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 was the radiologist that often reported

   1     it, and I would quite often do a summary.
   2   Q. You thought that he looked suitable for an arterial
   3     switch operation with closure of the VSD?
   4   A. He was discussed at our joint meeting and I, amongst
   5     others, felt that that was the correct course of
   6     treatment.
   7   Q. That would be in May 1994, and so before the letter
   8     which was written in June from the anaesthetists talking
   9     about a need to look at the arterial switch programme,
  10     about which you did not know until December.
  11        Who listed Joshua Loveday for operation?
  12   A. The control of admissions was totally under the control
  13     of the surgeons, for the open-heart surgery, so
  14     Mr Dhasmana would have been making those arrangements.
  15   Q. So it follows that Mr Dhasmana must have put Joshua
  16     Loveday's name down upon the operating list some time in
  17     November?
  18   A. My understanding is that after the discussion note,
  19     which was I think in -- when we sat down as a group to
  20     discuss his care, which was in June, he subsequently saw
  21     him in the outpatient clinic and I believe he would have
  22     been put on the waiting list for operation at that
  23     stage.
  24        The actual putting on the printed operating list
  25     that was sent out to all the departments and the actual

   1     scheduling of the operation would have been done by
   2     Mr Dhasmana for a January operation, I presume, some
   3     time in December.
   4   Q. We have been told elsewhere, I think, in November, so
   5     the chronology thus far is catheterisation May,
   6     discussion June, waiting list, and comes up in November
   7     or December -- November I suggest -- for operation in
   8     January.
   9        Is there anything remarkable about that
  10     time-scale --
  11   A. In what way do you mean?
  12   Q. -- for the condition that he suffered from? It was
  13     a classic Taussig-Bing syndrome, was it not?
  14   A. Certainly. I think when we originally discussed him
  15     I gained the impression from our discussions that we
  16     would be offering him surgery within three or four
  17     months, I think I put in my original note, or one note
  18     I penned.
  19        As it was, when Mr Dhasmana saw him in the
  20     outpatient clinic I think he said four to six months,
  21     I think perhaps with an expectation that it would be
  22     four rather than six, but perhaps you will have to ask
  23     him that.
  24        I saw him in the Outpatients Clinic in November
  25     and was concerned about the fact that he had been

   1     waiting longer than I had anticipated, and was concerned
   2     that any prolonged wait would subject him to additional
   3     risk.
   4        I think I spoke to Mr Dhasmana, as I have already
   5     said, at some stage -- I am not sure exactly when --
   6     after that outpatient visit towards the end of
   7     November. That prompted his comments.
   8   Q. Forgive me, I think when you saw him on 21st November
   9     1994 -- the reason I quote these dates to you without
  10     showing you the records is that you have recently,
  11     I think, had an opportunity to see and go through the
  12     records. By all means, if you want to see a particular
  13     record, stop me and ask me and we will go to it and have
  14     a look at it. Otherwise, it may be quicker to do it the
  15     way I am doing it.
  16        On 21st November 1994 when you saw him in the
  17     Joint Cardiology Clinic in Gloucester, there was no
  18     obvious change, was there, in his condition from the way
  19     in which he presented in May?
  20   A. My recollection, and certainly having looked previously
  21     at my note of that occasion, was that he was "moderately
  22     cyanosed" is my description, i.e. he was quite blue and
  23     that did not surprise me because he was blue when I had
  24     undertaken his catheter study. It was very difficult to
  25     assess whether that was getting worse. Knowing his

   1     anatomy and the likely progression, I would expect him
   2     to become progressively more cyanosed, progressively
   3     bluer, given time. Would it help if I explain the
   4     mechanism of that?
   5   Q. Certainly.
   6   A. He had a band on his pulmonary artery to restrict flow
   7     of blood to his lungs. When a child grows, that band
   8     becomes relatively tighter as time goes on. The effect
   9     of that, in a child with his condition, is for him to
  10     become progressively bluer as time goes on.
  11        The reason I was concerned about him when
  12     I catheterised him initially, and certainly
  13     subsequently, was that when I did his catheter study,
  14     I think from memory his aortic saturation was very low,
  15     at that stage 61 per cent, and he had quite a high blood
  16     count, polycythemia. In view of that, I felt there was
  17     some degree of clinical urgency to his case and that is
  18     what we expressed, what I expressed and as a group we
  19     expressed, at the group meeting.
  20        We know that with his anatomy, as he grows, that
  21     band is going to become tighter, he is going to become
  22     bluer and the risks of waiting become -- it is not
  23     a cut-off, but there is a risk to waiting for
  24     a prolonged period in that setting, both with regard to
  25     low oxygen levels, which in themselves can have

   1     a deleterious effect on heart function in the long term,
   2     but also you start to run the risks of what are termed
   3     thrombo-embolic problems, if you like strokes, related
   4     to the high blood count and the low oxygen levels.
   5        You also run the risk of stimulating muscular
   6     hypertrophy, that is muscular thickening of the heart,
   7     which in itself can cause problems around the
   8     peri-operative period when it comes to surgery. I know
   9     this was a factor that was fairly prominent in our minds
  10     at that time, that particular factor about the muscular
  11     hypertrophy, in view of a case that Mr Dhasmana had
  12     between when we discussed him and later when I saw him
  13     in November -- again, I am not going to refer to the
  14     case because I am not sure whether I should.
  15   Q. Do not mention the name of that case.
  16   A. I felt, based on that experience, there were dangers in
  17     waiting, so when I saw him in November, I was concerned
  18     that he had been waiting longer than I had anticipated
  19     and I was concerned about him running into problems from
  20     that.
  21        He was quite restricted physically. I think he
  22     was just sitting at that stage, developmentally he was
  23     behind, which again probably reflects, to a certain
  24     degree, his cardiac status at the time and
  25     a cardiac problem of that severity would hold back his

   1     development.
   2        Having looked at that note, I think I was
   3     concerned about him becoming progressively less well if
   4     we waited; there was a danger of that.
   5   Q. The only way of telling with any accuracy whether
   6     a child has become more cyanosed is to measure the
   7     oxygen saturations, is it not?
   8   A. That gives you a moment in time. I am not sure in my
   9     outpatient clinic in Gloucester, whether -- I do not
  10     think at that stage I would have had an oximeter to
  11     measure his oxygen levels, so you would be relying on
  12     your clinical assessment. I tend to grade cyanosis as
  13     mild/moderate to more than moderate. It is very rare to
  14     say "severe" but it is not easy to put a figure on it.
  15        Oximeters are unreliable, I would say,
  16     particularly if the oxygen levels are low in a cyanosed
  17     patient, so you cannot rely on them entirely. Probably
  18     a most accurate statement of his oxygen status would be
  19     that obtained at the catheter study, which was very
  20     low. We use what is called a co-oximeter there which
  21     gives a very accurate measure of the oxygen saturation,
  22     whereas most of the other equipment used gives you
  23     derived values which are not very reliable.
  24   Q. At catheter in May his saturation of 61, as you have
  25     said, and at operation in July, 62 per cent, as you

   1     know, having looked at the notes?
   2   A. I am sorry, at ...
   3   Q. At the operation?
   4   A. I do not know what those are. I have not seen that
   5     figure.
   6   MR LANGSTAFF: Let us look at that after the break, if we
   7     may. Sir, it is now an appropriate time for such
   8     a break, perhaps until 1.15?
   9   THE CHAIRMAN: Yes, thank you Mr Langstaff. Let us adjourn
  10     now and reconvene at 1.15.
  11   (12.40 pm)
  12            (Adjourned until 1.15 pm)
  13   (1.15 pm)
  14   MR LANGSTAFF: What I have looked out for you is the record
  15     of the operation which took place on 12th January: what
  16     you see highlighted on the screen, I will show you the
  17     whole document in a moment, is the oxygen saturations
  18     and you can see clearly there what they are. I was in
  19     error in saying "62". It should have been 73 and I was
  20     quoting I think from Mr Dhasmana's operation note where
  21     he was recording your history albeit inaccurately
  22     because he said "62" not 61.
  23        Let us have a look at the whole document. This is
  24     a record of measurements taken during operations, is it
  25     not?

   1   A. Yes, it looks like an anaesthetic chart.
   2   Q. We can see between 8.00 and 9.00 in the morning, if one
   3     goes up to the events line. We had better have this
   4     highlighted because it is very small print, it is not
   5     easy to read?
   6   THE CHAIRMAN: For the transcript purposes may we make sure
   7     we read the reference into the transcript?
   8   MR LANGSTAFF: MR 164/13.
   9   THE CHAIRMAN: To make it clear, we do have the consent of
  10     all involved?
  11   MR LANGSTAFF: We do. "Events", you see the time there in
  12     that line, going across, 8.00, 9.00, 10.00 and so on,
  13     the usual anaesthetic record. We see it highlighted
  14     there. Can we go back to the highlighted one. We see
  15     bypass begins at 9.00, so it appears?
  16   A. (Witness nodding).
  17   Q. So before bypass, between 8.00 and 9.00, if one looks
  18     down to the bottom of the screen we have the oxygen
  19     saturations measured 73 and 74.
  20        As measured at operation the oxygen saturation was
  21     no worse than it had been when you conducted the
  22     catheterisation the previous May; is that not right?
  23   A. A couple of things I would like to comment on that.
  24     I am not sure what basis that saturation is based upon.
  25     If it was based on a pulse oximeter recording, which it

   1     might well have been, on an anaesthetic chart, then, in
   2     low saturations they are notoriously unreliable. So
   3     I would not personally give much credence to it. They
   4     give you an idea as to whether the child is cyanosed or
   5     not. We very commonly compare oximeter recordings in
   6     the catheter lab to what we get on the co-oximeter when
   7     we do the saturations as part of the catheter test and
   8     it is very common for us to see an overestimation on the
   9     saturation in that setting.
  10        That finding there does not say really, in my
  11     opinion, whether there has been any change in
  12     saturation.
  13   Q. Let me go back, if we may, to the pulse oximetry record
  14     taken in May when you carried out your catheterisation.
  15      MR 395/37.
  16        If it would help to have a hard copy of the
  17     records in front of you then please ask and it will be
  18     provided. Here we have the oxygen saturation, the same
  19     line, if we can go down to the bottom. You are
  20     absolutely right in saying the measurements are not
  21     quite the same as the catheter measurement, we measured
  22     61 but on the pulse oximetry 76 is the lowest figure
  23     there, the starting figure which is very little
  24     different from the 73/74 recorded at operation some
  25     eight months later.

   1   A. It is also evidence if you see the sequential recordings
   2     there, there was unlikely to be any major fluctuation in
   3     saturations when the patient is anaesthetised and you
   4     see wide variation there. I think all that points out
   5     is the pulse oximeter recordings in this setting with
   6     low oxygen saturations are unreliable. I would be loath
   7     to make any strong comparisons but if you look at that
   8     trend of that sequence there, they to me look higher
   9     than they were at the time of the operation.
  10        Can I make a comment about that? You are focusing
  11     very much on whether there has been any change. I think
  12     I have tried to explain that the measurements in
  13     themselves which you have brought up here are
  14     unreliable. As a cardiologist and I guess as a surgeon
  15     one has also to be aware of what you expect to happen,
  16     what you know will happen in that child's heart defect.
  17        As I have already indicated, a child with
  18     a pulmonary artery band in this setting is not going to
  19     get less blue, they inevitably will have to become bluer
  20     with time. I do not know if that is something perhaps
  21     you want to ask for any comment from Dr Silove, but
  22     I would have thought a child with a saturation of
  23     61 per cent on a reliable co-oximeter -- we check these
  24     regularly, we know these figures are accurate -- is an
  25     indication of moderately severely low oxygen levels and

   1     that is also backed up by the blood count in his case
   2     which was elevated, he quite significant polycythemia.
   3   Q. You invited me to ask Dr Silove and I will ask Dr Silove
   4     and Dr Deverall.
   5        You have seen here the records. How far can one
   6     rely upon those records as indicating any change or
   7     otherwise in this child's condition given the natural
   8     progression of the disease?
   9   DR SILOVE: The oxygen saturations that we are looking at
  10     suggest that, for the reasons that Dr Martin has already
  11     given, there is probably not a significant difference
  12     between the pulse oximetry oxygen saturations to the
  13     time of the catheter and at the time of the operation.
  14     They both are taken under anaesthetic. A reading of
  15     over 70 per cent is not all that unreliable when it
  16     comes to oxygen saturations in a small child. I do not
  17     think it is quite as unreliable as Dr Martin is
  18     suggesting, but I do accept that it is not entirely
  19     reliable.
  20        I also agree with him that the oxygen saturations
  21     would not have got any better over a period of seven or
  22     eight months from the time of the catheter -- seven
  23     months from the time of the catheter to the operation,
  24     and one would expect him to get worse if anything.
  25        But we do not actually have any direct

   1     measurements of the oxygen saturations that I have been
   2     able to see during that intervening period.
   3        The haemoglobin level was if I recall around 18.6,
   4     which is high and does confirm that the patient was
   5     cyanosed and blue and compensating by producing more red
   6     blood cells.
   7        Overall the patient was obviously very blue, as
   8     Dr Martin has said, and I think his anxiety about
   9     leaving the patient for a long period of time from the
  10     time of the cardiac catheter is justified. I mean
  11     I think ideally this patient should have had an
  12     operation very soon after the cardiac catheter if he was
  13     going to have an operation at all.
  14   Q. In terms of what one can divine from the notes about
  15     whether the condition was progressing so as to make an
  16     operation urgent when it had been left for some seven or
  17     eight months hitherto, what do you say about that?
  18   DR SILOVE: I think the operation was urgent in May when the
  19     cardiac catheter was done. It was probably gradually
  20     becoming slightly more urgent all the time because the
  21     patient was growing. I do not know that there is a huge
  22     difference between a matter of weeks but certainly
  23     months can make a big difference.
  24   Q. Mr Deverall, having looked at the records, how do you
  25     see this child having changed between May and January?

   1   MR DEVERALL: I would agree with Dr Silove. There was a
   2     strong indication to intervene very soon after the
   3     cardiac catheter procedure and, for whatever reason,
   4     once a delay had taken place that clinical indication
   5     was still there but there is nothing that I could see in
   6     the notes that said from Day 1 to Day 2 there had been
   7     sudden -- a dramatic change changing an urgent operation
   8     into an emergency operation.
   9   Q. I do not know if you want to comment on either of those
  10     views?
  11   A. No, that basically concurs with my assessment at the
  12     time. I think we felt when we first saw him that he was
  13     relatively urgent. That is why I had the view that he
  14     would be likely to be operated on within three or four
  15     months and when I saw him in the outpatient clinic in
  16     November and he still was waiting, I was concerned about
  17     waiting.
  18   Q. You agree, however, do you, that there was so far as one
  19     could tell no significant immediate deterioration in
  20     Joshua Loveday's condition from one day to the next so
  21     as to change an operation which was needed pretty soon
  22     to one which was an emergency?
  23   A. I think we have discussed that. I think we would have
  24     expected to see a progressive decline and I think the
  25     issue is really what you gain by waiting and what

   1     potential risk you subject that child to.
   2        If you are coming on to the question of how long
   3     do you wait. Following the meeting of the 11th, it was
   4     my feeling at that stage that a delay of a few weeks
   5     would be acceptable, along the lines of what Dr Silove
   6     said, particularly if there was a clinical indication
   7     for it. So for instance if he had been seen by the
   8     junior staff and felt to have an intercurrent infection
   9     then, fine, that would be a good reason to delay surgery
  10     for that sort of time period.
  11        But I felt that a longer delay would subject him
  12     to risks from his polycythemia from his thickened blood
  13     with regard to strokes. His low oxygen levels may might
  14     well have a long-term effect on his heart function.
  15     I was also, I think as I have already said, quite
  16     concerned about the possibility of him developing
  17     progressive muscular hypertrophy because we had seen
  18     this not that long before in another child which I think
  19     probably made that child's operation very high risk. It
  20     certainly was a factor in it and I did not want Joshua
  21     going through that same process if at all possible.
  22   Q. Apart from seeing him in outpatients in November 1994,
  23     did you see Joshua Loveday again before 11th January
  24     1995?
  25   A. No, I did not see him on that admission at all.

   1   Q. On 11th January 1995, is it right that you had last seen
   2     Joshua on 21st November 1994?
   3   A. That is correct, yes.
   4   Q. The last time that you had carried out any
   5     investigations into Joshua's condition was in May 1994?
   6   A. Certainly that was the time I did the cardiac catheter
   7     test. It is possible I might have -- as investigations
   8     in the outpatient clinic have an echo machine in the
   9     clinic, whilst I do not always comment on it I may have
  10     had a look at his heart at that stage, I cannot remember
  11     to be honest.
  12   Q. You may have made some investigation but not recorded
  13     the results?
  14   A. It would not be unusual to have a quick look at the
  15     heart but I do not remember doing so in his case.
  16   Q. We may take it if anything happened, if anything turns
  17     upon it, that the last stage any investigation had
  18     occurred was in May 1994?
  19   A. Probably, yes.
  20   Q. By 8th December 1994 there was a meeting at Hyam Joffe's
  21     house, was there?
  22   A. Yes, there was.
  23   Q. You were present?
  24   A. I was.
  25   Q. Dr Underwood was present. Was Dr Masey present?

   1   A. Yes, I think Dr Masey was present. I cannot be certain
   2     -- I am fairly sure she was.
   3   Q. What was the purpose of the meeting?
   4   A. It was one of our "evening" meetings as you might want
   5     to call it, where a number of issues can be discussed.
   6     We particularly planned to discuss the arterial switch
   7     programme at that meeting. There may have been other
   8     things discussed but that was the primary focus I think.
   9   Q. Because it was in someone's house it was I expect much
  10     less formal than it would have been had it been in
  11     level 7 of the University or in one of the rooms of the
  12     hospital?
  13   A. It depends what you mean by "formal". You know, it is
  14     a meeting where everyone sits down and talks and
  15     discusses issues. I do not know, they were not minuted
  16     meetings so they were not formal from that point of
  17     view, but in other ways they were very similar to
  18     meetings you would have at other times.
  19   Q. Refreshments offered?
  20   A. Yes, you would have refreshments, but --
  21   Q. The usual sort of social courtesies observed, as it
  22     were?
  23   A. Yes.
  24   Q. Comment was to be made that if there were to be anything
  25     critical said it is difficult for a critic to do it when

   1     he is eating someone's biscuits and drinking their wine;
   2     is that fair do you think?
   3   A. I do not think that has any bearing whatsoever. It
   4     certainly had no impact on anything I might have wanted
   5     to say.
   6   Q. At the meeting in December, do you recollect whether
   7     Mr Dhasmana went through any of his series of operations
   8     on the switch?
   9   A. I do have some recollections of it, I must say. As
  10     I have been able to look at more in the way of documents
  11     later since I gave evidence to the General Medical
  12     Council I have been able to clarify my thoughts a little
  13     bit. Yes, I do remember him specifically presenting
  14     data at that meeting.
  15   Q. We will need to have this redacted, but may we have
  16     a look at UBHT 54/86. What Joshua Loveday suffered
  17     from --
  18   THE CHAIRMAN: I am just wondering whether we should take
  19     the months out as well, but you will advise me?
  20   MR LANGSTAFF: No. Do you have it on the screen?
  21   A. I do now, thank you.
  22   Q. What Joshua Loveday suffered from was the Taussig-Bing
  23     syndrome, was it not?
  24   A. That is another name for it, yes.
  25   Q. That we see represented, do we, on this chart by --

   1   A. Yes, double outlet right ventricle, the subpulmonary VSD
   2     is sometimes called the Taussig-Bing anomaly.
   3   Q. At the bottom of that series, number 25 is
   4     Joshua Loveday. This typed-up version plainly came
   5     after Joshua Loveday had sadly died. But is this the
   6     sort of material that was presented at the meeting of
   7     8th December?
   8   A. I think Mr Dhasmana had handwritten sheets with the data
   9     on. I would have to look at them again to be sure of
  10     whether they correspond exactly with what you are
  11     showing me there.
  12   Q. If we look back at the history before he comes to
  13     operate on Joshua Loveday. Number 23 is Taussig-Bing
  14     syndrome. June 1994 when the child died?
  15   A. (Witness nodding).
  16   Q. If one goes back to the sheet before, which is
  17      UBHT 54/85, the next earlier such operation was April
  18     1991 on a four-year old child who survived.
  19        There had not been an operation conducted on
  20     a non-neonate by Mr Dhasmana for this syndrome for
  21     getting on for four years apart from the one in June
  22     1994 who died?
  23   A. I am not sure I would agree with that. I am not sure
  24     how accurate this classification would be. You are
  25     really talking about transposition with a subpulmonary

   1     VSD, the degree of override of the great artery can be
   2     quite variable. Many of these patients with TGA and VSD
   3     might have had a very similar anatomy, so how one
   4     classifies it may be open to debate.
   5   Q. We can ask Mr Dhasmana about that because this is his
   6     classification. For some reason he has chosen to
   7     identify Joshua Loveday as being double outlet right
   8     ventricle, as we see, with a subpulmonary VSD and the
   9     only other time he has used that classification within
  10     the previous four years was the operation, 16th June
  11     1994, who died. Operation number 23.
  12   A. It is I think fair to say, it is a relatively rare
  13     abnormality.
  14   Q. It causes difficulties, does it, because instead of
  15     having the great arteries, one anterior to the other,
  16     they are side by side?
  17   A. I think it is often true that the arteries are side by
  18     side but that is also true of many of these other
  19     patients here. So that is certainly not unique to that
  20     particular diagnosis.
  21   Q. I accept that. In Joshua Loveday's case the arteries
  22     were side by side?
  23   A. They were, they were side by side in Joshua's case, that
  24     is true.
  25   Q. In the operation to correct congenital transposition,

   1     the difficulty with the operation is relocating the
   2     coronary arteries; a particular difficulty is relocating
   3     the coronary arteries from one vessel to the other, is
   4     it not?
   5   A. It is certainly a part of the operation. Not being
   6     a surgeon I think maybe that sort of question is better
   7     directed at a surgeon, maybe Mr Deverall. Yes, it does
   8     involve transferring the coronary arteries, I would
   9     totally agree with that.
  10   Q. Where the arteries are side by side there frequently is
  11     a problem because the right or left coronary artery
  12     necessarily has to move further than it would do if the
  13     arteries were in their more usual anterior/posterior
  14     position?
  15   A. My understanding is that can be a problem for any
  16     orientation of the great arteries depending on the
  17     particular origin and origin of the vessel or vessels
  18     and their particular distribution. So it is certainly
  19     not a problem restricted to that diagnosis.
  20   Q. Mr Deverall, was this a particularly difficult
  21     operation?
  22   MR DEVERALL: Yes, they are all difficult operations.
  23     I think by this period there was ample documentation in
  24     the peer review literature to suggest that the problem
  25     was greater with the particular anomaly of great

   1     arteries that was present in Joshua's case compared to
   2     more straightforward transposition, obviously that is a
   3     broad generalisation and of course there are exceptions
   4     to any such rule. But there are several references
   5     dating back to 1983 up to 1991 stating that from
   6     a variety of authors.
   7   Q. What we have here is an operation which although
   8     naturally complex is more than usually complex, do we?
   9   A. It was a re-do operation, which is always difficult.
  10     I say that because the heart is surrounded with an
  11     envelope called the pericardium and normally there are
  12     no adhesions within the pericardial cavity which makes
  13     visualisation, manipulation, access, everything easier,
  14     but this child had had a pulmonary artery banding
  15     procedure which by definition had invaded that pristine
  16     territory and there would be inevitably to a greater or
  17     lesser extent adhesions which complicated procedure, on
  18     top of which this particular child had to have therefore
  19     reconstruction of the pulmonary artery which is another
  20     problem and the translocation of the coronary arteries
  21     and particularly the pattern which is described in
  22     Mr Dhasmana's operation note, in that particular
  23     side-by-side relationship it is one which would give
  24     concern to the surgeon right from the moment he saw
  25     where the coronary arteries were.

   1        Yes, it makes the operation -- it would have been
   2     difficult, extra difficult, triply difficult.
   3   Q. Do you accept that?
   4   DR BAKER: I would not argue with Mr Deverall on that point,
   5     no.
   6   Q. From the cardiologist's point of view, knowing that the
   7     arteries were side by side you might have anticipated --
   8     it did not turn out to be the case -- but you might have
   9     anticipated that the coronary artery might very well
  10     have been an intramural one, might you not?
  11   A. My understanding is you can have intramural coronaries
  12     in any relationship, any setting. We have certainly
  13     seen it in a whole variety of great artery
  14     arrangements. I do not think it would be something
  15     unnecessarily to be thinking, but it is something that
  16     has to be considered any time as I understand it you are
  17     doing an arterial switch operation. The surgeon has to
  18     carefully evaluate the coronary arteries on the table to
  19     look for the branching pattern, to look for evidence of
  20     intramural course.
  21   Q. Do you not tend to suspect such a condition might exist
  22     even more so where you have side-by-side location of the
  23     arteries rather than anterior/posterior?
  24   A. I do not know the evidence for that.
  25   Q. Dr Silove?

   1   DR SILOVE: I cannot really give you documented evidence.
   2     It is an experience which many of us have had. When the
   3     great arteries are side by side there is an increased
   4     tendency to find intramural coronary artery. But as
   5     Dr Martin says, it can happen no matter how the great
   6     arteries are lying. But certainly side-by-side
   7     relationship makes you look even more carefully for
   8     intracoronary, intramural --
   9   MR LANGSTAFF: I think the point here, to be fair to
  10     Dr Martin, he had not come across that in his own
  11     experience. Is it fair to him to say "There is no
  12     reason to criticise him for not having been aware of
  13     it"?
  14   DR SILOVE: Yes, I think that is correct.
  15   Q. We have here an operation which is of particular
  16     difficulty which is a re-do operation which the previous
  17     one, upon the surgeon's own annotation, within the last
  18     four years has been one which has resulted in a tragic
  19     outcome.
  20        At the meeting on 8th December, what was decided
  21     about the continuation or not of the non-neonatal
  22     arterial switch programme?
  23   DR MARTIN: My recollection is that we looked at the figures
  24     both for neonatal and non-neonatal switches at that
  25     meeting and there was agreement that it would not be

   1     appropriate to do neonatal switches but that the results
   2     in patients outside of the neonatal range were what were
   3     acceptable, therefore that the programme of non-neonatal
   4     arterial switches should continue.
   5   Q. At some stage after that, did you become aware that the
   6     decision to operate on Joshua Loveday had been
   7     questioned?
   8   A. Yes, I think the main incident there would be on the day
   9     before his operation when I heard that -- I think
  10     I probably heard from Mr Wisheart that he wanted to
  11     arrange a meeting to discuss this matter with regard to
  12     non-neonatal arterial switches obviously with the focus
  13     that Joshua Loveday's operation was planned for the
  14     following day.
  15   Q. You were spoken to, were you, by amongst others
  16     Professor Vann Jones?
  17   A. No, I do not recall any contact with Professor Vann
  18     Jones.
  19   Q. Let me tell you what he told us -- I am sorry, it was
  20     after the meeting, I beg your pardon. You will have to
  21     forgive me on that one.
  22        You spoke, did you, to Professor Angelini?
  23   A. Yes, I had had a conversation with him. Again I cannot
  24     be certain when it was but I know he rang me whilst
  25     I was undertaking a clinic in a peripheral hospital.

   1        My understanding was that he was questioning
   2     whether this operation that was planned as a switch
   3     operation was a neonatal operation and I think
   4     I informed him that Joshua was an older child, I may
   5     have told him his age, I cannot remember, and I felt he
   6     was under a misapprehension that this was a neonatal
   7     operation or a younger operation.
   8   Q. He told us that the conversation you had lasted some
   9     15 or 20 minutes; is that about right?
  10   A. I do not think so.
  11   Q. How long do you think it took?
  12   A. I can only remember a very brief conversation on the
  13     telephone in the midst of a very busy clinic at another
  14     hospital. As I say, I cannot be certain which one it
  15     was.
  16   Q. He tells us that he questioned the wisdom of doing the
  17     Loveday case in the BRI, and plainly from your
  18     recollection he did at the outset at any rate?
  19   A. As I say, my recollection is that he was under
  20     a misapprehension about the exact clinical nature of the
  21     case. My recollection is only that we discussed that.
  22     I do not remember any more detail than that.
  23   Q. Did he suggest sending the child to Birmingham to Bill
  24     Brawn?
  25   A. Not that I remember.

   1   Q. He says he did; may he be right on that?
   2   A. I do not remember him saying that.
   3   Q. Did you tell him that the operation was not urgent?
   4   A. I do not remember discussing it in those terms. I may
   5     well have indicated that whilst it was not an emergency
   6     operation, there was some degree of urgency, as we have
   7     already discussed, but I do not recall those details.
   8   Q. Did he ask why the child could not wait until Mr Pawade
   9     took up office?
  10   A. I do not remember.
  11   Q. May he have done so?
  12   A. He might have done so, but I do not recall him saying
  13     it, so I cannot say yes or no.
  14   Q. Did he say words to the effect of "The child has been
  15     waiting, why not wait a little longer?"
  16   A. Not to my memory.
  17   Q. Did you express the view to him that the competence of
  18     the surgeon to do this particular operation in a child
  19     of this age was adequate?
  20   A. I do not remember that conversation at all.
  21   Q. He says that the conversation ended with he and you in
  22     complete disagreement.
  23   A. I only remember a very short conversation on the
  24     telephone. I would be surprised if in the timescale
  25     that my memory serves we would have gone through all

   1     those issues.
   2   Q. The meeting was convened by Mr Wisheart, as you recall
   3     it, on the 10th or the 11th?
   4   A. Yes, I do not think I became aware of it until the 11th.
   5   Q. Was it usual in your experience to have a pre evening of
   6     theatre conference of this sort?
   7   A. It is extremely unusual.
   8   Q. At the meeting -- let us have a look at UBHT 54/11.
   9     This is Dr Monk's note. Can we scroll down to
  10     paragraph 2, please?
  11   A. I do not have it yet.
  12   Q. The first two paragraphs suggest that the mortality
  13     figures were looked at and considered. Would you like
  14     to read through those first two paragraphs to yourself
  15     and tell me whether you agree or disagree that they are
  16     an accurate record of what took place?
  17   A. I would agree entirely with paragraph 1. We certainly
  18     discussed the significance of the figures with regard to
  19     risk of surgery compared -- we basically looked at the
  20     mortality statistics in Bristol compared to the Cardiac
  21     Registry. As has already been discussed, the Cardiac
  22     Registry data is difficult to interpret. So we looked
  23     at, I think it may be Dr Hayes, I cannot remember
  24     exactly, gave some data from a 1992 American paper which
  25     I think probably was the multi-institutional paper for

   1     the arterial switch operation and I remember certainly
   2     discussing that we felt that the outcomes in Bristol
   3     were within the expected range of mortality.
   4        I do not remember the next bit because I do not
   5     remember us having figures for comparison to those four
   6     centres there. I am not aware of us reviewing any data
   7     from those four units. I would agree that these figures
   8     did not support the withdrawal or stopping of the
   9     present non-neonatal programme and everyone agreed that
  10     the programme should continue with the exception of
  11     Steve Pryn who was absent, yes, because he left after
  12     a little while.
  13   Q. Let us focus on the bit you do not recall or do not
  14     agree with: do you think there was discussion about
  15     centres such as Melbourne, Great Ormond Street,
  16     Birmingham and Boston?
  17   A. We might have had a paper from Melbourne, it is
  18     possible.
  19   Q. It is not so much paper, it is discussion that is being
  20     referred to here.
  21   A. I do not know that we had any data for discussion from
  22     Great Ormond Street or Birmingham. We might have had
  23     data to discuss from Boston. If I remember rightly,
  24     that was part of the multi-institutional study.
  25   Q. Did you have a view as to how good results were in

   1     Birmingham?
   2   A. I do not think I knew for sure. As I said yesterday,
   3     I think we generally had an impression that Birmingham's
   4     results for the arterial switch operation were good, but
   5     I had no documentary evidence of that and that was an
   6     impression gained from talking to other people and also
   7     from Mr Dhasmana.
   8   Q. Let us have a look, shall we, at HA(A) 123/53? This is
   9     notes of a meeting with you and Dr Joffe. Could we turn
  10     over the page, please, 54. This is, just so we identify
  11     the person making the note, bottom of the page,
  12     Dr Baker.
  13        Can we go back up? The first paragraph
  14     "Malconnections of the great arteries are now being
  15     tackled by the so-called switch operations. Operative
  16     mortality of between 5 and 10 per cent is being achieved
  17     at centres like Birmingham. Follow-up from the neonatal
  18     period now extends for 10 to 12 years."
  19        Someone gave the figure of 5 to 10 per cent in
  20     respect of Birmingham, it must have been either yourself
  21     or Dr Joffe to Dr Baker; do you remember?
  22   A. I remember meeting with Dr Baker. I do not think he
  23     would have got that figure from myself. In fact
  24     I believe I wrote a letter afterwards indicating that
  25     I am not sure I knew what their mortality was. 5 to

   1     10 per cent may be doing them an injustice.
   2   Q. Shall we have a look at it, 123/70. 5th September 1995,
   3     it is only a matter of months after January. Your
   4     letter to Dr Baker:
   5        "Thank you for sending me your draft of the paper
   6     following our earlier discussion meeting"; that is the
   7     draft we have just been looking at, is it not? The last
   8     paragraph:
   9        "I think the operative mortality for switch
  10     operation at Birmingham may well be less than
  11     5 per cent. The figure of 5 to 10 per cent is that
  12     achieved nationally based on the cardiothoracic surgeons
  13     registry.  Having said that, we do not ourselves have
  14     figures for Birmingham directly so the low mortality
  15     I have suggested is a little conjectural."
  16        You did not have the exact figures but you were
  17     prepared to put a range on it, were you not?
  18   A. What I was indicating I think there is that I did not
  19     know their mortality, I did not want a document going
  20     out into the public domain suggesting that their
  21     mortality was anything that they were not happy with.
  22     I think that suggests I do not know what the mortality
  23     was.
  24   Q. That is not the point. The point is that in a letter to
  25     the consultant in public health medicine for the region

   1     you were prepared to give your name to a range where you
   2     thought the results in Birmingham lay, between 0 and
   3     5 per cent; that is what you did, is it not, in the
   4     letter?
   5   A. It says "It may well be less than 5 per cent" and that
   6     without any accurate figures I felt it was unwise to
   7     either over- or understate the mortality, I just did not
   8     know.
   9   Q. Forgive me, I find that difficult, Dr Martin, for these
  10     reasons: there is a draft submitted to you from Dr Baker
  11     which says "we think", that is doctors Joffe and Martin
  12     in discussion with Dr Baker, "we think the operative
  13     mortality at Birmingham is 5 to 10 per cent", give a
  14     range. I can understand your responding by saying "we
  15     do not actually know at all what Birmingham is it, it
  16     could be anything, it could be 100 per cent, 0 per cent,
  17     somewhere in between, because we just do not have the
  18     figures"; that I understand but that is not what you
  19     have done.
  20        What you have done is say "5 to 10 per cent is
  21     probably unfair to them. It may well be less than
  22     5 per cent". In other words, your best judgment is that
  23     it was less than 5 per cent, that is what you seem to be
  24     saying; is that not the case?
  25   A. It may be, yes.

   1   Q. If that is your impression in September 1995, what was
   2     your impression in January 1995 as to the likely
   3     operative results in Birmingham?
   4   A. As you may well have imagined, there was a lot of
   5     discussion about the switch operation around that time
   6     and subsequent to it, so it is possible that in the time
   7     limit we are talking about we may have had further
   8     discussions.
   9   Q. Can I ask the question again?
  10   A. Yes, of course.
  11   Q. In January 1995, what was your best impression of the
  12     operative results in Birmingham?
  13   A. I understood their results to be good. I could not be
  14     sure of anything more accurate than that. As I have
  15     already said, I had no data at all.
  16   Q. You had no data in September and you were prepared to
  17     put a range on it?
  18   A. As I have said, it is conjectural.
  19   Q. Can I go back from that to UBHT 54/11. We were looking
  20     at the second paragraph. Picking up on something you
  21     said earlier so that we know what you recollect: were
  22     there in fact any papers circulated in respect of
  23     results at Melbourne?
  24   A. I do not remember. The only paper I think I remember
  25     was the multi-institutional study from the United

   1     States.
   2   Q. Which is a study I think known to have an estimate of
   3     mortality which is higher than one would expect in the
   4     UK because of the number of institutions it covers
   5     during one or two operations only, we have been told?
   6   A. You have been told that. I am not sure I am in
   7     a position to comment on that.
   8   Q. On that point, I wonder if I may ask Dr Silove,
   9     Mr Deverall. The multi-institutional study in the
  10     states, were there problems with it or not?
  11   DR SILOVE: I think Mr Deverall is probably better equipped
  12     than I am on that.
  13   MR DEVERALL: The answer is yes, particularly the first
  14     report of the congenital multi-centre database which had
  15     flaws of design and included centres doing very little
  16     specialised surgery. The subsequent paper which was not
  17     published until after these events took place, tried to
  18     apply a statistical method to correct that, but the
  19     initial paper was of all 17 centres, and I think I am
  20     correct in saying, but I may be wrong, that of the total
  21     number of patients included, about 80 per cent came from
  22     five of the 17 centres and the 17 centres at that
  23     particular time had the least satisfactory results.
  24     Then there was a great deal of soul-searching in the
  25     United States after that and in the United Kingdom

   1     because it applied to us as well.
   2   Q. But you never mentioned any hesitations over the
   3     American comparison?
   4   DR MARTIN: I thought it was one of the best -- in fact as
   5     far as I am aware it was the only data, looking at more
   6     than one centre's experience that was available at that
   7     time and the only other data that would have been
   8     available would have been individual centres' reports
   9     which, I think as I have already indicated, one has to
  10     be a little bit careful about because good results tend
  11     to get reported in the literature and less good results
  12     often are not or pioneering work might be.
  13        So one always has to look at medical literature
  14     being aware of its limitations.
  15   Q. Can we have at look at UBHT 126/51. Do you recognise
  16     this sheet of paper?
  17   A. I do, yes.
  18   Q. This is its edited form. If we go over the page to
  19     page 52 we see its original form because there was
  20     adjustment for the number of patients that Mr Wisheart
  21     had operated upon. If we scroll down, the consequent
  22     alterations on the percentages. But back to page 51.
  23     When did you see this paper?
  24   A. The second paper certainly was shown at the meeting on
  25     11th January.

   1   Q. Joshua Loveday you would class as a non-neonate, would
   2     you not?
   3   A. Yes, he was not even in the infant period, he was
   4     greater than one year.
   5   Q. So far as non-neonates are concerned, if we focus on the
   6     line of mortality for Mr Dhasmana, it is the second
   7     box. If we highlight the line which says
   8     "non-neonates", the range over the period that he had
   9     performed such operations showed 33 per cent mortality?
  10   A. Yes, from 1988 to 1994 there was 33 per cent mortality
  11     and the figures are further subdivided into two groups
  12     which show what might be a change or an improvement in
  13     mortality, though with small numbers involved.
  14        I think one has to be a little wary of that but we
  15     felt that probably the most representative figures with
  16     regard to Joshua would be the latter figures from 1990
  17     to 1994 and that those would apply to him, though as you
  18     have already heard, this whole group which we discussed
  19     earlier is a very heterogeneous group and to a large
  20     part risk has to be individualised but looked at in
  21     context.
  22   Q. Focusing on these figures for a moment: if you break
  23     down any large group of figures into smaller units you
  24     are bound simply as a matter of probability to come upon
  25     some figures which are of a low percentage, some of

   1     a high percentage, figures like this, are you not?
   2   A. I think that is always a danger. Certainly if you are
   3     looking at surgical results overall there are so many
   4     small groups of operations that are undertaken you are
   5     bound to see quite wide fluctuations in each individual
   6     group.
   7        This group which is called a single group is a
   8     mixture of different types of anatomy, different
   9     patients.
  10   Q. Trying to get an accurate picture cannot simply be given
  11     by looking at a point estimate, I suspect?
  12   A. I think it is very difficult. I think you have to look
  13     at the patient's own clinical condition, you have to
  14     look at any other factors that might be important.
  15     There are a whole range of factors there outside of the
  16     heart that might influence mortality, he may have
  17     congenital abnormalities in other symptoms. When it
  18     comes down to the individual it has to be an individual
  19     assessment based on what we know about that patient
  20     plus, put in context as best one can compared to what
  21     one has seen previously.
  22   Q. If one were to focus simply on the figures for neonates
  23     over 1 year, one would go down to the bottom of that
  24     box, one would be looking at one death in eight
  25     operations, 13 per cent. As I have already shown you,

   1     if one further subdivided that and asked "Let us look at
   2     operations for double outlet right ventricle with
   3     a VSD", one would be looking at 101, 100 per cent. That
   4     is an indication, I suspect, of the dangers of looking
   5     at too small numbers?
   6   A. Are you talking about non-neonates rather than
   7     neonates?
   8   Q. I am looking at non-neonates, over one year?
   9   A. It said "neonates".
  10   Q. I am sorry, it is my fault.
  11   A. Yes, I think there is a danger if you subdivide into too
  12     small groups that you cannot get an accurate picture,
  13     which is why you have to individualise things as best
  14     one can, but this group here i.e. greater than --
  15     a non-neonatal arterial switch operation plus VSD
  16     closure, that is the best estimate one can obtain at
  17     that time and the one we used, I think, on Joshua was
  18     during that four or five-year period we had seen 15
  19     patients with a similar anatomy, not identical, on which
  20     there were three deaths.
  21   Q. 20 per cent?
  22   A. Yes.
  23   Q. That is 1994. The comparison would be on this sheet, we
  24     are going down to the bottom, with "The UK's Cardiac
  25     Surgical Register data" and it is the highlighted bold,

   1     TGA and VSD group, is it not? If one goes down to the
   2     bottom range, the comparison figures we have just seen,
   3     3 out of 15, 20 per cent. In the UK cardiac surgical
   4     register as a whole we see that that was pretty much the
   5     result nationally that they were getting in 1990. 1991
   6     it is getting better. 1992 it is down to 12 per cent,
   7     albeit still relatively small numbers.
   8        So the comparison would be, would it, between
   9     20 per cent between 1994 and 12 per cent 1992?
  10   A. There are two points there: one is that we already know
  11     that the UK cardiac surgical data has certain
  12     limitations. We do not know that all those patients had
  13     an arterial switch operation for instance. It is likely
  14     most did, but we do not know that for sure as far as
  15     I am aware.
  16        Also you have to appreciate that the 20 per cent
  17     refers to 1990 to 1994 so it covers that whole time
  18     period. It does not just reflect 1992 figures. So the
  19     comparison we were making were group databased over
  20     a certain time period. If you are suggesting you should
  21     ignore the 1990 and 1991 data that would not be valid
  22     with this particular comparison.
  23   Q. I am not. I think the suggestion I am making is rather
  24     more subtle than that, it is that the best available
  25     comparison you have shows a rate of 20 per cent if you

   1     separate the neonates and the non-neonates for
   2     a selected time period, 1990 to 1994. The data from the
   3     UK generally shows a decreasing trend from under 20 to
   4     just over 12 per cent over the three years, 1990 to 1992
   5     when it was common knowledge that the switch programme
   6     people were gaining experience throughout the country;
   7     that was common knowledge, was it not?
   8   A. I think it is experience. You are always acquiring
   9     experience as time goes on. Yes, greater numbers going
  10     through a programme and increased experience in all
  11     centres was occurring. I think you have to be very wary
  12     about overstressing this particular comparison. I am
  13     not a statistician, but I would think it is very
  14     unlikely there would be any statistical difference
  15     between those groups. Looking at those numbers it only
  16     takes one or two different to make -- it takes just two
  17     extra deaths, does it not, to change your mortality from
  18     12 per cent to certainly greater than 15 per cent.
  19   Q. If one is looking at the best available figures, because
  20     these no doubt were the best available figures, there is
  21     very nearly double the risk of mortality in Bristol
  22     compared to the United Kingdom as a whole; that is
  23     a matter of figures, is it not?
  24   A. I do not think you can make that sort of comparison for
  25     reasons that I have already said.

   1   Q. Let me look at it this way --
   2   A. We felt, based on that, our assessment, our
   3     interpretation when we looked at this data was that
   4     there was no objective difference as far as we could see
   5     between the surgical results in Bristol and what was
   6     reported in the UK surgical register with all its
   7     limitations. We were aware of its limitations at that
   8     stage I think. I think with the numbers involved it is
   9     very difficult to be more -- any firmer than that. That
  10     was our belief.
  11   Q. The conclusion the meeting reached was that there was no
  12     material difference between 20 per cent and what was
  13     indicated by the range of 19.5 per cent, 12 per cent and
  14     presumably dropping?
  15   A. Well, we do not know that.
  16   Q. You for your part when you perhaps had further
  17     information you do not know put a figure on Birmingham's
  18     results later the same year, you felt able to say it was
  19     less than 5 per cent probably?
  20   A. I said it may be less than 5 per cent, but that was
  21     conjectural and I did not have the figures. You may
  22     also be -- you are talking about different groups of
  23     patients here. I think that initial document was as
  24     much referring to transposition with intact septum which
  25     would be the neonatal switch rather than this group of

   1     patients as well.
   2   Q. Conjecturally would the child not have been better off
   3     in Birmingham?
   4   A. I have no way of knowing. We felt our results were
   5     adequate to carry on with the non-neonatal arterial
   6     switch programme.
   7   Q. Can I go back to the note of the meeting which we have
   8     at UBHT 54/11. Paragraph 3:
   9        "Discussion on the political position of the
  10     Trust ensued, revealing that Dr Bolsin had contacted the
  11     Department of Health to inform them"... et cetera.
  12         "General and specific discussion on the risks of
  13     performing a surgery with a fatal outcome was
  14     discussed. The option of delaying for a week or until
  15     the arrival of the new surgeon was proposed strongly by
  16     Dr Bolsin as much could be lost by the death of the
  17     child ..." and it sets out a discussion which you were
  18     not party to.
  19        Your own note, page 54/13. When did you make this
  20     note?
  21   A. I am not certain when I made it. It was typed by my
  22     secretary the Monday after, but I obviously dictated it
  23     prior to that. I cannot be certain when it was written,
  24     I think it probably was the following day after the
  25     meeting, I know it was not the evening of the meeting,

   1     it was some time during the following day most likely,
   2     probably in the afternoon but I am not certain.
   3   Q. Do you know whether it was before or after
   4     Joshua Loveday died?
   5   A. I cannot be sure, I think it was before I knew of the
   6     outcome of Joshua's operation but I am afraid I am not
   7     certain.
   8   Q. You see what is said there, the sixth paragraph down:
   9        "There was a discussion as to whether it would be
  10     appropriate to proceed with the planned operation on
  11     Joshua Loveday. The general feeling expressed was that
  12     there was no clinical reason for deferring the surgery.
  13     Dr Bolsin expressed the opinion that it would be
  14     preferable to defer surgery for a few months until the
  15     new setup had been organised."
  16        What we have been told by Dr Pryn is that in the
  17     course of the meeting you said the child's -- that is
  18     Joshua Loveday's -- clinical condition had deteriorated
  19     such that he was too sick to wait for the new surgeon to
  20     arrive and indeed was too sick to be transferred to
  21     another hospital. Therefore, he says in his mind that
  22     meant you had to do the case in Bristol.
  23        What do you say about that?
  24   A. I do not think that is true, I certainly did not --
  25     those are not my words, those are obviously his

   1     recollections.
   2        My recollection is: I was concerned, as we have
   3     already discussed, about the clinical urgency of Joshua
   4     therefore I did not think that postponing him for
   5     a period of a number of months until Mr Pawade arrived
   6     was indicated.
   7        My recollection is that regarding referring out,
   8     that we had a group meeting where everyone felt -- this
   9     was, as Dr Monk and my note have already noted --
  10     unanimously felt that there was no clinical reason why
  11     the planned operation should not proceed.
  12        I indicated his clinical urgency and I do not
  13     think I would have used -- I may not have used the term
  14     "deteriorating" but I would probably have indicated
  15     that with his known problem with regard to the pulmonary
  16     artery banding like we have already discussed, it is
  17     a condition that is only going to get worse rather than
  18     better.
  19   Q. Did you as you recollect it say that the child required
  20     surgery urgently?
  21   A. I think as I have already indicated, I indicated that
  22     there was a degree of clinical urgency to this case
  23     which I think we have already discussed with Dr Silove
  24     and Dr Deverall. It was my opinion that a delay of
  25     a few weeks would be, if there was a medical reason to

   1     defer would be acceptable but any deferment of the
   2     operation, if he was going to be operated on in our unit
   3     which we had agreement to, would subject him to an
   4     increased risk and if there was a gain to him being
   5     deferred then I was happy to go along with that but
   6     I did not feel that that was likely.
   7   Q. They seem to be a contradiction. The GMC 19/51, the
   8     foot of the page:
   9        "I know we discussed whether Joshua's case was
  10     one that could wait for a number of months, and it
  11     certainly was not my opinion that that was advisable.
  12     Certainly there would be no clinical urgency to the case
  13     in terms of delaying for a week or maybe even a small
  14     number of weeks. Equally I am sure that there would
  15     have been anything to gain clinically by that." That is
  16     what you say at one stage.
  17        19/92, the middle of the page:
  18        "If you do not remember the precise words, would
  19     the gist be this: that the child's condition was not
  20     improving, in fact deteriorating, and you felt that the
  21     operation had to be done sooner rather than later.
  22        Answer: I felt that there was clinical urgency to
  23     his case, that is correct, because, as I previously
  24     stated of the degree of hypoxia that he had at that
  25     stage.

   1        Question: So you felt there was clinical urgency
   2     to the case?
   3        Answer: Correct.
   4        Question: And that opinion of yours, namely that
   5     there was clinical urgency was an opinion which you had
   6     conveyed to Mr Dhasmana?
   7        Answer: Yes."
   8        What are we to take from this, was it your view
   9     that there was clinical urgency; was it your view that
  10     there was not; how do we reconcile those two passages?
  11   A. I must be being confused here, I do not see any
  12     inconsistency in what I have said already. I have
  13     stated, and it tallies exactly to my mind with what
  14     I said here, that there was a degree of clinical urgency
  15     to his situation. I cannot see an inconsistency there.
  16     Perhaps you can point it out.
  17   Q. At one stage you are recorded as saying "no clinical
  18     urgency" in the sense that it does not have to be done
  19     next week or the week after. In the other you appear to
  20     be saying there was clinical urgency. Is the resolution
  21     this: obviously what one decides in one's mind as being
  22     urgent may be flexible, it may take place within
  23     a matter of weeks. That may be urgent to you as
  24     a clinician. That does not mean to say it is an
  25     emergency and needs to be done the next day?

   1   A. I do not think at any stage I voiced the opinion that it
   2     had to be done the next day.
   3   THE CHAIRMAN: I think, Mr Langstaff, if we go to an answer
   4     maybe three, four lines further down you will see that
   5     perhaps the reconciliation is there for you insofar as
   6     Dr Martin repeats what he had said previously at page
   7     50-whatever.
   8   MR LANGSTAFF: Yes. That is how we reconcile those two
   9     answers.
  10   A. Sorry, you have lost me now.
  11   Q. Go down the page: "My recollection is that I was
  12     thinking in terms of his needing surgery within a matter
  13     of a few weeks ..."
  14        The reason I did not take you earlier to that
  15     answer was what it is that you said at the meeting as
  16     opposed to what you thought. You appear to have thought
  17     there was no urgent need in the sense of needing an
  18     operation tomorrow, he might need one in the next few
  19     weeks, did you say so?
  20   A. When it says "thought" here I presume I communicated my
  21     thoughts to my colleagues along those lines. What their
  22     recollection of it is I cannot comment on, but as far as
  23     I am aware I put across what I have described here along
  24     the lines of my thoughts.
  25   Q. If we go back to page GMC 19/88, bottom of the page, it

   1     was put to you by Miss Davis for Mr Dhasmana -- do you
   2     have it?
   3   A. Yes, it is just it has the patient's name on it.
   4   MR LANGSTAFF: Can we scroll down, please, or highlight the
   5     bit at the bottom? Can we take it off the screen?
   6   THE CHAIRMAN: It is off. Dr Martin, I am very grateful to
   7     you, thank you.
   8   MR LANGSTAFF: We now have on the screen the bit at the
   9     bottom of the page. Do you remember telling the meeting
  10     you had seen Joshua recently, that he was getting bluer
  11     and needed to be done fairly soon.
  12         "Answer: I do not remember the details of the
  13     conversation, but that is likely to be what I would have
  14     indicated based on having seen him recently."
  15        Having looked at that can we go to page GMC 19/92,
  16     it is the third line down on the screen:
  17        "I do not remember saying that he was getting
  18     bluer, but he was certainly blue enough that one would
  19     be concerned about waiting."
  20        It is put to you -- you were under
  21     cross-examination there -- you appear to accept that you
  22     said something along the lines of "he is getting
  23     bluer". Then you are uncertain about it or do not
  24     remember saying it at a later stage; did you say
  25     something to that effect or not?

   1   A. I do not remember saying "he was getting bluer", but
   2     I would have indicated that knowing his underlying
   3     anatomy that was likely to be the case. As it states
   4     here, my comment here that he was blue enough that one
   5     would be concerned about waiting was certainly true.
   6   Q. Can we go back from there to the note of the meeting
   7     itself at UBHT 54/13, bottom of the page please:
   8         "After this general discussion there was a joint
   9     discussion between myself, Mr Dhasmana and Mr Wisheart
  10     regarding whether it was clinically appropriate to
  11     proceed with the operation the following day."
  12        Can I understand what happened here? There was
  13     a general meeting, then there was a separate meeting in
  14     a sideroom between you, Mr Wisheart, Mr Dhasmana; is
  15     that all?
  16   A. Yes, I think Mr Dhasmana, Mr Wisheart and myself left
  17     the meetings room. This was a meeting at the Children's
  18     Hospital in the cardiac catheter laboratory. We left
  19     the main meetings area and went to a nearby coffee area
  20     and carried on our conversation there.
  21   Q. You came back to the meeting afterwards?
  22   A. We certainly came back to meet up with others that were
  23     still there at that stage. I think by that stage many
  24     of the people who had been in the meeting earlier may
  25     well have drifted away, though I am not sure who was

   1     there when we went back.
   2   Q. So you did go back. At any rate Dr Monk was there at
   3     that stage because he tells us about that in his own
   4     note?
   5   A. Yes.
   6   Q. In this meeting was Mr Wisheart expressing a view about
   7     whether or not the surgery should go ahead?
   8   A. I think he was concerned about the potential political
   9     repercussions if you like of it going ahead and
  10     questioned whether -- there was certainly discussion as
  11     to whether that might influence Mr Dhasmana's
  12     performance in the operation and that was a concern
  13     I shared.
  14   Q. He was asking, was he not, whether it was necessary to
  15     go ahead; effectively what he was saying "cannot we put
  16     it off for a while"?
  17   A. He asked whether that would be feasible. I do not know
  18     whether that was necessarily discussed at that stage,
  19     but it might well have been. That is when we discussed
  20     the clinical urgency of the case. To a large part he
  21     was largely aware of it anyway, I think he may have been
  22     party to previous discussions, but I am not sure.
  23   Q. Here he is, the medical director saying "look cannot we
  24     put this off for a few weeks, do we need to go ahead
  25     with this tomorrow", words to that effect. "Is it

   1     feasible to put it off" to which the answer, from what
   2     you have said about urgency is plainly "yes", is it not?
   3   A. It was a question of whether it could be put off for
   4     a period of, my memory is a few weeks was suggested and
   5     --
   6   Q. The answer to that?
   7   A. And the answer to that is: I did not personally feel
   8     that was in Joshua's best interests because any further
   9     prolonged delay without any obvious gain to him in the
  10     longer run, I did not see that that was in his best
  11     interests. You know the question was whether, if you
  12     like, the political considerations should take
  13     precedence over the clinical considerations for Joshua
  14     and being one of the clinicians involved I felt that his
  15     clinical status was important.
  16   Q. The urgency you have described is an urgency for the
  17     operation to go ahead in a matter of weeks as opposed to
  18     the next day. Here is Mr Wisheart saying to you as you
  19     recollect it: "is it not feasible to put it off for a
  20     while?" Here we have a child who you had not seen to
  21     investigate since the previous May and you had last
  22     examined some six weeks earlier, longer perhaps,
  23     21st November?
  24   A. Seven weeks, yes.
  25   Q. Why is it you said: "This operation should go ahead

   1     tomorrow"?
   2   A. As I have already stated, I was concerned about his
   3     clinical status based on my knowledge of his underlying
   4     heart problem, if you like the clock is ticking with
   5     this particular abnormality. I think Dr Silove earlier
   6     indicated that he felt this case was urgent at the time
   7     of the catheter study and I still held that view that
   8     that was the case. I was quite happy to consider
   9     deferring the operation if that was to be an advantage
  10     for the patient. But I could not see any situation that
  11     could be resolved in the next two or three weeks where
  12     that would be changed and I did not feel that -- I was
  13     certain that a wait of a number of months until
  14     Mr Pawade arrived would not be in his best interests.
  15   Q. If you thought the operation was so urgent why had you
  16     not arranged it urgently back in the previous May or
  17     June?
  18   A. I had discussed that and my concerns were that he should
  19     not -- I think in my original discussion notes
  20     I indicated three to four months. In an ideal world it
  21     is something that you would like to get on with
  22     straightaway, but that was not feasible in most units,
  23     it certainly was not feasible in that unit in the
  24     Children's Hospital, in the Royal Infirmary at that
  25     stage. Inevitably there would be some wait and you have

   1     to make a judgment as best you can as to what degree of
   2     wait is acceptable.
   3        I felt three or four months when I first saw him
   4     was acceptable. Mr Dhasmana when he saw him in the
   5     clinic felt that a wait of about four months was
   6     acceptable. By this stage we were seven months after
   7     the cardiac catheter study. I was seriously concerned
   8     that prolonged wait would put him into problems, both
   9     with regard to potentially to progressive dropping in
  10     his oxygen levels and also this stimulation of the
  11     muscular hypertrophy we had seen in this patient which
  12     I have mentioned earlier that year which had then ended
  13     up in that patient being in a situation where the risk
  14     of surgery was very high and that patient sadly died.
  15     I was very conscious that we should avoid that
  16     situation.
  17   Q. That has not the answered the question I was asking,
  18     which was: why back in May if there was a relatively
  19     urgent operation needed and the situation had not
  20     changed between May and January, except that the months
  21     had gone past, why did you not take more active steps do
  22     you think looking back on it to have the child seen, if
  23     not in Bristol then in Birmingham or Southampton or
  24     somewhere else following your intervention, your
  25     catheterisation in May?

   1   A. I thought I had already answered that. I felt that that
   2     degree of wait would not disadvantage him but a much
   3     more prolonged degree of waiting potentially might.
   4     I had, based on my assessment when I saw him in
   5     November, no concerns about waiting longer and that is
   6     when I spoke to Mr Dhasmana, so I passed on those
   7     complaints. We then listed him, I believe he was
   8     provisionally listed for surgery in December but at the
   9     request of his parents it was deferred following our
  10     conversations, and he was then listed for January.
  11   Q. Can we go back to the note, UBHT 54/13, the very bottom:
  12        "Based on the results we have discussed we did
  13     not feel it was appropriate for referral to another
  14     centre."
  15        Would anything have prevented you from referring
  16     this child to another centre?
  17   A. No, I would have been quite happy referring him
  18     elsewhere, in fact we referred many patients after this
  19     to other centres, but I was basing that assessment in
  20     the letter on the group review of the figures and also
  21     of Joshua's situation which unanimously suggested it was
  22     clinically reasonable to proceed with the planned
  23     surgery. There was nothing stopping me referring him
  24     away. Mr Dhasmana could have referred him away. We did
  25     not feel that was indicated.

   1   Q. Forgive me, the first time I think you have put it quite
   2     so positively: before as I understood it what you have
   3     said in relation to the switch programme has been that
   4     there was no reason not to do it which I see, and
   5     I invite your comment on, as something rather different
   6     from saying "it is reasonable to do it in an individual
   7     case"; do you follow the difference?
   8   A. I think I am not sure I do see a major difference
   9     between the two.
  10   Q. Let me leave you with this, it is probably time that we
  11     had another break although I have not finished this
  12     topic I am afraid just yet.
  13        You spoke I think to, amongst others,
  14     Professor Vann Jones, I suggest, because he has told us
  15     this is what happened; tell me if it is wrong. I will
  16     tell you what his recollection of it is: he spoke to you
  17     after the meeting, you said to him -- I will have to
  18     come back to it, I apologise for that.
  19        The point which I will come back to after the
  20     break and you may wish to think about it, is whether it
  21     is one thing to say: "we have looked at the results for
  22     the neonatal switch programme, there appears on the
  23     basis of those results to be no reason to stop doing the
  24     operation"; that on the one hand, and a view that says:
  25     "this is just such an operation because of the decision

   1     we have reached earlier therefore we should do this
   2     operation".
   3        I am asking: is it right that a decision that
   4     there is no reason not to do a particular series of
   5     operations becomes in any individual case a reason to do
   6     it; that is the point and that is what I want to leave
   7     you thinking about during the quarter of an hour break
   8     which, sir, perhaps we may now have.
   9   THE CHAIRMAN: Thank you, Mr Langstaff. Until just after
  10     3.00.
  11   (2.45 pm)
  12               (A short break)
  13   (3.00 pm)
  14   MR LANGSTAFF: Dr Martin, you have had a chance, I hope, to
  15     think about that question that I asked you, which was,
  16     if you remember, is it right that a decision that there
  17     is no reason not to do a particular series of operations
  18     becomes, in any individual case, a reason to do it?
  19   A. I think we felt that there was no reason not to do it.
  20     There are many reasons to go ahead and do an operation
  21     in that setting that we were faced with there. We had
  22     a child already in hospital, prepared for surgery. You
  23     had a child that was well at that stage, no intercurrent
  24     infections, so there is an opportunity to do it. His
  25     parents were, if you like, ready to go ahead, so there

   1     are many reasons why you would go ahead in that
   2     situation. You do not cancel operations lightly the
   3     night before, so there are positive reasons to proceed.
   4   Q. That sounds a little like a negative reason to me: that
   5     one does not cancel an operation lightly, which is
   6     effectively what you are saying: "We are all here ready
   7     to go. Because we are there, let's go ahead"?
   8   A. But there are many reasons for going ahead, as I have
   9     already indicated. You have everything set up in the
  10     hospital, you have the resources there, you have the
  11     parents all psyched up; they are likely to have made
  12     special arrangements for that child's stay, so you do
  13     not wish to cancel unless you have to in that setting.
  14     We are very reluctant to cancel.
  15   Q. Taking you back to your conversation with Mr Wisheart,
  16     Mr Dhasmana, we have heard from Mr Bryan that his view
  17     of Mr Dhasmana is that he would not have been
  18     particularly happy to go ahead with the operation --
  19     obviously he had agreed to do the operation, but he,
  20     Mr Bryan, does not accept to his knowledge that
  21     Mr Dhasmana was happy to do so.
  22        We have heard from Dr Monk that he had discussions
  23     with Mr Dhasmana before the meeting that took place on
  24     the 11th, at which it appeared to him Mr Dhasmana was
  25     saying, "I do not really want to go ahead and do this

   1     operation".
   2        How reluctant did Mr Dhasmana appear to you to be
   3     during the course of your side meeting with Mr Wisheart
   4     and Mr Dhasmana?
   5   A. I guess it is something you are going to have to ask
   6     him, exactly what his feelings were, but the impression
   7     I gained was that he was not reluctant to proceed.
   8     I certainly did not gain that impression. He naturally
   9     listened to everyone's concerns and I think he took
  10     careful notes of what people said. I presume he was
  11     reassured by the fact that as a group we had all sat
  12     down and looked at it and felt it was appropriate for
  13     him to continue.
  14        We specifically, in that separate meeting, did
  15     discuss whether we thought, if you like, the political
  16     aspects, perhaps the implied criticism there had been,
  17     might affect his performance in theatre. That was
  18     a concern. But he assured us that that was not the case
  19     and I was happy under those circumstances to give my
  20     approval, or support him, if you like, in the decision
  21     to proceed with the operation.
  22        When it comes down to it, it has to be his
  23     decision. I cannot make him do an operation. I was
  24     concerned that we might be put in a situation where he
  25     was going into it, as you put it, reluctantly, but I did

   1     not gain the impression that was the case.
   2   Q. The meeting had been acrimonious, had it?
   3   A. I think most of the meeting had been very open and fair
   4     and the only, what one might term "acrimonious" period
   5     was when there was discussion I think with Dr Bolsin
   6     about contacts he had had with the Department of Health
   7     and the acrimonious aspect there, I think there was
   8     quite a heated conversation, shall we say, between
   9     Dr Masey and Dr Bolsin.
  10   Q. You described it as "vehement" elsewhere; is that right?
  11   A. I think that is a good --
  12   Q. Shall so a vehement conversation in which Dr Masey was
  13     accusing Dr Bolsin of whatever?
  14   A. I think she was concerned about the contacts he had made
  15     without anybody else knowing. We have already had
  16     evidence from her, but you will have to ask her opinion
  17     as to exactly why she was so vehement, if you want to
  18     use that term.
  19   Q. Did the meeting know that the Department of Health had
  20     been in touch with Dr Roylance and Mr Wisheart seeking
  21     to postpone the operation?
  22   A. No. I am sure we were not aware of that.
  23   Q. If you had been, would that have made a difference, do
  24     you think, to the decision so far as you were concerned?
  25   A. I think that would have been a decision for those in the

   1     management side. I was taking the view of what was best
   2     for Joshua clinically. If someone in the management
   3     side had said "You must cancel this operation because
   4     the Department of Health told us to", then I would of
   5     course have listened to it.
   6   Q. Did you have any idea that there had been, so we have
   7     been told, a discussion between Mr McKinlay and
   8     Dr Roylance before Christmas, the outcome of which was
   9     that there was to be an investigation, that Mr McKinlay
  10     told us had been agreed by Dr Roylance, into the
  11     outcomes in the arterial switch operation?
  12   A. No, I was not aware of that.
  13   Q. If that had been told to you, do you think that would
  14     have made some difference?
  15   A. I do not know. It might have done. It is a possibility
  16     it could have done, but I think it is very difficult to
  17     judge hypothetically.
  18   Q. Did the meeting know that Gianni Angelini had spoken to
  19     you before the meeting, expressing his view that the
  20     operation should not go ahead?
  21   A. I do not remember that being discussed.
  22   Q. Did you tell them?
  23   A. I do not remember doing so.
  24   Q. Did you tell the meeting that --
  25   A. My recollection is not that he was saying it should not

   1     go ahead; my recollection of our conversation, as I have
   2     indicated, was that he was under a misapprehension about
   3     the precise nature of the operation that I wanted to
   4     discuss, so I do not think that was something that
   5     needed to be brought to that meeting.
   6   Q. I was perhaps being unfair to you in the question that
   7     I put. Did the meeting know that you had not seen
   8     Joshua Loveday yourself since November 21st?
   9   A. Certainly Mr Dhasmana and Mr Wisheart knew that I had
  10     not had the opportunity to see him. I cannot speak for
  11     anyone else who was there. They were all working in the
  12     system, if you want to call it that, as it was at that
  13     stage, and it was not normal practice for the
  14     cardiologists to re-evaluate the patients on admission
  15     at that stage.
  16        So certainly my cardiological colleagues I do not
  17     think would have anticipated that I had examined him or
  18     looked at him again on that day. I cannot speak for the
  19     anaesthetist. I am not sure what their perceptions
  20     were.
  21   Q. You said a moment or two ago -- I am going to take issue
  22     with you on it -- that the meeting had agreed the
  23     operation should go ahead.
  24        The position would be, would it not, that those
  25     who are concerned with the clinical care of the children

   1     would make the decision -- that is yourself and
   2     Mr Dhasmana -- no doubt taking into account the views
   3     expressed to you by others, but the anaesthetist would
   4     be in no position to judge the current clinical
   5     condition of the child, would he, or she?
   6   A. I think probably putting it in context, I was called to
   7     this meeting, as you know, on the 11th. If I had been
   8     asked to review the child by Mr Dhasmana, I would have
   9     done my best to try and do that. I was not in the
  10     hospital the previous day; I was visiting another centre
  11     in Scotland on that day, so I would not have been able
  12     to see him that day.
  13        My understanding is that the anaesthetists also
  14     knew the system as it worked so it would have been
  15     unlikely unless requested that I would have specifically
  16     evaluated Joshua. They were well aware of how the setup
  17     worked and it would be relatively uncommon for the
  18     cardiologist to specifically review patients
  19     pre-operatively, unless requested.
  20   Q. So far as any assessment of urgency or otherwise of the
  21     operation was concerned, they would have deferred to
  22     you?
  23   A. And also Mr Dhasmana, whom he was primarily under, yes.
  24   Q. Can I come back to that word in the third line up from
  25     the bottom of the page on the screen, UBHT 54/13, "We

   1     did not feel it was appropriate for referral to another
   2     centre."
   3        The clinical interests of Joshua had, we agree, to
   4     predominate. One must take a decision in the best
   5     interests of the patient. We agree on that, you and I,
   6     do we?
   7   A. I think so, in the context of what is feasible and
   8     possible for that -- there are constraints to any
   9     treatment programme that you offer. You have already
  10     heard a little about time constraints, waiting list
  11     constraints. There are inevitably waiting list
  12     constraints in any child you are dealing with. There
  13     are also resource problems that affect your ability to
  14     deliver the treatment you would like to be able to
  15     offer.
  16        So when you are making decisions about whether it
  17     is appropriate to refer, what you have to decide is
  18     whether, in your centre, based on all these other
  19     issues, it is appropriate to do that. We felt that was
  20     the case: "There are a number of positive reasons to
  21     continue with treatment in our centre". I had been
  22     reviewing him locally; I could carry on local
  23     follow-up. Mr Dhasmana had done his first operation so
  24     already had contact with the family. So there are many
  25     positive reasons why one would want to carry on the

   1     treatment in the way we used.
   2   Q. Let me run through essentially what you would have known
   3     on 11th January. You have a surgeon whose results had
   4     been criticised, which is the reason for having the
   5     extraordinary meeting the night before surgery.
   6        That is bound, however much he may deny the fact,
   7     to have some effect which is not beneficial upon the
   8     surgery, is it not?
   9   A. I am not sure that that necessarily can be inferred.
  10     I can only put an analogy of myself. If I am
  11     undertaking an interventional catheter procedure, when
  12     I am doing that procedure I am concentrating on that
  13     child, I am not thinking about outside issues. They
  14     very rarely come into play when you are in the midst of
  15     doing a procedure or an operation or whatever. I cannot
  16     speak for Mr Dhasmana himself, but I certainly gained
  17     the impression that he felt it would not interfere with
  18     his ability.
  19   Q. I appreciate your answer, but a moment or two ago you
  20     told me, before the break, that you had been concerned
  21     that it might affect him?
  22   A. I was concerned it might do, but was reassured by his
  23     statement, his explanation, that he did not feel it
  24     would.
  25   Q. You appreciated the possibility that it might therefore

   1     affect him?
   2   A. I appreciated that that was a concern, but after his
   3     reassurance, I did not think that was a concern that
   4     should affect any decision-making.
   5   Q. This was an operation of a general type, that is
   6     arterial switch, of which the last two of such
   7     operations performed, the children both died.
   8        The last one of this particular type, the only one
   9     of this particular subspecialty, since 1990 -- over the
  10     last four years -- the double outlet right ventricle,
  11     had died. Did anyone look at the record in those terms?
  12   A. I would be very wary of looking at it in those terms.
  13     I think, whilst one has to learn lessons from individual
  14     cases, one has to look at each case in detail, and we
  15     had looked at all of these cases in detail at
  16     clinico-pathological conferences, to see if there was
  17     any reason for patients surviving and those who did not,
  18     and generally we felt we had identified in some of those
  19     patients reasons why things had not worked out.
  20        Based on that, I think we felt happy with the
  21     overall results in that particular group, although one
  22     has obviously to be cautious about overinterpreting. We
  23     have already talked a little about statistics. You
  24     cannot extrapolate from two cases to a generality; you
  25     might have been faced with a very bad cluster of

   1     problems that -- clusters of difficult cases, in which
   2     the case mix you are seeing might have affected those
   3     particular results.
   4        So, for instance, of the two previous patients,
   5     I know at least one of them we discussed recently had
   6     a banded pulmonary artery and a muscular heart secondary
   7     to that, and I think that was a very major factor in why
   8     that patient did not survive.
   9   Q. Let me ask you what may seem to be an unfair question,
  10     because it would inevitably be answered with hindsight,
  11     but suppose that tomorrow you had a case in which you
  12     were the referring cardiologist. What you knew about
  13     the case was that the surgeon in whose list the case was
  14     was someone who had last operated upon any such case six
  15     months earlier; that a new surgeon, a specialist in the
  16     area was due to come, no doubt because it was thought
  17     that a specialist was necessary for particular
  18     operations in the unit; thirdly, that the night before
  19     the operation, concern had been expressed by the
  20     Department of Health and by other senior clinicians
  21     within the hospital as to the desirability of going
  22     ahead with the operation; fourthly, that the Medical
  23     Director had asked whether or not the operation might
  24     not better be postponed; fifthly, that the child
  25     concerned, although needing an operation in the near

   1     future, was not an emergency case; sixthly, that the
   2     results for the surgeon in whose list he was were, on
   3     available statistics, with all their uncertainties,
   4     worse, it appeared, a bit than the national average, and
   5     considerably worse, perhaps four times as bad as the
   6     best estimate that might be made of a recognised
   7     specialist unit down the road; and next, the surgeon
   8     would have to operate in circumstances where it was
   9     known to him that there was considerable dissent and
  10     dissension about performing the operation and therefore
  11     there might be, at the back of his mind, some unease.
  12        If that combination of circumstances happened
  13     tomorrow, and I appreciate it is something of an unfair
  14     question because you can only answer it with hindsight,
  15     do you think you would make the decision that such
  16     a child should go ahead and have that operation, or
  17     would you, do you think, refer the child elsewhere?
  18   A. There are so many questions in that I do not know where
  19     to start. I must say, I do not have your recollection
  20     for all of the points and I am not sure I would agree
  21     with all of the points you have said, so --
  22   Q. Can I put it compendiously. If Joshua Loveday's case
  23     happened tomorrow, do you think you would make the same
  24     decision?
  25   A. It is very difficult to be certain. I believe we acted

   1     on the best evidence we had at that stage and I believe
   2     our reasons for proceeding with surgery were on the best
   3     information we had. We acted on the best information we
   4     had, and tried to act in the best interests of the
   5     patient. That is all I can say. I think it is very
   6     difficult to say in such a hypothetical case, whether
   7     I would still do that. I think I would need to look at
   8     the circumstances individually for each patient and then
   9     discuss it with my colleagues.
  10        None of these decisions are single decisions; they
  11     are made as a group. There are many people interacting
  12     at all of these discussion meetings when we decide
  13     a treatment strategy. This meeting you are talking
  14     about was a little bit unusual, I agree, but in many
  15     ways it is very similar to a discussion that goes on for
  16     any case you have prior to deciding surgery, perhaps not
  17     in quite the depth that we discussed.
  18   Q. Tell me: was anything of the uncertainties about the
  19     situation, the dissent there had been amongst
  20     clinicians, was any of that expressed to the parents?
  21   A. I do not know. You would have to ask Mr Dhasmana who
  22     saw the parents that evening.
  23   Q. So you were not involved with the parents after this
  24     meeting?
  25   A. I did not see them afterwards, no.

   1   Q. Shortly after this, obviously there was
   2     a considerable disharmony in the unit, reflected I think
   3     by the de Leval and Hunter report. May I pick up one
   4     matter which I asserted or asked you about earlier,
   5     which is whether or not you had been present with the
   6     surgeons when Messrs Hunter and de Leval spoke to you;
   7     do you remember?
   8   A. Yes.
   9   Q. Can I say that it has been brought to my attention
  10     that in the evidence of Mr Hunter to this Inquiry, we
  11     are told that he saw you after having seen the surgeons
  12     and said in evidence that he thinks he saw the
  13     cardiologists, you and Dr Joffe, separately from the
  14     surgeons:
  15        "I think we saw everyone together at the end of
  16     the day, but I think we saw them separately, but you
  17     have may evidence to the contrary. That is my
  18     recollection."
  19   A. That concurs with my recollection.
  20   Q. Having had the chat with you the night before?
  21   A. Yes, we met up the night before, or the evening before,
  22     I think we had informal discussions over supper.
  23   Q. A little while after this, then, you saw, did you, the
  24     draft of the Hunter/de Leval report?
  25   A. I saw the report. I know there were two forms. I am

   1     not certain that I saw the first draft, but I certainly,
   2     I think, saw the second draft.
   3   Q. Can we have UBHT 61/356, please? Can we scroll down and
   4     go overleaf to 357,359, the very bottom of the page? This
   5     is looking at the results of open-heart surgery and
   6     looking at the results from particular series, tetralogy
   7     of Fallot, VSD, AV canal and comparing two consultants.
   8     Consultant number 1 is Mr Wisheart; consultant number 2
   9     is Mr Dhasmana.
  10        Did you see the report in this form?
  11   A. I am not aware of seeing it in this form, no.
  12   Q. The conclusion that was made before the report was
  13     amended was that consultant 1 would be amongst the
  14     higher risk surgeons, the very last sentence on that
  15     page.
  16   A. Yes.
  17   Q. Were you aware that that had been said of Mr Wisheart in
  18     respect of that series of operations?
  19   A. My recollection more relates to mortality for different
  20     conditions that was looked at. I have not got good
  21     memories of the actual document you are talking about,
  22     certainly not this one, even the second one, but
  23     I remember the tables of figures being drawn up for that
  24     meeting and I remember that that was the stage that
  25     I saw Mr Wisheart's AVSD results for the first time, and

   1     noted that the mortality in that group seemed higher
   2     than certainly I had expected.
   3        I do not remember there being any significant
   4     difference within any of the other subgroups. In fact,
   5     my memory of it was that the results were very similar
   6     for most of the different groups of operations that we
   7     were dealing with. VSD, for instance, I am sure the
   8     results were very similar. I cannot remember whether
   9     there was a statistically significant difference with
  10     tetralogy of Fallot. I would have to look at that.
  11   Q. Were you aware of the question mark at least over the
  12     AVSD series of Mr Wisheart before he ceased operating as
  13     a paediatric surgeon?
  14   A. I was aware, yes, after the Hunter/de Leval report and
  15     the figures that were drawn up then, that there was
  16     concern over his results in that single group. I was
  17     surprised at that and felt that that is something that
  18     needed more detailed evaluation.
  19   Q. Can we look at UBHT 61/390?
  20        "After detailed consideration by cardiac surgeons,
  21     anaesthetists, paediatric cardiologists and the
  22     radiologists involved in the care of children ... an
  23     agreed and fully supported protocol has been confirmed
  24     as follows ..."
  25        It deals with the period up until 1st May.

   1     Mr Wisheart will continue to operate for all conditions
   2     excluding the AV canal and will continue to see new
   3     paediatric referrals up to 1st May 1995, and then will
   4     stop, effectively. That was the protocol, was it not?
   5   A. Yes.
   6   Q. Do you remember the case of Andrew Peacock? We have
   7     full consent.
   8   A. I do, yes.
   9   Q. He was a child who came for operation right at the very
  10     end of the period before Mr Pawade came into Bristol.
  11   A. He is a patient that had been under my care for -- well,
  12     from fairly soon after his birth, been operated on by
  13     Mr Wisheart on two occasions. I might need to check his
  14     medical records, actually, to be certain of those
  15     details. I am fairly certain I referred him for surgery
  16     at some stage in 1994.
  17   Q. Yes. Can we have a look at WIT 11/17? Scroll down to
  18     the bottom of the page. You are looking at the
  19     statement of the mother, Mrs Sharon Peacock. A clinic
  20     of 25th April 1995 is described. She recollects you
  21     asking her whom she wanted to perform surgery on
  22     Andrew. She says you did not mention the new surgeon's
  23     name.
  24        Is that something, do you think, you would have
  25     done, to have a chat with the parent about the surgeon

   1     who should perform the operation?
   2   A. I think I remember a conversation that I had with
   3     Mrs Peacock around that time. I was aware that Andrew
   4     had been waiting for surgery for a little time and
   5     I thought it only right and proper to let her know what
   6     the current situation was with regard to Mr Wisheart
   7     operating. There had obviously been a fair bit written
   8     in the media at that stage, and I believe I, if you
   9     like, offered the option of -- he was already on the
  10     waiting list for surgery with Mr Wisheart. I believe
  11     I discussed whether she wished for me to change that
  12     referral to Mr Pawade, who had not started at that
  13     stage. I personally felt there were some advantages to
  14     him continuing under Mr Wisheart's care because he had
  15     done the previous surgery and his type of surgery did
  16     not fall into a category that the previous document that
  17     you showed me suggested should not be done. He was
  18     over 1, it was to repair coarctation of the aorta, and
  19     I therefore felt it appropriate to inform Mrs Peacock of
  20     the current situation, as I was aware of it at that
  21     stage, and to see if she had any feelings about it.
  22   Q. Did you say to her, "Mr Wisheart is not going to operate
  23     on children after 1st May"?
  24   A. I do not remember whether I said that specifically.
  25   Q. His operation, as it happens, was 30th April, as you may

   1     recollect?
   2   A. Yes.
   3   Q. Did you give any reason why she might prefer one surgeon
   4     rather than the other?
   5   A. I do not believe so. I do not believe I did. At that
   6     stage, of course, I had no idea, although I had met
   7     Mr Pawade when he came over for the interview, obviously
   8     I did not have a knowledge of Mr Pawade in action, if
   9     you like.
  10   Q. I am sorry, I was concentrating on the day before the
  11     operation, 30th April. The operation itself took place
  12     on 1st May. It is my fault entirely.
  13        So here was a surgeon who was ceasing, on 1st May,
  14     to operate. In fact, he performs an operation on
  15     1st May, which you referred to him in his list for
  16     1st May?
  17   A. I had no input into that scheduling as such. He had
  18     been on the waiting list as I understand it, from the
  19     end of November, from some time in 1994, so he had been
  20     waiting a while, I think.
  21   Q. You have, I think, seen Mrs Peacock on a number of
  22     occasions since the operation. Let me pick up some of
  23     the matters which she raises and give you an opportunity
  24     to respond to them.
  25        If you could look at WIT 11/26, after the

   1     operation it appears that Andrew suffered from athetoid
   2     movements and Mrs Peacock asked you, she says, a list of
   3     questions that she had prepared. She remembers, she
   4     says, she asked whether all the cases of athetoid
   5     movements were caused by the bypass machine and what
   6     else might cause them if this was not the cause. She
   7     says she never received an answer to that question.
   8        "They said that no long-term damage or
   9     side-effects would be caused by the medication that
  10     Andrew was taking.
  11        "We also asked Dr Martin if Andrew would be back
  12     to his old self after the movements had stopped. He
  13     replied that Andrew would probably be quiet and
  14     withdrawn at first but would gradually return to normal.
  15     It might take a little time."
  16        Do you recollect that conversation?
  17   A. I remember the meeting with Dr Sharples, a consultant
  18     paediatric neurologist, and myself and Mrs Peacock.
  19     So, yes, I do remember that meeting.
  20   Q. Did you say something to that effect?
  21   A. I think obviously some of the input to that would have
  22     come from Dr Sharples. She is an experienced paediatric
  23     neurologist and would have discussed -- she has more
  24     knowledge of this particular abnormality than I have.
  25     I had seen these choreo-athetoid movements following

   1     cardiac surgery previously. I certainly had seen it in
   2     Liverpool, I think also perhaps previously in Bristol,
   3     I am not quite sure about that, and in those cases where
   4     I had seen it before, it had been a self-limiting
   5     condition.
   6        So based on what I knew from my own experience,
   7     what Dr Sharples knew from her previous experience and
   8     also fairly extensive literature on the subject, I tried
   9     to be reassuring as best I could that, based on what we
  10     knew, it was very likely that this would be
  11     a self-limiting condition.
  12   Q. So you may well have said something along those lines?
  13   A. Along the lines I have just said, yes.
  14   Q. As we know, Andrew died. After the death, you, I think,
  15     spoke to Mrs Peacock. Her recollection of what is said
  16     is at WIT 11/29, the bottom of the page. You are
  17     reporting there some brain damage.
  18        She says in the last four lines, she asked if
  19     Andrew had suffered from a lack of oxygen at any point,
  20     and she says you responded saying that this might have
  21     happened when Andrew was on the heart and lung machine.
  22     She says she asked why she had not been informed that
  23     Andrew had pneumonia, and Dr Martin, she says you said,
  24     "Perhaps you should have been told of this."
  25        Is that again a conversation which you accept, or

   1     reject?
   2   A. I think I may well have said something along those
   3     lines. Whether I used those exact words, I do not
   4     know. What I meant by that -- perhaps I did not get it
   5     across accurately -- was that I believe that Mrs Peacock
   6     and others had been informed that Andrew had a chest
   7     infection. Technically pneumonia is a chest infection,
   8     but it has different connotations from a parental point
   9     of view if you have pneumonia, so viewed as a more
  10     serious problem than if you have a chest infection.
  11     I should have indicated that he had pneumonia rather
  12     than a chest infection. I think he certainly had
  13     problems with aspiration, which quite commonly produces
  14     infection or an aspiration pneumonia, but I do not know
  15     whether we actually used those words.
  16   Q. Can I raise with you some of the matters while I am
  17     going into this area that other parents recollect you as
  18     having said? My apologies for it being something of
  19     a quick look at points, but you need to have an
  20     opportunity to comment upon them.
  21        Can we have a look, please, at WIT 227/6?
  22        This is the statement of Mrs Jane Elliott about
  23     her son Ben Elliott, whose operation was in 1989. If we
  24     scroll down the page, paragraph 21, the last sentence:
  25        "Dr Martin advised me", she is saying this in the

   1     context of you being very helpful to her, "that
   2     Mr Dhasmana was a top cardiac surgeon and this, again,
   3     gave me confidence."
   4        Do you think you said that about Mr Dhasmana in
   5     1989?
   6   A. I had a high opinion of Mr Dhasmana, so whether I used
   7     those exact words, I do not know. I think certainly
   8     I would have been happy that he was a good cardiac
   9     surgeon, certainly for doing the shunt operation, and
  10     I would have been trying to be as reassuring to the
  11     family as possible, based on what I knew.
  12   Q. I understand reassurance. I think it is the word "top"
  13     as opposed to "good" because it suggests a range of
  14     comparison. From what you told us earlier, you had no
  15     comparison you could have made between Mr Dhasmana and
  16     anybody else?
  17   A. "Top", I agree, I have no way of saying who is top and
  18     who is bottom. Perhaps a better term would be
  19     "experienced specialist paediatric cardiac surgeon",
  20     if one is going to be technical about it, but these are
  21     phrases that often get bandied about in informal
  22     conversations. I do not know whether I used those exact
  23     words. I might have done.
  24   Q. The question is really, having said you might well have
  25     said something along those lines, one for your comment

   1     as to whether you think it is appropriate to say
   2     something which is in essence comparative, albeit with
   3     the intent of reassuring parents, if actually there is
   4     no objective basis for it.
   5   A. A lot of things in life and medicine you do not have
   6     objective comparisons, so that does not mean to say you
   7     cannot perhaps offer an opinion, perhaps, sometimes.
   8   Q. A similar point if we look at the case of Diamond,
   9     WIT 310/6, the last sentence:
  10        "Dr Martin told us that Bristol was equal to the
  11     other hospitals and was a centre of excellence."
  12        The conversation here is a bit more detailed,
  13     because the context that is recollected by Mr Diamond is
  14     that his wife had said, "Should we go to Southampton or
  15     London rather than Bristol?" You have been asked to
  16     make a comparison, and he explains the reason for that
  17     which you see in the next sentence, and recollects five
  18     children up to Bristol, only one had survived that they
  19     knew of. It records you as having said that Bristol was
  20     equal to the other hospital and was a centre of
  21     excellence.
  22        Again, is that something you might well have said
  23     in an attempted reassurance of parents, or not?
  24   A. I think, if I remember the details of that case, and
  25     again, I might need to check back in a bit more detail,

   1     but we had fairly recently reviewed the results for --
   2   Q. It was pulmonary atresia, with intact ventricular
   3     septum.
   4   A. That is right, and she had undergone the first stage of
   5     moving towards total cavopulmonary connection, and
   6     I know around that time, or a little after when we had
   7     this conversation, which I think was -- do you know when
   8     this conversation was?
   9   Q. 1991. That is the recollection of the parent.
  10   A. I am not sure whether that -- I know we had
  11     a conversation much later, when we went in detail into
  12     results.
  13   Q. I will come to that and perhaps it is helpful to show
  14     you that now, so you can see which one comes when.
  15     That, I think, is at page 13. There is a conversation
  16     between him and you about the results of pulmonary
  17     atresia with intact ventricular septum, and we go down.
  18     You see what is said in paragraph 25, at the top there.
  19   A. Yes. I think we met up and had a discussion quite late
  20     on, so at that stage we had the de Leval/Hunter -- no,
  21     the statistics drawn up for that report, and I discussed
  22     those with them. We also had the results of
  23     a multi-centred trial around the UK for pulmonary
  24     atresia with intact septum. We had seen provisional
  25     results around that stage, so we knew we had some

   1     information from the UK at that stage, from I think
   2     virtually every institution on that particular
   3     condition. So what I was doing, I was feeding back that
   4     information to the family.
   5   Q. Paragraph 26: you were supposed to have said to the
   6     parent that there were a number of factors that have
   7     been altered following discussions in 1989 to 1990.
   8     Some change has been made to the operative procedure
   9     that had led to improvements. Post-operative management
  10     had also been altered and is likely to have helped
  11     matters, and those have been introduced following
  12     audited figures.
  13        Do you now recollect whether you did say, in
  14     around about 1991, that Bristol was a centre of
  15     excellence?
  16   A. I do not remember saying that at that time. That is
  17     a long time ago. I do not remember saying that.
  18   Q. May you have said it?
  19   A. Conversation eight years ago is very difficult to
  20     recall.
  21   Q. It is not easy, because you must have had many
  22     conversations with many parents. I give you the
  23     opportunity for doing so, because otherwise one has the
  24     parents' recollection, which is probably singular in
  25     most parents' cases.

   1        Is it the sort of thing you might have said, do
   2     you think?
   3   A. It is possible.
   4   Q. If you had said it, and one comes back again to the same
   5     point, there would have been no comparative
   6     justification because there were no figures to justify
   7     it at that time?
   8   A. No, it would have to be based on impression, what I had
   9     seen from patients I had referred and discussions we had
  10     had previously, prior to that time. I am sorry, the
  11     mortality figures here, though, were for this child's
  12     specific abnormality and certainly in that subgroup, we
  13     felt that the overall mortality figures, the results for
  14     that particular operation, were comparable to other
  15     centres, based on the cardiothoracic surgeons' register.
  16   Q. The changes that were made to the post-operative
  17     management: what were they?
  18   A. That might be better directed towards others who are
  19     more involved with post-operative management, but as
  20     I understand it, there was a move around that time to
  21     aim for earlier extubation if at all possible in these
  22     patients, to get the patients spontaneously breathing,
  23     which has been shown to be helpful in this group of
  24     patients. There may be others, but you will perhaps
  25     have to ask others about that.

   1   Q. Can I go from this case to that of Mallone, at
   2     WIT 155/1? The statement of Mr Jonathan Mallone. He
   3     tells us in the statement about the birth of his child,
   4     Josie.
   5        If we go to page 6, paragraph 16, Mr Wisheart came
   6     to speak to them about the operation, and said that the
   7     operation had not gone exactly as planned, but had
   8     nonetheless been successful. He explained he had been
   9     forced to cut Josie on both sides because when he made
  10     the incision on the left-hand side, he had discovered
  11     that the branches of Josie's aorta were arranged
  12     anomalously.
  13        He appears to be describing anatomy he had not
  14     anticipated in this surgery. Are you able to help with
  15     whether that is something --
  16   A. I think I would need to check the records to remember
  17     exactly the details to be able to answer that question.
  18   Q. Can we look in the same context at page 10. There are
  19     two cardiologists involved with her case. I think you
  20     were one and Dr Jordan was the other. If we go down,
  21     please, Dr Joffe himself, I think, had been involved.
  22        Can we go on, please, to page 17, paragraph 47?
  23        Josie had died, and it is recorded here by
  24     Mr Mallone that you came and certified her as being dead
  25     and said that there had to be a postmortem and the

   1     parents did not want one. You said it was a legal
   2     requirement to protect patients. And you see what was
   3     argued about.
   4        The process of telling parents about postmortems:
   5     is it easy?
   6   A. It is an extremely difficult time to talk to the parents
   7     of course after the death of a child. So, yes, I would
   8     agree, it is not an easy time to --
   9   Q. Would it normally be you or the anaesthetist or the
  10     intensivist or the surgeon?
  11   A. It could be me; it could be a cardiac surgeon; it could
  12     be an anaesthetist involved with the care of the child.
  13     There are a number of people that might be involved in
  14     discussing the issue of postmortem examination.
  15   Q. Do you quite often get parents reacting in the way that
  16     the Mallones appear to have done?
  17   A. I do not think any family wishes their child to have
  18     a postmortem examination. It is very unusual for them
  19     to want that. In this particular case, we felt it was
  20     one that needed to be referred to the Coroner, which is
  21     why my comments there are that there had to be one,
  22     because we felt that it was a death that we had to refer
  23     to the Coroner.
  24   Q. Because of ...
  25   A. Because it was a death after surgery and there had been

   1     complications related to that surgery, so we believed.
   2   Q. Have you had any training, apart from experience, in
   3     breaking news like this to parents?
   4   A. No formal training, no.
   5   Q. Do you think it would be helpful?
   6   A. I think it would be very helpful, actually. It
   7     certainly was not part of my undergraduate or
   8     post-graduate training. Yes, I agree, I think it would
   9     be helpful.
  10   Q. You would wish, I am sure, to be sensitive to the
  11     feelings of any parents, and yet have to appreciate that
  12     parents might very well differ in what they would regard
  13     as an appropriate sensitivity?
  14   A. I would always try and be as sensitive as possible, but
  15     it is a very difficult conversation, or group of
  16     conversations, that ensue after the death of a child.
  17   Q. Can we go overleaf [WIT 155/18].
  18        What the Mallones describe here is that they came
  19     to visit Josie in the Chapel of Rest and they were told
  20     about the postmortem. You described how the pathologist
  21     would go into Josie from the back so she would look like
  22     the same old Josie. They describe the difference
  23     between 14th January and 17th January. Just read it to
  24     yourself for the moment. (Pause).
  25        That is a reaction of parents which you would no

   1     doubt want to avoid if it was at all possible?
   2   A. It is obviously very sad, the circumstances they are
   3     faced with. I do not understand part. It seems to
   4     indicate what they were seeing was before the
   5     postmortem, rather than after, but --
   6   Q. On 14th January, yes. The 15th, not. I think what they
   7     are saying is that they visited Josie who is lying in
   8     the Chapel of Rest, and she was taken to the postmortem
   9     on the 14th. They had erroneously supposed that she had
  10     had the postmortem beforehand, and it had taken place
  11     later than they thought.
  12   A. But this is a description of events after the
  13     postmortem, is it?
  14   Q. So they got a horrible shock and surprise from seeing
  15     the baby in a state which they had not expected, and
  16     I think what is suggested is that they feel that she did
  17     not look like the "same old Josie" any more, and that
  18     caused particular distress?
  19   A. I would share their distress based on what they have
  20     described. I did not have the opportunity of witnessing
  21     what they witnessed, so --
  22   Q. What liaison was there between the clinician who was
  23     dealing with the need for the postmortem and advising
  24     parents on postmortem, and the pathologist, so that
  25     parents who had particular concern that their child

   1     should look untouched so far as possible, was presented
   2     in that way following postmortem? Was there any?
   3   A. I do not remember discussing that specifically with any
   4     of the pathologists. It was my understanding that
   5     postmortem examination was always done in a way that
   6     externally there would be relatively few signs of it.
   7     So my initial discussion was based on that assumption.
   8     Obviously it is distressing when clearly it has not
   9     happened as I had expected.
  10   Q. Can we look at UBHT 308/19? This is a letter which
  11     Dr Jordan sent to Dr Berry, and if you scroll down,
  12     please, copied to you. Let us go back up. It is
  13     a letter about "Coroner's 'cardiac' postmortems."
  14        I think if we go to the page before, we will see
  15     the nature, I think, of the letter to which it is
  16     responding. This letter is addressed to Mr Dhasmana,
  17     but the essence of it, I think, is probably the same
  18     because it is contemporaneous.
  19   A. It is three years apart, though, is it not?
  20   Q. I am sorry, can we go back to UBHT 308/19, the note that
  21     Professor Berry (Dr Berry as he was) circulated, was in
  22     relation to the Home Office Circular which we have and
  23     which I will show you in a moment.
  24        What Dr Jordan is expressing is:
  25        "I think we ought to attempt to put pressure on

   1     them at a central level", pointing out that there is
   2     a give-and-take between the hospital and the university
   3     pathologists on the one hand and the Home Office
   4     requirements on the other. It is suggesting that it
   5     would be sensible to attempt to implement a suggestion
   6     that parents sign a separate consent form in respect of
   7     the retention and use of tissue.
   8        The circular is at WIT 43/153. You will see in
   9     the last sentence:
  10        "We wish to remind your pathologist that Ministers
  11     are concerned that tissue and organs should not be taken
  12     for teaching or research purposes from Coroner's
  13     postmortem examination cases."
  14        It is that which it appears Dr Jordan was
  15     responding to in that letter of 1989.
  16        Let us go back to the letter --
  17   A. Can I see the start of that letter?
  18   Q. Yes, let us go back to 152. The newsletter, or the
  19     letter from Mr Jordan?
  20   A. That document there, because I do not recognise it.
  21   Q. I am sorry, we only have, on this reference, that
  22     extract. 153. It is an extract which it appears was
  23     circulated. I do not know, and you can help me, whether
  24     you came upon or remember seeing this document or having
  25     met this view expressed?

   1   A. I certainly do not remember seeing this document, it is
   2     only an extract from it, but I do not remember seeing
   3     that.
   4   Q. Can we go back to 308/19? Again, we cannot help you
   5     with the note that came from Professor Berry in terms,
   6     because we do not have a copy of it, but do you remember
   7     any discussion about the retention of tissue amongst
   8     cardiologists at this time, 1989? It would have been
   9     about a year after you had started in post.
  10   A. No, I do not remember any discussion. I vaguely
  11     remember myself receiving a letter from Professor Berry
  12     about this issue, and I think I remember seeing this
  13     copy from Dr Jordan in reply, which I do not think
  14     I took matters further myself. I do not think
  15     I specifically replied, having seen that Dr Jordan had
  16     replied. I was still fairly new in the unit at that
  17     stage, in fact.
  18        I do not remember any discussion of the
  19     implementation of what Dr Jordan has put in his last
  20     paragraph there.
  21   Q. So it follows you cannot really help us about the
  22     retention of tissue?
  23   A. No.
  24   Q. When it came to talking to parents about postmortems,
  25     did you raise with any parent the fact that tissue might

   1     be kept, as it happened, following postmortem for one
   2     purpose or another?
   3   A. I would be requesting postmortem examinations relatively
   4     infrequently, I have to say, so I was not heavily
   5     involved with that task. I know on occasions I will
   6     have discussed retention of tissues; in fact I think the
   7     postmortem request form changed at some stage, I am not
   8     sure of the timing, to incorporate that. But it was
   9     certainly well after this. I think there was a fairly
  10     basic request at that stage.
  11   Q. There are two other main areas which I need to canvass
  12     with you. The first is to ask you about particular
  13     cases which have arisen from the Case Note Review. Let
  14     me deal with this fairly shortly. You have, I think,
  15     seen cases in which the cardiological management of the
  16     patient has been criticised by the reviewing doctors,
  17     the reviewing panels in the Case Note Review, have you
  18     not?
  19   A. I have seen a small number where that is the case.
  20   Q. I think in the case of two of those, you recollect that
  21     you were not the cardiologist under whose care the case
  22     came, although you did have some involvement at some
  23     stage in the care?
  24   A. I think you supplied me with a list of four cases to
  25     review. Of those four cases, for two I was not the

   1     primary cardiologist involved but I did have some
   2     involvement. I cannot speak broader than that.
   3   Q. In one case you were the cardiologist involved, and that
   4     was the case of Ben Fitzgerald.
   5        Ben Fitzgerald was a case which, put it in its
   6     context, he was transferred from Newport to the
   7     Children's Hospital aged 1 day, back at the beginning of
   8     1990.
   9   A. That is right, yes.
  10   Q. If we have a look, please, at the medical report for
  11     Ben Fitzgerald, just give me one moment --
  12   THE CHAIRMAN: Mr Langstaff, while you are looking, perhaps
  13     you could, in every case we look at, remind us that we
  14     have appropriate permission to do so.
  15   MR LANGSTAFF: The only cases which we refer to from the
  16     Case Note Review are those where we have full consent.
  17   THE CHAIRMAN: It is very important for us always to remind
  18     ourselves of that.
  19   MR LANGSTAFF: MR 3130/108, please. We see the "aged 1 day,
  20     transferred from Newport", and the diagnosis is
  21     a queried transposition. As it turned out, if we go to
  22      110 and 114, please, and we have a look at the echo
  23     findings there at the bottom, it is pulmonary atresia
  24     with VSD and an aortic override, a similar condition to
  25     Fallot's tetralogy, I think, is it?

   1   A. At the extreme end of the spectrum of that condition,
   2     yes.
   3   Q. What happens to Ben Fitzgerald after this? He goes into
   4     the Children's Hospital. He is an inpatient and he is
   5     given prostaglandin to keep his arterial duct open.
   6        On the 18th February, so the day after he comes
   7     in, he is recorded as having had apnoeic episodes. Two
   8     days later -- look at page 114 -- the top of the page,
   9     four apnoeas overnight. So this is a young baby who is
  10     having periods of time when the baby is not breathing.
  11     Is that the best way to describe it in layman's term, an
  12     "apnoeic" episode?
  13   A. Apnoea does mean a period where you stop breathing, and
  14     this is something you quite commonly see in small
  15     neonates particularly, when they are treated with
  16     prostaglandin infusion needed to keep the arterial duct
  17     open. It is something which is quite commonly seen.
  18     Very often they are short-lived and self-limiting; often
  19     with a bit of stimulation the child will settle. But if
  20     they are severe, then sometimes it results in the child
  21     needing ventilatory support.
  22   Q. If they are repeated at all, plainly apnoeic episodes do
  23     not do the child any good in general terms, do they?
  24   A. If they are short-lived they are unlikely to cause any
  25     harm. They are a very common occurrence, particularly

   1     in a pre-term infant without heart disease and without
   2     treatment.
   3   Q. After a night like this, where four apnoeic episodes are
   4     recorded, would you have expected the unit to have
   5     ventilated the child at that stage?
   6   A. Not necessarily. If they were short-lived, particularly
   7     responding to stimulation, you would not necessarily
   8     ventilate and intubate that child at that stage.
   9   MR LANGSTAFF: Would you like to comment on that,
  10     Dr Silove?
  11   DR SILOVE: I think at that stage, if there are short-lived
  12     apnoeas, it would be reasonable not to ventilate, but
  13     I think if the apnoeas continued, one would go for
  14     ventilation. It is a premature baby, it is on prostin:
  15     it is likely to continue having apnoeic attacks.
  16     I think, especially as Dr Martin said, on a baby who is
  17     on prostin -- prostaglandins -- there is quite a risk of
  18     the baby having repeated apnoeas. It is a question of
  19     judgment as to when you are going to ventilate. Perhaps
  20     on the 20th one would not; on the 21st, if there are
  21     more apnoeas, I think one ought to. Mind you, there had
  22     been apnoeas already on the 18th, had there not?
  23   MR LANGSTAFF: The 18th, yes; the 20th, four apnoeas; the
  24     21st, page 114, two apnoeas overnight.
  25   DR SILOVE: I must say that obviously one has to allow the

   1     clinicians looking after the patient to make a decision,
   2     but if I had a patient who was getting that many attacks
   3     of apnoea, I am sure we would plan to ventilate probably
   4     on the 20th.
   5   MR LANGSTAFF: Who takes that decision to ventilate,
   6     generally, in your unit?
   7   DR SILOVE: I do not really know whether the baby is on
   8     a ward at the present time or on the Intensive Care
   9     Unit, but probably on the ward, if we have a patient on
  10     the ward who is getting repeated apnoeas, we would want
  11     the baby to move to the Intensive Care Unit so it can be
  12     watched very carefully and properly ventilated.
  13   MR LANGSTAFF: Do you want to come back on that at all,
  14     Dr Martin?
  15   DR MARTIN: From memory, I think this child would have been
  16     on the Intensive Care Unit at that stage, so would have
  17     been closely observed. In that setting one has to make
  18     a judgment based on the severity and length of any
  19     apnoeas. I totally agree with Dr Silove, no, you do not
  20     want to leave apnoeas going on. If they are very
  21     short-lived, there might not have been an indication for
  22     ventilation, but that would probably have been assessed
  23     by the anaesthetic team predominantly on the Intensive
  24     Care Unit.
  25        The baby had, I think, problems which included

   1     a difficulty with disease of the intestine, necrotising
   2     enterocolitis, and went, we know, for surgery in early
   3     March. If we go to page 144, this is the operation
   4     note: right thoracotomy and the classical
   5     Blalock-Taussig shunt.
   6        We see, in looking at the operation note, that the
   7     right pulmonary artery was said to be very small,
   8     measuring two millimetres.
   9        Earlier, I think, you had interpreted the
  10     echocardiogram, or it had been reported. Page 136:
  11     is that your writing?
  12   A. It is, yes, well, the top entry is. The second one is
  13     not.
  14   Q. You are measuring there the pulmonary artery, the right
  15     pulmonary artery, 3.1 millimetres. The left pulmonary
  16     artery, 3 millimetres. There is plainly a difference
  17     between your measurement on echo and that which the
  18     surgeon records on his operation note, if we go back to
  19     the operation note, measuring about two millimetres in
  20     outside diameter.
  21        How do we read that? Is this the surgeon making
  22     a mistake in measurement or giving an estimate, or is
  23     this something the size of which varies, or what?
  24   A. Can I just perhaps put this in context? Would that be
  25     helpful? It may be particularly helpful for those who

   1     have not seen the case notes.
   2        It is a child, as you rightly say, with pulmonary
   3     atresia with a VSD, but in a child where the pulmonary
   4     arteries were extremely small. When I first evaluated
   5     this child, I felt that the pulmonary arteries were too
   6     small to consider a shunt operation at that stage, and
   7     in that era we would have been considering
   8     a Blalock-Taussig shunt.
   9        I believe we discussed the treatment plan around
  10     that time with Mr Dhasmana, I think it was, and the
  11     decision was made to try and see if we could get the
  12     pulmonary arteries to grow by encouraging a flow into
  13     them through the arterial duct by keeping the duct open,
  14     so there had been a period of about three weeks or so on
  15     prostaglandin infusion, trying to see if we could
  16     encourage the growth of those very small pulmonary
  17     arteries in the hope that one might meet a situation
  18     where that was treatable.
  19        The measurements on echo, in my view, are
  20     unreliable in many ways. The resolution of echo in 1990
  21     would not perhaps be as good as it was now, and for most
  22     echo measurements a millimetre difference is not
  23     unexpected.
  24        We also might have been talking about the right
  25     pulmonary artery at different points. Where the surgeon

   1     sees it when he is doing a shunt might be slightly
   2     different to where I was describing, which might be the
   3     origin of the vessel. So there may be many reasons for
   4     that difference in finding.
   5        We knew, before that operation, that this was
   6     a child with small pulmonary arteries.
   7   Q. Can you tell me why it should be that for a child of
   8     this age -- because at 14th March we have a child who is
   9     less than a month old -- there should be a classic
  10     Blalock-Taussig shunt?
  11        The reason I ask is because the standard textbook
  12     on cardiac surgery at that time was Kirkland and
  13     Barrett-Boyes, was it not?
  14   A. The most widely read one, yes.
  15   Q. That would tell anyone reading it, I think, that the
  16     classical Blalock-Taussig shunt formed with the
  17     subclavian artery arising from the innominate artery in
  18     the side opposite that of the aortic arch is one of the
  19     preferred initial palliative procedures except in
  20     infants under two to three months of age?
  21   A. I think that question is better directed at a surgeon.
  22     I am quite happy to give you my view of it, if you wish,
  23     but I can only comment on Mr Dhasmana's practice.
  24     Generally, in that age group, he would normally have
  25     undertaken a modified Blalock-Taussig shunt. In that

   1     you insert a prosthetic tube --
   2   Q. A Goretex graft?
   3   A. Yes, usually a Goretex graft, 4 to 5 millimetres quite
   4     commonly, between a branch of the aorta, quite commonly
   5     the subclavian artery, and the pulmonary artery on the
   6     same side.
   7        Why he particularly chose a classical shunt, I am
   8     not sure. I think he may have been concerned that
   9     a Goretex graft might have distorted the pulmonary
  10     arteries more than using the patient's own tissues, but
  11     that would be my best guess. I think probably
  12     Mr Deverall would be in a better position to answer that
  13     one.
  14   MR LANGSTAFF: Can you help, Mr Deverall, or Dr Silove?
  15   MR DEVERALL: I do not think I can help. I would agree with
  16     what has just been said, that the -- which era are we
  17     talking about? 1990? I would have thought it was
  18     standard practice to use Goretex in the first three
  19     months of life at that stage. I might qualify that, if
  20     I may, in that in the particular condition -- and most
  21     surgeons preferred to do that on the side of the aortic
  22     arch -- I would disagree with what is in Kirkland and
  23     Barrett-Boyes textbook, the chapters of which were
  24     written -- I apologise, because I was involved in
  25     helping to write them nine years before the text of that

   1     draft of Kirkland's book was written in 1982, because --
   2     I will not bore you with the details, but I know that to
   3     be a fact.
   4        Most of us by this stage had found that in very
   5     tiny babies it was safer, more predictable and quicker
   6     to do the operation on the side of the aortic arch --
   7     there are technical reasons for that -- with one
   8     exception: babies whose survival is dependent on the
   9     ductus arteriosus, where placing clamps or ligatures
  10     around the pulmonary artery can distort that duct, cut
  11     off the supply of blood to the lungs and result in
  12     instant death for the child. That is why, in my
  13     understanding, Mr Dhasmana decided to do the operation
  14     described.
  15        Having said that, he was up against certain
  16     extreme technical difficulties, the most dominant of
  17     which was the very small size of the pulmonary
  18     arteries.
  19        May I say, in relation to your discussion about
  20     pulmonary arteries, the size of the pulmonary arteries,
  21     either on the echo or at the time the surgeon does the
  22     operation, is partly determined by their morphology,
  23     structure, and partly by the amount of blood going
  24     through them. That varies with time, so I have no
  25     problem with different measurements at different points

   1     in time.
   2   MR LANGSTAFF: I do not know if you want to comment on
   3     that?
   4   DR SILOVE: No, Mr Deverall is an expert on surgery.
   5   MR LANGSTAFF: Once the shunt has been done, is it essential
   6     to make sure it is open and not blocked?
   7   MR DEVERALL: Sometimes it is very obvious that the shunt is
   8     working: it is visibly obvious, it is palpably obvious
   9     to the surgeon. On other occasions it is not so
  10     obvious, but you can be sure the shunt is working
  11     because the child's clinical condition, notably its
  12     arterial oxygen saturation, immediately improves.
  13        There is a third group in whom you have technical
  14     difficulties usually and in whom you do not think the
  15     shunt is working. I believe most surgeons would say
  16     that diagnosis has to be established either then and
  17     there in the operating room, or as sometimes happens,
  18     that clinical circumstance becomes evident very early
  19     after the initial operation. I believe most surgeons
  20     would feel that that diagnosis needs to be established
  21     and an intervention carried out immediately, if that is
  22     what you are -- I presume you are not talking about
  23     anti-coagulation?
  24   MR LANGSTAFF: In this case we have looked at the records,
  25     and we know you have, too. We know following the

   1     operation on 14th March there was no echocardiogram done
   2     until 16th March, in which it was difficult to see the
   3     shunt. The reference is page 148 in the medical
   4     records, if we need it.
   5        Is that an appropriately early echo check that the
   6     shunt is working or not?
   7   THE CHAIRMAN: Mr Langstaff, may I propose that you take
   8     that question to a short break? It is 4.30. I am
   9     conscious of the fact that it is getting late and we
  10     perhaps need to change over our stenographer, so why
  11     don't we take 10 minutes and reassess how late we are
  12     going to sit tonight?
  13   MR LANGSTAFF: Sir, I have very little left, Dr Martin will
  14     be pleased to hear, which is why I was soldiering on,
  15     but I am happy to have a short break.
  16   THE CHAIRMAN: I think it will help all, and then we can
  17     have a short session.
  18   (4.30 pm)
  19               (A short break)
  20   (4.45 pm)
  21   MR LANGSTAFF: We were discussing the case of Ben
  22     Fitzgerald. You were commenting, I think, upon whether
  23     there is a need for immediate observation by any means
  24     available for a cardiologist of whether the shunt is
  25     working or not after operation.

   1   DR SILOVE: Yes, as I recall the operation was done on
   2     14th March. Mr Dhasmana seemed to be rather pessimistic
   3     about the outcome of that operation.
   4   Q. We see the words of this "poor result", fourth from the
   5     bottom line of the sheet as it stands on the screen.
   6   A. Which suggested that he was not really confident that
   7     the shunt was working. I feel that an attempt should
   8     have been made the following day at the latest to do an
   9     echocardiogram and get some idea of whether the shunt
  10     was working and I think that the approach really would
  11     have been for the cardiologist and the surgeon to have
  12     had a discussion as to what the next step should be.
  13        I think the outcome of that discussion would have
  14     been that the patient should have had a cardiac catheter
  15     very soon, like the 15th or 16th March and the surgeon
  16     re-explore depending on the findings at the time of the
  17     catheter. Meanwhile the baby had continued on prostin,
  18     which was keeping the duct open so the baby was
  19     surviving on that, but it seemed as if it was not only
  20     the shunt that was blocked or partially blocked, but
  21     there was very little flow going to the right lung.
  22   Q. In terms of the timing to check to see whether the shunt
  23     is patent or not, particularly given the operation note,
  24     do you agree with what Dr Silove says or not?
  25   DR MARTIN: Yes, I agree in part. I think what one has to

   1     realise when you are looking at the records is it may
   2     not tell the whole story, there may well be other things
   3     going on that you are not aware of. They do not always
   4     get put down into the written record. It was a long
   5     time ago, but I do have some memories that might perhaps
   6     clarify things.
   7        Again to put it in context, as you have already
   8     heard this baby was extremely sick pre-operatively with
   9     very severe necrotising enterocolitis, had bowel
  10     perforation, was desperately sick. That had been
  11     treated and had improved but still was not completely
  12     under control.
  13        Immediately following surgery my memory of it was
  14     that Mr Dhasmana was very pessimistic that he managed to
  15     achieve a satisfactory result. The child was extremely
  16     sick after the procedure and I am fairly certain we did
  17     discuss whether it was appropriate to go in and do
  18     further surgery at that early stage, but I think it was
  19     felt that the child's clinical condition perhaps would
  20     not tolerate it.
  21        I believe also during this time period there was
  22     some discussion with the parents about the
  23     appropriateness of doing further treatment in what was
  24     quite a severe abnormality.
  25        I cannot remember the conversations in detail but

   1     I know at some stage his mother expressed a view that we
   2     should not be going on to do any further surgery, did
   3     not want to go through further surgery. Whether that
   4     was at that stage or slightly later on, I cannot be
   5     sure, I am not sure about the timing but I know that was
   6     a factor that might have influenced the timing and
   7     scheduling of any investigations.
   8        As it was, when I did the echocardiogram, was it
   9     two days after the operation?
  10   Q. The 16th, yes, page 148. Let us have that on the
  11     screen.
  12   A. I felt it was unlikely that the shunt was working and
  13     I think further discussions occurred after that as to
  14     whether it was appropriate to reinvestigate by cardiac
  15     catheter and with a view to going on to further
  16     surgery. Those discussions would have involved parents,
  17     would have involved Mr Dhasmana and maybe others on the
  18     Intensive Care Unit.
  19   Q. It needs to be pointed out I think that the catheter was
  20     conducted on 21st March.
  21   A. Yes.
  22   Q. That revealed, as we know, a blocked shunt with no
  23     filling of the right pulmonary artery and the small left
  24     pulmonary artery supplied by what was described as
  25     a tortuous duct.

   1        So we have an operation on the 14th and
   2     catheterisation a week later on the 21st.
   3        Do you want to say anything further in response to
   4     the history as Dr Martin has given us?
   5   DR SILOVE: I take the point that he is making and the baby
   6     had been very sick and, as it turned out, the baby
   7     became even more sick after the second operation. But
   8     I am sorry that I did not pick up anything in the
   9     medical records if there was anything. I looked fairly
  10     carefully but there was not anything to give me a clue
  11     as to what suggestions were taking place with the
  12     parents and so on.
  13        Also there was no very clear evidence in the
  14     medical records that the baby's bowel had become
  15     a problem again between the time of the first operation
  16     on 14th March and the cardiac catheter on 21st March.
  17     One has to take a lot of things into consideration, but
  18     I still feel that the surgeon, if he was going to
  19     consider doing anything, should have done it earlier
  20     rather than later. The original reason for the
  21     operation was because the baby needed one and it had not
  22     worked and one was concerned about the continued prostin
  23     perhaps contributing to necrotising enterocolitis.
  24   MR LANGSTAFF: As I have said already we are not here
  25     resolving the liability for Ben's death but exploring

   1     some of the issues which the Case Note Review has thrown
   2     up. It might be said that this case may, it may not,
   3     throw up an issue as to communication between the
   4     cardiologist and the surgeon post-operatively and the
   5     availability of investigations on ICU post-operatively,
   6     the echo not having been done here until the 16th and
   7     the catheter not done for a week.
   8        Would it be fair, do you think, Dr Martin, to take
   9     from this case some reflection of the difficulties that
  10     it may well have been the split site caused in what
  11     appears on the face of it to be a tardiness in having
  12     the first echo post-operatively?
  13   DR MARTIN: That has nothing to do with the split site as
  14     such because it was all on the one site, for me anyway,
  15     though I appreciate for Mr Dhasmana that was not the
  16     case, he working at the Royal Infirmary and at the
  17     Children's Hospital.
  18        I cannot answer why an echocardiogram was not done
  19     on the following day. It is very difficult to
  20     reconstruct these things in great detail so long down
  21     the line. I would agree that in an ideal world we would
  22     have normally done an echocardiogram certainly the
  23     following day after the procedure. As it was it was
  24     another 24 hours later. It may be that was because we
  25     were unhappy with the stability of the child and did not

   1     feel it would influence our treatment at that stage.
   2     There were probably other things going on that I just
   3     cannot remember now.
   4   Q. We are told that, certainly after the echo, the child is
   5     stable. I do not know, again, can you recollect any
   6     reason for there being a delay in the catheterisation to
   7     see whether the shunt in fact was blocked as the echo
   8     suggested it might be?
   9   A. I think the feeling was that I would arrange a cardiac
  10     catheter study with a view to possibly carrying on the
  11     surgery thereafter and it may well have been trying to
  12     interlink it with cases we already had going through the
  13     unit. We would not have been the only case having
  14     studies. It would also be linked in with Mr Dhasmana's
  15     availability to do further surgery. There may be many
  16     factors that would affect that scheduling process.
  17   Q. I do not want to ask you further about Ben Fitzgerald's
  18     case because further questions may be more appropriately
  19     directed to Mr Dhasmana about it. Is there anything
  20     else you want to add about this particular case?
  21   DR SILOVE: No.
  22   Q. One or two matters which I must pick up on. The first
  23     is this: when we were talking earlier we talked about
  24     statistics which Mr Wisheart had put to a meeting in
  25     March 1992. Can we have a look at UBHT 55/121, please?

   1     These are the figures I think in his handwriting, are
   2     they?
   3   DR MARTIN: Yes, I think that is Mr Wisheart's handwriting
   4     and it certainly looks like the data that he showed at
   5     that meeting because he kindly gave me a copy and I kept
   6     a copy of it, as I think did some of my colleagues.
   7   Q. We can scroll down the page. Could we turn over and
   8     have a look at the next page? It has grouped the
   9     operations into simple, moderate and complex. Do you
  10     want to say anything about the range of surgery which is
  11     demonstrated there?
  12   A. Perhaps just to comment that we have looked at a few
  13     isolated groups of surgery but there was a whole range
  14     of other operations being undertaken within the unit and
  15     many if not most show results percentage-wise which were
  16     very, very similar to the UK figures which they were
  17     compared to here based on the UK Registry for a similar
  18     period. If you go back to the previous page again that
  19     can be seen from a variety of abnormalities there.
  20   Q. I think you should know if you do not know, if you have
  21     been following the Inquiry's progress: plainly these
  22     were the figures you had at the time. The Inquiry has
  23     carried out a careful statistical synthesis of the
  24     various data sources available to it and checked through
  25     the records. The evidence before it at the moment from

   1     the statisticians is broadly to the effect that the
   2     mortality in Bristol for open heart surgery, closed
   3     heart surgery being a different matter, was roughly
   4     double that elsewhere. This is very broad,
   5     I appreciate, and to get the exact figures one would
   6     have to go back to the reports.
   7        But a picture --
   8   THE CHAIRMAN: Under 1 year old.
   9   MR LANGSTAFF: I am grateful, under 1 year old.
  10        If one is looking at that as a generalisation
  11     across the board, did you have any sense of that whilst
  12     you were involved in the period up to 1995 or not?
  13   A. If you look at these groups you can see variations in
  14     mortality between the different groups. For individual
  15     lesions, and I think we generally felt there were some
  16     groups that we were having good results with; there were
  17     some subgroups where results were less good. But if you
  18     are looking at the overall figures, again I am not
  19     a statistician, if you are looking at this period here,
  20     we are saying there was definitely a statistically
  21     significant mortality overall in patients during this
  22     period. I am not a statistician, I have not analysed
  23     the data in detail.
  24   Q. To be fair to you, Dr Martin, I do not want you to
  25     comment at the end of a long day "on the hoof". You may

   1     like to comment if you wish to do so having reviewed the
   2     statistical material which has come before the Inquiry
   3     which you can have and you can write in to us if you
   4     wish to do that so we can have your reaction to it.
   5        My question was simply: if this was the position,
   6     the mortality in the other ones was double that in the
   7     UK, across the board, taking a check across the board,
   8     did you ever have any sense of that? That was the
   9     question.
  10   A. I am not sure these figures demonstrated that and
  11     I certainly did not have that sense, no.
  12   Q. Can I move on again picking up threads. If we go to
  13     UBHT 126/50, let us move on to UBHT 126/51 and 126/52.
  14     52 is the one I want. You will see this is what we
  15     recognised in evidence as being the original of the
  16     completer picture on page 51, the revised picture of
  17     51. There is handwriting on this. Can we scroll down.
  18     It is not very clear, but there are figures which have
  19     been altered and figures written in at the bottom.
  20     Do you recognise the handwriting at the bottom?
  21   A. I apologise for it, it is my handwriting. Yes, this
  22     draft document was one that was discussed. I am not
  23     absolutely certain at what time we discussed it prior to
  24     that meeting on the 11th. It was amended at that stage
  25     and I have written on here "Comparable data as best we

   1     had it from the UK Registry and from the
   2     multi-institutional study for arterial switch operation
   3     in the United States" which is "US 22 per cent TGA with
   4     multiple VSD, 16 per cent TGA, transposition with single
   5     VSD", and then on the right "Transposition of the great
   6     arteries with VSD, UK registry figures from 1990, 1991
   7     and 1992".
   8   Q. Those are the figures we saw on the typed sheet, those
   9     latter figures. When were those figures given in order
  10     for you to note them down?
  11   A. I am not certain. I am not sure whether this particular
  12     document was available for the meeting at Dr Joffe's on
  13     8th December or whether it was later than that. I think
  14     it may have been later than that but I am not certain.
  15   Q. The third matter which I need to ask you about:
  16     Joshua Loveday on his admission on 10th January 1995,
  17     you told us was not reviewed by you or by any
  18     cardiologist. Was he seen by the surgical team before
  19     the meeting of the 11th?
  20   A. Yes, he was reviewed by Mr Dhasmana's junior surgical
  21     staff on the 10th when he was admitted, had his
  22     investigations done at that stage, which would be blood
  23     counts et cetera.
  24   Q. How normal a practice is that, that the surgical team,
  25     the junior surgical members of the surgical team as

   1     opposed to the cardiologist should see the patient on
   2     admission?
   3   A. That was the standard practice in our unit that all
   4     patients coming in to the Royal Infirmary would be
   5     admitted under the care of one of the cardiac surgeons
   6     and that the junior surgical team would look after them.
   7   Q. The fourth matter is to refer you to an answer which you
   8     gave. For reference it is page 169, line 25, going on
   9     to page 170. I will read it to you. We were talking
  10     about the question of whether you had told any parent
  11     that tissue might be kept following a postmortem. You
  12     said that you were involved in postmortem examinations
  13     infrequently so you were not heavily involved with that
  14     task. You said this:
  15        "I know on occasions I will have discussed
  16     retention of tissue."
  17        Then the postmortem request form changed at some
  18     stage, you are not sure of the timing, to incorporate
  19     that but certainly well after the Mallone case we were
  20     talking about?
  21   A. I do not know that it was necessarily after the Mallone
  22     case. I am sorry I cannot remember where it relates to
  23     that.
  24   Q. You do recollect, do you, talking about the retention of
  25     tissue?

   1   A. I would not necessarily have discussed it in every case,
   2     but if a family asked what was involved with postmortem
   3     examination I would, on some occasions, have discussed
   4     that tissue samples were retained.
   5   Q. Was that in relation to Coroner's postmortems or just in
   6     relation to hospital autopsies?
   7   A. That would have been hospital autopsies. I would not
   8     have had any discussions regarding the Coroner's
   9     autopsies where I believed the question on whether or
  10     not to retain tissues was dependent on the pathologist's
  11     instructions.
  12   Q. Hospital autopsies only, hence your reference to the
  13     particular form of consent?
  14   A. Yes, and what tissues were retained again would be
  15     dependent on what the pathologist felt was indicated in
  16     any individual case.
  17   MR LANGSTAFF: Thank you very much, Dr Martin. I have asked
  18     you a number of questions and it may be there are some
  19     from Miss O'Rourke and some from the Panel to come.
  20     Before I finish asking questions, one last one: is there
  21     anything you wish to add, whether to clarify, to explain
  22     or to raise something which you think should have been
  23     raised but has not been?
  24   DR MARTIN: Not at this stage, thank you very much.
  25   MR LANGSTAFF: I do not know, gentlemen, whether before

   1     Miss O'Rourke asks any questions you have any particular
   2     comment from your aspect you wish to make about any of
   3     the evidence you have heard and which you think would
   4     assist the Inquiry?
   5   DR SILOVE: I do not think I have anything to add at this
   6     stage, no.
   7   MR DEVERALL: No, I have listened with great interest and
   8     not a little sympathy to what I have heard. I have not
   9     heard all the sides of this story and particularly not
  10     that which may be expressed by Mr Dhasmana.
  11        I can only say, speaking as a fellow surgeon, that
  12     the particular circumstances which came to apply when
  13     Joshua's operation was being considered were, I believe,
  14     extremely difficult for everybody concerned and as
  15     a comment which you may take and explore when I am not
  16     here, I could not but help think of somewhat similar
  17     circumstances over a personal career and the need on
  18     those occasions for an independent older person to give
  19     you wise counsel.
  20   THE CHAIRMAN: There was one question from the Panel,
  21     Mrs Maclean?
  22             Examined by THE PANEL:
  23   MRS MACLEAN: It is a question to our experts to ask for
  24     some context in which to put what we have heard about
  25     the examinations of Joshua Loveday on his admission.

   1     Could you help me to understand how far it would be
   2     customary in other centres in your experience for
   3     a cardiologist to examine on admission or not to do so?
   4   DR SILOVE: Speaking from my own experience, the patients
   5     who had come in off the waiting list for cardiac surgery
   6     come into our hospital in which there are cardiologists
   7     and surgeons all in the same hospital and the patient is
   8     seen by the cardiology SHO, he is seen by the cardiology
   9     Registrar, has an echocardiogram done and if the
  10     consultant cardiologist has not seen the family for
  11     a significant period of time or if the patient has been
  12     unwell, he will be seen by the consultant cardiologist,
  13     but not necessarily so.
  14        Certainly the patient will be seen also by the
  15     surgical Registrar and by the consultant cardiac
  16     surgeon.
  17   MR LANGSTAFF: Before Mrs O'Rourke rises to re-examine
  18     I wonder if Dr Silove has expressed all of that in the
  19     present tense; is what he is saying, does that apply to
  20     1995.
  21   DR SILOVE: Yes, this applies right back to the early 1980s
  22     or late 1970s.
  23   THE CHAIRMAN: Miss O'Rourke?
  24           RE-EXAMINED BY MISS O'ROURKE:
  25   MISS O'ROURKE: Just a couple of questions about

   1     Joshua Loveday in re-examination. Firstly, as far as
   2     11st January is concerned, I think you told us you were
   3     away on the 10th, the day he was admitted; where were
   4     you that day?
   5   DR MARTIN: I was visiting a colleague in Glasgow learning
   6     a new interventional procedure, being trained in the new
   7     interventional procedure.
   8   Q. On the 11th, as far as you were concerned was there any
   9     reason for you to see or examine him?
  10   A. Not that I was aware. He would have been admitted by
  11     the surgical team at that stage. I had not heard that
  12     there were any concerns or that they would wish me to
  13     examine him so I was not aware of any reason why
  14     I should be specifically asked to see him and was not
  15     asked.
  16   Q. Even with the benefit of hindsight and obviously knowing
  17     what Mr Dhasmana wrote in his note when he examined
  18     pre-operatively in what Dr Andrew would have wrote in
  19     her note when she examined preoperatively, do you think
  20     you would have gained anything by going to examine him
  21     and would it have affected your advice or your decision?
  22   A. I think it was highly unlikely it would have had any
  23     effect on any discussions we had. The anaesthetist
  24     primarily would be the person deciding whether that
  25     person is fit to go through the anaesthetic and that

   1     would not have been my role. I do not believe, based on
   2     what I know or knew of Joshua, that anything I found on
   3     that day would have altered my assessment. I still
   4     believe it to be accurate.
   5   Q. If you had gone to examine, what would you have been
   6     doing? Would it just have been a quick look, clinical
   7     assessment? What would it have been?
   8   A. I could have done a clinical assessment. I had done
   9     fairly recently or what I would term fairly recently
  10     when I saw him in the clinic in Gloucester.
  11   Q. You said "fairly recently"; it was 6 to 7 weeks before.
  12     Do you consider that in a medical or clinical context
  13     fairly recently?
  14   A. It is relatively recent in that clinical situation.
  15   Q. Finally on Joshua Loveday: during the meeting on
  16     11th January do you think you said anything or in any
  17     way inferred to anybody else that you had seen him and
  18     examined him during that admission?
  19   A. I am sure I would not have given that implication, that
  20     suggestion because people there know how the unit worked
  21     at that stage and would not have expected it, it would
  22     have been unusual for them to expect that.
  23   Q. Two final questions, not about Joshua. Firstly, you
  24     were asked about the letter you wrote to Mr Baker in
  25     September 1995, do you recall, where reference was made

   1     to the Birmingham mortality rates. Your state of
   2     knowledge in September 1995 as opposed to on
   3     11th January 1995, was it any different as far as
   4     statistics around the country?
   5   A. We certainly had a lot more statistics following the
   6     Hunter/de Leval report. At that stage we had certain
   7     specific data, we had a lot more information. I do not
   8     believe we had any more information from around the
   9     country other than the Cardiothoracic Surgeons'
  10     Registry.
  11   Q. Finally you were asked yesterday about giving parents
  12     certain specific data. I think the context of the
  13     question was, would you ever say to a parent "This
  14     surgeon's last three patients have died." Is that the
  15     sort of conversation you have ever had with a parent or
  16     consider appropriate to have with a parent?
  17   A. I do not think that is the sort of conversation
  18     I necessarily would have. I think each case that you
  19     are dealing with has to be dealt with on its own merits
  20     and each case is different. If you had had three
  21     children that died previously you would want to know the
  22     precise reasons and background to that. So comparing
  23     their child to what has gone on before may not be
  24     valid. You have to look at each individual child in
  25     depth, compare it to your best expectation of what you

   1     might expect based on the information you have.
   2   MISS O'ROURKE: Thank you, sir. Thank you, Dr Martin.
   3   THE CHAIRMAN: Dr Martin, it remains to me to say thank you
   4     very much for yesterday and today. We have kept you for
   5     a long time and you have been very patient with us. We
   6     have learnt a great deal and we are very grateful.
   7     Thank you very much for coming.
   8   MR LANGSTAFF: Sir, I wonder if we may publicly remind
   9     Dr Martin that of course he is free to give us whatever
  10     he may wish in writing and we have indicated one or two
  11     areas which it might be helpful, not least any comment
  12     he has upon the statistical material we have had given
  13     to us by our statisticians.
  14   THE CHAIRMAN: I blame myself and it must be somewhat later
  15     than the norm. I should have said, Dr Martin, before
  16     I paid that encomium that there may be other things you
  17     would wish to bring to our attention and you will be
  18     advised on -- indeed, one has arisen in our conversation
  19     towards the end. We would be very grateful to receive
  20     anything that you may think would help us further.
  21     Thank you again.
  22        Of course may I also thank Mr Deverall and
  23     Dr Silove for their help during the day and yesterday.
  24     It has been extremely useful to us.
  25        Mr Langstaff?

   1   MR LANGSTAFF: Tomorrow Mrs Shortis is followed by
   2     Dr Jordan, a 9.30 start.
   3   THE CHAIRMAN: We reconvene at 9.30. Good afternoon to
   4     everyone and to you, Mr Langstaff.
   5   (5.15 pm)
   6   (Adjourned until Wednesday, 17th November 1999 at 9.30 am)
   7
   8
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  10
  11                I N D E X
  12
  13
  14     DR ROBIN MARTIN (recalled)
  15         Examined by MR LANGSTAFF (continued) ...... 1
  16         Examined by THE PANEL ..................... 196
  17         Re-examined by MISS O'ROURKE .............. 197
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001