- he did the programme for the actual
  13     programme for the register and he arranged for the
  14     employment of a secretary/data clerk to input that
  15     data. The only direct input I have had to the Register
  16     myself would be there were occasional patients, usually
  17     with complex abnormalities that the coder or the
  18     secretary would have trouble coding into the coding
  19     system within the database and I would amend that so
  20     that it was in the appropriate diagnostic group. That
  21     would be my only real direct input to it.
  22   Q. What information did you get out of the Register that
  23     was helpful in auditing your own results?
  24   A. I think there were limitations with the database that we
  25     were aware of and particularly with regard to the

   1     diagnostic coding within the database, but for some
   2     broad groups it was quite useful to retrospectively
   3     identify patients with a particular abnormality.
   4        So, for instance, if I wanted to look up more
   5     patients that had been seen with a condition like
   6     hypertrophic myopathy, we could go to the database, we
   7     could get out, often after quite a long wait because it
   8     was a fairly limited programme at that stage, or
   9     certainly fairly early on, we could get out a list of
  10     patients' names with a particular diagnosis and that
  11     then would mean you could identify the patients with
  12     that condition, you could go and obtain the medical
  13     records for that group and analyse, look at them in
  14     detail retrospectively.
  15   Q. It was a means of identifying patients who suffered from
  16     the same type of condition so that you could have a look
  17     at the records, learn lessons from those, rather than
  18     a means of analysing a series of results?
  19   A. It would be very difficult to do it as far as I am aware
  20     with that programme, as it were. Certainly in its
  21     infancy it was a very difficult programme to use. It
  22     was changed at some stage in the 1990s, I am not sure of
  23     the exact date, from a very early basic programme to
  24     a programme called Paradox and that did make access
  25     a little bit quicker, but it was still rather limited in

   1     its ability to divulge data, if you like.
   2        You could not, say, analyse easily -- for
   3     instance, if I had wanted to look at all the cardiac
   4     catheter tests I had performed it would be very
   5     difficult for me to use it to look at those. To tell me
   6     what conditions I had treated et cetera, it really was
   7     not robust enough to be able to look in detail like
   8     that.
   9   Q. Let me turn to another data source: can we have a look,
  10     please at UBHT 126/125? The British Cardiovascular
  11     Intervention Society, we see that you were the person
  12     completing a form to return to the Society for
  13     1st January to 31st December 1990. If we turn overleaf
  14     we will see the nature of the forms. Go down, please.
  15     There is a recommendation made there. Turn overleaf and
  16     scroll down. You see the nature there of the return in
  17     those two pages that was made to the British
  18     Cardiovascular Intervention Society.
  19        What was the purpose of that Society and those
  20     returns?
  21   A. It is an umbrella organisation which I think is
  22     a subgroup of the British Cardiac Society and the main
  23     thrust of it I have to say would be in adult cardiology
  24     where figures were collected for cardiac catheter
  25     studies, coronary angioplasty but also certainly in the

   1     earlier years, 1991 perhaps and 1992 and they also
   2     collected information on paediatric cardiac catheter
   3     interventions. I had a particular interest in that,
   4     that was if you like one of my subspeciality areas
   5     I took on, so I took responsibility for filling in the
   6     data and returning the summary data to the Society.
   7   Q. What it would tell us is limited to catheter
   8     investigations and it does not tell us anything in
   9     respect of paediatrics after 1992; is that the position?
  10   A. I am not sure of the exact date in 1992, but the British
  11     Cardiac Intervention Society stopped collecting
  12     paediatric data at some stage around that time, it may
  13     have been the year after that, I am not sure, and there
  14     was then some discussion amongst our group, which had by
  15     then split away and become the British Paediatric
  16     Cardiac Association as to whether as a group we should
  17     be collecting data for this sort of intervention.
  18   Q. UBHT 126/139. We have the 1992 returns specifically for
  19     paediatric procedures but I cannot trace such a return
  20     in the papers we have after that.
  21   A. I think they stopped collecting paediatric data around
  22     about that time so that was a change in policy of the
  23     British Cardiac Intervention Society, so far as I am
  24     aware.
  25   Q. The sources of comparative data between Bristol as

   1     a unit and anywhere else in the country in the 1990s was
   2     what, simply the Cardiothoracic Register?
   3   A. I certainly had no comparative data from the rest of the
   4     country for paediatric interventional catheter
   5     procedures. The only data that would be available on
   6     surgical outcome would be the Registry from the Society
   7     of Cardiothoracic Surgeons. I must say I did not myself
   8     receive that data directly, that data I presume would
   9     have gone directly to the surgeons.
  10   Q. If we, with that in mind, have a look, please, at
  11     PAR 2/181.
  12        It is going back to one of the forms we saw
  13     yesterday, but this time I want to have a look at what
  14     is said in it. If you go down to"Audit Topic, Criteria
  15     Reviewed"; "Paediatric Surgical...", this is your
  16     writing, is it?
  17   A. It is, yes. It was a meeting chaired by Mr Wisheart.
  18     If you like, he presented the data at the meeting and
  19     I took some notes and prepared this.
  20   Q. It looks at the mortality over three years for various
  21     classes of operation and sets out percentages, as we
  22     see: 9 per cent for the VSDs, 20 per cent mortality for
  23     the AVSD series, 3 per cent for transposition of the
  24     great arteries; that would have been largely the Senning
  25     operation at this stage, would it?

   1   A. That would be entirely the Senning operation, I think.
   2   Q. Therefore "good results", it says. Then "poor results
   3     in TAPVD and truncus. The mortality of a closed
   4     procedure is low." By what standard were good results
   5     and poor results measured?
   6   A. It was very difficult to make an assessment of that but
   7     I think at that same meeting when Mr Wisheart presented
   8     the figures, I think he did include some comparative
   9     data from the Society of Cardiothoracic Surgeons'
  10     Register and though it is not something that was put to
  11     rigorous statistical analysis, I think just comparing
  12     areas, we felt those two areas identified there, the
  13     results were not as good as -- there was certainly room
  14     for improvement and what you have to realise is that you
  15     were looking at lots of different subgroups of
  16     operations of relatively small numbers and one always
  17     has to be wary in making these comparisons that this is
  18     a case mix. I think that was certainly something we
  19     were conscious of at that time.
  20   Q. The last point under "Inferences and Hypothesis: Need to
  21     increase infant and neonatal open cardiac workload".
  22        Help me with the reasons for that; is that again
  23     a reflection of experience, practice, making better?
  24   A. I think there was a general impression, and it is not
  25     something you can really pick out clearly from the

   1     figures but there was a general impression in the unit
   2     at that time, certainly I held it and I cannot speak for
   3     everyone else, that we would expect to see an
   4     improvement in the results for infants in neonatal work
   5     if the throughput of that particular group of operations
   6     was increased. That was our feeling at the time, that
   7     that would be a way of making an improvement to overall
   8     care and patient results.
   9   Q. If we scroll down the page: can you help me with the
  10     last part of that page, 4: "Miscellaneous group of
  11     patients with high mortality include infants with CCTGA
  12     and VSD"?
  13   A. There was a group that was classified as "miscellaneous"
  14     as part of the Surgical Register I think at that stage
  15     and that included often rare and unusual, you know,
  16     heterogeneous group of often quite rare and unusual
  17     problems. One of those fairly rare and unusual problems
  18     is CCTGA plus VSD, that is congenitally corrected
  19     transposition of the great arteries with ventricular
  20     septal defect which is a rare abnormality. I think --
  21   Q. It is the next three words; is that "query should
  22     consider"?
  23   A. Yes, "query should consider banding in that particular
  24     group", that is patients with congenitally corrected
  25     transposition with ventricular septal defect. I think

   1     it is well recognised these are quite a challenging
   2     group of patients and you may wish to ask the experts on
   3     this, but there has always been a lot of debate about
   4     the best treatment strategy for that group. It is known
   5     for instance that closing the ventricular septal defect
   6     has a high risk in that setting and we were questioning
   7     at that stage whether rather than going for primary
   8     correction of the closure of the ventricular septal
   9     defect and maybe correction of any other abnormalities,
  10     whether perhaps consideration of banding should be
  11     considered in that group of patients. It sometimes was.
  12   Q. Item number 3: "the problem of the split site identified
  13     as important in mortality of sick neonates and
  14     infants."
  15        What that appears to suggest is that the results
  16     would improve if there were no split site?
  17   A. I do not think it necessarily says that. What I think
  18     that comment was referring to is that we certainly had
  19     identified anecdotally one or two patients that had
  20     become more unstable on transfer from the childrens'
  21     hospital down to the Royal Infirmary. I think we felt
  22     that might be a factor that could potentially increase
  23     the risk of surgery in some of these patients and that
  24     was of concern.
  25        There were a number of other issues involved in

   1     the split site argument, and I suspect that is something
   2     you have talked about already, but from memory that
   3     particular comment was mainly related to anecdotal, one
   4     or two cases that we had noticed instability occurring
   5     during transfer.
   6   Q. It is the way you put it. It is not identified as
   7     a potential problem, it is identified as important in
   8     mortality. If it is important in mortality that would
   9     suggest as a matter of language, does it not, it makes
  10     a difference?
  11   A. What one writes in a document like this where perhaps
  12     you are looking at it from a legalistic point of view,
  13     is slightly different to what as a clinician I would be
  14     viewing it. I think to be strictly accurate I would
  15     probably -- I would add a "may be important" before
  16     that, but these are brief notes taken at the time of a
  17     meeting rather than, I would have to say, expecting to
  18     be a rigorous legalistic document, if you do not mind me
  19     saying.
  20   Q. I do not want to over-analyse it, it is a matter of
  21     trying to understand the English that is used rather
  22     than looking at it as a legal document. Anyway, we have
  23     your explanation for it. I will come back to the
  24     question of the split site in a moment or two, if
  25     I may.

   1   THE CHAIRMAN: May I add one further question to that,
   2     Dr Martin: you said that it might have involved one or
   3     two patients. At the risk of being accused equally of
   4     being legalistic, you say "sick neonates and infants":
   5     that might imply more than one or two?
   6   A. It is possible my use of English for this document was
   7     not as precise perhaps as it could be. I do not have
   8     enough recollection to know exact numbers, so whether it
   9     is referring to four or two or three I am not sure I can
  10     be absolutely sure.
  11   MR LANGSTAFF: Tell me, this, as we can see "figures,
  12     discussed, recorded" at a meeting, a meeting which had
  13     a report form in common with other disciplines as we saw
  14     yesterday, even though you do not recollect as the case,
  15     nothing recorded after 1993 despite your letter saying
  16     "Let us have audit meetings in 1993".
  17        Were you aware in 1993 or earlier of any concerns
  18     amongst anaesthetists about mortality figures?
  19   A. I do not remember being aware in 1993 or earlier about
  20     any concerns, certainly none were expressed to me.
  21   Q. When the Private Eye article was published, which after
  22     all was 1992, did it occur to you or any of your
  23     cardiological colleagues so far as you know that there
  24     was any concern within the unit as to the mortality
  25     results that were being produced?

   1   A. Sorry, can you repeat that for me?
   2   Q. Was there a concern about mortality figures at the time,
   3     well reflected in discussions at the time, with the
   4     Private Eye article?
   5   A. Again I cannot speak for my colleagues, but I do not
   6     think at that stage we had concerns about the overall
   7     performance of the unit. We could see areas that we
   8     thought could be improved, clinical care is constantly
   9     evolving, I think you can always see areas that you wish
  10     to improve and we felt there were areas that could be
  11     improved and the document here to a certain extent was
  12     a means of trying to advance that.
  13   Q. Which particular areas do you have in mind?
  14   A. I think we felt that the split site particularly might
  15     be an area of importance and there had been discussions
  16     over the preceding period and afterwards about unifying
  17     the site, by unifying the service on one site at the
  18     Children's Hospital. We felt that was potentially quite
  19     an important issue.
  20   Q. Was there any concern about any particular series of
  21     operations?
  22   A. When are you talking now, sir, 1990 --
  23   Q. 1992/1993.
  24   A. I think there was not particular concern about
  25     a particular group that I can remember. We were looking

   1     to improve all areas and we thought that by perhaps
   2     incorporating a unified site it was more likely we would
   3     be able to improve the care of the younger children,
   4     particularly neonates and infants, because on the site
   5     based at the Children's Hospital we would have had
   6     a full range of paediatric specialists, a greater input
   7     from paediatric nurses and we felt that might impact
   8     particularly in the younger age group. We did not know
   9     for sure, but that was an impression we had.
  10   Q. Jumping ahead for a moment from 1993. We have heard
  11     several times in this inquiry that two matters were
  12     regarded as important in advancing or improving
  13     paediatric cardiac surgery at the UBHT. One was
  14     remedying the split site by unifying the service. The
  15     second was the appointment of a consultant paediatric
  16     surgeon.
  17        Can I ask you in respect of the second because you
  18     have not mentioned that: was the appointment of such
  19     a person something which you supported?
  20   A. Yes, I think as a general impression from around the
  21     country, from around the world internationally, that
  22     having a surgeon who specialised just in paediatric
  23     cardiac surgery or congenital heart surgery might be
  24     a way of improving overall results of surgery. That is
  25     a general feeling. As I say, there is no data

   1     necessarily to support that.
   2   Q. Can I unravel that in the context of Bristol? It was
   3     felt that a specialist paediatric surgeon would improve
   4     results or might improve results?
   5   A. It was felt that it might do.
   6   Q. The accent there is on "specialist paediatric surgeon"?
   7   A. Yes, I think any surgeon -- there was a change around
   8     that time from having cardiac surgeons that did mixed
   9     practice, that is adults and paediatric practice, to
  10     those that exclusively did paediatric and congenital
  11     heart practice. That does not mean to say those that
  12     were doing adult and paediatric practice were not
  13     specialised. They were extremely specialised, all of
  14     them would have undergone specialist training in that
  15     field. But I think there was a general feeling that the
  16     more you are doing of a particular type of operation the
  17     more likely you are to be able to improve the overall
  18     outcomes. That is I think a view widely held in many
  19     fields of medicine.
  20   Q. What interests me about the decision is that it was not
  21     along the lines of "We have Mr Wisheart, we have
  22     Mr Dhasmana, both of whom do paediatric cardiac surgery
  23     and they may become specialist, they do after all have
  24     a specialism by concentrating entirely upon children and
  25     we can appoint an adult cardiac surgeon to do the adult

   1     work"; it was "Let us have a specialist paediatric
   2     cardiac surgeon". That is the flavour of it.
   3        Why else should it be thought that a specialist
   4     paediatric cardiac surgeon was necessary unless it was
   5     thought that, doing their best as they tried, perhaps
   6     Mr Wisheart and Mr Dhasmana were not producing such good
   7     results as a specialist paediatric surgeon/cardiac
   8     surgeon probably would?
   9   A. I do not think I would accept that we had any concerns
  10     that they were not performing adequately with regard to
  11     the surgical results. We were, if you like, following
  12     the general trend that people were recommending in other
  13     units. We were not ourselves feeling there was any --
  14     it was not in response to any inadequacies as we saw it
  15     in surgical practice, it was a general move that we
  16     wished to improve care for all of the children we were
  17     looking after and there was a national/international
  18     trend to move towards that and we were reflecting that
  19     trend.
  20   Q. I will put the question a different way and then I shall
  21     move on. The desire to appoint a specialist paediatric
  22     cardiac surgeon may be thought of as indicating if not
  23     a dissatisfaction with results at least a view that the
  24     results would be better in different and specialist
  25     hands. In your view, is that comment justified?

   1   A. They might be better.
   2   Q. I was talking to you when we began this discussion about
   3     the paediatric surgeon and you focused upon the split
   4     site about whether you knew of any particular concerns
   5     in paediatric cardiac surgery in 1992 and 1993. So far
   6     as your answer goes thus far, it is only in relation to
   7     the infrastructure, the split site. Was there any
   8     particular concern apart from that, of which you are
   9     aware?
  10   A. I do not recall any other issues at this stage.
  11   Q. In very early 1994, 20th January 1994, there was
  12     a meeting which you have already told us you recollect
  13     at which Mr Wisheart presented some results, level 7 at
  14     the University, presenting the results of what appears
  15     to have been a white board, to an assembled company of
  16     anaesthetists, cardiologists. Tell me, that meeting was
  17     specially called, was it not?
  18   A. Yes, presumably it was. I cannot remember now the exact
  19     mechanism of who called it and what it was in response
  20     to.
  21   Q. Do you not recollect that having been called because
  22     there had been concerns expressed within the unit about
  23     the overall surgical performance?
  24   A. I have memories that that was an issue around that time,
  25     as I say, 1994. It was January 1994, was it not?

   1   Q. Yes.
   2   A. But I do not think I knew any details at that stage that
   3     I can remember.
   4   Q. Was it or was it not a matter of corridor conversation
   5     amongst the cardiologists that there were disputes over
   6     figures or whatever in relation to operations?
   7   A. I do not remember whether that was around that time or
   8     later. I certainly at some stage remember some
   9     discussion of dispute over results. My memory is that
  10     was later, but I might be wrong on that, I am not sure
  11     of the timing.
  12   Q. Perhaps you can help a little with this: can we have
  13     a look, please, at UBHT 275/131? Just to put this in
  14     context, we see what it is, it is a paper setting out
  15     options for the development of the adult paediatric
  16     cardiac services.
  17        Let us go back to the page before. It is from
  18     Linda Harris, planning manager. I want to draw your
  19     attention to the words that appear in the memo:
  20        "I enclose a first draft of a report for
  21     consideration."
  22        The next sentence: "The draft contains
  23     contributions from as many working party members as
  24     possible."
  25        The working party was a working party looking at

   1     the potential expansion of surgery and a working party
   2     looking at the question of getting rid of the split
   3     site, was it not?
   4   A. Yes, I think so.
   5   Q. It included a number of people who were working as
   6     surgeons, cardiologists, as health professionals in the
   7     cardiac services directorate?
   8   A. Yes.
   9   Q. Were you one of them?
  10   A. I do not remember being a part of the working party, no.
  11   Q. Certainly it was copied to you?
  12   A. Yes.
  13   Q. Let us now have a look at what is said. In the second
  14     paragraph:
  15        "UBHT is fortunate in having the Bristol Royal
  16     Children's Hospital which enjoys an international
  17     reputation as the centre of excellence for the provision
  18     of dedicated paediatric care for a wide range of
  19     conditions. A significant exception is the provision of
  20     open heart surgery which is located in the BRI ..."
  21        That appears as a matter of language to be saying
  22     that the provision of open heart surgery is an exception
  23     to the Royal Children's Hospital's reputation as
  24     a centre of excellence. It appears to be accepting on
  25     the face of it, does it, that open heart surgery is not?

   1   A. This is a document as I believe it to be written by
   2     a manager not a clinician and I do not honestly think
   3     that means that. I think it is purely indicating that
   4     open heart surgery where paediatric patients were being
   5     cared for was located at the BRI rather than the
   6     Children's Hospital. I do not think it is making any
   7     comment at all about the quality of that service from
   8     what it is saying there.
   9   Q. I wondered if you might say that, which is partly why
  10     I took you to the first page to show that the manager
  11     setting it out records having received contributions
  12     from those in the service. Later on in the same
  13     document, page 139, paragraph 1, second sentence:
  14        "There is a perception that the quality of
  15     paediatric cardiac services in UBHT does not match the
  16     standards of the Trust's major competitors ..."
  17        That would appear to put it beyond doubt, would it
  18     not, that the absence from the "centre of excellence"
  19     referred to in the first paragraph is saying "paediatric
  20     cardiac surgery is the exception, that is where we are
  21     not excellent"?
  22   A. I do not think those two are linked at all and it
  23     certainly was not my perception at that stage because we
  24     were -- we have already touched on it the other day and
  25     discussed to a certain amount -- we had very very little

   1     comparative data, certainly did not have comparative
   2     data compared to what we viewed as competitors for that
   3     period and I think the fact that it says "competitors"
   4     is very much a management term. I do not think it is
   5     something as clinicians we would normally consider.
   6     I would prefer the term "colleagues around the region",
   7     I think, myself, if I was writing that document.
   8   Q. Let us look at it further. If we go down the page:
   9        "A certain critical mass in terms of volume of
  10     operations performed is essential in order to remain
  11     viable, and the Society of Thoracic Surgeons cites
  12     a minimum of 200 cases per annum."
  13        Of course the unit was not doing that number of
  14     cases, was it? Earlier on we have already seen there
  15     was a need perceived to increase the throughput.
  16   A. Can you repeat the question? You want me to comment on
  17     that paragraph, do you?
  18   Q. The question actually was: the unit was not doing that
  19     number of cases at that time, was it?
  20   A. The number of cases I would imagine around that time
  21     would have been around 250 of which about 150 would be
  22     open cases and approaching 100 would be closed cases.
  23     So a total number of cases would be about 250.
  24   Q. "The throughput is static even though demand is
  25     increasing. UBHT performs fewer cases for certain

   1     conditions."
   2        That appears to be comparative and the manager
   3     herself says which one is not clear?
   4   A. Was this a draft document?
   5   Q. A draft document, yes, that is why I showed you the
   6     covering letter.
   7        If we go down to 4: "The opportunity to become the
   8     sole specialist paediatric centre for the south and west
   9     may be lost if the image of cardiac surgery in UBHT is
  10     not improved."
  11        We see what is then said about the surgeon. These
  12     views are being expressed, albeit by a manager but she
  13     attributes them to the working party and to people
  14     working in the service. Did you not hear such views
  15     expressed yourself?
  16   A. I think, as I have already stated, we had a general
  17     impression or general feeling as a group, I certainly
  18     had a feeling -- the impression that by unifying the
  19     site you know it would be very likely we would be able
  20     to improve our service. Again, as I have already said
  21     it was the general feeling that the more throughput you
  22     have the greater chance you have of achieving high
  23     quality results in all areas and there was a general
  24     move along those lines and that document there is
  25     totally in line with that.

   1   Q. The question I was asking you was whether you were aware
   2     at the time that this was at least the perception of
   3     other people with whom you worked?
   4   A. I was aware, what, of the opportunity to become a self
   5     specialist centre? Yes, I was aware --
   6   Q. That the image of cardiac surgery in UBHT needed to be
   7     improved?
   8   A. We could see areas that needed improving.
   9   Q. Was it, do you think the view of those with whom you
  10     worked regularly, that the view that the image was poor
  11     such that it needed to be improved?
  12   A. I would not use the term "poor" but I think we all could
  13     see areas that needed improving and, as I have said, the
  14     unification on one site we felt was important for that
  15     and the ability to increase throughput we felt would
  16     also be helpful.
  17   Q. Can I, again with the assistance of this paper, identify
  18     one or two of the problems of the split site
  19     throughout? I suspect we will be on common ground
  20     here. If we go back to page 135 and we scroll down we
  21     can see that this records, rightly or wrongly, at the
  22     top of the page that Bristol is the only centre apart
  23     from Edinburgh which had a split site. Edinburgh it
  24     appears had recognised future needs and was amalgamating
  25     on to one paediatric site. As far as you know is that

   1     probably right?
   2   A. Yes, I think that is true with regard to open and closed
   3     surgery being at separate sites, if that is what you
   4     mean by a split site.
   5   Q. Paragraph 4 deals with the problem of patients and
   6     parents sometimes experiencing considerable trauma due
   7     to the need to transfer. Again, was that a problem?
   8   A. I think it is an issue. When you move a child and
   9     a parent from ward to intensive care unit, it is
  10     a potential issue whenever you have to move a child.
  11   Q. You have already said that in the course of transfer
  12     a couple of children were less stable than you would
  13     have wished. No doubt that is a reflection of the fact
  14     that there is a split site?
  15   A. As I say there were certainly a number of cases where
  16     that occurred. This is also obviously talking about
  17     parents' experience and patients' experience rather than
  18     necessarily talking about clinical care. So as
  19     I understand it that is referring to the overall
  20     environment and change of environment.
  21   Q. If we go down towards the bottom of the page:
  22        "70 per cent of the BRCH nursing staff are sick
  23     children's nurses, compared with only two whole time
  24     equivalents in the BRI cardiac unit."
  25        As a reflection of what was the position in 1994,

   1     that is right, is it?
   2   A. I cannot speak for the validity of those figures.
   3     I know there was a very high number of RSCNs at the
   4     Children's Hospital because essentially that was where
   5     I was based, that was where the bulk of my work was. At
   6     the Royal Infirmary I would not necessarily know the
   7     nursing establishment there. I know there were some
   8     paediatric trained nurses there, but the exact numbers
   9     I could not comment on.
  10   Q. Page 136., 137. If we scroll down, it is item number 2 at the
  11     bottom:
  12        "The pressure to increase adult cardiac surgery
  13     combined with less complex care management and shorter
  14     lengths of stay, tends to militate against selection of
  15     paediatric cases for admission in the BRI, resulting in
  16     unacceptably long waiting lists. In a solely paediatric
  17     speciality this competition would not exist, enabling
  18     improved waiting list management, and reduction in
  19     waiting times."
  20        Is it the case that the fact of doing adult and
  21     child cardiac surgery on the same site meant that on
  22     occasion the need to operate upon an adult meant that
  23     child's surgery was delayed?
  24   A. There are always constraints on any service and I must
  25     say, not being based at the Royal Infirmary it is very

   1     difficult for me to comment well on that. It was
   2     certainly my impression that there were times when we
   3     had patients waiting at the Children's Hospital for
   4     perhaps a number of weeks for space to be identified on
   5     ward 5 at the Bristol Royal Infirmary for them to have
   6     their surgery. There were always competing demands and
   7     I was not in a position to judge those competing demands
   8     between adult and paediatric patients. That was a task
   9     for the surgeons.
  10   Q. But it was certainly your perception from what you have
  11     been telling us that the fact of doing the two together,
  12     adults and children, sometimes meant children were
  13     delayed for longer -- this appears to be suggesting here
  14      -- than they would have delayed had it been one service
  15     for children at one place?
  16   A. That might have been a factor. Equally it might just
  17     have been the actual allocation of paediatric beds
  18     within the adult department was inadequate for the
  19     throughput. By increasing the numbers on transferring,
  20     I think with the transfer from the Royal Infirmary to
  21     the Children's Hospital you would have gone up from
  22     essentially what were three beds being utilised to five
  23     or six and that would immediately have an impact on
  24     waiting.
  25   Q. You told the GMC, did you not, that the need for

   1     children having to compete with the adult list for
   2     paediatric time in the theatre made the delays ensue, or
   3     at least that was your general impression?
   4   A. As I have said, it is difficult for me to judge exactly
   5     whether it was pressure on theatre, pressure on beds on
   6     the intensive care unit, but I was aware that certainly
   7     some patients were waiting at the Children's Hospital
   8     longer than I would have hoped for.
   9   Q. For a number of the conditions that paediatric cardiac
  10     surgery is concerned with delay can be fairly important,
  11     can it not?
  12   A. It can be for some patients, yes.
  13   Q. Particularly if there is high pressure of blood going
  14     through the lungs, you can get eventually irreversible
  15     changes?
  16   A. There are a number of conditions where delay is
  17     a potential issue. No one wants a delay for any child.
  18     In an ideal world you want that child to be operated on
  19     the next day, but there are always competing demands for
  20     resources and as clinicians we have -- as a cardiologist
  21     we would have to help in the assessment of urgency for
  22     a particular case and my job would perhaps be to
  23     indicate my view of that to the surgeon. The surgeon
  24     would have to indicate his view as well and when it came
  25     to the surgical organisation I had no input into that

   1     other than our discussions directly to the surgeons,
   2     I was not actually involved with the organisation of the
   3     surgery.
   4   Q. I am not asking you here about something for which you
   5     are personally responsible. I am asking you really for
   6     a picture of what was going on. What we have heard in
   7     the statistical review which was presented to us
   8     a couple of weeks ago was that it appeared that Bristol
   9     was operating upon children at a later age by and large
  10     than other centres were in the UK. From what you are
  11     saying now that appears to coincide with your
  12     perception. You may not have had a complete perception
  13     of elsewhere. Am I right in thinking that it coincides
  14     with the perception you have been expressing in the last
  15     few answers?
  16   A. Yes, my perception was that there were delays very often
  17     in patients having surgery. Whether those delays were
  18     acceptable or not I think is another matter, but there
  19     were delays and, as I say, the way the site was
  20     organised with the split site arrangement we felt was an
  21     important factor. Resources I am sure, overall
  22     resources to the unit would also have been a factor.
  23   Q. If we can move on from this: quite apart from the
  24     difficulties mentioned in the paper, you had the
  25     difficulty of working as a cardiologist from the Bristol

   1     Children's Hospital where you were centrally based but
   2     having patients at the Royal Infirmary.
   3        Did that cause difficulties do you think?
   4   A. For me personally do you mean?
   5   Q. For the service generally.
   6   A. Would it be helpful if I just outlined a little bit
   7     about what a cardiologist workload involves; would that
   8     be helpful because not everyone may be aware?
   9        Certainly in the time period we are talking about
  10     my role would mainly be assessment of children referred
  11     for assessment of heart disease. A lot of that work is
  12     outpatient work, so probably one or two days per week on
  13     average I would be out of the hospital at a different
  14     hospital within the region doing outpatient work and
  15     that would involve quite busy consultations undertaking
  16     usually echocardiographic examinations of patients
  17     referred.
  18        There would also be clinics for paediatric
  19     cardiology at the Children's Hospital, both consultation
  20     clinics and echocardiographic clinics, and those occupy
  21     a good deal of your time. There is also the need for
  22     more specialist investigation, cardiac catheter study
  23     particularly, so I think each cardiologist would have
  24     one or two cardiac catheter sessions per week.
  25        I personally also had a major interest in foetal

   1     echocardiography so I would be undertaking a lot of
   2     foetal cardiac assessments and also you would be
   3     responsible for inpatients under your care which, in my
   4     case, would all be at the Children's Hospital and you
   5     would be doing ward rounds and doing the sort of
   6     day-to-day things you had to do with your inpatients.
   7        With regard to patients having open heart surgery,
   8     with our busy commitments at the Children's Hospital it
   9     was often very difficult for me to get to the Royal
  10     Infirmary on an absolutely regular and fixed basis. Not
  11     everyone may know the geography of the area, they are
  12     separated by about a five-minute walk downhill but it is
  13     a very steep hill coming back so it does involve some
  14     effort if you like going up and down, it does involve
  15     some time going up and down.
  16        That obviously does not stop you travelling, we
  17     are quite used to travelling, but your commitments at
  18     the Children's Hospital often made it very difficult to
  19     get down there at set times so usually I would visit the
  20     patients I had been involved with that were undergoing
  21     open heart surgery often later in the day, so it was
  22     often evening time by the time I had finished my duties
  23     at the Children's Hospital before I could get down to
  24     see the children. That made it very difficult to be
  25     actively involved in the day-to-day management of those

   1     patients, or minute to minute management of those
   2     patients.
   3        I did my best, I tried to get down there as often
   4     as I could to see the children, see the families.
   5     I think that may not get probably the recognition that
   6     occurred on reviewing the case notes because I would,
   7     for instance, very rarely be writing the case notes so
   8     my visits would be probably, if you like, unminuted
   9     quite often.
  10        I would do my best, mainly as a social thing, to
  11     keep in touch with the families as much as anything, to
  12     see the families when I could. That was not always
  13     possible, you are often away for periods so it was not
  14     always feasible.
  15   Q. Can I summarise what you are saying in these terms and
  16     see if it reflects what you are saying to me: with the
  17     best will in the world it was difficult because of the
  18     geographical separation of the two hospitals for you to
  19     spend as much time in the BRI as you would have wished?
  20   A. Yes, yes, I think that is very kind.
  21   Q. Had there been a hospital on one site you would probably
  22     have spent more time, perhaps quite a bit more time with
  23     the patients in the BRI throughout the day rather than
  24     having to make a special effort as you did to go and see
  25     those children?

   1   A. If you like they would become part of my practice that
   2     was already happening at the Children's Hospital.
   3   Q. Your experience no doubt would be shared by the other
   4     Paediatric Cardiologists, would it?
   5   A. I imagine so. I am sure you will get the opportunity to
   6     ask them.
   7   Q. When we have a reflection in the case note review that
   8     has been carried out by Dr Silove giving us evidence
   9     a couple of weeks ago that all the teams were surprised
  10     by the absence of significant reference in the notes to
  11     the presence of the cardiologist postoperatively, that
  12     is due to a mixture of two things in your case: one is
  13     the natural geographical difficulties making it
  14     inevitably the case you would be there less, and partly
  15     because of your own practice in not making a record of
  16     it; is that fair?
  17   A. Yes, to a certain extent. As I say, reviewing the
  18     clinical case records you may not have been aware of our
  19     input into visiting. I personally found it difficult to
  20     get actively involved in the care of the patients down
  21     there. Patients were under the care of the surgeons,
  22     the surgical team were looking after the patients in
  23     conjunction with the anaesthetic team. It was very
  24     difficult to arrange a time when you could be there when
  25     other people were there to discuss the individual case,

   1     so usually when I went down I would find there was no
   2     one else actually physically there that I could talk to
   3     about the case and --
   4   Q. The communication between yourself and the surgeon would
   5     necessarily have particular difficulties because of
   6     that?
   7   A. It would be difficult, yes. There would be occasions
   8     when surgeons or anaesthetists might specifically ask
   9     for an opinion about this or that and of course we would
  10     give that opinion and there would be some discussion.
  11     But just in the day-to-day management it was very
  12     difficult to get very actively involved.
  13        That was not due to not wanting to, it was very
  14     difficult. You felt a little bit of an outsider when
  15     you went down there to visit patients; that was not my
  16     primary base; you felt as though people did not know you
  17     quite as well. You were not primarily directing their
  18     care so any advice you might give, whilst I am sure
  19     people would say it would be listened to, it may not
  20     have been acted upon.
  21   Q. You would not be in a position to be back to make sure
  22     that it had been because you were --
  23   A. Not necessarily, no. I might be down at the Royal
  24     Infirmary once or twice a day on occasions. I did have
  25     also adults, clinics at the Royal Infirmary so I would

   1     be down there for some outpatient work on occasions,
   2     I might be down there for other specialist
   3     investigations, magnetic resonance, scanning, exercise
   4     testing was at the Royal Infirmary, so there may be
   5     other reasons for me being there as well.
   6   Q. I am going to bring Dr Silove in on this because I think
   7     it may be useful for him to clarify any impressions
   8     which have been given by the teams in the case note
   9     review and for you to be able comment on what he has to
  10     say from your own perception.
  11        Dr Silove, does what has been said correspond or
  12     not with the impression given to you by the teams and
  13     from your own review of the case note records.
  14   DR SILOVE: I think it does. I think Dr Martin is
  15     essentially confirming the difficulty he has had in
  16     getting to the BRI for various reasons. If I may make
  17     a suggestion, I have just jotted down some of the
  18     activities he has described in his working week. I am
  19     not sure that comes across sufficiently clearly as to
  20     just how busy he is and I wonder whether during the
  21     coffee break it might be an opportunity for him to write
  22     down just how many hours a week he spends doing what, it
  23     sounds to me as if he spends a lot more time than
  24     a normal working week which would make it very difficult
  25     for him to get to see postoperative patients at the

   1     Royal Infirmary.
   2        But, yes, to sum it up: all the teams reviewing
   3     the clinical case records did comment on various cases
   4     that there does not appear to be a presence of
   5     cardiological input into the postoperative management of
   6     the patients at BRI.
   7   MR LANGSTAFF: I think what you have been explaining is that
   8     that is probably right and you are giving the reasons
   9     for it I think.
  10        It may be you want to take up the invitation
  11     Dr Silove has given so the panel can have an assessment
  12     of really how stretched you were in terms of time.
  13        Reference to time of course brings me to perhaps
  14     this being a proper occasion for a break.
  15   THE CHAIRMAN: Yes, 15 minutes until 11.00 then.
  16   (10.45 am)
  17              (A short break)
  18   (11.05 am)
  19   MR LANGSTAFF: Dr Martin, have you had a chance to look,
  20     over the break, at your diaries to give us some idea of
  21     a typical week? First of all, let us put it in
  22     context. Roughly how many hours per week do you think
  23     you spent doing the job?
  24   A. I probably would work on average about 60 hours a week,
  25     something of that order.

   1   Q. You want to tell us, I think, about two or three typical
   2     weeks, or random weeks?
   3   A. I suppose one thing to say is that there is no such
   4     thing as a typical week. Each week is different, so
   5     I just chose three weeks, roughly at random, really, to
   6     give an idea of some scope of the things we were
   7     undertaking.
   8        The first week I have chosen is 1994, the week
   9     commencing Monday, June 27th. The morning, I was in the
  10     cardiac catheter laboratory doing some duct occlusion,
  11     a transcatheter procedure to close the arterial ducts.
  12     A lunchtime meeting at the Institute of Child Health.
  13     In the afternoon I had an echocardiographic clinic,
  14     which would go on probably until about 6 or so.
  15        This would be a week when I was not actually on
  16     call, so these would be just standard duties. The
  17     following day, Tuesday morning I would probably normally
  18     have done a ward round. I tended to do ward rounds most
  19     days starting about 8.15/8.30 at the Children's
  20     Hospital, and seeing my own patients there. I think if
  21     I was in the hospital and, if you like, not out at one
  22     of the peripheral hospitals, I would probably do a ward
  23     round with the patients most days.
  24        In the morning I was undertaking foetal
  25     echocardiography. That went on until lunchtime,

   1     probably through lunchtime by the looks of my diary. In
   2     the afternoon I was undertaking again cardiac catheter
   3     studies.
   4        The following day it looks as though I had
   5     a morning in the cardiac cath' lab, again performing
   6     transcatheter occlusions of the arterial duct. The
   7     Wednesday afternoon, my normal Wednesday afternoon
   8     outpatient clinic at the Children's Hospital. In the
   9     evening I had a GP research meeting.
  10        On to the next day: Thursday I had a morning
  11     clinic at the Bristol Royal Infirmary which would be for
  12     adults with congenital heart disease. I had an exercise
  13     test lunchtime, and then an echocardiographic clinic in
  14     the afternoon at the Children's Hospital.
  15        Friday, the following day, two cardiac catheter
  16     studies in the morning and in the afternoon I had
  17     a teaching commitment for junior doctors.
  18        That would be a not unusual week where I had no
  19     outside commitments outside of the Children's Hospital.
  20        The week commencing, in 1994, August 1st, a much
  21     heavier commitment to peripheral hospital work.
  22        August 1st I have down that it was an all day
  23     clinic in Gloucester so I would have been at Gloucester
  24     Royal Hospital starting a clinic at 9, usually finishing
  25     about 6, travelling to and from there.

   1   Q. When you say "travelling to and from", is that included
   2     in the 9 to 6?
   3   A. No, the consultations would run from 9 to 6, and then
   4     travelling time on top of that.
   5   Q. In the way of the world, for those of us who have ever
   6     waited for a doctor's consultation, does that mean you
   7     probably overran the 6 o'clock?
   8   A. When I am saying 6 o'clock, probably patients would be
   9     booked until about 4.30/5.00, and then allowing for some
  10     lapse of time, usually it was 6 o'clock by the time you
  11     finish, sometimes later. An average Gloucester clinic
  12     around that time, I probably would be seeing 30 to 35
  13     patients during the day, so a fairly heavy clinical
  14     workload there.
  15        The following day I was back at the Children's
  16     Hospital in the morning, doing foetal work in the
  17     morning. Again, a lunchtime meeting followed by
  18     assisting one of my colleagues with a cardiac catheter
  19     study in the afternoon.
  20        The following day, the Wednesday, two cardiac
  21     catheter studies in the morning followed by my standard
  22     Wednesday afternoon outpatient clinic at the Children's
  23     Hospital.
  24        The following day, Thursday, again, a peripheral
  25     clinic at Bridgend, Prince of Wales Hospital. Again,

   1     that would start round about 9 to 9.30 and finish around
   2     5.00 to 6.00, plus you have the travelling time on top
   3     of that.
   4        The following day, outpatient clinic in Exeter,
   5     again running from 9 until 5-ish, with two hours plus
   6     travelling time for both those clinics on top of that.
   7        That would be a fairly busy week with regard to
   8     peripheral clinic activities, but not that unusual.
   9        I have one more, which is an early week in
  10     January, the week commencing 9th January 1995. Again,
  11     on the Monday I would have had a clinic in Gloucester,
  12     much as the previous one.
  13        Tuesday was a little bit unusual in that I went up
  14     to one of my colleagues in Glasgow to run through use of
  15     a new catheter device and receive some training in that,
  16     and appreciation of that. So I went up there for the
  17     day, to undertake those procedures, flew back that
  18     evening, fairly late back, as I remember.
  19        The following day, I was doing a pacemaker in the
  20     morning, foetal echo in the afternoon and a pathology
  21     meeting in the evening.
  22        The following day, Thursday, adult clinic in the
  23     morning at the Royal Infirmary, exercise tests around
  24     lunchtime at the Royal Infirmary and then I was back up
  25     at the Children's Hospital.

   1        Friday morning, a brief consultation, I think
   2     I had a consultation with a family in the morning,
   3     probably the following morning, a ward round, and then
   4     I had a meeting in London, the Association of Insurers
   5     about insurance issues for adults.
   6   Q. So you selected those three weeks at random. They show
   7     us two things: the peripheral clinics, from your
   8     description, they take all day?
   9   A. Most of the peripheral clinics are all day consultation
  10     plus you have obviously the travelling times on top.
  11   Q. So because of the travelling times, because it is all
  12     day, it is unlikely, I suspect, that on those days you
  13     managed to get into either the BRI or the BCH, or do you
  14     start there or finish there?
  15   A. I might well. Most of the times I would probably not be
  16     at either place before the clinic started. That just
  17     would not be feasible. If I was on call, which you
  18     quite often would be on call with one of your colleagues
  19     covering you on the day whilst you are out, then I would
  20     call back to my home centre, which I would view as the
  21     Children's Hospital, in the evening and see any patients
  22     that were there.
  23   Q. In all of this workload which you have described and
  24     which bears out, I think, what Dr Silove had anticipated
  25     before the break, did you have the assistance of any

   1     junior staff?
   2   A. Not "on the road", if you like, when I went to the
   3     peripheral clinics. Those were totally consultant-based
   4     usually, sometimes in conjunction with local
   5     paediatricians, so it was very important for building
   6     links locally there. There might be junior medical
   7     staff present during the clinics as a means of them
   8     learning about cardiac defects.
   9        At the Children's Hospital, again, the staffing
  10     varied throughout the time period you are talking about
  11     and throughout the time period I was there, but normally
  12     we would have a Senior House Officer looking after the
  13     cardiology patients, variable input from middle grade
  14     general paediatric registrars, one or parts of one, if
  15     you want to use that term, shared care with some of the
  16     other paediatricians, and it was not, I think, until
  17     1993 that we had a specialist trainee in paediatric
  18     cardiology. So it was very much a consultant-led
  19     service with general paediatric SHOs at the Children's
  20     Hospital.
  21   Q. You did not then have a paediatric cardiological
  22     Registrar?
  23   A. Not someone training in paediatric cardiology until --
  24   Q. 1993, you said.
  25   A. I think it was 1993 it started, yes.

   1   Q. There were problems, were there, in 1991 over the
   2     accreditation?
   3   A. There were a number of issues. I applied to the Joint
   4     Committee on Higher Medical Training for approval of
   5     a post, I think it would have been round about 1991 --
   6     it might have been 1990 when I actually made the
   7     application. We were visited by Dr Shinebourne to look
   8     at the potential setup of the post that we proposed and
   9     the training opportunities that it gave.
  10        So that was round about 1991.
  11   Q. It was January 1991, I think, just to refresh your
  12     recollection on it. UBHT 195/15. We see there the
  13     programme, Thursday 17th January.
  14   A. Yes.
  15   Q. So that is when Dr Shinebourne came and he toured. His
  16     recommendation was that there should not be
  17     accreditation; am I right?
  18   A. Yes, that is correct.
  19   Q. The basis for that was what?
  20   A. I think he accepted that we had plenty of cardiological
  21     throughput and training opportunities. As I remember,
  22     his main objection, or main concern, was the separation
  23     of the two sites for surgical care and it is an
  24     important part of training for the Senior Registrar, as
  25     it was then, the Specialist Registrar, to have input and

   1     participation in post-operative care of open-heart
   2     cases. That is specified in the training programme.
   3     He was concerned that that would not be feasible.
   4   Q. So the knock-on effect from having two sites was not
   5     only that you had the additional workload, the
   6     difficulty of maintaining presence in both sites and the
   7     person on occasions feeling a bit like someone
   8     interfering from outside in the BRI, but also that you
   9     did not have the trainee assistance at Registrar level
  10     you might otherwise have hoped for in a combined unit?
  11   A. Yes. If that was his only objection to approval, then,
  12     yes, that would be the case.
  13   Q. The effect of not having a Registrar is to put more
  14     responsibility on your shoulders?
  15   A. In theory, Senior Registrars are meant to be there to be
  16     trained, so in some ways it might be looked at as an
  17     extra workload for the consultants. In practice, as you
  18     have indicated, they obviously do have a major input
  19     into clinical care.
  20   Q. In your own days as a Registrar, is it not the case that
  21     all Registrars expect to do an awful lot of the work?
  22   A. A proportion, guided by people that are training you.
  23   Q. Under supervision, no doubt, but we have heard -- I do
  24     not think we have heard a contrary noise in the Inquiry,
  25     that to a large extent the hospital service depends upon

   1     junior doctors in training doing a lot of the work.
   2   A. Yes. At Senior House Officer, and middle grade, if you
   3     want to use that term, level Registrar. They are an
   4     important part of the infrastructure of the unit.
   5   Q. The simple point that I was really asking you about was,
   6     if you do not have someone at the Registrar level,
   7     obviously, the work he or she might otherwise have done
   8     has to be covered by somebody and it is going to put
   9     a heavier load on consultants and no doubt others?
  10   A. I think, as I said, supervision is important in this
  11     setting. Certainly, when you start with a new trainee,
  12     you will be supervising them most of the time; they will
  13     be doing very little work solo, if you like. So at the
  14     start it may have relatively little impact, but as they
  15     gain experience, as trainers, as we are happier with
  16     their performance, they obviously take on more and more
  17     responsibility, building up to around the time
  18     accreditation is achieved, when they are working at near
  19     consultant level.
  20   Q. We have dealt thus far with workload, with assistance.
  21     Can I turn to the question of equipment? Can I ask you
  22     to have a look at UBHT 146/50?
  23        It is 3rd March 1994, addressed to you amongst
  24     others from Dr Peter Wilde. Can we just scroll down?
  25     What he says is that echocardiography on a cardiac

   1     surgical unit is certainly unsatisfactory at present and
   2     could potentially be very much better if there was an
   3     organised strategy:
   4        "I feel sure that a high quality supporting echo
   5     service would undoubtedly lead to improvements in
   6     cardiac surgical outcomes."
   7        What is he talking about?
   8   A. I think the issue here is he felt the need to improve
   9     the echo service for all patients up at Bristol Royal
  10     Infirmary, so that I would include -- it might be mainly
  11     adult patients, to be honest, but also the paediatric
  12     patients. I think there were issues with regard to
  13     ageing equipment and the need to replace equipment, and
  14     also, the technical support that might be necessary for
  15     undertaking echo examinations there.
  16   Q. When he says "organise strategy", what does he have in
  17     mind? He is looking at presumably the management of it
  18     in some way?
  19   A. I do not know for sure what he was referring to there.
  20     I presume this relates to him and his colleagues, his
  21     radiologist who did the bulk of the echo work there,
  22     looking at the mechanisms of referral for echo
  23     assessment, et cetera, and being able to provide the
  24     service, by either a consultant radiologist undertaking
  25     the examinations or a technician. I think shortly

   1     following this, this was used as a spur, as a way of
   2     employing an additional technician for undertaking adult
   3     echos.
   4        My understanding is that it was primarily an adult
   5     document.
   6   Q. Primarily, but as you say, it has an impact on
   7     paediatrics?
   8   A. Sure.
   9   Q. On the same vein, can I ask you to look at JDW 1/46 --
  10     I am sorry, can I take you back to the last document for
  11     a moment?
  12        That, of course, talks about circulating this
  13     document. Can I just have a look at the next page, the
  14     first page of the document? You will see if we scroll
  15     down, please, areas of need. At 6 -- perhaps I ought to
  16     go through this in a little more detail.
  17        What Dr Wilde is saying is that trans-thoracic or
  18     trans-oesophageal echo is needed because there are some
  19     diagnostic aspects incomplete or uncertain, under 1.
  20     2 speaks for itself. 3, post-operative transoesophageal
  21     echo. 5, intraoperative transoesophageal studies in
  22     selected cases for assessment of repair or for
  23     monitoring of left ventricle function. 6, the above all
  24     apply especially to the paediatric group (often
  25     requiring a high level of expertise from the operator)."

   1        So in Dr Wilde's mind when he wrote this, he is
   2     saying it is not just an adult problem, it is very much
   3     a paediatric problem too. You accept that, do you?
   4   A. I cannot speak for him. I think we would have all
   5     supported any improvements to improve the echo service
   6     at the Royal Infirmary, and he is absolutely correct
   7     that in the paediatric group you need a high level of
   8     expertise to undertake the echocardiography to make it
   9     worthwhile, which would mean that very often
  10     a technician undertaking those procedures would not be
  11     the best person, unless they have had quite extensive
  12     training in the assessment of congenital heart disease.
  13        Peter Wilde himself is a very good congenital
  14     heart echocardiographer, quite experienced in that, runs
  15     courses on it, and certainly he, over preceding years,
  16     had been very helpful in undertaking echo assessments at
  17     the Royal Infirmary. But he is not available all the
  18     time, and I think his colleagues varied in their
  19     expertise in the congenital heart area. I think they
  20     are all well practised in adult practice, but perhaps
  21     have less exposure to paediatric practice.
  22        So I presume that is what he is referring to in
  23     his latter comment there.
  24   Q. Do you agree with the five aspects he identifies as
  25     being areas of need?

   1   A. I would not agree with 1, that there would necessarily
   2     have been the need, at the Royal Infirmary, for
   3     post-operative TOE or transthoracic echo. Those
   4     patients would have been evaluated at the Children's
   5     Hospital prior to coming in for surgery.
   6        There certainly is a need to look
   7     trans-thoracically, post-operatively in some patients,
   8     so I would agree with 2, that there is a need for that
   9     in paediatric patients, in the setup as it was then.
  10        Ditto, I suppose, for trans-oesophageal studies.
  11     I think we had, by that stage, a paediatric
  12     trans-oesophageal echo probe that was available, that we
  13     could use on Ward 5, but that had not been present for
  14     long.
  15        I would agree that predischarge studies are
  16     desirable, and certainly intraoperative
  17     trans-oesophageal echo can be helpful in some cases.
  18     I think opinions vary on that. It is quite commonly
  19     used in adult practice and paediatric practice.
  20     Intraoperative assessment depends to a large part on the
  21     wishes of the surgeon.
  22   Q. Would it depend upon the availability of the
  23     cardiologist to interpret the echo?
  24   A. It would be dependent on having either a cardiologist or
  25     radiologist to be available to undertake those studies,

   1     yes.
   2   Q. So it was, for reasons such as you explained,
   3     particularly difficult for the cardiologist to get into
   4     the theatre?
   5   A. Yes, it was difficult but we always did our best to try
   6     and attend. We always attended when asked.
   7        In adult practice it is slightly different in that
   8     the anaesthetists have taken on the role of doing these
   9     studies in the theatre.
  10   Q. Can we scroll down to the bottom of the page, just to
  11     see what the equipment is? We can see there the
  12     equipment, "Mobile unit based in Ward 5, has not been
  13     upgraded recently, since 1990", so I think the
  14     implication is that it was getting a bit old?
  15   A. Yes. I have to say, I had not appreciated it was
  16     present. I thought it was later that it was purchased,
  17     that mobile unit, but certainly it was a relatively
  18     basic unit, as he says, of a low specification which
  19     certainly had not been upgraded recently. So that is
  20     correct. It was not an ideal machine, but it gave you
  21     some images.
  22   Q. Let me just bring Dr Silove in on this. Dr Silove, we
  23     have seen Dr Wilde's wish list here. Is what he wants
  24     reasonable? Does it reflect good practice, best
  25     practice, beyond what you would expect, or what?

   1   DR SILOVE: I think that every one of the points that he
   2     made is a very valid point. I think it really reads as
   3     an excellent document in terms of the needs and the
   4     reasons for those needs.
   5        In any service where you are looking after
   6     paediatric cardiac patients, it is not only desirable
   7     but I believe essential to have echocardiography
   8     post-operatively available at any time to look at
   9     a variety of problems on the intensive care unit.
  10   Q. Were there any comments or reflections in the case
  11     records survey of there not being post-operative echo
  12     when it might have been desirable to have one done?
  13   A. There were quite a number of comments, "post-operative
  14     echocardiography not done", or "does not appear to be
  15     available".
  16   Q. I was going to take you on from this to something we
  17     have had from Mr Wisheart, which is JDW 1/46. If we go
  18     down to the bottom of the page, can we go overleaf?
  19        "The ultrasound service", I suppose I had better
  20     give you a date for this. If we can go back to page 45,
  21     you can see there what it is. If we scroll down,
  22     please, it is a report in respect of 1989. Can we go
  23     overleaf, back to 47? Looking at it in 1989, the
  24     ultrasound service, the top of the page, "continues to
  25     be provided in cramped and wholly unsuitable

   1     accommodation. Negotiations are taking place with
   2     management to identify an alternative site. The
   3     electrocardiographic service for cardiac and other
   4     patients in the Children's Hospital is provided by
   5     technicians from the BRI as before", and it deals with
   6     the major development of the cardiac surgical unit was
   7     completed in 1988.
   8        Was that a fair description of the ultrasound
   9     service at the end of 1988, the start of 1989?
  10   A. This document is mainly talking about the ultrasound
  11     service at the Children's Hospital rather than at the
  12     Royal Infirmary. I would agree that when I arrived and
  13     started work in 1989, I think there were two ultrasound
  14     machines in service at that stage. As it indicates,
  15     there was an old ATL Mk 6, or Mk 4 -- I cannot remember
  16     the exact type, and I think a Hewlett Packard with
  17     colour flow had just been transferred up, so that was
  18     quite a reasonable piece of equipment for that era,
  19     1989; it had reasonable facilities.
  20   Q. I think what is being focused on in that sentence is the
  21     site, the location of it, rather than the equipment.
  22   A. I was just going to that. At the start the echo room
  23     was next to the Intensive Care Unit. That was where
  24     outpatient echos and to a certain extent the inpatients
  25     were taken for their scans, although the equipment could

   1     be moved to the patient if necessary. That room was
   2     quite small and cramped.
   3        There was some development work fairly soon after
   4     that to develop an old lecture theatre in the Children's
   5     Hospital which was converted into an echocardiographic
   6     room, suite, if you want to call it, which is still what
   7     we use for our echo service at the Children's Hospital.
   8     That was a two-bay unit. At that stage we would have
   9     had one what I would call "adequate" echo machine, which
  10     would be the Hewlett Packard machine, an older machine
  11     which was getting near the end of its useful life span
  12     now, an ATL. That would have been the position in 1989
  13     and 1990.
  14        I was very keen to improve the echo equipment at
  15     the Children's Hospital and I felt that the usage of
  16     that one useful machine was fairly stretched, so soon
  17     after that, in 1991, I was successful in getting bids
  18     for a second up-to-date echo machine, if you like,
  19     approved and that was purchased around that time.
  20        That has been further developed subsequently over
  21     the years and we now have three reasonably up-to-date
  22     machines.
  23   Q. Obviously from the description you are giving, the
  24     usual -- I do not know if it is the usual, but the
  25     struggle to get better equipment continuously, looking

   1     to improve the facilities, I take it?
   2   A. Yes.
   3   Q. The effect of the electrocardiography: can I just look
   4     at some references and see if you can help me with
   5     them?
   6   A. I am sorry, did you say "electro" or "echo"?
   7   Q. "Echo", I am sorry. Can we look at UBHT 61/149? Let us
   8     go back to the page before, please. And the page before
   9     that, two pages back. [UBHT 61/146]. 28th July 1991.
  10     If we return to UBHT 61/149, this is dealing with
  11     tetralogy of Fallot patients.
  12        Mr Dhasmana said he reviewed specific deaths with
  13     paediatric cardiologists and had found in some cases the
  14     information provided was just not good enough, with
  15     specific reference to the pulmonary artery anatomy and
  16     the coronary anatomy.
  17        Can I just explore that with you? Were you the
  18     paediatric cardiologist that he spoke to, do you
  19     remember?
  20   A. I presume that should be "paediatric cardiologists",
  21     because I would not imagine he would speak to myself in
  22     isolation. It would not be his normal practice, I would
  23     not have thought, so I imagine it would have been
  24     a number of people he would have spoken to, my
  25     colleagues essentially, Dr Joffe, Dr Jordan and myself.

   1   Q. What he appears to be complaining about is that he, the
   2     surgeon, has had difficulties because when he has
   3     conducted the operation, the anatomy of both the
   4     pulmonary artery or the coronary arteries has not been
   5     sufficiently well described beforehand to him to give
   6     him assistance in the operation.
   7        Is that the point he is making?
   8   A. That is what it states there. Whose document is this,
   9     did you say? I am not sure who produced it.
  10   Q. Let us go back three pages: paediatric surgical and
  11     anaesthetic group.
  12   A. Yes, but who?
  13   Q. If we go down, it appears to be surgeons and
  14     anaesthetists.
  15   A. I wonder who produced the document. That was what I was
  16     not quite clear of.
  17   Q. It appears to be minutes and we can find out who
  18     produced it if we go to the end and see if there are
  19     initials. Let me see if that can be done while we are
  20     focusing on the text.
  21   A. I would be interested to know, because obviously the
  22     perspective of any minutes like this might be different,
  23     depending on who wrote them.
  24   Q. I think it is Dr Bolsin.
  25   A. Is it? Right.

   1   Q. So the anaesthetic perspective.
   2   A. Right. I can comment on that in that I know we had
   3     discussions around that time to see if we could change
   4     or improve our pre-operative evaluation of tetralogy of
   5     Fallot patients. I think it coincided with, as is
   6     indicated there, Mr Dhasmana had seen some individual
   7     cases which presumably had been discussed at the
   8     clinico-pathological meetings, and we, as part of that
   9     discussion, of course looked to see if we can identify
  10     ways of improving definition of what the surgeon is
  11     going to see when he gets into the operating theatre.
  12        The two areas which I think are well known to be
  13     somewhat difficult pre-operatively are the
  14     identification of the coronary artery anatomy in
  15     tetralogy of Fallot and to a certain extent the
  16     pulmonary artery anatomy. Again, you may want to get
  17     comments from Dr Silove on this, but the particular
  18     issues, as I would see it, would be coronary artery
  19     anatomy. One of the potential problems you can have is
  20     you can have an anomalous origin of one of the branches
  21     of the coronary arteries and sometimes one of these can
  22     cross the outflow tract and might interfere with the
  23     repair, make it difficult to do the repair. That can be
  24     very difficult to demonstrate either
  25     echocardiographically or angiographically. We looked at

   1     that time at perhaps changing our angiographic views to
   2     see if we could improve the evaluation of the anomalous
   3     vessels. So that was one factor that we actually put
   4     into place after that.
   5        The second factor was the demonstration of
   6     pulmonary artery narrowings, which, again, can be
   7     somewhat difficult to interpret what you see on the
   8     angiograms compared to what the surgeon finds in
   9     theatre. Evaluating the length and severity can be
  10     quite difficult in a complex 3-dimensional structure
  11     when you are looking at it from one angle, if you like.
  12        So we looked at different angiographic
  13     projections, as they are termed, to evaluate that to see
  14     if that would improve the definition of the severity and
  15     extent of pulmonary artery narrowing as far as is
  16     possible.
  17   Q. There are perhaps three ways of looking at the comment
  18     which Mr Dhasmana is reported to have said. One is that
  19     the problem which he has identified, assuming that it is
  20     a real problem, may be caused either by inadequate or
  21     insufficient equipment; secondly, may be caused by
  22     inadequate or insufficient analysis of the results by
  23     the cardiologist; or thirdly, it may be inevitable
  24     because that is the way life was, given the best
  25     equipment and the best interpretation available.

   1        How would you see it at this time?
   2   A. I would not agree with -- it is not saying it is
   3     inadequate. What we are looking at always is to improve
   4     our methods, clinical care. You are constantly evolving
   5     a clinical practice and we were in the process of
   6     re-evaluating, auditing if you want to use that term,
   7     a form of audit, I guess, evaluating our clinical
   8     practice and looking at ways of improving investigation,
   9     management, generally.
  10        That is what you see. That is part of that
  11     process of evaluating what you are doing. That is part
  12     of the audit process, I would suggest.
  13        That does not mean to say what was being done
  14     initially was inadequate; it means you are looking for
  15     ways of improving your practice. Medical practice has
  16     evolved constantly over the years along these lines.
  17        We looked at some what were then relatively new
  18     projections to look at the coronary arteries around that
  19     time, the "down the barrel" coronary artery view which
  20     has been reported by others as being successful, so we
  21     were looking at newly reported methods and projections
  22     to look at the coronary arteries.
  23        We looked also at newer methods just reported to
  24     look at new projections in pulmonary arteries. What we
  25     were doing was standard practice from what I was doing

   1     in previous centres, it does not mean it was
   2     inadequate. There were three bits you said there?
   3     I have answered the first bit.
   4   Q. I think I was suggesting, is it equipment, is it
   5     analysis, is it inevitable, given the equipment and
   6     standards at the time? I think you are indicating that
   7     it is really the third of those three, although you
   8     would not use the word "inevitable" because you say you
   9     can always improve?
  10   A. I think the equipment we had, the angiographic equipment
  11     was fairly standard for the time. It was a relatively
  12     good non-digital angiographic equipment. With regard to
  13     interpretation, interpretation was something that was
  14     done as a group. I have mentioned a little bit about
  15     how patients were reviewed. Each patient is reviewed in
  16     detail by a group of clinicians. That would include
  17     cardiologists, that would include cardiac surgeons,
  18     cardiac radiologists who specialise in angiographic
  19     techniques and ultrasound.
  20        We would sit down as a group and try and interpret
  21     the images, and then try and give the surgeon as much
  22     information as possible to forewarn him what he is going
  23     to see when he gets into the operating theatre.
  24   Q. It is important, I take it, for all sorts of reasons,
  25     amongst them the length of time the operation might

   1     take, if the surgeon has the best available information
   2     when he begins the operation. If he has to try to
   3     understand the anatomy of what he is operating and if it
   4     has not been conveyed to him, for whatever reason,
   5     beforehand, it must delay the length of time or take
   6     longer for the operation, must it not?
   7   A. It is important that we get the information as accurate
   8     as is possible within whatever limitations there are.
   9     It is important that the process of him understanding
  10     what we think we can see is transferred and that is the
  11     purpose of the joint meetings, that that process
  12     hopefully is there.
  13        If he is not happy with what he is seeing on the
  14     investigations, then he feeds that back to the group and
  15     we discuss whether anything else can be done. So it is
  16     a dynamic process.
  17   Q. You came to Bristol in 1988, and began in 1989 as
  18     a cardiologist. I do not know whether you ever saw the
  19     article which we have at UBHT 308/76. Because you are
  20     the first cardiologist to give evidence to us, I will
  21     ask you some questions about this.
  22        It is from the Journal of Clinical Pathology 1989,
  23     from Russell and Berry and you recognise them as being
  24     the pathologists attached to the Royal Hospital for Sick
  25     Children.

   1        If we can go to the second page of that, if we
   2     scroll down, describing a number of cases in which
   3     additional cardiac lesions were found at necropsy, and
   4     the reviewers have subdivide those into four groups: the
   5     first subgroup is where the cardiac diagnosis before
   6     death is completely wrong; then where only partially
   7     correct and additional lesions were missed that might
   8     have influenced the management; 3, cardiac surgery
   9     imperfect or inappropriate; and 4, substantially correct
  10     but additional lesions found at necropsy that would not
  11     have affected management had they been diagnosed in
  12     life.
  13        So looking at 29 cases, 38 per cent of the series
  14     they were reviewing, and identifying those four
  15     subgroups. We see the numbers. Only one case in
  16     subgroup 1, completely wrong, and you can read what it
  17     says at the bottom of the column there to yourself.
  18        Then table 1, at the top of the page on the
  19     right-hand side. Have you got that?
  20   A. Yes, I have.
  21   Q. Table 1 shows the missed cardiac lesions that are set
  22     out with the additional findings. They are described as
  23     "missed". In the second paragraph, in seven cases
  24     surgical flaws were found. In five of these, the
  25     surgical problem was probably a contributing factor in

   1     the patient's death. The flaws were of more doubtful
   2     clinical importance in the other cases.
   3        I do not suppose you were involved in any of these
   4     cases because it was before your time?
   5   A. No, not at all. I have seen the paper before, but not
   6     for a little while. I have not reviewed it recently.
   7   Q. They are reporting on the cases which arose in Bristol,
   8     therefore no doubt using the equipment and the systems
   9     that were in place. That is why I wanted to ask you
  10     about it.
  11   A. It is very difficult for me to comment on cases I have
  12     not been involved with. You might be better directing
  13     that to the experts or the other cardiologists involved
  14     at that time.
  15   Q. I will involve them in a moment, if I may. The reason
  16     for putting this paper to you, as I say, is that it has
  17     been raised before in evidence. Questions have been
  18     asked about it. It is important for the Inquiry to get
  19     a view as to why it may be that these particular
  20     findings such as in table 1 may have been missed and
  21     whether it was something which one can properly call
  22     "missed" in the sense of should have been found, or
  23     "missed" in the sense of well, that is unfortunately
  24     inevitable, given the equipment, the techniques and
  25     standards at the time, or what one is to make of the

   1     reasons for these particular items being found on
   2     pathological examination, but not in life.
   3   A. I can comment generally about that group of conditions,
   4     if you wish.
   5   Q. It is a general feeling that I am after.
   6   A. There are two patients there with interrupted aortic
   7     arch and aortopulmonary window, which is extraordinarily
   8     rare, in my experience. I think it is generally
   9     recognised that aortopulmonary window is a difficult
  10     diagnosis to make, and certainly in that era, pre colour
  11     flow, would have been very difficult.
  12        Unilateral partial anomalous pulmonary venous
  13     drainage, again without colour flow Doppler which would
  14     not have been present in the unit at that stage, you
  15     would have very little chance of diagnosing that, and
  16     probably would not have any impact, anyway, in the
  17     management of the child.
  18        Atrioventricular septal defect and cleft mitral
  19     valve cusp may well relate to the identification or
  20     whether the defect is a ventricular septal defect or an
  21     atrioventricular septal defect, which can be difficult,
  22     echocardiographically, sometimes.
  23        Mitral valve dysplasia: that may well be a minor
  24     abnormality of the mitral valve. Some flow through
  25     a shunt which was thought to be closed on echo, again,

   1     in the era pre colour flow Doppler, I do not think would
   2     be very surprising at all.
   3        Secundum ASD misinterpreted as dilated coronary
   4     sinus, again, the interpretation of that can be
   5     difficult sometimes, and again, with the echo equipment
   6     that would have been available in that era, not that
   7     surprising. Those would be my comments on that, just in
   8     general terms. I cannot speak specifically about the
   9     cases.
  10   Q. It is a general reflection that I want, particularly
  11     since you obviously know, as it were, the local
  12     circumstances which gave rise to these cases?
  13   A. I did not know the local circumstances at that time.
  14   Q. You came in, of course, in 1989/89?
  15   A. Something published in 1989 would have been written and
  16     submitted probably at least a year before that.
  17   Q. I take your point. Dr Silove?
  18   DR SILOVE: I am having difficulty in trying to understand
  19     whether this applies to echocardiographic diagnosis
  20     alone. It must apply to a combination of echo and
  21     angiography, and -- Mr Deverall has pointed out to me --
  22     surgical diagnosis.
  23        I agree with most of the reservations that
  24     Dr Martin has expressed in that list he went through in
  25     that table. What stands out for me is the very unusual

   1     presence of an atrioventricular septal defect and cleft
   2     mitral valve in a patient with transposition of the
   3     great arteries. It would be an extremely unusual thing
   4     to happen in a patient with transposition, but I feel
   5     that echocardiographically, it is a more or less
   6     barn-door diagnosis and it is surprising that
   7     a diagnosis like that should have been missed on
   8     echocardiography. It can be missed on angiography.
   9        I am just not quite certain -- I have not read
  10     this whole article and I am not sure of the context of
  11     everything here.
  12        Yes, I suppose if there is a surgical case, that
  13     particular one, and the surgeon has done a Senning's
  14     operation, for example, he must have been aware at least
  15     of there being a ventricular septal defect, so he
  16     probably had a look inside, and you would have thought
  17     the surgeon would have discovered there was an AVSD.
  18     I find that case very difficult. On the others, I agree
  19     with Dr Martin, there can be significant difficulties.
  20   MR LANGSTAFF: Mr Deverall, do you want to comment?
  21   MR DEVERALL: No. I think people of my age have lived
  22     through the whole evolution of paediatric cardiac
  23     surgery from the phase when most of the diagnosis was
  24     made by the surgeon at exploratory cardiotomy, which was
  25     awful, and then there was the phase of progressive

   1     improvement in pre-operative diagnosis, ultimately
   2     complemented by echocardiography, which, as it were,
   3     completed the circle.
   4        I am trying to think to the period of time
   5     relevant to this paper. I think surgeons were
   6     sufficiently frequently surprised by finding things
   7     which had not been diagnosed that many of us even had
   8     a check-list held by the anaesthetist in the operating
   9     room which we went through item by item at the beginning
  10     of every operation and during the external and internal
  11     examination of the heart, not because we did not trust
  12     our paediatric cardiologist. At that stage, and I think
  13     if these patients probably went back right into the
  14     early 1980s, echocardiography was relatively new, as
  15     Dr Martin has implied, certain angiographic developments
  16     had not taken place. There was still an element of
  17     surprise for a surgeon and you had to develop techniques
  18     to cope with that.
  19        That has changed now.
  20   Q. How has that changed during the late 1980s and early
  21     1990s?
  22   A. I think partly as a result of surgical pressure; partly
  23     as a result of improved diagnostic techniques. It would
  24     be the combination of the cardiologist, his equipment
  25     and experience. It would be very unusual to go to an

   1     operation now without a precise pre-operative
   2     knowledge. I could not emphasise too strongly how
   3     different that is from when I started in the late 1960s
   4     and early 1970s. This period goes back to the early
   5     1980s, halfway between.
   6   THE CHAIRMAN: We think it is 1985 to 1987, looking at the
   7     paper.
   8   MR DEVERALL: I would say we are about halfway, maybe
   9     a little more, to where we are today.
  10   MR LANGSTAFF: You agree with those comments?
  11   DR MARTIN: Yes, absolutely.
  12   Q. Can you tell me, you came into the unit after this
  13     article had been written. You remember seeing it. Were
  14     any particular lessons, do you think, learned in the
  15     unit from the article, or not?
  16   A. I think you are always learning from your previous
  17     experience. I am sure lessons were learned. This very
  18     rare association of interrupted aortic arch and
  19     aortopulmonary window is something I do not think I had
  20     seen a case myself at that stage, and it is something
  21     I thought I must always look out for in patients with
  22     this condition if you do not see a VSD. The next case
  23     I saw with it was about a year ago. So you are dealing
  24     with fairly rare conditions here, but there are always
  25     lessons that you do pick up from any piece of research

   1     audit work that was performed.
   2   Q. Can I move away from what I have been asking you about,
   3     which is essentially the use of echo equipment and the
   4     circumstances in which it was used?
   5   THE CHAIRMAN: Mr Langstaff, before you do, I wonder whether
   6     for my own satisfaction we could go back to one document
   7     you showed a moment ago, UBHT 61/149. That was the
   8     meeting, you recall.
   9        I did not quite understand Dr Martin's response,
  10     when I think I heard you say that it was not being said
  11     that the information provided was inadequate, whereas
  12     the words used here are "just not good enough".
  13        Is your explanation of that that it does not mean
  14     that, or that is not what is intended to be said, or
  15     what?
  16   A. I cannot speak for Dr Bolsin, who wrote this, but my
  17     understanding from that time was that we looked at ways
  18     of changing our evaluation practice to see if that would
  19     improve things.
  20        Whether you call that not good enough, I am not
  21     sure I have a value judgment on that. As I say, you are
  22     always looking to improve your methods of assessment.
  23     Those, as I say, would not be the way I would
  24     necessarily put it.
  25   Q. That is all that we can ask, that we hear how you would

   1     describe it. You do not adopt those words, or you do,
   2     or you have a different form?
   3   A. Without going back through those cases in detail,
   4     I think it would be very difficult for me to comment,
   5     but I think it does refer to a few patients with
   6     tetralogy of Fallot around that time, and I am afraid
   7     I cannot remember the details well enough to have firm
   8     convictions of that time, but I gained the general
   9     impression that there were areas that we could change in
  10     the hope that we could improve the evaluation. I would
  11     not necessarily put it stronger than that.
  12        Have I answered your question? I probably have
  13     not.
  14   Q. I am working at understanding it. Room for
  15     improvement?
  16   A. Yes, room for change.
  17   DR SILOVE: May I just make a comment on this particular
  18     issue of tetralogy of Fallot and coronary artery
  19     abnormalities? That has always been an important thing
  20     for surgeons to know about. I do not believe it really
  21     was standard practice everywhere in 1989 for aortograms
  22     to be done specifically to look at coronary artery
  23     anatomy.
  24        We were doing it in Birmingham at that time, but
  25     I do not think that everybody was doing it. I think

   1     that the culture of doing it sort of began to come in
   2     around that time. I think that people were looking at
   3     coronary arteries, but not specifically doing aortograms
   4     to look at the coronary artery anatomy.
   5   THE CHAIRMAN: Dr Silove, this is 1991. Would that affect
   6     your answer?
   7   DR SILOVE: I am sorry, I thought it was 1989. I am sorry.
   8     Perhaps even 1991, it had not really taken hold
   9     everywhere, but I think by that time it was beginning to
  10     take hold, and I think that there were demands by
  11     surgeons that they needed to know more about the
  12     coronary artery anatomy.
  13        It was an angiographic focus, not an echo focus.
  14     That is the only other point I want to make. It was an
  15     angiographic diagnosis.
  16   DR MARTIN: May I just comment, if that is possible?
  17   MR LANGSTAFF: Yes, certainly.
  18   A. I think it would have been standard practice in the unit
  19     at that stage to undertake aortography in the vast
  20     number of cases to look at the coronary anatomy. What
  21     we are talking about using different projections,
  22     different views, to see if you can get a better
  23     understanding of the branching pattern. My
  24     understanding is that there is still no completely
  25     accepted way that you can be 100 per cent accurate with

   1     that. We have looked at a number of different ways of
   2     evaluating the vessels and it can be very different.
   3   DR SILOVE: I agree with Dr Martin there. It can be very
   4     difficult.
   5   MR LANGSTAFF: Can I move away, then, from equipment?
   6     I have been asking you about 1994 and your knowledge of
   7     concerns about paediatric cardiac surgery. What, as you
   8     see it, were relationships between the various different
   9     disciplines providing paediatric cardiac surgical
  10     services like during 1994 and early 1995?
  11   A. Any particular disciplines?
  12   Q. Were they harmonious?
  13   A. Which particular disciplines are you referring to?
  14   Q. Let me break it down. Cardiac surgery is a team effort,
  15     is it not?
  16   A. Yes.
  17   Q. The team consists of the surgeon, the cardiologist, the
  18     anaesthetist, the perfusionist, the intensivist, if
  19     there is one, the nursing staff. There may be others --
  20   A. There are others, yes.
  21   Q. If I missed them off that list, then if the omission is
  22     particularly significant, you will mention it, otherwise
  23     those who listen I hope accept my apologies.
  24        But all those people play a part. It is
  25     important, if they are going to work as a team, that

   1     they are able to function as a team harmoniously to that
   2     end, is it not?
   3   A. Yes.
   4   Q. From your perception of events in 1994/95, did the
   5     surgeons who were performing paediatric cardiac surgery
   6     function harmoniously together, first of all? "Yes" or
   7     "No"?
   8   A. Between Mr Dhasmana and Mr Wisheart?
   9   Q. Yes.
  10   A. As far as I was aware, yes.
  11   Q. Did they, so far as you were aware, function
  12     harmoniously with the cardiologists?
  13   A. Speaking for myself, I always felt I had harmonious
  14     relationships with both Mr Wisheart and Mr Dhasmana.
  15     I gained the general impression that there was a good
  16     working relationship between the cardiologists and the
  17     two cardiac surgeons.
  18   Q. With the anaesthetists?
  19   A. Whom are you talking about now?
  20   Q. The surgeons and the anaesthetists?
  21   A. I was aware of certain individuals where relationships
  22     have been less than harmonious, shall we say.
  23   Q. Whom do you have in mind?
  24   A. I think that relationships between surgeons and
  25     Dr Bolsin at around that stage became a little

   1     difficult.
   2   Q. Anybody else, apart from Dr Bolsin?
   3   A. I was not aware of any other concerns or problems, no.
   4   Q. What about the relationships between the cardiologists
   5     and the anaesthetists?
   6   A. We had very good relationships and day-to-day
   7     relationships with the anaesthetists at the Children's
   8     Hospital. We were working together in a unit, we had
   9     been involved in the management of patients on intensive
  10     care, so in the sort of latter part of that era, 1994,
  11     that would have been Drs Hughes --
  12   Q. O'Higgins?
  13   A. He might have retired by then. He retired around that
  14     time, I think -- no, he probably was still there at that
  15     stage.
  16   Q. Mather?
  17   A. Dr Mather, Dr Thornton, good working relationships with
  18     them. Personally, I have relatively few contacts with
  19     the anaesthetists undertaking the open-heart surgery,
  20     which at that stage, I suppose, would have been --
  21     I think they changed at that stage, but Dr Masey,
  22     Dr Underwood, Dr Bolsin, Dr Monk, Dr Pryn presumably
  23     would have been there by then, and possibly Dr Davies.
  24     So I had relatively little contact with them at that
  25     stage. Dr Masey probably was the one I had most contact

   1     with. Prior to that she used to come --
   2   Q. She was the one who used to come to meetings?
   3   A. Yes, particularly to meetings, at an early stage after
   4     I started.
   5   Q. Thus far we have looked at consultant level. Were you
   6     aware of particular concerns within the surgical sector
   7     in so far as junior hospital staff were concerned, at
   8     SHO level?
   9   A. Was I aware? No, I do not think I was, no.
  10   Q. We have had in this Inquiry a report which was produced
  11     by Kapila and May, which, in 1994, appears to indicate
  12     that Senior House Officers were dissatisfied with their
  13     lot in surgery, feeling they had inadequate training and
  14     were not learning, were not doing what they had expected
  15     to be there for.
  16        Did any of that reach you?
  17   A. I was not aware of it. As I have already said, my
  18     clinical base being at the Children's Hospital, it is
  19     quite likely I would not have been informed of that.
  20   Q. If we go to UBHT 61/378, if we scroll down, this is the
  21     report which Messrs Hunter and de Leval produced. At
  22     page 382 we see, if we scroll down, please, 5:
  23        "The tension which has arisen from this long saga
  24     has created an atmosphere of distrust and lack of
  25     confidence which has made the working conditions for

   1     these surgeons very difficult indeed."
   2        The "long saga" is a reference, I think, to events
   3     which began in 1993 and went on through 1994 into 1995.
   4     How accurate do you regard that statement by
   5     Messrs Hunter and de Leval as being?
   6   A. I think it is fair to say that whilst I was aware that
   7     there were difficulties -- I do not know whether
   8     "distrust" and "lack of confidence" I really go along
   9     with, but there had been difficulties between the
  10     surgeons and some of the anaesthetic group. In amongst
  11     all my other clinical work, I do not think I ever was
  12     aware that it had got to a position where the working
  13     conditions for the surgeons were very difficult indeed.
  14     That certainly was not communicated back to me that it
  15     had that effect.
  16   Q. The original description of it in the first report,
  17     PAR (2)1/101, has slightly different wording:
  18        "Made the working conditions for the surgeons
  19     nearly untenable."
  20        Did any of that feeling they are describing reach
  21     you?
  22   A. I was not aware of that. Whether that is a true
  23     reflection, obviously that is the perception of
  24     Mr de Leval and Dr Hunter. That clearly was the
  25     impression they gained. I was not aware that the

   1     working conditions for the surgeons became nearly
   2     untenable. That was not something I was appreciating at
   3     that stage.
   4   Q. Let us go back to the start of this, PAR (2)1/99, the
   5     middle of the page, the programme for the visit.
   6     Messrs Hunter and de Leval say whom they met there, do
   7     they not: Mr Dhasmana, Mr Wisheart, joined by you and
   8     Dr Hayes?
   9   A. Yes.
  10   Q. Dr Bolsin, Dr Monk, Sister Thomas, Professor Angelini,
  11     Dr Hughes and Mr Barrington of the Children's Hospital,
  12     and Dr Pryn and his consultant anaesthetist.
  13        So they speak to really quite a limited number of
  14     people, of whom are you are one, and formed the view
  15     they expressed.
  16        Were you present when Mr Dhasmana, Mr Wisheart and
  17     Dr Hayes spoke to Messrs Hunter and de Leval?
  18   A. From memory, I think Mr de Leval and Hunter spoke to, if
  19     you like, individual groups separately, so I think he
  20     spoke to the cardiologists, myself and Dr Hayes, spoke
  21     to I think -- I think he may have spoken to Dr Bolsin
  22     separately.
  23   Q. Is your memory right on that?
  24   A. I do not know; I am not sure.
  25   Q. "Mr Dhasmana and Mr Wisheart were then joined by two of

   1     the paediatric cardiologists".
   2        What he appears to be describing, as a matter of
   3     English, is that the four of you are there together.
   4     He has spoken to the two surgeons first and then the two
   5     cardiologists identified come along and chat as well.
   6        Is that what happened, as you recollect it?
   7   A. I do not recollect whether that was the case or whether
   8     he met us separately. My general feeling was that we
   9     had met separately, but whether that is correct or not,
  10     I do not know. That suggests it is not, but whether
  11     that is true or not, I do not know.
  12   Q. However one puts it, whether one says it is difficult
  13     for the surgeons or nearly untenable for the surgeons,
  14     the view as to how the surgeons are placed essentially
  15     has to come from the surgeons, has it not?
  16   A. I would have thought so, but whether that view was
  17     expressed just when we might have been there -- I do not
  18     remember them expressing that opinion when I was there.
  19     As I say, I do not remember us having that meeting at
  20     the same time, but I presume they might have met
  21     separately as well.
  22   Q. Did you have regular contact with Mr Dhasmana and
  23     Mr Wisheart?
  24   A. Yes.
  25   Q. You would expect, would you, to have been aware of their

   1     feelings about the way in which they related to their
   2     colleagues if it was affecting their work?
   3   A. Well, not necessarily, no. We had a professional
   4     working relationship. I was not a close social friend
   5     of either Mr Wisheart or Mr Dhasmana, so I do not think
   6     one can necessarily infer that they would have passed
   7     that on to me.
   8   Q. Did you, after the operation on Joshua Loveday, then
   9     have any sense that relationships between the surgeons
  10     and anaesthetists within the department, the unit, were
  11     as bad as Messrs Hunter and de Leval paint it?
  12   A. I think it is true to say that after that meeting
  13     I became aware how strong the feelings were. I would
  14     say that it was some anaesthetists, not all
  15     anaesthetists, in the friction that had developed, if
  16     you like, between the surgeons and the anaesthetists,
  17     I did not get the impression that it was the whole group
  18     of anaesthetists, I got the impression it was -- some
  19     might say two "factions", but there were different
  20     groups, some of which were happier than others, or
  21     unhappier than others.
  22   Q. You were aware, were you, that in about October 1993,
  23     a decision was made not to continue with the neonatal
  24     arterial switch programme?
  25   A. No. I was not aware of that. My understanding of the

   1     situation was that that decision was not finally made
   2     until towards the end of 1994.
   3   Q. Were you aware that in June 1994 six anaesthetists
   4     signed a letter asking for a thorough review of the
   5     arterial switch programme?
   6   A. I am aware of the letter you are referring to. I think
   7     I first -- as far as I am aware, the first time I saw
   8     that was December 1994.
   9   Q. So you saw it in December 1994?
  10   A. I think it was.
  11   Q. Were you aware of it beforehand?
  12   A. No. I think it was produced -- I think it may have been
  13     produced at a meeting we had in Dr Joffe's house in the
  14     early part of December -- I think it was the 8th or
  15     something. I was not aware of it prior to that.
  16   Q. Before seeing it at that meeting on the 8th, had you
  17     been aware of disagreement or unhappiness about that
  18     particular series of operations, the switch operation?
  19   A. I was not aware of anything specifically on the arterial
  20     switch operation, so far as I can remember, at that
  21     stage. In fact, I know I spoke to Mr Dhasmana towards
  22     the end of November when we were talking about
  23     scheduling -- am I allowed to say the patient's name?
  24   Q. You can mention Joshua Loveday?
  25   A. We were talking about the fact that I had seen Joshua

   1     Loveday in the Outpatients Department and I was
   2     concerned about his waiting. At that stage, I think he
   3     said that he had been told by the anaesthetist that he
   4     could not do an arterial switch operation without prior
   5     discussion.
   6        I am pretty sure that was news to me at that
   7     stage, from what I remember. I indicated that I was not
   8     aware of that and I felt that we should have a meeting
   9     to discuss it and talk to the various parties. I think,
  10     if I remember rightly, that was why the meeting of
  11     December 8th was called, and it centred around the
  12     arterial switch programme, both in neonates and in older
  13     children.
  14   Q. So far as Joshua Loveday is concerned, he was a patient
  15     of yours, was he?
  16   A. Yes. I was not involved in his first admission when he
  17     was under the care of Dr Joffe, which was for repair of
  18     interrupted aortic arch and pulmonary banding, but
  19     I subsequently took up his care, as you have already
  20     heard, as I undertook the Gloucester peripheral clinic,
  21     which was their clinic, and was the prime cardiologist
  22     looking after him after that.
  23   Q. Let me just understand the chronology. You see him more
  24     than once: in Gloucester, 5th August 1993; your
  25     Registrar sees him on 4th October 1993; you see him on

   1     10th January 1994, in Gloucester. He comes into the
   2     Children's Hospital for a catheterisation on 22nd May
   3     1994, and has that on the next day, 23rd May.
   4        Did you perform an echo?
   5   A. I would have performed an echo.
   6   Q. There is no record of it.
   7   A. Right. I would have undertaken an echocardiogram at
   8     some stage. Whether I did one on his catheterisation --
   9     would be my normal practice, but I do not honestly
  10     remember.
  11   Q. You describe, I think, the coronary arteries following
  12     the catheterisation in these terms:
  13        "Left coronary artery arises in its usual position
  14     but the left main coronary artery runs posteriorly
  15     around the pulmonary artery and gives rise to a left
  16     anterior descending and circumflex branch. The right
  17     coronary artery is large and rises anteriorly, giving
  18     rise to a major distribution, including a large conus
  19     branch. There is a large VSD and the pulmonary valve
  20     arises more from the right ventricle than the left."
  21   A. I am sorry, is that my description?
  22   Q. I thought I was quoting?
  23   A. I am just saying, if it is coming from the angiographic
  24     report, then the general angiographic reporting would be
  25     Dr Wilde's, who