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 17th 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 heard from two witnesses, Mrs Maria Shortis, mother of Jacinta Shortis and Dr Stephen Jordan, Emeritus Consultant Cardiologist, UBHT, retired 1993. Mrs Shortis told the Inquiry about the her daughter Jacinta, who was born in November 1986 and died in January 1987 following corrective complex heart surgery performed by Mr Janardan Dhasmana at the Bristol Royal Infirmary. Mrs Shortis focussed her comments around issues regarding communications between clinicians and between patients and clinicians and the importance of audit in improving the quality of services provided by clinicians. Dr Stephen Jordan began his evidence to the Inquiry today. He was asked to comment of a series of cases which had been reviewed by Independent experts as part of the Inquiry’s Clinical Case Note Review. Dr Jordan’s evidence continues tomorrow. 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 78, Wednesday, 17th November 1999
   2   (9.40 am)
   3   THE CHAIRMAN: Good morning, everyone.
   4   MISS GREY: Sir, your first witness today is Mrs Maria
   5     Shortis. Mrs Shortis is represented by Mr Lissack of
   6     counsel.
   7            MRS MARIA SHORTIS (SWORN):
   8            Examined by MISS GREY:
   9   MISS GREY: Mrs Shortis, you are here today to tell us about
  10     the life and the death of Jacinta, your daughter; is
  11     that right?
  12   A. That is correct, yes.
  13   Q. You prefer I think to be known as Maria throughout your
  14     evidence?
  15   A. I do, thank you.
  16   Q. Maria, you have given two statements to the inquiry.
  17     Could we have a look first at the first one, WIT 222/1.
  18     Is that a statement relating to Jacinta's birth, her
  19     life and then her death?
  20   A. It is.
  21   Q. If we turn, please, to page 23, is that your signature
  22     at the bottom?
  23   A. It is.
  24   Q. Are the contents of the statement true to the best of
  25     your knowledge and belief?

   1   A. They are.
   2   Q. If we turn on then to page 25, we see there your second
   3     statement; is that right?
   4   A. That is correct.
   5   Q. That deals with events after April 1995 and the events
   6     which led you to become, amongst other things, a founder
   7     member of the Bristol Heart Children Action Group; is
   8     that right?
   9   A. That is correct.
  10   Q. Again if we turn to page 52 of that statement, do we
  11     have your signature on the bottom?
  12   A. That is correct.
  13   Q. Again, is this true to the best of your knowledge and
  14     belief?
  15   A. Yes, it is.
  16   Q. If we could go back to the first statement to page 1
  17     again, please. For the sake of those who are not as
  18     familiar with Jacinta's story, forgive me if I run
  19     through the very summary events and dates in her life.
  20   A. Yes.
  21   Q. She was born, was she not, on 15th November 1986?
  22   A. She was.
  23   Q. And she was born at Southmead Hospital in Bristol?
  24   A. That is correct.
  25   Q. She was then transferred for a catheterisation on

   1     17th November?
   2   A. On the Monday, yes.
   3   Q. And that took her then to the Children's Hospital at the
   4     Bristol Royal Infirmary; is that right?
   5   A. The catheterisation took place at the BRI and then after
   6     that she was transferred to the Bristol Children's
   7     Hospital.
   8   Q. She was on the ward in the Children's Hospital. We are
   9     talking about a time during which catheterisations were
  10     still being performed at the BRI?
  11   A. That is correct.
  12   Q. On 22nd November she underwent a shunt operation
  13     performed by Mr Dhasmana?
  14   A. That is correct.
  15   Q. Finally on 6th December she was well enough, it was
  16     thought at that stage, to discharge her home?
  17   A. Yes.
  18   Q. She had to be readmitted, however, on 13th December and
  19     again came home to you and your husband on
  20     17th December?
  21   A. That is correct.
  22   Q. Finally Jacinta died, is that right, on 22nd January of
  23     the next year?
  24   A. Of 1987, yes.
  25   Q. Jacinta was, we learn from your statement, very

   1     seriously ill?
   2   A. She was.
   3   Q. If I run through the medical conditions she suffered
   4     from, heart defects, are these familiar to you from your
   5     knowledge and much experience gained at the time.
   6     Firstly, dextrocardia?
   7   A. Yes.
   8   Q. She also had atrioventricular discordance?
   9   A. Yes.
  10   Q. Transposed aorta?
  11   A. Yes.
  12   Q. A common AV canal and pulmonary atresia?
  13   A. And pulmonary stenosis.
  14   Q. I think it is right, is it not, that when you first saw
  15     Dr Joffe you were told just how seriously ill she was?
  16   A. Yes, I saw Dr Joffe at 8.30. Jacinta had been diagnosed
  17     as having some problem at about 11.00 on that morning,
  18     that is Sunday morning. So we were being given bits and
  19     pieces of how ill she was throughout the day. It was
  20     the Senior Registrar who first told us that having done
  21     the echocardiogram, he had not seen anything like it and
  22     we would have to wait for Dr Joffe's diagnosis to
  23     confirm it.
  24   Q. Perhaps we could look first then at your description in
  25     your statement of the discussion with Dr Joffe's deputy

   1     or Registrar. It is at paragraph 13 of your statement,
   2     page 7, please.
   3        You talk about seeing there a doctor in his late
   4     20s and he gave the impression to you that he was scared
   5     and he did not know what to say to you. What was your
   6     impression in general terms of the experience that he
   7     had in dealing with parents who were in the situation
   8     that you had found yourself?
   9   A. I mean I do take quite a detailed notice of people's
  10     body language and it was quite obvious -- it was a wide
  11     grimace on his face, that the news was not going to be
  12     good. If I put it in context, we had gone from
  13     a perfectly normal child when she was born to "there is
  14     a slight problem" to meeting this doctor. I think what
  15     came up to me was that he was not the consultant. He
  16     did have bad news to tell us and so in a sense I felt
  17     a responsibility to help him to give us that bad news.
  18     I had already, having spoken to my father who was
  19     a doctor, prepared myself that Jacinta would have
  20     a limited life-span.
  21        So I asked him if she would have a limited
  22     life-span. At this stage I was thinking about 10 years
  23     because to actually have to engage with that reality
  24     after you have given birth is very very difficult. He
  25     was very relieved that I asked about the limited

   1     life-span and said "Oh, no, just 2 or 3 at the most".
   2     So although I can understand his relief that we had
   3     engaged with the severity of her condition, receiving
   4     that information like that was -- I remember feeling as
   5     if I had been hit and the world just stops at that
   6     information that was given to me.
   7   Q. I think the point that comes through in this paragraph,
   8     if I may say so, is one that you seem to be attempting
   9     to make about the training or experience in
  10     communication skills, that junior doctors or relatively
  11     junior doctors in the position of this particular doctor
  12     may have?
  13   A. I think it is always difficult for doctors to break bad
  14     news and they do tend to look at things in terms of
  15     being able to cure the patient. Where you have a child
  16     like Jacinta who was so obviously sick, to break bad
  17     news is difficult and if they have not had any training
  18     in it, it is even more difficult.
  19   Q. If we go on then please, in your statement you talk
  20     about of course being, as you said, appalled by the news
  21     and the way in which it was broken. After that you took
  22     the decision to baptise Jacinta. Was that partly
  23     because you were afraid that the worst would happen
  24     shortly?
  25   A. What was difficult about this whole situation was that

   1     he gave us the news, he was relieved and then he said
   2     "We will leave you to have a cup of coffee". It just
   3     seemed like "I do not want to be left alone at this
   4     point". I was with my husband. We were left. It was
   5     that sense of disappearing.
   6   Q. What more could he have realistically done?
   7   A. I think there could have been a nurse sent in to be with
   8     us. There was a nurse with him who said nothing. I do
   9     not think parents should be left at that point. I have
  10     forgotten what it was you asked me.
  11   Q. I asked you what could have been done. I think you
  12     answered the question.
  13        I think it is right to note, I think you have
  14     perhaps been hearing some of the evidence throughout the
  15     course of the Inquiry. It is right to note that the
  16     events you talk about predate the appointment of
  17     Mrs Helen Vegoda as a cardiac counsellor at the BCH. If
  18     there had been a figure such as Mrs Vegoda whose
  19     specific job it was to talk to parents in the midst of
  20     an experience such as this and to be there if they
  21     wanted someone to talk to, did it follow from your
  22     previous answer that that would have been a welcome
  23     help?
  24   A. I did speak to Dr Joffe during this time I was in the
  25     hospital with Jacinta, for there to be someone who would

   1     liaise between parents and the cardiac team and he said
   2     at that point that that was in the pipeline.
   3   Q. If we go on, please, to page 9 of your statement, you
   4     speak there about meeting Dr Joffe. You say that he was
   5     welcoming, but apologetic?
   6   A. Yes.
   7   Q. And you then go on to talk about what he told you.
   8   A. Yes.
   9   Q. In general how did you find Dr Joffe in your dealings
  10     with him?
  11   A. I have always found Dr Joffe up until April 1995 very
  12     caring in the way he spoke to me face to face. I had
  13     some difficulties with his reactions to Jacinta's death
  14     that caused a lot of unnecessary grief, but on the whole
  15     I did respect him.
  16   Q. We will come on to the precise circumstances of his
  17     reaction to Jacinta's death.
  18        Looking at the statement again, you have described
  19     there what Dr Joffe told you about the problems that
  20     Jacinta was suffering from. If we scroll down
  21     a little --
  22   A. Could I just say that where I put "It was readily
  23     apparent that Jacinta did not stand a chance of
  24     survival", that was the conclusion I came to, I was not
  25     told that at any point, that is my impression.

   1   Q. Does it follow she did not stand a chance of survival
   2     unless something could be done medically to intervene?
   3   A. Within the first two weeks.
   4   Q. And give her such a chance?
   5   A. Within the first two weeks of her life.
   6   Q. Dr Joffe, however, went on to explain options to you?
   7   A. He did.
   8   Q. He says, according to your statement that it would be
   9     necessary to perform a shunt operation during the first
  10     week of Jacinta's life?
  11   A. Yes.
  12   Q. Why do you use the word "necessary"?
  13   A. He said it would be necessary because her duct was
  14     likely to close up, therefore she was duct dependent,
  15     therefore if they were going to do surgery it would be
  16     necessary to do it within the first week of life.
  17   THE CHAIRMAN: It is my fault, we are having a bit of
  18     difficulty hearing you, we may move the mike -- forgive
  19     me for this interruption, but we are anxious to make
  20     sure we hear.
  21   A. Is that better?
  22   THE CHAIRMAN: Much better, thank you.
  23   MISS GREY: It was necessary because, as he was outlining
  24     the options to you there was either a shunt operation or
  25     the alternative, to switch off the prostaglandin that

   1     was keeping the duct open and allow Jacinta to die; is
   2     that right?
   3   A. That is correct. I and my husband were asking these
   4     questions so the conversation was being led by us. He
   5     did say that Jacinta was a strong child, she had got
   6     a very good birth weight and that she was worth fighting
   7     for. I think both my husband and I felt that her
   8     condition was so severe that her life was not viable
   9     with life and the one question we asked was "If she does
  10     have an operation, what kind of quality of life would
  11     she have for the 2 years that was envisaged that would
  12     be her life-span?" Dr Joffe said very clearly that she
  13     would have as near normal childhood as is possible.
  14   Q. What did you understand "as is possible" to mean?
  15   A. I did not follow it up but what I heard was "a near
  16     normal childhood". I had a 2 and a half year old child
  17     at the time, my son Sam, and we made the decision to go
  18     ahead with the operation on the fact that we had been
  19     bombarded by the reality that Jacinta was going to have
  20     a limited life-span. Do we turn the prostaglandin off
  21     and she dies not experiencing our love, or do we give
  22     her 2 years of unconditional love and she can die having
  23     been loved that was the only sole decision upon which
  24     that operation, we agreed to it.
  25   Q. To say to you that she would have "as near a normal

   1     childhood as possible" could be quite a severe
   2     qualification on the "near normal" childhood?
   3   A. It could be. Had Dr Joffe said "but you must understand
   4     that every time she gets an infection she may be
   5     admitted to hospital" or "she might vomit after every
   6     time she has been given some medicine" or that "she is
   7     not going to put on weight", that would have not been
   8     a near normal childhood to me. He did not qualify it
   9     and I did not ask him to do so.
  10   Q. You did not understand, for instance, that she might
  11     fail to thrive, that is to put on weight, to grow
  12     normally, to be very vulnerable to colds, respiratory
  13     tract infections?
  14   A. That was not the picture that Dr Joffe was giving us at
  15     that stage.
  16   Q. If we turn over the page, please, we can see that in
  17     order to decide whether or not a shunt operation was to
  18     proceed first a cardiac catheterisation was planned and
  19     that Jacinta was transferred, as we have already said,
  20     to the BRI initially for that to take place.
  21        At the bottom of that page, paragraph 21, we can
  22     see that Dr Joffe tells you that you are going to meet
  23     Dr Dhasmana the following day and he says according to
  24     your statement that you were lucky to be at a "centre
  25     of excellence"; can you remember those exact words?

   1   A. He told me I was in the best unit in the country. That
   2     he had worked with Christian Bernard that I was very
   3     lucky to be there, that many parents had to travel from
   4     Wales and other places in the South West, and I was very
   5     relieved by that comment and I trusted him.
   6   Q. Maria, your statement -- this statement is dated July
   7     1999?
   8   A. Yes.
   9   Q. I think it is right also that you gave a statement to
  10     the General Medical Council; is that correct?
  11   A. Yes.
  12   Q. That would have involved you recalling these events in
  13     1997; is that right, or thereabouts?
  14   A. When I gave the statement to the General Medical
  15     Council, they very much wrote it. This statement was
  16     very much written by me.
  17   Q. So this statement then was drawn up by you some 13 years
  18     approximately after the events we have been talking
  19     about?
  20   A. Yes.
  21   Q. How good is your recollection of those events?
  22   A. When I wrote this, looking back in my diary I realised
  23     it was Wednesday, November 19th that we actually met
  24     Mr Dhasmana. I would just say that the actual events
  25     themselves I remember very clearly, the dates I may have

   1     got wrong within that first week.
   2   Q. But you are recounting at several places in your
   3     statement the precise words used by doctors in
   4     conversations?
   5   A. Yes.
   6   Q. Can you genuinely recollect those after such a gap?
   7   A. I think there are certain statements made to you when
   8     undergoing a traumatic life experience that are etched
   9     on your mind for the rest of your life, words to the
  10     effect of it.
  11   Q. Is there not a danger you replay them in your mind
  12     perhaps in slightly different fashions as time goes on
  13     and potentially false memories get etched in your mind?
  14   A. Can you show me that I have done that?
  15   Q. Clearly Maria, I cannot suggest to you that you have
  16     falsified or in any way misrecollected things. All I am
  17     seeking to do with you is to explore how certain you can
  18     be now of the words doctors used to you when you were
  19     going through this trauma. I would like you to comment
  20     on that.
  21   A. I can be sure of the content of what was said to me.
  22   Q. Because you were?
  23   A. Because I think that -- personally when I have
  24     experienced a traumatic life event, and this is not the
  25     only one I have experienced, I react in a very calm way,

   1     I am very aware of what is going on at an emotional
   2     level and I am aware of what is going on at a rational
   3     level, and there are comments which are made which are
   4     etched in your mind.
   5   Q. You mentioned a diary; how much did you record in the
   6     diary, to what extent did you draw on that when making
   7     the statement?
   8   A. Very little. I recorded a few, you know, different
   9     points.
  10   Q. But not for instance the conversations between doctors
  11     and so on?
  12   A. No.
  13   Q. You said that Dr Joffe said you were very lucky to be at
  14     a centre of excellence. I think later on in your
  15     statement you suggest that nurses as well said similar
  16     things to you; is that right?
  17   A. Yes.
  18   Q. If we turn over the page, please, we can see that on the
  19     morning of 18th November, that is the Tuesday, you were
  20     standing in the Intensive Care Unit and you met
  21     Mr Dhasmana?
  22   A. Yes.
  23   Q. Then at 11.00 you say "There was a rather more formal
  24     consultation with Mr Dhasmana"?
  25   A. Sorry, on the morning -- it was actually Wednesday the

   1     19th, we were standing in the Intensive Therapy Unit and
   2     we were ready to meet Mr Dhasmana, yes. There was only
   3     one meeting with him.
   4   Q. The impression that is given, the account that is given
   5     in your statement here and on the following page where
   6     we see rather more discussion between yourself and
   7     Mr Dhasmana, is that there was a difference of opinion
   8     between him and Dr Joffe on what the best thing for
   9     Jacinta would be; is that correct?
  10   A. Certainly there was a difference in opinion between
  11     Mr Dhasmana and Dr Joffe. I think the important part
  12     for me was the effect from a parent's perspective that
  13     that had on us as parents.
  14   Q. What do you mean by that?
  15   A. We had spoken to Dr Joffe who had said that Jacinta was
  16     worth fighting for, that there was an operation that
  17     could be done, a shunt operation, that it would give her
  18     a limited life-span of maybe 2 years and that really
  19     that is what we should go ahead with, and we agreed with
  20     him. He told us that we would be seeing Mr Dhasmana and
  21     that Mr Dhasmana would be telling us the details of the
  22     operation he would carry out and he would explain that
  23     to us. So we went to that meeting expecting to hear
  24     that information.
  25   Q. To hear the same information reinforced by the surgeon?

   1   A. Yes, we expected to hear how he was going to operate,
   2     what he was going to do and the risks of the operation.
   3   Q. And instead you heard something to the contrary, that an
   4     operation was not necessarily the best way forward?
   5   A. What he said as we walked in the door and were about to
   6     sit down, was "Had I got to you first, I would have told
   7     you that your child was inoperable. I have cancelled
   8     the operation. Why do you want to put her through such
   9     misery?"
  10   Q. What co-ordination and consultation did you get the
  11     impression had been carried out between Dr Joffe and
  12     Mr Dhasmana before that meeting took place?
  13   A. I assumed, and it was an assumption, that -- I assumed
  14     that Dr Joffe had spoken to Mr Dhasmana, that the
  15     operation had been listed for -- I think it was listed
  16     for that day and I assumed as consultants they would
  17     have spoken to one another about the process of my
  18     daughter's care.
  19   Q. It follows from what you have just been saying that you
  20     do not actually know whether or not Dr Joffe and
  21     Dr Dhasmana had an opportunity to discuss the case
  22     before you were seen by Mr Dhasmana?
  23   A. I assumed that they had discussed it. As an ex-catering
  24     manager in the NHS, I -- as a manager I would have
  25     discussed different concerns that people might have

   1     raised. I mean this is a child who is severely ill and
   2     has very little chance of survival. I rightly or
   3     wrongly assumed that the consultant and the consultant
   4     cardiologist and the consultant surgeon would at least
   5     have had a conversation about what they were going to do
   6     in her best interests.
   7   Q. If we turn over the page to page 12, please, we can see
   8     there that you had the impression that Mr Dhasmana was
   9     telling you the truth but that his communication skills
  10     were appalling. That was because he was presenting you
  11     with a conclusion, was it, rather than discussing the
  12     options with you, or what?
  13   A. I think if I put this in the context of being a parent,
  14     to be told "Had I got to you first" sounds to me a bit
  15     like a race. "I would have told you your child was
  16     inoperable", yes, I would agree with you. "She is
  17     inoperable, why do you want to put her through so much
  18     misery?" I do not as her parent want to put her through
  19     any unnecessary misery. So I felt it was blurted out.
  20     He then said "I have cancelled the operation". This
  21     meant as informed consent was concerned, as her parents
  22     we were not part of that decision-making process, it was
  23     a fait accompli and I felt we were being drawn into
  24     hospital politics.
  25        So I had to test out with Mr Dhasmana the reasons

   1     why he did not want to operate on Jacinta. I was faced
   2     with a centre, a very good centre; I was faced with
   3     people who I thought were experts; I had no reason to
   4     doubt Dr Joffe in the way that he had spoken to us, in
   5     the way he had dealt with us but I could see Mr Dhasmana
   6     was right in saying that she was inoperable and so I had
   7     to summon all my strength to say to him "Do you not want
   8     to operate on Jacinta because she is going to die
   9     anyway?"
  10        The response was that he pushed his chair back,
  11     came forward and said "I am not talking about death,
  12     I just like seeing my patients through".
  13   Q. You describe that exchange a little further in the
  14     statement at paragraph 26, if we scroll down a little.
  15     The word that you use there is "shouted". The word you
  16     have just used in describing the experience to us again
  17     was "said"; is that not more accurate?
  18   A. No, when I say he shouted it, it was his response, it
  19     was an emotional response, it was not a non-emotional
  20     response. It was not a "I am not talking about death"
  21     it was "I am not talking about death".
  22   Q. It was said with emphasis?
  23   A. Yes.
  24   Q. And it was the response perhaps of someone who is
  25     emotionally engaged in this discussion and not remote

   1     from it?
   2   A. I would have to say he was emotionally engaged in the
   3     discussion but I could not make sense of the logic of
   4     that comment.
   5   Q. You go on to say in commenting on his statement "I am
   6     not talking about death, I would just like to see my
   7     parents through": "but the implication of this was that
   8     he liked to have a good success rate". Why do you say
   9     that, because surely the natural implication to be drawn
  10     from that sentence, if I could suggest it, is simply
  11     that he does not like to see his patients die?
  12   A. That is a possibility. It was not what I picked up at
  13     that point.
  14   Q. Why is it that you thought that he liked to have a good
  15     success rate rather than he was expressing a dislike for
  16     having patients go through operations but subsequently
  17     die?
  18   A. I said to him "Is the problem the operation? Will she
  19     not survive it?" and she said "No, there is no problem
  20     with operation at all, it has a 95 per cent rate" so
  21     I could not understand then if the operation had
  22     a 95 per cent success rate for Jacinta that he did not
  23     want to operate on her.
  24   Q. Was he perhaps concerned about the quality of life that
  25     Jacinta might have afterwards?

   1   A. If he was he did not follow that through. That is why
   2     I was asking him why he did not want to operate on her
   3     and he did not follow that through.
   4   Q. So he did not discuss with you either the problems that
   5     Jacinta might have even if the operation was technically
   6     successful?
   7   A. He had said "Why do you want to put her through such
   8     misery?" and he may well have said that she would pick
   9     up infections, but if we go on I then asked him what did
  10     he want to do if he did not want to operate and he said
  11     he wanted to take her off all her drugs and see how she
  12     would do.
  13   Q. Were you ever able to achieve with Dr Dhasmana
  14     a discussion of what he meant by saying that her life
  15     might be a misery or why you were putting her through
  16     misery?
  17   A. No.
  18   Q. Can you think why that was?
  19   A. I cannot think why it was, no, I still do not
  20     understand. I do not understand -- I could not see that
  21     there was a logical conclusion that he was trying to
  22     make and I think I talk about that in the statement.
  23   Q. If we are talking about barriers to communication in
  24     that particular meeting, since it is a theme that recurs
  25     throughout your statement, what do you think the

   1     particular barriers that were operating in that
   2     discussion were?
   3   A. I do not know. I could not make sense of it.
   4   Q. If we can go back up again to look again at
   5     paragraph 25, you say at the bottom of that paragraph
   6     that you felt that he had been drawn into
   7     interdepartmental politics particularly between those
   8     two men. Why use the word "politics" there?
   9   A. I felt maybe he did not want to operate on Jacinta,
  10     purely from a management point of view, at the time.
  11     This is what I was thinking, "Well, I would not want to
  12     operate on a child if she is not going to live and it
  13     costs a lot of money and there may be another child who
  14     has a better chance of recovery and there is an
  15     emergency". These things were going through my head
  16     with a managerial hat, you know, is it money funded,
  17     because I was not expecting to be in a situation where
  18     I was told that there was not an operation.
  19   Q. Did anyone ever suggest to you or use words that
  20     suggested to you that those factors, those financial
  21     factors perhaps were influential or were a factor in the
  22     care of Jacinta?
  23   A. Not at all. They were my own views from working in
  24     a teaching hospital in London where everything was
  25     money-led and funding was at a minimum, from my own

   1     experience.
   2   Q. You have described, Maria, a sharp disagreement between
   3     these two doctors on the care of Jacinta. Can you tell
   4     us how you felt as a parent, trying to reconcile those
   5     views and decide what you and your husband should do for
   6     Jacinta?
   7   A. I felt we had been drawn into an impossible situation as
   8     the main carers of our daughter, I felt we had
   9     a responsibility for her care. I believed the
  10     consultants were there to provide a service, to advise
  11     us on her best care in her best interests and I felt, as
  12     I say, caught in the cross-fire between difference of
  13     opinion which I felt should have been settled before
  14     they came to us. If they had come to us and said "We
  15     cannot do this operation, Jacinta is inoperable, what
  16     she will go through after her operation is an amount of
  17     unnecessary suffering", we would have had to take the
  18     decision to face the reality that maybe we had to turn
  19     off the prostaglandin.
  20        It is a very emotional situation and I do not
  21     think parents should be put through that kind of
  22     unnecessary grief.
  23   Q. Are there any wider lessons that you would like to draw
  24     to the Panel's attention from this experience on the
  25     specific issue of communication we have just been

   1     talking about?
   2   A. Yes, I think on the point of communication parents need
   3     to be given, can I say, genuine communication that does
   4     not give false hope. I am not talking about brutal
   5     reality, I am talking about genuine honest information
   6     where a child so severely ill as Jacinta was, that maybe
   7     the best thing is to take her home, certainly not to be
   8     drawn into a cross-fire situation where you have
   9     a disagreement over your child's life.
  10   Q. The counter argument might be that whilst you were
  11     caught in the most distressing of cross-fires, as you
  12     have just described, this was a case at least in which
  13     the differing points of view as to how Jacinta's case
  14     might be managed were in some shape or form brought to
  15     your attention.
  16        Is there a danger in the contrary course that
  17     doctors might make all the important decisions behind
  18     closed doors without involving the parents?
  19   A. I think if Dr Joffe and Mr Dhasmana had sat down with us
  20     we could have worked out the proper course of care for
  21     Jacinta; they did not.
  22        We saw one doctor who psyched us up as it were for
  23     one process of care and then another doctor who pulled
  24     the rug from under our feet and we were left -- well,
  25     I was left thinking "How do I do the best for Jacinta

   1     with a consultant who obviously does not want to operate
   2     on her, but will not say, 'Yes, she will die and if we
   3     do operate she is not going to have a good quality of
   4     life'?" I was not being given the information I needed
   5     by Dr Dhasmana to come to a rational and reasonable
   6     decision for Jacinta and his last comment was "Well, you
   7     have been promised the operation, I will have to do it,
   8     so I will have to do it anyway". I did not think it was
   9     a professional way of behaving as a consultant cardiac
  10     surgeon.
  11   Q. If we turn over the page we can see these events
  12     described in your statement. We see there that
  13     Mr Dhasmana is suggesting that you withdraw the
  14     prostaglandin and see what happens and the choice that
  15     you felt that presented you with. Then at paragraph 28
  16     you describe the conversation you have just told us
  17     about Mr Dhasmana having promised the operation and
  18     saying that he supposed he would have to do it.
  19        At the end of the discussion with Mr Dhasmana, is
  20     it right then that you had reluctantly agreed to
  21     withdraw the prostaglandin and to see what happened to
  22     Jacinta after that happened but obviously to restore the
  23     drug if she became cyanosed and was not coping?
  24   A. I felt I been plunged into a nightmare, that my
  25     daughter's life was definitely on the line, that

   1     Dr Joffe had made it very clear that she would be dead
   2     within 48 hours, he used the word "succumb" and as her
   3     mother I was not ready I think at that point for her
   4     death, I was not ready for her death. So I was faced
   5     with no operation. So what did Mr Dhasmana want to do?
   6     I tried to ask him if he did not want to operate, what
   7     care did he think Jacinta needed? In his saying
   8     "I would like to take her off all her drugs", again
   9     Dr Joffe said "She will die within 2 days if that
  10     happens."
  11        I felt if I took some control as her mother and
  12     said "Okay take her off all her drugs but if she becomes
  13     cyanosed I would like to have the prostaglandin
  14     restored" so I can make the decision as her mother or we
  15     as her parents can make that decision to end her life.
  16   Q. If we look at Medical Record 2388/19. Maria has,
  17     I think, given consent for the use of the medical
  18     records. We can see halfway down that page a record
  19     written by Mr Dhasmana of a discussion with yourself and
  20     your husband:
  21        "Talked to parents about extremely difficult
  22     problem here. Shunt is needed to provide blood flow to
  23     the lungs which at the moment is being provided by the
  24     duct with or without the need for prostin. Decided to
  25     see if patient can manage without prostin infusion, if

   1     not I would do the shunt".
   2        Do you think that is an accurate record of the
   3     discussion that you recollect taking place?
   4   A. There was one point when I said to Mr Dhasmana "If you
   5     take Jacinta off the drugs she will die?" and he said
   6     "I have seen patients walk in here at the age of 18
   7     with a duct still intact", to which I replied "But
   8     I suspect they did not have five major heart defects".
   9        The actual conversation and getting to this
  10     decision which, written there is, yes, that was the
  11     outcome, yes, took a huge amount of work and
  12     negotiation.
  13   Q. Going back to your statement. You have described at
  14     paragraph 29 -- this is page 13 -- the course of events
  15     when the drug was stopped; you recollect that it was
  16     perhaps closed off, I think the implication is from your
  17     statement on 18th November, but that there was
  18     a particular incident on the 19th where matters came to
  19     a head?
  20   A. As I recollect, I stayed with Jacinta that day and I am
  21     afraid I have got the dates wrong, so it would be the
  22     19th and the 20th. As I remember it, and I have not
  23     read her notes until today, she did not seem any worse
  24     without her drugs for that first day. As I remember it
  25     I was not going to come back in the evening on the next

   1     day, but I did and she was very cyanosed.
   2   Q. I think I said the 19th, your statement relates this
   3     incident occurring on the 20th, but I think having
   4     looked at the medical records we can agree it was
   5     probably the 19th?
   6   A. Yes.
   7   Q. If we go over the page we can see the incident itself
   8     where you say Jacinta had been moved to the other end of
   9     the ward. She was clearly very cyanosed and you formed
  10     the clear impression she had been left to die?
  11   A. It was a gut feeling that I had left her in the hospital
  12     near other babies and when I had gone in that evening
  13     and I was not expected to go in, they were quite
  14     surprised to see me. Jacinta had been moved to the end
  15     of the ward and she was very much in isolation and my
  16     gut instinct seeing her cyanosed was, that possibility,
  17     that they had left her there to die.
  18   Q. If we can go back to the medical record we were looking
  19     at, at Medical Record 2388/19. We can see firstly that
  20     the note we have just looked at in which Mr Dhasmana is
  21     saying if she cannot manage without prostin he would do
  22     the shunt?
  23   A. Yes.
  24   Q. He is outlining a course of management there that
  25     involves not leaving a child to die, but in fact

   1     operating if things do not go well after the trial; is
   2     that not right, is that not what had been agreed with
   3     him?
   4   A. As I said, he said "I suppose I will have to do the
   5     operation as you have been promised it".
   6   Q. If we go down a little further to the rest of the note
   7     here, I think I can probably read it out, it is the 19th
   8     at 5.00:
   9        "Prostin stopped, IV tissued" I think that means
  10     the cannula would no longer be able to insert prostin
  11     into the vein.
  12        Then the note says "Remains pink pro tem. If blue
  13     or transcutaneous oxygen goes down", that is the little
  14     downward arrow, "restart prostin"?
  15   A. Yes.
  16   Q. So the notes again do assume that if things go wrong the
  17     drug will be resumed?
  18   A. Yes.
  19   Q. We have a note at the bottom: "9.45 pm, rapid arrest,
  20     central cyanosed also associated with a drop in
  21     transcutaneous oxygen to 7 to 12".
  22        I think that is a reading that would be consistent
  23     with severe cyanosis?
  24   A. Yes.
  25   Q. "Restart prostin".

   1        There is a note of an incident in which Jacinta is
   2     very severely cyanosed indeed and that would accord with
   3     your recollection, would it not?
   4   A. My experience was that I went into the hospital. I was
   5     not expected to go in that evening. They were surprised
   6     to see me. I saw Jacinta at the end of the ward.
   7     I went up to her, she was severely cyanosed, that was
   8     about 8.00 in the evening, and I insisted very calmly
   9     for almost an hour -- I negotiated with Mr Dhasmana that
  10     Jacinta be restarted on the prostaglandin -- that is
  11     what I thought the drug was -- if she had become
  12     cyanosed and it took an hour for them to call a doctor
  13     to put her on that drug and then she rapidly turned
  14     round and became pink.
  15   Q. I think for the sake of completeness we ought to look
  16     also at page 120. If we scroll down the page. This
  17     just gives us the date, Maria. Again, the 19th, night.
  18     The relevant entries are over the page, please,
  19     page 121.
  20        We can see on the fourth line: "Not for theatre
  21     this afternoon, carbon dioxide monitor applied,
  22     prostaglandin is reduced". Then at 8.00 pm
  23     a discrepancy there between the 5.00 pm in the note we
  24     saw before, but "IV tissued and prostaglandin stopped
  25     and discontinued".

   1        Then it talks about, dropping four lines down
   2     "Surgery postponed to see how Jacinta copes without
   3     prostaglandin".
   4        At around the same date, again not quite the same
   5     time, there is a record of Jacinta being "cyanosed plus
   6     plus", so severely cyanosed. Dr Hicks is informed and
   7     there is a recommencement of the prostaglandin
   8     infusions?
   9   A. Yes.
  10   Q. I think the point that appears to be documented in the
  11     records is that there was a plan to restart
  12     prostaglandin if Jacinta became cyanosed?
  13   A. Yes, there was a plan because I negotiated it with
  14     Mr Dhasmana, there certainly was a plan. The fact that
  15     it took me an hour to insist to the nurses that that was
  16     what the plan was and it took an hour before Dr Hicks
  17     came up to give her the prostaglandin was an hour in
  18     which I formed the impression that she had been left to
  19     die.
  20   Q. Can you remember, Maria, whether or not they had to
  21     insert a new line to resume the prostaglandin?
  22   A. No, I do not. My concern was getting a doctor to
  23     restart the prostaglandin. So if you are asking me now
  24     from memory, no, I was just pleased to see the doctor,
  25     I was not concerned, as I was in a sense in one of the

   1     best units in the country, that the doctor was not going
   2     to do anything but the best for Jacinta. It was
   3     actually getting him up to do it and I think the nurses
   4     were a bit unsure what to do because Mr Dhasmana was not
   5     there and here was a parent saying "This is what we have
   6     planned, please would you go and get a doctor to carry
   7     out what was planned?"
   8   Q. Were they trying to get hold of Dr Dhasmana and failing?
   9   A. My recollection is there is a sense of: what do we do
  10     here?
  11   Q. Perhaps we could go back to your statement, then,
  12     page 14. You talk about seeing Dr Joffe again after
  13     this incident. He apologised for what had happened in
  14     the course of your meeting with Mr Dhasmana?
  15   A. Yes, and he apologised for what had happened the night
  16     before.
  17   Q. You said earlier in your statement that Dr Joffe was
  18     always apologising?
  19   A. Well, he met us on an apology he had been out all day.
  20     That was fair enough, that was very kind. He was very
  21     kind, but he was very apologetic.
  22   Q. Here at the bottom of paragraph 31 -- I made reference
  23     to this earlier -- where you say that additionally you
  24     had been told many times that the BCH was a "centre of
  25     excellence" both by Dr Joffe and the nurses and you say

   1     that you believed the staff were skilled experts in
   2     cardiac surgery even if they did not have much skill in
   3     talking to parents.
   4        There was obviously a contrast there between the
   5     technical expertise of the staff and perhaps their
   6     emotional skills?
   7   A. I can put this in some context for you and that having
   8     grown up in a medical household with a father who was
   9     a doctor. I have to say that he always took the view
  10     that surgeons may be technically skilled but they were
  11     not terribly good at communications skills, so that is
  12     the context in which I placed that.
  13        In one sense I could forgive them the lack of
  14     communication to some degree, because you know they were
  15     not connecting on that level particularly.
  16   Q. When you say they were "not connecting on that level
  17     particularly", is there a wider point you are making
  18     there about the nature of communication skills and
  19     medical training?
  20   A. Yes, of course there is. I think the point I would be
  21     making is the academic technical perspective that
  22     obviously surgeons have to have, they have to have
  23     technical expertise to do the job they do and to give
  24     Mr Dhasmana his due I think he, if only he could have
  25     followed through his communication skills he was very

   1     much trying to paint a picture of the reality of
   2     Jacinta's condition. I think had he followed that
   3     through I would not perhaps be here today.
   4   Q. Followed it through?
   5   A. To its natural conclusion. That, yes, she was going to
   6     die. That, yes, she would have a poor quality of life
   7     and that "Perhaps", you know, "I should have been there
   8     with Dr Joffe. I am sorry that you have been put
   9     through this mismanagement". I think it was
  10     a mismanagement of communication.
  11   Q. You think Mr Dhasmana would have done better in your
  12     eyes to have been blunter and more forthcoming?
  13   A. I do not know whether he had to be blunter but I think
  14     to have put it in context -- it appeared to me that they
  15     did not know how to communicate. Had he been able to
  16     either have come with Dr Joffe to see us because Jacinta
  17     was such a rare case and she was so severely ill,
  18     I think from that point of view, engaging with parents
  19     that this is a child of 1 in 3 million, that the
  20     information given to us at that point should have been
  21     with both of them not with one and then the other.
  22        I do feel some sympathy for Mr Dhasmana, strangely
  23     enough I do, that he could not follow through the
  24     questions I asked him about whether she was going to die
  25     and that is why he did not want to operate on her.

   1   Q. We know that after the failed trial of withdrawal of
   2     prostaglandin and its restoration, the shunt operation
   3     was carried out?
   4   A. Yes.
   5   Q. And Jacinta had a difficult postoperative period but --
   6   A. I did not think she did, no, I thought she came through
   7     intensive care quite quickly really. That was not
   8     difficult. She was out of intensive care within I think
   9     two, three days. It was after discharge on 6th December
  10     that we had problems again.
  11   Q. I think what I was referring to was at paragraph 16.
  12     Just to put my comment in context, at the danger of
  13     paraphrasing a statement, you will have to forgive me.
  14     If we look at paragraph 36 we can see Jacinta came
  15     through ITU very quickly and did well, which is just as
  16     you have been saying. You mention at the bottom about
  17     an incident which alarmed you in which she turned
  18     visibly grey?
  19   A. Yes, it alarmed all of us, we all witnessed it, yes.
  20   Q. If we turn over the page we can see that on
  21     13th December you again had reason to be alarmed by
  22     Jacinta's condition and she had to be readmitted to
  23     hospital in an ambulance?
  24   A. Yes.
  25   Q. You talk about an incident at the bottom of that

   1     paragraph, paragraph 38, in which you had an interchange
   2     with a young female doctor which again you found
   3     unhelpful. Why did you use the word "sneered"?
   4   A. I think one of the problems that we encountered was
   5     assumptions being made about us. My husband at the time
   6     of this incident -- we had just bought a huge big old
   7     house and he was developing it (the only room that was
   8     done in the house was Jacinta's room) and he had been
   9     knocking through something downstairs. In Victorian
  10     houses there is a lot of dust and he wondered whether or
  11     not the dust had been the cause of Jacinta's coughing,
  12     whether it got to her lungs.
  13        At that point he had just finished, it was late at
  14     night and we had rushed into the hospital. He had not
  15     had time to change, and this was not just the first
  16     incident that he offered advice, was looked at and
  17     sneered at and assumptive values were made about him
  18     because of the way he was dressed, I would have to say.
  19     I do not know if he would agree; he is here -- no, he is
  20     not, he has gone out.
  21        It was dismissive, it was a very sensible thing to
  22     say and it was completely dismissed.
  23        I observed that with other people who asked
  24     questions, as I was in the ward people would be
  25     dismissed according to their, if you like, social

   1     status, this is my own impression.
   2   Q. Sticking to this particular incident, the difference
   3     between a sneer and a smile can be quite a small one,
   4     can it not?
   5   A. It was not a smile it was a put down. It was a very
   6     genuine put down.
   7   Q. If you are making a point about pushing people down
   8     because of their social status, which is what I think
   9     you have just said?
  10   A. It is what I am saying, yes.
  11   Q. That is probably a problem that is not confined to
  12     doctors, is it?
  13   A. I am not saying it is, I am just saying it is not
  14     helpful when you have a very severely ill child who has
  15     gone limp, you rush her into casualty and you try to
  16     give some information that you regard as important or
  17     a possibility that that is what could have happened and
  18     you receive a put down; it is not helpful.
  19   Q. Going on to paragraph 39 of your statement, over the
  20     page please page 18. You had again a difficult time
  21     from a communication and information point of view
  22     because you were kept waiting for a long period of time
  23     before you were seen by anyone?
  24   A. Yes.
  25   Q. If we scroll down, please, we see Dr Joffe's explanation

   1     of Jacinta's condition at that stage. You say there
   2     that:
   3        "Dr Joffe stated the shunt had brought on
   4     Jacinta's heart failure"?
   5   A. It is in her notes. After Mr Dhasmana operated and we
   6     went to see him after Jacinta had come out of the
   7     operating theatre, he was very pleased with how the
   8     operation had gone and he said he put in an extra large
   9     shunt which should keep her going for some time.
  10     Dr Joffe explained that the larger shunt sometimes
  11     causes heart failure in children, which was not
  12     explained to us before the operation was done that that
  13     is what they were going to do.
  14   Q. It had been explained to you that a shunt was going to
  15     be placed clearly?
  16   A. Yes.
  17   Q. You are saying that the associated risk of heart failure
  18     was not explained to you; is that correct?
  19   A. Yes.
  20   Q. What discussion, just to go back on it again, we have
  21     agreed I think you were not told about risks of Jacinta
  22     not thriving or respiratory tract infection. What
  23     discussion of any was there of the possibility of heart
  24     failure?
  25   A. There was not any.

   1   Q. If we go to the medical notes because you have just
   2     referred to that information from Dr Joffe being in the
   3     medical notes?
   4   A. Yes.
   5   Q. If we could look please at page 8. This gives us the
   6     first page, it is the discharge summary. It is sent
   7     then to your GP. The first page, if we scroll down, you
   8     will see just sets out the course of events until after
   9     Jacinta is discharged the first time round.
  10        If we turn over the page please we can see,
  11     continuing the account of her progress on ITU before she
  12     is discharged for the first time, there is a mention
  13     there of "signs of heart failure probably as a result of
  14     the large shunt".
  15        That is associated in fact with the first period
  16     of ITU before she was discharged for the first time.
  17     Were you told about that at the time?
  18   A. No.
  19   Q. If we go down to the last paragraph on that page,
  20     Dr Joffe writes that:
  21        "The situation was discussed fully with
  22     Mrs Shortis. It is likely that Jacinta will manage with
  23     this shunt for some time, possibly a few years."
  24        Would you agree that that was discussed with you?
  25   A. Dr Joffe came right down the corridor as I was holding

   1     Jacinta and -- when I say "shouted" because he was
   2     behind me -- he said "I have very good news for you,
   3     Mrs Shortis, Jacinta will live until she is 7".
   4   Q. Then he goes on: "though she would remain prone to
   5     respiratory tract infections and may not thrive."
   6        What discussion of that, if we have not covered it
   7     already?
   8   A. Going on from him saying to me: "Mrs Shortis I have good
   9     news for you, she will live until she is 7". I turned
  10     round to him and said "I do not think that is good news,
  11     Jacinta has not put on weight since her operation, she
  12     has vomited every feed, I cannot see beyond 3 months.
  13     If you are telling me she will live until she is 7 she
  14     will, one, know that she is dying, that is not good news
  15     for her. I can manage 2 years because it will be our
  16     grief not hers and she will die not knowing that she is
  17     dying at the age of 2 hopefully", and I did say to him:
  18     "what happens if she dies within the next -- before she
  19     is 3 months old and I come back to you and say 'but you
  20     said she would live until she is 7'". So I did the
  21     discussion that she may not thrive; I said it was not
  22     fair on him, doctors to give out arbitrary numbers like
  23     that.
  24   Q. Do you think that this information to your GP contains
  25     anything then that you were not told at the time from

   1     looking at this now?
   2   A. I was not told by Dr Joffe that she may not thrive.
   3     I could not see how Jacinta could live in the state that
   4     she was in and the care that I was giving her every day
   5     when she was not thriving, it was obvious to me that she
   6     was going to die. That was not there what they said,
   7     what he said: "she will live until she is 7", that is
   8     not saying "she is going to die".
   9   Q. If we go back to your statement please at page 19, we
  10     can see at paragraph 43 the difficulties that you had
  11     with Jacinta when she returned home, that she "developed
  12     stomach cramps, became constipated and continued to
  13     regurgitate every feed and it took some 2 hours to feed
  14     her". Over the page you say that the side effects of
  15     the drug she was on were not explained to you; is that
  16     right?
  17   A. They were not and I did ask at the time because from the
  18     moment she started taking the dioxin she started
  19     vomiting a lot and I telephoned the hospital and I did
  20     say to them "Jacinta is being very sick", the reply was
  21      "babies are sick", I said "not this sick". I did ask
  22     for the side effects and I was not given an answer.
  23   Q. Is there a possibility that the question of side effects
  24     gets rather lost in the enthusiasm, as it were, to see a
  25     child continue to survive. The assumption may be that

   1     provided the child is still alive that is what we have
   2     to achieve and there is not enough discussion of the
   3     quality of life?
   4   A. It depends which perspective you are looking at. As the
   5     mother of my daughter I very much wanted her to live.
   6     I very much wanted her not to have five major heart
   7     defects.
   8   Q. Perhaps I should rephrase the question, Maria: do you
   9     feel that in your discussions with the doctors there was
  10     enough emphasis placed on informing you and discussing
  11     with you the quality of Jacinta's life?
  12   A. No, no, I do not.
  13   Q. What was the focus of the discussions instead, then?
  14   A. It was the desire that she would make it. I can put
  15     this again in context: Dr Joffe had made it very clear
  16     it was a palliative operation, but he also said to me
  17     that perhaps in the future there was a grain of hope
  18     that there might be an operation she could have, which
  19     I did not actually want to hear because I felt that this
  20     is drawing out an agony for her. She was suffering in
  21     very real way for the six weeks she lived, or seven
  22     weeks that she lived after the operation. I do not
  23     think they were looking at the reality of her condition.
  24   Q. You go on at paragraph 45 to describe Jacinta's death.
  25     There is no need, unless you would like to, to read that

   1     out.
   2   A. No.
   3   Q. At paragraph 46 you talk about Dr Joffe's reaction. You
   4     say there that he did not offer you any condolences; why
   5     do you say that?
   6   A. I expected Jacinta to die; I cannot say I expected her
   7     to die on that day, but she was extremely ill. My
   8     father described her as a child who looked as though she
   9     had marasma, an emaciated child, just from the
  10     photographs he had seen of her. So when in fact she did
  11     die -- which I am very glad she died at home and had
  12     a peaceful death -- after I had telephoned my father to
  13     tell him (I obviously was in a state of shock at that
  14     point), I telephoned the hospital and spoke to a nurse
  15     and told her that Jacinta had died and I think, I am not
  16     quite sure whether Dr Joffe telephoned me or
  17     I telephoned him later the next day, but what I was
  18     expecting was "I am very sorry, Jacinta has died, but
  19     she was a severely ill child". Instead he said "I am
  20     surprised Jacinta has died, she should not have done",
  21     and then he said "but you always thought that she would
  22     not survive for very long", which in a sense was right
  23     but I was surprised; I was expecting to hear "I am sorry
  24     but it was to be expected".
  25        The result of that was that I felt as if I had

   1     killed her and I needed then to -- it was awful, you
   2     know at the time a child dies, death is such a big
   3     reality it is almost unreal and I needed to know that my
   4     care for her had not caused her death. So, much against
   5     my husband's wishes, I asked for a postmortem to be
   6     carried out on her.
   7   Q. I think you link in your statement the decision to ask
   8     for a postmortem to that response from Dr Joffe?
   9   A. Yes.
  10   Q. Why is that?
  11   A. Because he did not expect her to die. I did expect her
  12     to die from the way in which she was suffering.
  13   Q. So you were worried that if he had not expected it that
  14     might be something that you or your husband had been
  15     doing?
  16   A. I felt the burden was being put on us as parents, that
  17     it was our care which had caused her death rather than
  18     the five major heart defects she was suffering from. He
  19     was still the expert, if the expert is telling me that
  20     a child with five major defects should still be living,
  21     then where does the responsibility lie.
  22   Q. Would it be fair to suggest that from Dr Joffe's
  23     perspective he might simply have been expressing a more
  24     optimistic faith in the success of the shunt procedure
  25     that had been carried out?

   1   A. I cannot speak for Dr Joffe, I imagine it was an
   2     academic perspective he was coming from and not one of
   3     a bereaved parent.
   4   Q. Maria, I have been asking you a number of questions over
   5     a long period of time. If you would like a break please
   6     say so, whether now or at any other time.
   7   A. I am happy to carry on.
   8   Q. After Jacinta's death there was a continued contact, was
   9     there not, with both Dr Joffe and to some extent
  10     Mr Dhasmana?
  11   A. I felt, as I alluded to it earlier on, that although
  12     I was not impressed by their communication skills
  13     I still believed they were experts in their own right
  14     and therefore I wanted to write to Mr Dhasmana and to
  15     Dr Joffe to thank them for what they had done. I did
  16     not feel I could raise the unnecessary grief that I had
  17     felt, that was something I did not know how I was going
  18     to deal with.
  19        So, yes, there was some contact. I certainly
  20     wanted to read the postmortem to understand and try to
  21     understand -- I think to look at Jacinta she was a very
  22     beautiful baby she really was very pretty and to look at
  23     her it was very difficult to believe she had such
  24     serious heart problems. Therefore I felt I had to read
  25     this postmortem to understand.

   1   Q. So you asked for a postmortem to be carried out. You
   2     arranged it, is this right, to talk through it or to see
   3     it in the presence of Dr Joffe?
   4   A. I did, yes.
   5   Q. That was at your initiative, was it?
   6   A. Yes.
   7   Q. If we could look please at page 64 of the medical
   8     records; do you have that?
   9   A. Yes.
  10   Q. That is a letter that you and your husband wrote to
  11     Dr Joffe, is that right?
  12   A. It is.
  13   Q. You set out there some very personal things about
  14     Jacinta's funeral?
  15   A. Yes.
  16   Q. You also thank Dr Joffe firstly for explaining the
  17     results of the postmortem and also thank him for the
  18     help and the courage he gave you, express appreciation
  19     and suggest that Jacinta could not have been in better
  20     hands; is that a fair summary of your feelings at that
  21     time?
  22   A. In the context that I believed I was in one of the best
  23     units in the country, yes. You know, yes, as I say,
  24     I had spoken to him, for instance about the fact that he
  25     had said she would live until she was 7. I was able to

   1     talk to him and say what I thought and he listened to
   2     that. We may not have agreed, but all of this was in
   3     the context that I was in one of the best units in the
   4     country and he was someone who it was easy to talk to.
   5   Q. If we look at page 65 of the records we can see there
   6     I think Dr Joffe's reply to your letter and that of your
   7     husband, thanking you for the letter and also
   8     suggesting, firstly, that he would be happy to see you
   9     again to discuss Jacinta's problems and suggesting
  10     a time that you can talk without the presence of the
  11     students. That was a reasonably considerate offer
  12     perhaps?
  13   A. Yes.
  14   Q. When you say that Dr Joffe did not offer you condolences
  15     in the initial telephone conversation which you have
  16     described, do you think that is something that he
  17     perhaps made amends for by the letters we have just
  18     seen, or those two meetings we are discussing?
  19   A. I spoke to him -- I do not think so there particularly.
  20     I did speak to him in 1995 and talked to him about that
  21     and he did write to me and say that he was very sorry if
  22     anything he had done had augmented my grief. I do not
  23     think he understood the impact of the words at that time
  24     on me as a parent.
  25        So I think it was this situation, that parents are

   1     living in a framework of emotional literacy and that the
   2     academic perspective of "well, she should not have died"
   3     is not helpful at the point where she has died and
   4     actually saying "I am very sorry that she has died"
   5     would have caused me not to have needed a postmortem.
   6     I think that is the point I am making.
   7   Q. Running through your continued contact with Dr Joffe,
   8     I think he arranged for genetic counselling so as to try
   9     and allay some of the concerns you might have had about
  10     the possibility of repetition of this?
  11   A. Yes.
  12   Q. If we look at page 44 we can see you writing after that
  13     had been done and commenting on the discussion you had
  14     with Dr Joffe. You found it a tremendous help; was that
  15     right?
  16   A. Going through the postmortem was a huge help to me. It
  17     was a huge relief to read that in fact she did have
  18     these five major heart defects and she had congestive
  19     heart failure, yes, and that he was there and was
  20     allowing me to do that. Yes, it was very helpful.
  21   Q. You say: "It was very kind of you to give up so much of
  22     your time to do this"?
  23   A. I do not know why I said that.
  24   Q. Did you get the impression that he had been generous and
  25     helpful in his time?

   1   A. I think he probably spent an hour with me and I imagine,
   2     having come up as I have in a medical household,
   3     consultants do not spend much time -- one assumes they
   4     do not have much time. Yes, I would say he gave me an
   5     adequate amount of time and I was acknowledging that.
   6   Q. I think you then kept in touch with Dr Joffe in fact, if
   7     we look at page 37?
   8   A. Yes, that was the last that I wrote to him.
   9   Q. So you felt sufficiently kindly towards him to write and
  10     tell him about Patrick's birth?
  11   A. Yes.
  12   Q. Dr Joffe I think acknowledged that at page 36, where he
  13     wrote back and hoped that he would give you much joy in
  14     the future. Finally on contact with Dr Joffe, I think
  15     your father as well wrote to him; is that right?
  16   A. He did, yes.
  17   Q. Can we look at page 73, please? He speaks about --
  18   THE CHAIRMAN: I think we need to take the address off the
  19     top first, do we not?
  20   MISS GREY: Thank you. He suggests that Dr Joffe gave him
  21     "tremendous" -- that is you and your husband --
  22     "support and encouragement and made the difficult
  23     decisions and realisations so much more easy".
  24        That was an impression that your father appears to
  25     have got from you; do you think you would have conveyed

   1     him that impression?
   2   A. I think there are two levels that are operating here.
   3     My father being a doctor understood the pressures
   4     et cetera and the work of doctors and would always write
   5     in that kind of vein.
   6        He telephoned me just after Jacinta died to say
   7     that he had found the whole process extremely
   8     difficult. He was 200 miles away, he had heart trouble
   9     himself and died shortly afterwards, but he just made
  10     the comment that he could not work out why they had
  11     decided to operate on Jacinta. He said: "I think they
  12     have lied to you but it may have been a compassionate
  13     lie and in this situation it is always very difficult to
  14     know what to do", but he did use those words. That
  15     would not stop him from writing to the doctors in
  16     appreciation of their efforts, you know, so there were
  17     two.
  18   Q. He was conveying, was he, the feeling that you had been
  19     given a falsely optimistic prognosis for what would
  20     happen to Jacinta after an operation?
  21   A. Absolutely, and he was saying to me -- he was 200 miles
  22     away he had actually offered to come up to speak to the
  23     doctors and I had said to him -- he had had a heart
  24     attack earlier that year and I felt it was too
  25     emotionally stressful, and I said: "I need you on the

   1     end of a telephone so I can telephone you and work out
   2     with you", just on an emotional level I needed him there
   3     as a support. He said it was a very difficult situation
   4     and that he felt they had given me false hope and that
   5     it was a compassionate lie, but he did not know why they
   6     had decided to operate.
   7        Taking that aside, he also saw that they had made
   8     their decisions and that difficult decisions do not
   9     preclude thanking people for what they have done.
  10   Q. If we look please at page 67, we can see there a letter
  11     now from Mr Dhasmana to you?
  12   A. Yes.
  13   Q. He is obviously expressing his condolences there to you,
  14     but he says:
  15        "Even though I knew that Jacinta's cardiac
  16     condition was inoperable"; so he is setting out there,
  17     is he, the considerably more pessimistic view he took of
  18     Jacinta's condition?
  19   A. Yes.
  20   Q. Was the inoperability something that was reinforced or
  21     made plain to you by Mr Dhasmana at the time?
  22   A. It was made plain to us that she was inoperable but he
  23     was going to do the operation -- we were not part of the
  24     decision-making process. There was an operation; there
  25     was not an operation; there was an operation; we were

   1     not part of that process. So, yes, I mean I believed
   2     she was inoperable but I did not know how to deal with
   3     that situation effectively.
   4   Q. To draw the conclusions that followed from it perhaps?
   5   A. No, not to draw the conclusions that followed from it,
   6     I was asking them to do that and they were not drawing
   7     the conclusions that followed from it so I was stuck,
   8     I felt I was stuck.
   9   Q. If we look please at page 66, this is your response to
  10     Mr Dhasmana's letter. You say there that you did know
  11     from the beginning that her condition was inoperable?
  12   A. Yes.
  13   Q. And that the overall feeling you put was:
  14        "Without your determined efforts we may not have
  15     had her with us for even 9 weeks."
  16        Would it be fair to say that at that time at any
  17     rate the overall feeling was gratitude that Jacinta had
  18     been with you for some period of time at least?
  19   A. I think I was recognising the fact that he had done the
  20     operation, that he was pleased with how the operation
  21     had gone. What I was not doing was making clear my own
  22     feelings because he had been the person, as I say an
  23     expert cardiac surgeon, who had I think been put in
  24     a very difficult position himself by the non-discussion
  25     at Jacinta's management and had felt obliged to carry

   1     out an operation that he may not have carried out had he
   2     got to me first and I think that letter is written in
   3     the spirit of -- he did actually carry out an operation
   4     perhaps against his better judgment and that that gave
   5     us those weeks of life.
   6   Q. Maria, I am shortly going to come on to the question of
   7     your second statement and the events that led to you
   8     being involved in the campaign to set up a public
   9     inquiry. It might be appropriate first to take a short,
  10     perhaps a 10-minute break?
  11   THE CHAIRMAN: Yes, shall we say 10 minutes until 11.15?
  12     Thank you.
  13   (11.05 am)
  14               (A short break)
  15   (11.15 am)
  16   MISS GREY: Can we have on the screen, please, WIT 222/25?
  17     This is your second statement, Maria. You describe
  18     there your reinvolvement with the BRI from April 1995
  19     onwards and the events that led you to become concerned
  20     in the campaign to obtain a Public Inquiry.
  21        Just looking at that page, the first instant that
  22     you report there is watching Dr Bolsin on a TV
  23     programme, and after that, seeing Dr Bolsin at his home
  24     on 8th April 1995?
  25   A. Yes.

   1   Q. You set out in the first few pages of your witness
   2     statement in some detail the account that Dr Bolsin gave
   3     to you at that stage.
   4        Why was that important to you?
   5   A. The programme surprised me, that a consultant would say
   6     that babies were dying unnecessarily. I had imagined
   7     when I left that hospital in 1987 that although I was
   8     not pleased with the lack of communication training,
   9     I had always believed I was in a unit of excellence.
  10        A consultant speaking out is an unusual occurrence
  11     in the medical profession, and therefore I could only
  12     think "Either there is a problem here or there is not
  13     a problem here, so why is he speaking out?" I wanted to
  14     go and listen to why he had taken that step to speak
  15     out.
  16   Q. At paragraph 19 of your statement -- this is page 28 --
  17     you say that after you had spoken to Dr Bolsin, you
  18     wrote to Mr McKinlay, together with your husband?
  19   A. Yes.
  20   Q. If we look, please, at MP 1/81, is that the letter that
  21     you were referring to there?
  22   A. Yes.
  23   Q. What was the point that you were trying to stress?
  24     Perhaps if we look at the last paragraph of that page,
  25     we might possibly see at least one point.

   1   A. There is a point in there about not giving parents false
   2     hopes. "There is a lack of training and communication
   3     skills", yes, but it is giving parents a false hope that
   4     more can be done than is necessarily the case. I think
   5     it is the academic perspective that doctors are trained
   6     to engage with, the disease, and illness, and not to see
   7     the whole person.
   8        What it appeared to me was happening was Dr Bolsin
   9     was joining up the dots and seeing that what was an
  10     academic problem resulted in children dying. That
  11     resulted in grief for parents. There is necessary
  12     grief, as we encountered, with Jacinta having
  13     a life-threatening problem. There is unnecessary grief
  14     which is an extra burden and needs to be limited for any
  15     parent who has a child with a life-threatening illness
  16     and there needs to be training done on that, because it
  17     is apparent that is through communication.
  18   Q. You set out in your statement that after having written
  19     this letter and becoming involved in this way, you saw
  20     Dr Joffe in his office.
  21   A. He responded to this letter by saying he would like to
  22     see me because all my facts were incorrect and he would
  23     like to put me straight on that. So I spent half an
  24     hour with him.
  25   Q. After that, Professor Angelini spoke to you?

   1   A. Yes, he responded to my letter and said it was very
   2     good, all the facts were correct, which really --
   3     "shocked" is the right word. Yes, it was almost saying
   4     "your facts are incorrect", "your facts are correct",
   5     there was a conflict. Yet again, there was a conflict
   6     between surgeons and cardiologists, and I asked
   7     Professor Angelini if I could speak to him.
   8   Q. Was that conflict influential in the work that you then
   9     did?
  10   A. Yes -- well, I decided I could only ask questions and
  11     Professor Angelini very clearly set out that there were
  12     serious issues; that the issues would be reduced to
  13     personalities and that he could not see how the story
  14     would come out because why should one person believe me
  15     and not the other person?
  16        This was about serious issues of what parents were
  17     being told about informed consent, of risks of
  18     operations, and not only that, but I was made aware of
  19     the 1989 report from the Cardiothoracic Society, the
  20     1992 report from the Royal College of Surgeons that had
  21     acknowledged that Bristol actually was not one of the
  22     best units in the country but actually perhaps one of
  23     the worst and it did not seem right to me that parents
  24     were being misinformed.
  25   Q. So all of these features and others indeed you have

   1     mentioned in your statement, led you to become central,
   2     perhaps, or heavily engaged in a campaign to ultimately
   3     a Public Inquiry?
   4   A. Yes.
   5   Q. One has started, it has been sitting for 78 days.
   6   A. Yes.
   7   Q. What are the things that you would like the Inquiry to
   8     take from the experience that you and your husband had
   9     with Jacinta?
  10   A. First of all, I would like to thank this Inquiry for
  11     having sat through so many days of oral evidence, and
  12     for being so rigorous in the way it is proceeding.
  13        There are many issues. At present, I have founded
  14     an organisation called "Constructive Dialogue of
  15     Clinical Accountability". "Constructive dialogue"
  16     because it challenges me to be constructive in my
  17     communication and I hope it flags up a respect for
  18     communication with doctors. There is no doubt that the
  19     medical profession, their morale has been severely
  20     dented by the Bristol cardiac disaster having come to
  21     the public arena, and I think there is a lot that needs
  22     to be done to restore public confidence in the medical
  23     profession that we have.
  24        I have to thank the Cardiothoracic Society for
  25     engaging in a very open and transparent dialogue with

   1     us, and we are looking with them at clinical audit as
   2     a tool of patient safety, and clinical excellence.
   3     Therefore, perhaps in the second phase, we would like to
   4     look at how competent doctors can be rewarded for their
   5     clinical excellence.
   6        I would like to make the point that you may have
   7     very dedicated doctors, but it does not mean that they
   8     are competent doctors.
   9        One of the things we were campaigning for is an
  10     independent medical inspectorate, which I believe has
  11     been set up. I do not know if it is an independent
  12     medical inspectorate or not, and I would like to have
  13     that clarified.
  14        What it highlights is that the lack of
  15     accountability in the Health Service has resulted in the
  16     avoidable tragedy. Yet again, the Cardiothoracic
  17     Society has said there is nothing in place yet to stop
  18     another Bristol from happening, and I know that when
  19     Mr Dobson announced this Public Inquiry, it was for
  20     grief resolution for parents primarily, and it was to
  21     put in structures that would stop another Bristol from
  22     happening.
  23        So I think some mode of accountability and
  24     regulation of doctors, other than self-regulation, is
  25     extremely important.

   1        The other very pressing need is for proper funded
   2     communication skills training. I think the consultants,
   3     personally, medical students -- it may take a whole
   4     generation to get through to consultants who are
   5     effective communicators in so far as they are giving
   6     impartial, genuine information to patients.
   7        I recently facilitated a workshop at the Child's
   8     Heart Foundation. If I may, I can give this to the
   9     Inquiry. The idea of this workshop was "What do you
  10     want to know?" These are parents whose children are
  11     undergoing heart surgery today.
  12        This is at consultation: "I need to know the
  13     truth, even if I do not want to hear it. I need to hear
  14     it with gentle honesty, not brutal reality. Parents
  15     have a responsibility to ask for the information they
  16     want. They have the right to expect the consultant to
  17     respect their need for genuine information, in
  18     recognition of the fact that parents are the people who
  19     know and care for their child, and ultimately have the
  20     responsibility of making very difficult decisions. So
  21     on informed consent, I would like to see a movement away
  22     from a paternalistic benevolent stance towards patients
  23     to one of patient autonomy --
  24   Q. If I could just stop you there for a moment. Two
  25     things. Firstly I think we would be very much assisted

   1     if you could send in to us the document summarising the
   2     outcome of the meeting that you facilitated, which you
   3     have just mentioned. We would be grateful for that,
   4     I am sure.
   5        The second thing was that you touched on training
   6     skills, communication training for doctors. I think you
   7     were suggesting it is not enough simply to attack it
   8     through medical schools; it needs a more thorough
   9     approach. Is that what you intended to say?
  10   A. I think medical students are all too willing to engage
  11     in effective communication skills training. I think
  12     when you get to the level of consultants who have a lot
  13     of power, who also have a lot of responsibility, they
  14     can be quite dismissive of patients, of parents, and
  15     therefore I think they need to engage with the parent
  16     perspective on a framework of emotional literacy,
  17     i.e. engaging to understand what parents need to know.
  18     But parents say they need to download the information,
  19     the expertise, expert information in consultants' heads
  20     to understand the process their children are going
  21     through. So I do think there needs to be a high level
  22     of communication skills training.
  23   Q. You have touched on accountability, on communication
  24     skills. I then interrupted you. What were you going on
  25     to say?

   1   A. I cannot remember, actually, but --
   2   Q. One of the themes that was coming through this morning
   3     was clearly the importance of informed consent.
   4   A. Yes.
   5   Q. Is there anything else that you would add to what we
   6     have heard this morning about that?
   7   A. Just what I have said: that I think there needs to be
   8     legislation introduced that makes parents, if you like,
   9     equal in status to the care of their children, and to
  10     acknowledge that they do have their own valuable input
  11     and they need to be heard and listened to, and they need
  12     to know that they are making decisions based on genuine
  13     information, so they need to be working with
  14     consultants, not having consultants make decisions for
  15     them.
  16   Q. I did interrupt your train of thought. Would you like
  17     to take a moment to think through what it is you were
  18     going to say?
  19   A. I was going to move on, actually, to say that there is
  20     one issue out of this Bristol debacle that I am not sure
  21     has been made clear, and I do seek clarification from
  22     the Inquiry on this point: that when we went to see
  23     Mr Dobson to negotiate the Inquiry, it was under the
  24     assumption that Mr Wisheart, as consultant cardiac
  25     surgeon, and Medical Director, had continued operating

   1     up until 1st May 1995, and that he was going to
   2     discontinue his cardiac surgery on children as soon as
   3     Mr Pawade took up his appointment, which also happened
   4     to be on 1st May 1995.
   5        I have been made aware very recently that
   6     Mr Wisheart continued operating on children after that
   7     date and I approached the BHCAG lawyers to ask for their
   8     confirmation of that. They said they would like to be
   9     able to confirm that but they could not because of the
  10     confidentiality clause they had undertaken, when
  11     Mr Wisheart's logbooks were handed over on a Discovery
  12     Order.
  13        So I presume, therefore, that the evidence is
  14     contained within those books and that the Inquiry can
  15     verify this.
  16        But if this is the case, that he did continue to
  17     operate, it was in spite of the Hunter/de Leval external
  18     review of February 1995, in spite of the letter from the
  19     Deputy Chief Executive, Mr Graham Nix, in March; in
  20     spite of the letter shown to me by Dr Joffe in April,
  21     all of this said that as soon as Mr Pawade took up his
  22     position, Mr Wisheart would cease operating.
  23        The point of this is to say that really the
  24     surgeon can run through major red lights without
  25     sufficient regard for patient safety, it would indicate

   1     that self-regulation on its own is a hopeless deterrent
   2     and cannot be trusted as a safe structure to limit
   3     patient harm.
   4        From the parents' point of view, I would like to
   5     know what they were told at that time, as to the current
   6     failure rate of a child being operated on in
   7     Mr Wisheart's hands. As far as clinical audit is
   8     concerned, there are implications. The Hunter/de Leval
   9     report covered audit up to 1995, and then the audit,
  10     paediatric cardiac review of Mr Pawade from 1995 to 1998
  11     showed only his figures, so where are these figures
  12     contained of Mr Wisheart?
  13        I would like some clarification on those issues
  14     I have raised.
  15        The CCDA would like to know how the recently
  16     established Commission for Health Improvement would deal
  17     with someone, a doctor who would proceed through
  18     external reviews and recommendations like that.
  19   Q. That is perhaps coming back to your theme of
  20     accountability, that last point?
  21   A. It is, yes. I also have something to say, if it is all
  22     right for me to say it, about Mr Dhasmana.
  23   Q. Could you just stop there a moment before moving on to
  24     that? I think I should just respond briefly to the
  25     point that has been raised about Mr Wisheart's continued

   1     operations. I think you put it really as a question for
   2     the Inquiry to investigate; is that right?
   3   A. I did, yes.
   4   Q. I should perhaps say that we are clearly aware of this
   5     issue; we have heard something about the circumstances
   6     of one operation just over the last few days, and that
   7     will continue to be investigated. Our provisional
   8     tentative findings are that we think that a further two
   9     operations were conducted by Mr Wisheart after 1st May,
  10     in addition to the cases we have looked at, but those
  11     are provisional findings that the Inquiry will need to
  12     look at further.
  13        It should be said now that, in response to your
  14     question as to whether or not the Inquiry is aware of
  15     it, the answer, I think, is yes, that is a matter for
  16     further investigation.
  17   MRS SHORTIS: Thank you.
  18   Q. You were about to talk about Mr Dhasmana?
  19   A. Yes. This is a personal view of my husband's and mine.
  20     It relates to the recent publicity about Mr Dhasmana's
  21     attempts to claim damages following his dismissal from
  22     the UBHT.
  23        As a family, we believe that Mr Dhasmana found
  24     himself in an extraordinary position following the
  25     ruling of the GMC. He was found guilty of serious

   1     professional misconduct and he was banned from operating
   2     on children for three years. I think we would like to
   3     have seen that as a lifetime ban, but however, we do not
   4     believe that he should face financial ruin and to put it
   5     in a meaningful context, he was there with two other
   6     doctors, both of whom were struck off but had retired,
   7     and had a pension to retire on. Added to that,
   8     Mr Wisheart had received nearly œ200,000 in his merit
   9     award. That merit award was conferred, reviewed and
  10     conferred upon again whilst he was the subject of the
  11     GMC investigation inquiry, and he will continue to
  12     receive that merit award until 2001.
  13        Whilst I do not condone what has happened to
  14     either of them, I do think there is an injustice that
  15     Mr Dhasmana is facing financial ruin and that
  16     Mr Wisheart has a merit award for his worldwide services
  17     to cardiac surgery, paediatric cardiac surgery. I just
  18     wanted to say to the Panel that I think this is
  19     a serious injustice, and I hope that in future this kind
  20     of balance is dealt with, is addressed.
  21   MISS GREY: Thank you. Are there any questions from the
  22     Panel?
  23   THE CHAIRMAN: Professor Jarman has a question.
  24            Examined by THE PANEL:
  25   PROFESSOR JARMAN: I wanted to pick up a general point. You

   1     said you would like to make the point that you may have
   2     very dedicated doctors, but it does not mean that they
   3     are competent doctors. Overall, do you feel that we
   4     have or have not got competent doctors in the country?
   5   A. I do not think we have any system that enables doctors
   6     to prove their competence and skills. Medical students
   7     certainly have to provide a level of competency in their
   8     examinations otherwise they would not become doctors.
   9     After that, I am not aware of doctors having to prove
  10     their competency on a regular basis.
  11   Q. I was really asking for your own genuine opinion.
  12   A. I believe we have a dedicated medical profession who
  13     work extremely hard. I do not know how competent they
  14     are.
  15   Q. You do not have an opinion with regard to how competent
  16     they are?
  17   A. I could not say how competent they are, because there is
  18     no system for me to read up on their competency.
  19   PROFESSOR JARMAN: Thank you.
  20   THE CHAIRMAN: I have no questions, but I look to Mr Lissack
  21     to see whether there is any re-examination.
  22   MR LISSACK: Just one question.
  23            RE-EXAMINED BY MR LISSACK:
  24   Q. Maria, just one matter which I know that you wanted to
  25     deal with, which is why I ask it, and I think it may

   1     assist the Inquiry. It is this: from 1995 to the
   2     present day, and no doubt continuing off into the
   3     future, you have played an active role on the wider
   4     stage than simply your own personal experiences at
   5     Bristol, as the Inquiry know.
   6        That has brought you into contact with consultants
   7     and experts in every discipline involved in paediatric
   8     cardiac surgery?
   9   A. Yes.
  10   Q. Ranging both from within and without the Bristol
  11     organisation, both as it was at the time material to the
  12     Inquiry and since.
  13        What I would like to ask you is this: some may
  14     perceive a gulf between an academic appreciation of
  15     something being wrong and a realisation that the
  16     something being wrong causes individual grief through
  17     the mortality or morbidity of children.
  18   A. Yes.
  19   Q. I just wondered whether, because I think I know the
  20     answer is yes, and I think I know what the answer will
  21     be, but I would like to have it in evidence, please:
  22     firstly, whether you share that perception?
  23   A. I do.
  24   Q. And if you do, what you have to say about it that may be
  25     of assistance to the Inquiry through your work and

   1     a parental perception with so many different
   2     professionals?
   3   A. I would say that parents need to be involved in feeding
   4     back to doctors and helping them to see how they engage
   5     with the reality of the suffering that can be inflicted
   6     upon them. I do not know whether I could say this
   7     afterwards to the Inquiry, but perhaps sitting here,
   8     having gone through what I have gone through this
   9     morning --
  10   MR LISSACK: I understand. Perhaps it may be better to
  11     leave the discussion from yesterday to be put in
  12     a further statement from you. Thank you very much
  13     indeed.
  14   THE CHAIRMAN: Thank you, Mr Lissack, I am grateful. Thank
  15     you also, Mrs Shortis. Miss Grey was exploring with you
  16     the themes that were emerging and your comments on them,
  17     and they have been extremely helpful. I think, if I may
  18     say one thing, you are asking us to be aware of the fact
  19     that there is so much that parents and patients can
  20     contribute, and I think we hear that.
  21        Secondly, I would seek to give you an assurance
  22     that all of the matters that you have mentioned, which
  23     are of interest to you, will be addressed in Phase II.
  24     You, for example, talked about incentives for clinical
  25     excellence, and you talked about communication skills.

   1     Amongst other things, these will be addressed, I give
   2     you that assurance.
   3        The one thing I cannot give you assurance on is
   4     that you asked for the Panel to put in structures. That
   5     is beyond our power, as we may only make
   6     recommendations, but we would seek to argue our
   7     recommendations sufficiently powerfully and forcefully
   8     that they are taken proper account of.
   9        Thank you for coming. It was I think Sam and
  10     Patrick who for a while were here, and I think it is
  11     helpful for them to see their Mum giving evidence.
  12     Thank you very much.
  13             (The witness withdrew)
  14   MISS GREY: Sir, our next witness this morning is
  15     Dr Jordan. Could I suggest we break until perhaps 5 to
  16     12 while people here upstairs go downstairs, and so on
  17     and so forth?
  18   THE CHAIRMAN: Yes, a short break of five minutes, thank
  19     you.
  20   (11.45 am)
  21               (A short break)
  22   (11.55 am)
  23   MR LANGSTAFF: Sir, this afternoon, or very nearly this
  24     afternoon, we have the evidence of Dr Stephen Jordan.
  25     We are assisted, as we were yesterday, by Mr Deverall

   1     and Dr Silove. Because they have been sworn yesterday,
   2     I think it is unnecessary that they should be required
   3     to swear again today. They know the oath they swore
   4     yesterday covers what they may say today.
   5        Dr Jordan, would you like to come forward,
   6     please? Dr Jordan, would you please stand to take the
   7     oath?
   8            DR STEPHEN JORDAN (SWORN):
   9            Examined by MR LANGSTAFF:
  10   Q. Dr Jordan, your full names?
  11   A. Stephen Christopher Jordan.
  12   Q. You were, for quite a number of years, the senior
  13     cardiologist dealing with paediatric cases at the
  14     Bristol Children's Hospital, were you not?
  15   A. That is correct.
  16   Q. I want to deal with the period between 1984, which is
  17     some time, I think, after you were first appointed to
  18     Bristol, and 8th May 1993, which is when you retired.
  19        Between that period, did you have particular
  20     interests in cardiology, which you sought to pursue?
  21   A. I should perhaps explain that my appointment was as
  22     a cardiologist with both adult and paediatric duties,
  23     and I continued that until 1990, when I gave up routine
  24     adult cardiology and another cardiologist was
  25     appointed.

   1        The particular things that I had an interest in
   2     generally in terms of the whole period of my appointment
   3     were, of course, paediatric cardiology and also more
   4     related to the adult work, cardiac pacing and
   5     electrophysiology.
   6   Q. I think you went so far as to publish a well-known book
   7     on paediatric cardiology?
   8   A. I am the joint author of a book which I should say is
   9     designed not to instruct paediatric cardiologists but to
  10     instruct paediatricians, with Dr Olive Scott, who was
  11     a paediatric cardiologist in Leeds, and there were three
  12     editions of the book, the last of which actually came
  13     out in 1989.
  14   Q. You will, in the course of your evidence, I think, tell
  15     us how you were instrumental in beginning and developing
  16     the South West Congenital Heart Register?
  17   A. Yes. It is correct that that was something that I --
  18     I did not actually start it. I converted it from
  19     something that was written in a ledger to something that
  20     was capable of being manipulated electronically.
  21   Q. I think there is something like a tinge of
  22     disappointment in your statement, as I read it, that the
  23     full advantage may not have been taken of modern
  24     computer systems to maintain that work?
  25   A. Yes. I mean, it would have been nice to have more

   1     support in terms of computer expertise, but particularly
   2     perhaps more support just at a general level of
   3     inputting and checking the data that went into it. We
   4     actually lost at one stage quite a lot of the earlier
   5     data -- I do not think it is anything that is going to
   6     affect this Inquiry, but we lost it and we never really
   7     had time to input it again into the more modern system,
   8     which is still in existence at the moment.
   9   Q. You were a member at one stage of the Royal College of
  10     Physicians Joint Committee on Higher Medical Training?
  11   A. Yes, that is correct.
  12   Q. For how long was that?
  13   A. I think the period was about three years, but I am
  14     afraid my recollection is somewhat hazy.
  15   Q. In the course of that, you would have visited other
  16     units?
  17   A. Yes. I am trying to remember whether I was actually
  18     a member of the committee, or simply one of their
  19     designated visitors. There may be a slight
  20     distinction. I was certainly associated with it from
  21     the point of view of visiting centres to agree whether
  22     Senior Registrar posts were or remained suitable for
  23     training.
  24   Q. Roughly when would that be?
  25   A. It was really I think the earlier part of the 1980s, as

   1     far as I can recall -- early to middle 1980s.
   2   Q. The way that we are going to ask you the questions on
   3     behalf of the Inquiry is to split your evidence into two
   4     parts. First of all, I will ask you to identify your
   5     statements and accept them as true and accurate. They
   6     will, of course, already have been read by the Panel and
   7     they can be read by anyone in the wider audience who
   8     wishes to see what you say in statement form.
   9        Then questions which arise from what one might
  10     call the "administrative" aspects to which you depose in
  11     those statements, will be asked by Mr Maclean and that
  12     will take place rather later today. I want to ask
  13     a number of questions about three or four of the cases
  14     which arise from the Clinical Case Note Review exercise
  15     which the Inquiry carried out, with a view to getting
  16     the benefit, while our two experts are still here, of
  17     your expertise, in helping to look at some of the themes
  18     which that review has thrown up, and to see whether
  19     cases are, in truth, examples of those themes or not, or
  20     what insight we may get into events in Bristol through
  21     one or two of the cases. That is the purpose of it.
  22        So the purpose of looking at those cases is not to
  23     attribute blame or compensation, or go through what one
  24     might describe as the traditional medico-legal analysis.
  25   A. I understand that.

   1   Q. Before I ask you questions about those, can I identify
   2     the several statements which you have given us, and we
   3     begin at WIT 99/1. That is the first statement you give
   4     us, essentially about the register. That goes through,
   5     does it, to page 7. That is your signature at 7th June
   6     of this year?
   7   A. Yes, that is correct.
   8   Q. Then the next statement begins at page 8 and goes
   9     through, does it, to page 28. That is in respect to
  10     what the Inquiry knows as Issue B. We see you signed
  11     that again, that is your signature, on 22nd September of
  12     this year?
  13   A. That is again correct.
  14   Q. The third statement, from pages 29 to 32, again signed
  15     on 21st September and that deals with the issues arising
  16     in respect of the split site, does it?
  17   A. That is correct.
  18   Q. Pages 33 to 34: a fourth statement, this time dated
  19     4th November of this year, which is supplementary to the
  20     statement you had earlier put in about Issue B?
  21   A. Yes. That is correct.
  22   Q. Then pages 35 to 38. Page 35 is referrals. Page 38,
  23     you sign that on 9th November. Then pages 39 to 44:
  24     signed on 9th November --
  25   A. Yes.

   1   Q. -- about pre-operative care. Pages 45 to 46: the same
   2     date, about post-operative care?
   3   A. Yes.
   4   Q. And pages 47 to 51: 10th November, last week, in respect
   5     of what you knew about the expression of concerns.
   6   A. Yes, that is correct.
   7   Q. That, I think, completes thus far your written
   8     evidence -- I say "thus far" because undoubtedly like
   9     other witnesses you will be invited to add anything you
  10     want to after having given evidence to us orally, and
  11     you are free to do so, and indeed, we invite you to do
  12     so if you feel so moved.
  13   A. I understand that.
  14   Q. Are the contents of those statements true and accurate?
  15   A. To the best of my recollection, yes.
  16   Q. As I have indicated, what I want to do is to take the
  17     benefit, this morning and early this afternoon, of your
  18     expertise and in the time that you have been in Bristol,
  19     the respect which you have gained, to help us with
  20     looking at the lessons that we might learn from some of
  21     the cases which come out of the Case Note Review.
  22        The first case -- you have had a chance, I think,
  23     to see the medical records in respect of the case of
  24     Marc Stevens, have you?
  25   A. Yes. May I just get out of my bag the forms and also

   1     some notes that I made when I went through them?
   2   MR LANGSTAFF: Please do. While you are doing that, if
   3     I may say, sir, of course, as is the case with any
   4     matter arising from the Case Note Review which is
   5     referred to in open session, we have full consent to
   6     refer to this case and the case notes.
   7   THE CHAIRMAN: Thank you, Mr Langstaff. We remind ourselves
   8     of that always.
   9   DR JORDAN: Can I please ask what is the reference number to
  10     this?
  11   MR LANGSTAFF: It is 2277 and 2278.
  12   DR JORDAN: I have numbers that go from 0 to 70. The reason
  13     I ask is that I actually deleted the names and dates of
  14     birth.
  15   MR LANGSTAFF: It is 70.
  16   THE CHAIRMAN: Dr Jordan, do make sure you are content and
  17     have everything you wish. I do not want you to feel
  18     rushed and not have the right papers. Take whatever
  19     time you need.
  20   DR JORDAN: Thank you, Mr Chairman. I think I am all
  21     right.
  22   MR LANGSTAFF: What we can do very easily is if we identify
  23     a page from the medical records which you want to refer
  24     to which I have not mentioned, then we can have it
  25     called up on the screen so that all can see it. If that

   1     means taking time, we will take time, but the important
   2     thing is to get the exercise right.
   3        Marc Stevens was a boy born on 3rd October 1985,
   4     was he not?
   5   A. I am afraid I have also --
   6   Q. Let me give you that date.
   7   A. I am quite happy that is the case. It fits in with
   8     everything else I have. I removed the date of birth as
   9     well, just in case.
  10   Q. He suffered from the condition known as double outlet
  11     right ventricle and it appeared at postmortem that he
  12     had a complete AVSD?
  13   A. I do not really want to get into the semantics of this.
  14     There are some people who would refer to the defect in
  15     other terms. I do not know whether you want me to go
  16     into that now, or whether we should come to it at a time
  17     when it is perhaps more related to something else you
  18     are going to ask me.
  19   Q. Shall we see how we go, and pick up the question of
  20     terminology, because I think terminology may be a matter
  21     of some importance in looking at certainly some of the
  22     earlier records in this case.
  23        If I can just tell you what I think the early
  24     history is about which no question arises, and then take
  25     you to the parts which I particularly want to ask you

   1     about.
   2        What I think the notes show us is that in early
   3     1986 he was transferred to the Children's Hospital
   4     because of the cyanotic episode. There was an ECG,
   5     which was within normal limits, and at the Bristol Royal
   6     Hospital for Sick Children, he was found to have mild
   7     central cyanosis and a loud systolic murmur. He was
   8     seen by you, and an echocardiogram performed which was
   9     not easy, and you recommended that he should have
  10     a catheter. No question arises thus far?
  11   A. That is correct.
  12   Q. The cardiac catheterisation took place in January 1986,
  13     and what I want to ask you about first is page 114,
  14     which is where we -- perhaps we will go to 113, Medical
  15     Report 2277/113, which is the report of the
  16     catheterisation, is it not?
  17   A. Before we go off that, could I just draw the Inquiry's
  18     attention to what it says at the top, and that is that
  19     this was a catheter carried out at Bristol Royal
  20     Infirmary? This was before we had the unit at the
  21     Children's Hospital.
  22   Q. You make a point in your statement, I think, that
  23     catheterisation facilities were much improved after
  24     1987/88, and this catheter was performed plainly in
  25     1986, before that improvement took place?

   1   A. That is correct.
   2   Q. If we look at page 114 and go to the foot of it, can
   3     I just ask to have highlighted what is shown under "LV",
   4     the paragraph at the bottom there?
   5        What is reported by, I think it is Mr Wilde, we
   6     see that at page 115 but I will come to that in
   7     a moment; Mr Wilde was a radiologist of some experience,
   8     was he?
   9   A. Peter Wilde, yes.
  10   Q. We heard yesterday from Dr Martin how he would place
  11     considerable reliance on any view Dr Wilde came to?
  12   A. Yes.
  13   Q. What he reports having seen is:
  14        "The left ventricle is well outlined and shows
  15     good contractility. The ventricle has a left
  16     morphology. The mitral valve functions normally. There
  17     is a large basal VSD with dense opacification of the
  18     right ventricle occurring also."
  19        He goes on to describe, at the bottom of the page,
  20     pulmonary artery is seen. Highlight the first paragraph
  21     at the top of the page.
  22         "The coronary arteries are abnormal with the
  23     right coronary artery arising from the left and passing
  24     around the aortic root (presumably posterially)."
  25        Going back to 114 at the foot, there may be some

   1     difficulty, perhaps, with nomenclature, but what would
   2     you understand by the expression "large basal VSD"?
   3   A. It is a defect in the part of the intraventricular
   4     septum which is closer to the origins of the mitral
   5     tricuspid valve than to the base of the aorta or the
   6     pulmonary artery.
   7   Q. So a surgeon, if he was presented with that expression
   8     "large basal VSD" at this time, in 1986, would begin to
   9     have alarm bells ringing, would he, as to what he might
  10     find when he opened up the heart?
  11   A. There is always worry about double outlet right
  12     ventricle with regard to the position of the ventricular
  13     septal defect and whether it is close enough to one or
  14     other of the aorta and the origins of the aorta and the
  15     pulmonary artery, to enable one or other of the types of
  16     corrective operation that might be applied in this
  17     condition.
  18        I am sorry if it is rather long-winded, but this
  19     one of the things that one has to determine with
  20     a patient with a double outlet right ventricle.
  21   Q. When one looks at page 115 and comes to "Conclusion"s at
  22     the foot of the page, the conclusion which Dr Walker
  23     draws from the work done by Dr Wilde is what is shown is
  24     a double outlet right ventricle with subaortic VSD.
  25        That is not quite what Dr Wilde has described, is

   1     it?
   2   A. Dr Walker would undoubtedly have looked at the
   3     angiograms and almost certainly would have looked at
   4     them with me as well, because Dr Walker was a Senior
   5     Registrar. But, yes, the answer is, he is saying
   6     something that is different, or potentially different,
   7     from what Dr Wilde is saying.
   8   Q. Can I bring you in on this and invite you to comment and
   9     interrupt at any stage, if you wish?
  10   DR SILOVE: Thank you very much. I agree with everything
  11     that Dr Jordan has said so far. It is a very difficult
  12     problem, this double outlet right ventricle, and I also
  13     would have understood a basal VSD to be somewhere near
  14     the atrioventricular valves, rather than being
  15     subaortic. So there is a discrepancy here, I think,
  16     between what Dr Wilde has said and what Dr Walker is
  17     interpreting, perhaps.
  18        There is just one other point that I wanted to
  19     raise with Dr Jordan, if I may. I have obviously looked
  20     at these medical records, and it was interesting that in
  21     the echocardiogram that was done by Dr Jordan which is
  22     on page 36 --
  23   MR LANGSTAFF: Just pause for a moment and let us get it up
  24     on the screen so we can all look at the same thing.
  25   DR SILOVE: I am looking for your note on -- it is

   1     difficult.
   2   DR JORDAN: Would you like me to try and read it, because
   3     I am probably better able to read my own writing?
   4   DR SILOVE: I have it, at the bottom of the page -- you read
   5     it for us, please.
   6   DR JORDAN: It says "Not easy, heart central and crying plus
   7     plus, query corrected transposition", which we will not
   8     go into, but --
   9   DR SILOVE: That was the point I was picking up on, because
  10     I am anticipating that by your writing "query corrected
  11     transposition" you might be raising the question about
  12     something unusual about the atrioventricular valves. It
  13     was a long time ago and I am sure you do not remember
  14     doing the actual echo, but it made me -- because in
  15     congenitally corrected transposition, the classical
  16     picture, I am sure you will agree, is that the left side
  17     of the AV valve is at a lower level than the right AV
  18     valve, whereas in the normal heart, it is the other way
  19     round.
  20        So I just wonder whether you probably suspected
  21     some possible abnormality around the atrioventricular
  22     valve area?
  23   DR JORDAN: I do not think I can say at this stage what
  24     I was thinking when I wrote that, I am sorry.
  25   DR SILOVE: It occurred to me afterwards that that might

   1     have been another possible alarm bell.
   2   MR LANGSTAFF: Could I just ask you to stop for a moment,
   3     and ask that we have a break, as it were, between each
   4     person talking for the benefit of the stenographer?
   5     I will try and moderate as much as I can the discussion
   6     which takes place, but it is partly my job and partly
   7     the Chairman's task, I know, to make sure that our
   8     stenographers get down the words, because it is a matter
   9     of importance.
  10        The point you are making is that it is a long time
  11     ago and you therefore can only go presumably by the
  12     records, or anything you do actually recall about the
  13     case, and it may not be much?
  14   DR JORDAN: That is correct.
  15   MR LANGSTAFF: Mr Deverall, if it had been reported to you
  16     that there was a large basal VSD when you were coming to
  17     an operation as a surgeon, how would you have reacted at
  18     this time?
  19   MR DEVERALL: I think I would have a sinking feeling in the
  20     pit of my stomach.
  21   MR LANGSTAFF: Because?
  22   MR DEVERALL: Because in the earlier years when exploratory
  23     cardiotomy was part of the complex approach to complex
  24     heart disease, you only had to experience once opening
  25     the heart and finding this and knowing you could do

   1     nothing, to then bend over backwards to avoid ever being
   2     in that situation again, and where it is quite clear
   3     that this child has the so-called double outlet right
   4     ventricle, by definition a condition, as Dr Anderson
   5     will have told you previously, where more than one and
   6     a half great arteries come from a single ventricle, the
   7     next thing a surgeon says is "Where is the VSD?", as
   8     Stephen Jordan has said.
   9        If there is the slightest suspicion that that
  10     ventricular septal defect is remote from the aortic or
  11     pulmonary valve, one's antennae would immediately say
  12      "Is this a large central -- ", we can get into the
  13     semantics of the types of VSD in the centre of the heart
  14     later, but one would be extremely concerned that this
  15     would be a major factor in dictating whether one could
  16     or could not correct the lesion.
  17   MR LANGSTAFF: If the matter was reported to the surgeon in
  18     the terms that Dr Walker had put it at page 115, as
  19     a double outlet right ventricle with subaortic VSD --
  20   MR DEVERALL: That is the most frequent type that we
  21     encounter and it is a relatively straightforward
  22     corrective operation.
  23   MR LANGSTAFF: So the distinction is actually of some
  24     importance to the surgeon.
  25   MR DEVERALL: Chalk and cheese.

   1   MR LANGSTAFF: There was a second catheter, I think,
   2     performed -- let us have a look at page 101. This is
   3     a catheterisation in February 1989, so it is some time
   4     after the original catheter that we have looked at. We
   5     see here a report by -- it is Dr Martin's report,
   6     page 3. Perhaps we ought to pick it up and go back to
   7     the beginning of it. It begins at 98. The top
   8     left-hand corner, we can see, page 1. It is referred to
   9     the hospital as your patient, but as we will see it is
  10     Dr Martin who actually does the report.
  11        Page 101 is page 4 of the report. Again, it is
  12     Dr Wilde doing the radiography. In the middle of the
  13     page, not easy to read but I will do my best from the
  14     typescript, beside the punch hole there:
  15        "Left ventricle: the left ventricle is well
  16     outlined and shows good contractility. There is
  17     a moderate size basal VSD which lies close to the mitral
  18     valve and fills the right ventricle immediately beneath
  19     the aortic valve. No additional VSD is seen. It is
  20     noteworthy that on this and previous injection, the
  21     coronary anatomy seems to be normal."
  22        Again, that is describing in slightly different
  23     words the same thing Dr Wilde had seen earlier: the
  24     basal VSD.
  25   DR JORDAN: Yes, I think so.

   1   MR LANGSTAFF: And what might give a surgeon cause for alarm
   2     might be the proximity to the mitral valve?
   3   DR JORDAN: Yes.
   4   MR LANGSTAFF: If we go back a page to page 100, and we look
   5     down at what is said about the left ventricle angiogram,
   6     just below the punch hole, is that a consistent
   7     description, calling it a "large malalignment VSD with
   8     subaortic conus"?
   9   DR JORDAN: I think my feeling would be that those two
  10     descriptions are not exactly identical, but bear in
  11     mind, of course, that what is going to take place is
  12     going to be viewed in detail, with the possibility of
  13     operation under consideration.
  14   MR LANGSTAFF: What we have been able to trace following
  15     from this is a discharge letter at page 93. This is
  16     signed by you because it was your patient, and we see
  17     the history:
  18        "Young man admitted for further cardiac
  19     catheterisation... originally admitted at the age of
  20     3 months on account of cyanotic episodes ... found to
  21     have a murmur."
  22        At that stage, catheterisation confirmed the basic
  23     diagnosis. He had a right BT shunt on 25th May 1986.
  24     Since then he had been generally stable and on
  25     examination was generally well.

   1        Then the echocardiogram. Let us highlight that,
   2     because it is difficult to see, just below the punch
   3     hole. I will read it and read it slowly, because it is
   4     not easy to see:
   5        "An echocardiogram demonstrated the basic
   6     anatomy - double outlet right ventricle and side by side
   7     great arteries. The pulmonary artery being slightly
   8     anterior. There was a large VSD mainly committed to the
   9     aorta, and a subaortic infundibulum with valvar and
  10     subvalvar stenosis. Cardiac catheterisation confirmed
  11     these findings".
  12        What you are reporting there, I think, was
  13     consistent with what Dr Martin had put in his report,
  14     was it not?
  15   DR JORDAN: Yes. The relationship of VSD to the aorta,
  16     I mean, it has to be said that large ventricular septal
  17     defects can both relate to the aorta and relate to the
  18     mitral valve. The two in fact, in hearts with
  19     reasonably normal anatomy, are normally contiguous. It
  20     is not that we are dealing with something as you might
  21     imagine in the sort of unravelled heart where one is at
  22     the top and one at the bottom. The left ventricle is
  23     normally folded up on itself so a defect could both
  24     extend to be below the aortic valve and also to be close
  25     to the mitral valve.

   1   DR SILOVE: I agree with that. If you have a very large
   2     ventricular septal defect, it can be an inlet VSD with
   3     extension to the outlet, so it is quite consistent that
   4     perhaps in one view this will look like an outlet VSD
   5     and yet in another view, it will look like this term
   6     which is being used, a "basal" VSD, which I think is an
   7     inlet VSD.
   8   MR LANGSTAFF: Could I ask for a surgeon's perspective on
   9     this, Mr Deverall? If you had seen and had reported to
  10     you what is in the note of Dr Wilde's examination,
  11     a moderate sized basal VSD which lies close to the
  12     mitral valve, would that have concerned you?
  13   MR DEVERALL: Very much. I think I would have had the
  14     response of almost knowing there was something unusual
  15     and hopefully -- and I am sure would have recontacted
  16     the individuals concerned and declined to proceed until
  17     we had used all other investigations, usually
  18     non-invasive echocardiographic investigations, to
  19     investigate the matter further. I would be very
  20     concerned.
  21   MR LANGSTAFF: As it happened, this was a child who was
  22     thriving reasonably and had to have an operation at
  23     a later stage and the question arose as to when that
  24     operation might be.
  25   DR JORDAN: I think that was the situation. I mean, this

   1     was an investigation carried out to determine, really,
   2     what was going to be the policy with regard to any
   3     attempt at correcting the abnormality.
   4   MR LANGSTAFF: Am I right in thinking -- again, I am
   5     covering fairly large tracts of the medical notes --
   6     that he was put down on a long waiting list to come in
   7     again and did so, which we will see if we go to medical
   8     note 2278, page 13?
   9   DR JORDAN: Can I help the Inquiry by saying that I think
  10     that where the decision will be documented will be on
  11     pages 95 and 96, because these are reports of two joint
  12     meetings that were held, one without the benefit of
  13     surgeons and the second one with the benefit of the
  14     surgeons, including, clearly, Mr Wisheart.
  15   MR LANGSTAFF: Let us look at 2277/95.
  16   THE CHAIRMAN: I have taken it off for just a moment,
  17     because we have an address on. Although we have consent
  18     to use the records, I would be anxious for addresses not
  19     to appear in public.
  20   MR LANGSTAFF: Yes. May we see the diagnosis which is
  21     discussed? What is repeated is the subaortic
  22     ventricular septal defect, which is, as you pointed out,
  23     inconsistent with Dr Wilde's report of what was there.
  24        The conclusion of the discussion between yourself,
  25     Dr Joffe, Dr Martin, Dr Wilde, Messrs Dhasmana and

   1     Wisheart, was that he was suitable for correction and
   2     the focus appears to be on the anomalous coronary artery
   3     anatomy, which is something which is going to make any
   4     correction more difficult and would have to be carefully
   5     managed by the surgeon at operation, would it not?
   6   DR JORDAN: Yes. What you are seeing here is a statement,
   7     if you like, of intent, produced after we had reviewed
   8     the available information. We probably would not
   9     actually have looked at the previous angiogram -- that
  10     was the one carried out in 1986 -- because to some
  11     extent this supplemented it, but we would have looked at
  12     the echocardiogram, which of course at that time was
  13     only what we call a transthoracic echocardiogram, and
  14     the various angiograms that were carried out which were
  15     quite extensive. As counsel quite rightly points out,
  16     there was some concentration on this particular problem
  17     of the anomalous origin of the right coronary artery.
  18   MR LANGSTAFF: This is, I think, in 1989, probably the date
  19     at the very top of the page. It is a bit difficult to
  20     make it out.
  21   DR JORDAN: I think it was 20/2/89, from my reading of the
  22     originals.
  23   MR LANGSTAFF: We see a handwritten note on the bottom
  24     right-hand side. Is that your handwriting?
  25   DR JORDAN: It says "Appt": that is Mrs Margaret Swainger,

   1     one of the cardiac secretaries.
   2   MR LANGSTAFF: She gave the child an appointment to come and
   3     see Mr Wisheart the following month, 29/3/89, I think,
   4     the outpatient appointment referred to in the last line
   5     of that note.
   6        So the plan was, because he had reasonable oxygen,
   7     89 per cent, that he should wait and it would all depend
   8     on whether he maintained that sort of oxygen level and
   9     his growth and development.
  10   DR JORDAN: I think that is the context of that note, yes.
  11   MR LANGSTAFF: Essentially, a child with this condition one
  12     would want to leave as long as possible so that the
  13     arteries grew and developed, because you would have to
  14     use a homograft, given the coronary artery anatomy,
  15     would you not?
  16   DR JORDAN: Yes.
  17   MR DEVERALL: Would it be helpful, as a surgeon, to explain
  18     to the Panel the problem? In carrying out operations
  19     for double outlet right ventricle with subaortic
  20     ventricular septal defect, the convention in 1989, 1990,
  21     1991, was to carry out the operative procedure by making
  22     an incision in the right ventricle. The surgeon made
  23     a hole and through that, he carried out the major
  24     operative procedure, the placing of the patch and the
  25     relieving of the obstruction to the blood flow to the

   1     lungs.
   2        The siting of that incision would normally have
   3     been about one third between the great arteries and the
   4     apex of the heart. That is precisely where this
   5     abnormal coronary artery runs, arising on the left
   6     unusually and extending to the right. So you cannot
   7     make an incision where you wish to, because the artery
   8     is in the way.
   9        In addition, the artery may be buried inside the
  10     muscle and you cannot see it. Then, if you find an
  11     obstruction of thick muscle where that artery lies, you
  12     cannot cut the muscle away. So a homograft, a tube
  13     taken from another human being is used. You make
  14     a lower incision in the ventricle, an incision in the
  15     artery above, and jump over the area at danger.
  16        My reason for bringing this up is that all
  17     homografts used under these circumstances wear out. We
  18     know we have ultimately to replace them. All children
  19     who undergo successful heart surgery, in the nature of
  20     things grow, so whatever size homograft you can put in
  21     at the age of 5, by the age of 10 or 12 will not be big
  22     enough and/or may be wearing out. So the convention, to
  23     my knowledge, and Dr Silove will correct me if he thinks
  24     I am wrong, at that time was providing the child's
  25     clinical condition was satisfactory, to wait until the

   1     child was nearer fully grown size in order that the
   2     largest possible homograft could be selected.
   3        In addition to that, there was well-published data
   4     in the literature to show that the mortality of this
   5     operation, including the insertion of the homograft, was
   6     greater up to the age of 5 or 6 than it was closer to
   7     the age of 10.
   8        I ran this through you, sir, to ask what was the
   9     indication to proceed at the age of 5?
  10   MR LANGSTAFF: I do not know if you can help us with that?
  11     Can you look at 2278/12, the admission note which shows
  12     the admission of the child on entry before operation.
  13     This is now taking us forward to 23rd April 1991, and on
  14     my calculation, Marc is now 5 and a half years of age.
  15        It is recorded as a routine admission. So that
  16     I get the procedure right, Mr Wisheart will have seen
  17     him back in 1989, put on a long waiting list, and then
  18     eventually he would have come in off that list, would
  19     he?
  20   DR JORDAN: That is one possibility. The other possibility
  21     is that although he was on the waiting list, his card,
  22     if you like, was marked with something to say, "wait
  23     until Dr Jordan tells us that there has been a change"
  24     or something like that.
  25        This is a patient I would almost certainly have

   1     been seeing in one of the joint clinics in Taunton,
   2     keeping him under review. We do not have -- at least,
   3     I have not seen the Taunton notes. There should be
   4     copies of letters, though, from the clinic in Taunton,
   5     if that was in fact the case.
   6   MR LANGSTAFF: There seem to be very few, actually.
   7   DR SILOVE: On page 91 there was a letter from Dr Jordan
   8     after seeing Marc on 10th October.
   9   MR LANGSTAFF: 2277/91. There you say he has remained
  10     generally well and quite active over six months --
  11   THE CHAIRMAN: We need to take the addresses out again,
  12     thank you.
  13   MR LANGSTAFF: Do you now have that on the screen?
  14        "Marc has remained generally well and quite active
  15     over the last six months." This is October 1989.
  16        "He has grown quite well, but still only just
  17     above the third percentile in both height and weight.
  18     On examination he remains only mildly cyanosed with no
  19     evidence of heart failure. Loud systolic murmur. His
  20     condition remains stable and as you know, we are hoping
  21     to defer surgery for another year or so on account of
  22     his coronary artery anatomy and the possibility that
  23     this might require his repair to include some form of
  24     conduit from the right ventricle to the pulmonary
  25     artery."

   1        That is the same as a homograft.
   2   DR JORDAN: That is right.
   3   MR LANGSTAFF: You are taking exactly the same line that
   4     Mr Deverall anticipates would have been the general
   5     situation in 1989, that one would want to wait and delay
   6     for as long as possible.
   7   DR JORDAN: Yes, but the thing that usually determines some
   8     action under these circumstances is that the child
   9     becomes more cyanosed. It is like the rather more
  10     common condition of tetralogy of Fallot, where there is
  11     inevitable progression in the cyanosis, partly because
  12     the obstruction to the way out for the blood into the
  13     lungs increases and partly because the effect of the
  14     Blalock shunt becomes less as the child grows and the
  15     shunt very often does not grow as well, so we would
  16     expect the child to become more blue.
  17        Additionally, of course, this is a child getting
  18     near to school age who would normally be getting quite
  19     active. A normal child of that age will be pretty
  20     active, and of course it is the sort of age when it
  21     becomes clear to everyone if the child is a lot more
  22     disabled and unable to do things, so that is an
  23     alternative reason for deciding to, if you like, take
  24     the plunge and go ahead with the operation: either that
  25     the child is seen to be becoming more blue, or it is

   1     reported that it is very much more difficult for him now
   2     because he cannot keep up with other children.
   3   MR LANGSTAFF: The best I can do to help on the oxygen
   4     saturations when he comes into hospital for operation,
   5     because there does not seem to be any record in these
   6     notes before then, is to take you to the anaesthetic
   7     chart at MR 2278/56. The oxygen saturation, the third
   8     line -- you know where it is but others will not --
   9     third line down, which shows that at operation, before
  10     he went on bypass, the oxygen saturations appeared to be
  11     88 and 90 which is pretty much what they had been
  12     before, so there is no obvious sign or measurement at
  13     any rate of any increasing cyanosis, is there, if those
  14     are right?
  15   DR JORDAN: Yes. I accept there is no objective evidence
  16     that the child is more cyanosed. As I say, there are
  17     the other factors of what is reported to us. There was
  18     also a mention in the note that came up that he was
  19     having cyanotic attacks, which I am afraid I cannot tell
  20     you about the authenticity of that. That was written by
  21     a surgical Senior House Officer on that admission.
  22   MR LANGSTAFF: Can I just take you back to 2278/12 to see
  23     that, and then I will invite Dr Silove to comment. That
  24     is the reference to the first entry in the history,
  25     I think, "cyanotic attacks".

   1   DR SILOVE: I was not quite sure what that meant either.
   2     I interpreted that as meaning that he had cyanotic
   3     attacks prior to having his Blalock-Taussig shunt. I do
   4     not know. I found it difficult to interpret that.
   5     There is certainly no mention in your letters that he
   6     had been having cyanotic attacks, but the last letter
   7     I was able to find in the medical records was actually
   8     the one we have just seen, in which it said "to be seen
   9     again in six months time". That clinic letter obviously
  10     did not find its way into these medical records from
  11     Taunton, presumably.
  12   DR JORDAN: Can I just say, yes, I mean, we have not got the
  13     evidence, but this actually says "cyanotic attacks
  14     precipitated by exertion", and "short of breath on
  15     exertion", so I think it is more likely that is
  16     referring to symptoms that were current at the time he
  17     was admitted for his operation.
  18   MR LANGSTAFF: Do we get any help with routine admission at
  19     the top of the page?
  20   DR JORDAN: No. I mean, he would have, even with that
  21     history, simply come off a waiting list. There are
  22     different sorts of routine admissions, I am sure the
  23     Inquiry is aware, from people who have been on waiting
  24     lists for a long time, people who are routine admissions
  25     but have been on a waiting list with a note to say,

   1     "within a certain time", or "very quickly" or something
   2     like that. I think all it implies is that he was not
   3     admitted to us, that would be at the Children's
   4     Hospital, as an emergency, and transferred for surgery.
   5   MR LANGSTAFF: If we look at page 13, the examination again,
   6     there are no measurements to help us, but the
   7     description, "Looks fit, no anaemia, cyanosis plus", and
   8     there is "no clubbing" and nothing wrong with the
   9     throat, which presumably is important for anaesthetic.
  10        Unless one had further information, one could not
  11     tell from these notes whether there was or was not any
  12     particular urgency about doing this child?
  13   DR JORDAN: I would agree with that on what we have seen.
  14   MR LANGSTAFF: So if we can turn ahead to page 18, to the
  15     operation note, the address needs to come out.
  16   MR DEVERALL: Mr Langstaff, could I ask Dr Jordan to explain
  17     something for my benefit?
  18   MR LANGSTAFF: Yes.
  19   MR DEVERALL: When a child like this was admitted to the
  20     Royal Infirmary under the surgeon, I notice somewhere
  21     else in the records that all the records relevant to
  22     this child were at the Children's Hospital. What was
  23     the mechanism whereby this child's data was reviewed
  24     immediately before the operation? Was there another
  25     meeting? Just in general, or specifically, if you wish.

   1   DR JORDAN: The general logistics of it are firstly that
   2     there were two different sets of notes, one for the BRI
   3     and one for the Children's Hospital. When a patient was
   4     put on the waiting list for an operation at the
   5     Infirmary, the normal practice was to in fact generate
   6     a set of BRI notes and to put into those all the most
   7     relevant data which would include things like cardiac
   8     catheter reports and so on.
   9        But at the time the child was admitted, he would
  10     still have Children's Hospital and BRI notes. Once he
  11     was admitted to the BRI, all the note-writing would be
  12     in the BRI notes.
  13        I think the Inquiry knows by now that there were
  14     difficulties that the cardiologist experienced in
  15     getting down to see children in the cardiac surgical
  16     unit at the BRI, both before their operation to review
  17     them and also subsequently, and although I made an
  18     attempt to get down and see every child who was waiting
  19     for operation, before they had their operation, that did
  20     not always happen.
  21        With regard to the review, when we first moved the
  22     catheter lab to the Children's Hospital and had our own
  23     meetings to discuss investigations, we did set out to
  24     review as well as the last week's investigations that we
  25     had done there, the investigations of patients who were

   1     being operated on the following week.
   2        But that fell through for a number of reasons,
   3     firstly that we were always pressed for time with these
   4     meetings anyway, to get them done in a reasonable time
   5     and they were done -- one was before the start of
   6     everyone else's working day and the other one was during
   7     the so-called lunch hour.
   8        The second was that the surgeons did not always
   9     get to these meetings anyway. The other reason was that
  10     quite often the operating list was changed so that when
  11     we were trying to do this, we would have the things all
  12     ready, and when the surgeons came, they would say, "Oh,
  13     well, we are not doing him because we cannot do another
  14     child, we are doing an adult", or something like that,
  15     and I am afraid we rather gave up on this.
  16        I have to admit that firstly I think quite frankly
  17     that is open to criticism; the other thing is that in
  18     the particular child, it was two years from the previous
  19     investigations and, having looked at that, I would have
  20     to agree that particularly under those circumstances,
  21     I would have hoped to have been aware that the child had
  22     been admitted, seen the child and at least myself had
  23     a look at the previous investigations, because I could
  24     be quite sure I would not remember what things looked
  25     like just from looking at the reports, of the cardiac

   1     catheters, or indeed of the meetings that had been held
   2     to look at it, as I say, two years previously.
   3   DR SILOVE: I am sure if you had had that opportunity,
   4     judging from what has been written before about the
   5     basal VSD and so on, I have no doubt you would have
   6     organised another echocardiogram and, looking very
   7     specifically at the atrioventricular valve region and
   8     looking at the attachments of the AV valves, because
   9     I accept that there was no trans-oesophageal
  10     echocardiography available, but I am pretty sure that
  11     with an apical four-chamber view or a subcostal view,
  12     you would have had a pretty good idea of what the
  13     atrioventricular valves looked like, and you would have
  14     seen an inlet VSD.
  15        It must be the sort of thing that observing
  16     a basal VSD on the angio, and also thinking back to your
  17     very original echo in which you must have thought of
  18     some possibility with the AV valve anatomy, it would be
  19     a logical thing, then, to have gone ahead with an
  20     echocardiogram. But quite clearly, the logistic problem
  21     just prevented that kind of thing from happening.
  22   DR JORDAN: Yes. I mean, as has been implied by both of us
  23     in comments, myself and Dr Silove, I think looking at
  24     this a year or two further on, one would have said this
  25     is exactly the sort of thing where trans-oesophageal

   1     echocardiography would be particularly valuable, but we
   2     did not have it at that time.
   3        Even so, I agree, if we had done another echo,
   4     there was clearly a chance that at least looking at
   5     that, one would have been able to say, "Look, this looks
   6     a bit worrying".
   7   MR LANGSTAFF: If one looks at the operation note which is
   8     there on the screen, this does look like a failure of
   9     communication for whatever reason it may be, because the
  10     diagnosis which one sees there, "double outlet right
  11     ventricle, subaortic VSD", does not give the surgeon --
  12     this is his description of the diagnosis as he
  13     understood it -- any sense of what Dr Wilde had
  14     worryingly put in his two earlier radiographic reports.
  15     It has just not come through, has it?
  16   DR JORDAN: I agree, although, as I said earlier, subaortic
  17     VSDs can be as it were confluent; they can extend down
  18     and become basal VSDs, if we are going to use this
  19     term. But yes, I agree that as it is written there, the
  20     diagnosis does not really reflect the complexity of the
  21     situation as it turned out at the time of operation.
  22   THE CHAIRMAN: Mr Langstaff, may I just interrupt for
  23     a clarification of the notes? You say there were two
  24     sets of notes generated first at the Children's Hospital
  25     and then at the BRI.

   1        The question that we have is whether, if the child
   2     moved from let us say the Children's Hospital to the
   3     BRI, did the Children's Hospital notes move with the
   4     child, and equally, when the child moved from the BRI to
   5     the Children's Hospital, did the notes from the BRI move
   6     with the child, whatever was in existence at the other
   7     hospital?
   8   DR JORDAN: The answer, Chairman, is that that was the
   9     intention, but once the child had two sets of notes,
  10     they were always filed together, and indeed, an awful
  11     lot of these notes have in my writing on the front of
  12     them notes like "Also has BRI hospital number
  13     [such-and-such]. Please file notes together at the
  14     Children's Hospital", usually the Children's Hospital
  15     because that is where the follow-up would be
  16     concentrated. That is where we were.
  17   THE CHAIRMAN: You say that was the intention. I suppose we
  18     are rather more concerned with the reality.
  19   DR JORDAN: I have to say, the reality was that this is not
  20     an arrangement that any medical records officer is
  21     terribly used to. I think they were actually very good,
  22     and the medical records officers in both hospitals were
  23     personally known to me and I could go and talk to them.
  24   THE CHAIRMAN: May I just pursue one last question? It is
  25     not only where they were ultimately filed or were they

   1     filed together, but did they travel physically with the
   2     patient?
   3   DR JORDAN: They would only travel with the patient if the
   4     patient was moved between hospitals, if that is the
   5     question I am being asked.
   6   THE CHAIRMAN: That is right. If the child was moved, you
   7     were saying one set would move with the child to the new
   8     location.
   9   DR JORDAN: The records officers of both hospitals were
  10     supposed to know if a child, for example, as this child
  11     was, was scheduled to be admitted to the BRI, that there
  12     would be Children's Hospital notes and that they should
  13     get those and they should be presented to the ward ready
  14     for the child's admission.
  15   MRS HOWARD: Sorry to press you; just to be absolutely
  16     clear, can I take it just a step further? If a child
  17     was admitted as has just been described to the BRI as
  18     a "to come in" arrangement, the child had BRI notes,
  19     knowing the child was a "tci", would the BCH notes be
  20     transferred in preparation for the admission of the
  21     child.
  22   DR JORDAN: That was the intention, yes. As I have
  23     indicated, I have to say, it did not always happen, but
  24     this was in recognition of the fact that we could not
  25     rely on this happening on every occasion, we instituted

   1     this business of setting up the BRI notes with what you
   2     might call, you know, core documents in them, so that if
   3     by any chance the Children's Hospital notes did not
   4     arrive -- I mean, there were perfectly good reasons why
   5     they might not, and I might have had the notes to take
   6     off to a clinic to see him in Taunton, for example, so
   7     they might not have been in the Children's Hospital when
   8     they looked for them.
   9   MRS HOWARD: Thank you.
  10   THE CHAIRMAN: Perhaps, Mr Langstaff, unless you want to
  11     finish something in particular --
  12   MR LANGSTAFF: I was hoping perhaps with a further 10
  13     minutes, we may finish the discussion of the Marc
  14     Stevens case, so we can start after lunch with a fresh
  15     case, if that is convenient?
  16   THE CHAIRMAN: By all means.
  17   MR LANGSTAFF: The operation note: obviously you were not at
  18     operation, but the surgeon obviously proceeds on the
  19     diagnosis which he understands, and we can see the
  20     procedure. Just to anticipate, because you have read
  21     through these notes, I am sure --
  22   DR JORDAN: I have, indeed.
  23   MR LANGSTAFF: -- the failure to appreciate what actually
  24     was found by Dr Wilde, and perhaps the failure to
  25     appreciate what the true diagnosis was that there was

   1     a VSD, if I can put it in layman's terms, in the wrong
   2     place for this to be an easy operation, we can see must
   3     have affected the way in which the surgeon went about
   4     the operation.
   5        Let me put some detail on that, and see if we
   6     agree.
   7        What Mr Wisheart begins to do -- it is the top of
   8     page 19 -- he begins by investigating the pulmonary
   9     artery. He opens it. He inspects the pulmonary valve.
  10     It is tricuspid, severely stenotic. That had been
  11     predicted, of course, in the diagnosis. Then he carries
  12     out a valvotomy; then prepares the coronary artery.
  13        Can I have a comment on this from Mr Deverall? At
  14     that stage, if he were then to open up the heart, as he
  15     did, and discover that the VSD was not where he expected
  16     it to be, but was where it in fact turned out to be, had
  17     he burned his boats?
  18   MR DEVERALL: It made things extremely difficult. It
  19     created a new irrevocable addition to the child's
  20     problems, that is, has done a pulmonary valvotomy
  21     without knowing whether the procedure can be carried out
  22     in the heart relevant to that pulmonary valvotomy.
  23        I have to say, and it is not Dr Jordan's comment,
  24     it is a surgical comment, but I would have thought it is
  25     a fundamental rule in any operation of the tetralogy

   1     group, let us broadly put this under the -- the inside
   2     of the heart is inspected before anything is done to the
   3     obstructed outflow tract; it is fundamental.
   4   MR LANGSTAFF: Suppose you had been a surgeon and you had
   5     had some suspicion that the VSD might not be the
   6     relatively normal and easy one to correct, but was of
   7     the basal variety that we have had described. And
   8     suppose that contrary to the analysis you have just
   9     given us, you might, had you thought it was normal, have
  10     proceeded to a pulmonary valvotomy, would you actually
  11     have performed a valvotomy knowing the true anatomy of
  12     the heart?
  13   MR DEVERALL: No.
  14   MR LANGSTAFF: Do you want to comment on the surgical
  15     aspects?
  16   DR JORDAN: No, I think it is too much technical surgical
  17     work for me really to have any input on that aspect of
  18     the operation.
  19   MR LANGSTAFF: Mr Deverall, perhaps we can deal with it
  20     shortly. We have the note on the screen there and we
  21     can see about the middle of the page -- the top punch
  22     hole -- "closer examination of the atrioventricular
  23     valves", if we go down to that. If we start where the
  24     yellow line is, he begins to describe the underlying
  25     anatomy. If we read down to the lower of the two punch

   1     holes, we see he describes a very large VSD and no ASD:
   2        "No way of correcting this condition could be
   3     identified. It was thoroughly discussed with
   4     Mr Dhasmana. Mr Dhasmana had not been in the operating
   5     team, so presumably he must have been called in to
   6     discuss what the surgeon found at operation. Would you
   7     like to comment on what had happened here?
   8   MR DEVERALL: What is being described is a common
   9     atrioventricular valve. I deliberately use that term
  10     rather than "atrioventricular septal defect" in order
  11     that the Panel do not get too confused. When Professor
  12     Anderson spoke with you, he described the anatomy of the
  13     atrioventricular septal junction, and I am quite sure he
  14     described in that the possibility of having that without
  15     an atrial component. This is what this condition is.
  16        I am sorry, Dr Jarman was shaking his head.
  17     Perhaps Professor Anderson did not say that?
  18   THE CHAIRMAN: No, quite, it was in admiration of the
  19     clarity with which you put it.
  20   MR DEVERALL: I cannot believe Professor Anderson would give
  21     a talk on that subject without that remark!
  22   MR LANGSTAFF: Success in this operation would depend upon
  23     the ability of the surgeon to close the VSD.
  24   MR DEVERALL: Yes. In double outlet right ventricle, it is
  25     not only closing the ventricular septal defect, but it

   1     is closing it in such a way that you connect the blood
   2     which will be in the left ventricle to the aorta. So it
   3     is not so much putting a patch on the VSD, it is in
   4     effect creating an intraventricular outlet tunnel, so
   5     that blood from the left ventricle flows to the anterior
   6     aorta. Way, way back at the very first cardiac
   7     catheterisation on 24/1/86, if I might paraphrase it, to
   8     save going back, Dr Wilde says the aorta has been
   9     transposed on to the right ventricle "and is clearly
  10     some distance", so in other words, you have to create
  11     a tunnel.
  12        Although there are, in the literature, one or two
  13     descriptions of the successful correction of double
  14     outlet right ventricle with a common atrial ventricular
  15     valve, the rarity of those descriptions makes mention
  16     that the mortality of other attempts must be extremely
  17     high.
  18   MR LANGSTAFF: What is described in the operation note
  19     further on down, various options were then considered,
  20     is a surgeon who is faced with a problem, he realises it
  21     might suggest that it is not easy to remedy the problem
  22     he is now in, having started in the way that he has, and
  23     he takes the course, does he, of putting in a further
  24     shunt?
  25   MR DEVERALL: Yes. It clearly is a most unfortunate

   1     situation, and having been in it myself, I have great
   2     sympathy for the feelings that go through your mind when
   3     you are faced with knowing that you cannot correct
   4     a situation and wanting desperately to end up with
   5     a live child. It is not easy to think on your feet
   6     under those pressures on bypass and under considerable
   7     stress, and under optimal circumstances, it is nice
   8     under those circumstances to be able to ask your
   9     paediatric cardiologist, your fellow surgical
  10     consultant, your anaesthetist, to stand back, if
  11     necessary, in my experience, to actually leave the
  12     operating room and cool down and decide what to do.
  13        The steps, to my mind, speaking personally, and
  14     I think Dr Silove agrees with me which in fact were
  15     taken, were the wrong steps, and I can only assume that
  16     they were steps taken without being able to do that
  17     process of analysing the situation to the best of their
  18     ability.
  19   MR LANGSTAFF: There would have been difficulties, am
  20     I right, in contacting you as the cardiologist, because
  21     of the split site and because of your duties elsewhere?
  22   DR JORDAN: The general answer to that question is
  23     "difficult, but by no means impossible". I did on
  24     occasions get called down to theatre, provided I was not
  25     in the middle of something like a cardiac catheter, that

   1     I could drop. I could get down there and get changed
   2     and into theatre probably in about 10 minutes, something
   3     like that, but I am afraid with the passage of time,
   4     I have no idea where I was or what my movements were on
   5     that particular day.
   6        But can I just say that I think it would have been
   7     particularly important -- I am very interested in what
   8     Mr Deverall says, because the note that I made was that
   9     if you look at the last cardiac catheter and the
  10     calculations that Dr Martin made on pulmonary blood flow
  11     and systemic flow, these are perhaps things that go
  12     through a cardiologist's mind rather more than
  13     a surgeon's mind --
  14   MR DEVERALL: I do not think the surgeon should not go
  15     through the same thought processes you are about to
  16     describe.
  17   DR JORDAN: Basically, to get to the point, he calculated
  18     that the pulmonary blood flow was actually considerably
  19     increased. It was nearly 2.8 to 1 was the figure, which
  20     means the pulmonary blood flow was nearly three times
  21     normal, and I would have liked to think if I had been
  22     there in theatre, discussing this, I would have latched
  23     on to that point and said "The last thing you want to
  24     do, I am afraid, is to do another shunt".
  25        I do not know whether that was particularly the

   1     point Mr Deverall was going to --
   2   MR DEVERALL: It is precisely the point.
   3   DR SILOVE: And my thought processes are exactly the ones
   4     which you describe: the Qp:Qs was described as 2.8 and
   5     clearly the child would have been far better off being
   6     put back to where he was before the operation than
   7     having additional blood flowing to his lungs.
   8   MR DEVERALL: I think for the stenographer, we should say it
   9     is "Qp:Qs", which stands for pulmonary blood flow
  10     compared to systemic blood flow. I am sorry, but
  11     perplexity was written on her face!
  12   MR LANGSTAFF: You are in a position better than I am, to
  13     see it!
  14        That raises the last question which arises before
  15     I see if we have reached a consensus on what this case
  16     can show us, and that is this: if you as a surgeon,
  17     Mr Deverall, had known what the true anatomy was before
  18     you started, instead of discovering it on the table,
  19     would you have carried out the operation at this time,
  20     or not? Was there anything you could do?
  21   MR DEVERALL: There are two assumptions. Let us assume the
  22     child was as stable as he appears to have been, that is,
  23     his haemoglobin was only marginally elevated, he was
  24     only marginally cyanosed and had no clubbing, then we
  25     would wish to review his clinical condition with

   1     Dr Jordan, his paediatrician, whatever. If surgery were
   2     indicated because his condition was deteriorating, and
   3     if we had known what was inside his heart, we would have
   4     carried out another palliative operation.
   5        If his condition was not deteriorating, then we
   6     would not have proceeded with the operation at all at
   7     that time.
   8   MR LANGSTAFF: Is that broadly what you would have agreed
   9     with the surgeon, do you think?
  10   DR JORDAN: Yes, I would agree. There is one point that has
  11     not been covered: the fact that this common
  12     atrioventricular valve, which Mr Deverall says has
  13     really replaced what the surgeon would find, which is
  14     a separate mitral tricuspid valve, is that there were
  15     these chordae, these fine strands which are very
  16     important to the function of the valve, and they
  17     actually crossed over the defects. Again, I am straying
  18     on to surgical territory, but in any patient with an
  19     atrioventricular septal defect where the surgeon has to
  20     repair the ventricle component of it, the one thing he
  21     does not want to find is that the only thing that is
  22     holding the mitral valve and stopping it flapping is
  23     this chordae going right across where he wants to put
  24     his patch. I do not know whether Mr Deverall wants to
  25     comment on that? If I read Mr Wisheart's operation note

   1     correctly, he is making that as a particular point.
   2   MR DEVERALL: I do not want to belabour this point too much,
   3     but referring back to the earlier literature, this is
   4     referred to as type B atrioventricular canal. Professor
   5     Anderson in his presentations and writings and numerous
   6     publications which appeared before this date, show this
   7     is a variant of free floating atrioventricular septal
   8     defect. I know we are getting into the world of
   9     semantics.
  10   MR LANGSTAFF: Coming back to where a layman might look at
  11     this, if I may for a moment, suppose you had not known
  12     the anatomy, but you had opened up the heart in the way
  13     you have described as being fundamental, so that you did
  14     not interfere with any of the strategies before you had
  15     opened up the heart and seen what was inside, what would
  16     you then have done, having discovered you had a defect
  17     of this character rather than that you had been led to
  18     suppose between the communication failures we have
  19     discussed?
  20   MR DEVERALL: I can only say that, based on experience, if
  21     there was the slightest doubt in one's mind about the
  22     intracardiac anatomy, you would open the heart in the
  23     least traumatic way in order to define what the problem
  24     was. That means you would not cut a pumping chamber,
  25     you would cut a collecting chamber, namely the right

   1     atrium, which in fact gives you a better view of this
   2     region of the heart than cutting the pumping chamber,
   3     which is obviously more traumatic to the heart.
   4        So you would seek to do the least traumatic thing
   5     to enable you to define the problem.
   6   MR LANGSTAFF: Having looked at the problem --
   7   MR DEVERALL: -- you would have closed the chamber and
   8     discontinued the operation. Obviously not just like
   9     that, but --
  10   MR LANGSTAFF: So in essence, you would start the operation,
  11     realise what was there, and then have returned the child
  12     to the situation he was in before?
  13   MR DEVERALL: Restored, exactly, correct.
  14   MR LANGSTAFF: So essentially what we have here is a case
  15     which illustrates, does it, a combination of
  16     difficulties with communication, compromised by
  17     a particular surgical approach, with the result that we
  18     sadly see.
  19        Is this a fair summary, do you think?
  20   DR JORDAN: I do not think I want to comment on the surgical
  21     approach, but the rest of it I agree with, yes.
  22   MR LANGSTAFF: Sir, may we look at our next case after the
  23     lunch break?
  24   THE CHAIRMAN: Until 2 o'clock, then, shall we say?
  25   (1.20 pm)

   1            (Adjourned until 2.00 pm)
   2   (2.00 pm)
   3   MR LANGSTAFF: Dr Jordan, can I ask you about the second
   4     case, Joseph Good? This case, I think, may tell us
   5     something about post-operative care and the difficulties
   6     that there may have been.
   7        Can I begin by going to the end of the story? We
   8     are going to hear, I think, about a lad who was born in
   9     June 1990, who sadly died following operation.
  10        In the notes for the Children's Hospital, we have
  11     a postmortem report at 1732/4.
  12   THE CHAIRMAN: We are just taking the address out.
  13   MR LANGSTAFF: We can get an idea of the history from
  14     looking first of all at the summary, which is set out
  15     here, and just set the context. The 18 month old male
  16     child admitted to the Infirmary on 7th January 1992, so
  17     he is 18 months, effectively, of age, with a view to
  18     pulmonary artery reconstruction under cardiopulmonary
  19     bypass.
  20        We see he suffered from Fallot's Tetralogy with
  21     the left pulmonary artery originating from the
  22     descending aorta via the ductus arteriosus.
  23        It describes how "cardiac surgery was performed on
  24     10th January. The pulmonary trunk found to be atretic.
  25     The right pulmonary artery anastomosed to the left

   1     pulmonary artery, both arteries then joined the anterior
   2     surface of the aorta using a shunt. Came off bypass
   3     satisfactorily, transferred to the ICU", and then it
   4     says this:
   5        "He soon developed congestive cardiac failure of
   6     uncertain cause and his condition rapidly deteriorated
   7     leading to death."
   8        If we look at the findings of the cardiovascular
   9     system, page 1732/6, about seven lines down:
  10        "Approximately 30 ml of clotted intra pericardial
  11     blood surrounded the anastomosis of the left and right
  12     pulmonary arteries with the Goretex shunt. The
  13     pulmonary veins were normal", and so on.
  14        30 ml of blood is a fair volume; it is bound to
  15     put fracture on the structures of the heart, or indeed
  16     the artery?
  17   DR JORDAN: I think this was really, you know, a surgical
  18     matter and the surgeons are much more inclined to know
  19     what is an appropriate amount of bleeding.
  20   MR LANGSTAFF: Perhaps I can ask, then, Mr Deverall.
  21   MR DEVERALL: Yes, that is one ounce, two large
  22     tablespoonfuls. I think that is correct, 15 ml per
  23     tablespoonful. Now you will have to help me. The
  24     estimated volume of blood in the heart of a baby that
  25     age is about the same volume as that, 25 to 30 ml of

   1     blood. I am trying to work it out as I go.
   2   DR JORDAN: I have an even greater problem than Mr Deverall
   3     in that it is even longer since I had to do this
   4     calculation myself. I do not think I will even try
   5     under the circumstances, I am sorry.
   6   MR DEVERALL: Assuming that the heart is putting out in
   7     equivalent terms a normal cardiac output and has a heart
   8     rate between 150 and 200 beats per minute, the volume of
   9     the heart is about the same as that.
  10   MR LANGSTAFF: So the amount of blood that one has here: is
  11     it, do you think, appropriate to describe the death as
  12     congestive heart failure? Is that a helpful
  13     description, do you think?
  14   MR SILOVE: I do not believe that it is really congestive
  15     heart failure. You really have gone a long way ahead.
  16     That amount of blood is likely to cause compression of
  17     the heart and the heart fails in a sense because of the
  18     compression, but it is the compression of the heart, not
  19     allowing the heart to fill adequately, that is the
  20     problem when you have a condition known as "tamponade".
  21     When we talk of a quantity of blood or fluid in the
  22     pericardial sac surrounding the heart and causing
  23     compression, that is the condition known as cardiac
  24     tamponade.
  25   MR LANGSTAFF: So looking at the description here, intra

   1     pericardial blood, does that suggest to you that
   2     condition.
   3   DR SILOVE: Yes, it does.
   4   DR JORDAN: Can I make a comment on that? My reading is,
   5     I am sorry, this is the first time I have realised that,
   6     if you like, the line of questioning you were going to
   7     pursue, which is clearly the question of whether this
   8     child had undiagnosed pericardial tamponade which caused
   9     his death, if you read that, what does it say. I have
  10     had to open the chest in the ITU of a child with
  11     open-heart surgery and has cardiac tamponade. The blood
  12     surrounds the heart. That is not what is described
  13     there. He does says intracardial blood, but he is
  14     talking about it being around the shunts. That does not
  15     make sense to me, I am sorry; that is not pericardial
  16     tamponade.
  17   MR LANGSTAFF: In the light of that observation, let me go
  18     back to the beginning. We see what the object of the
  19     discussion is.
  20   DR JORDAN: I see entirely now, yes. It had not occurred to
  21     me, I have to say, that that would be discussed as
  22     a possibility on what I read of the postmortem.
  23   MR LANGSTAFF: The case: we have seen from the description
  24     of the condition in the postmortem before the opening
  25     paragraphs of the postmortem report what the nature of

   1     the underlying condition was and if we go to the
   2     Children's Hospital's notes, the same volume at page 39,
   3     we see, I think, the catheter report, which was
   4     performed on an admission on 24th May 1991. The child
   5     was then 11 months old. He comes in for catheter, and
   6     we will see, I think, by looking at the second page,
   7     under "comments":
   8        "The pulmonary valve is tightly stenosed. The
   9     right pulmonary artery is well-developed but the left
  10     pulmonary artery is not attached to it. Aortogram shows
  11     what appears to be a low lying and slightly tortuous
  12     ductus connecting to the left pulmonary artery, which
  13     also seems well-developed."
  14        So there is a problem. If we go to page 43 we see
  15     the summary of it: tetralogy of Fallot with severe
  16     infundibular and pulmonary valve stenosis, and
  17     hypoplastic main pulmonary artery. Disconnected left
  18     pulmonary artery filled by small patent ductus
  19     arteriosus."
  20        So, entirely appropriate catheterisation, but
  21     requiring some treatment and we see, I think shortly
  22     after that, that Mr Dhasmana saw the patient and
  23     developed an operative plan, and I think he decided on
  24     an operation which we find at page 25, the operation
  25     report --

   1   DR JORDAN: I am sorry to interrupt you, but can I just say,
   2     you say Mr Dhasmana made up his mind to do the
   3     operation, but there was in fact a joint meeting. I do
   4     not have the reference to it --
   5   MR LANGSTAFF: It is page 38.
   6   DR JORDAN: 10/6/91, in which all three paediatric
   7     cardiologists, two cardiac surgeons and Dr Wilde were
   8     there, so this was in fact a meeting at which this was
   9     discussed and the decision was made.
  10   MR LANGSTAFF: Just going through that again so the records
  11     of those who follow from a distance can understand the
  12     discussion that will take place, it was agreed that
  13     Joseph needed to have the left pulmonary artery joined
  14     to the right or main pulmonary artery, which was as we
  15     have seen from the investigations disconnected, and the
  16     establishment of a central shunt. It clearly needed to
  17     be done on bypass, partly because the left pulmonary
  18     artery takes a considerable amount of blood and secondly
  19     because it would be very difficult to obtain an adequate
  20     side bite on the right pulmonary artery.
  21        That is the agreement, that he will need an
  22     operation, and we come to the operation in early 1992 at
  23     page 25.
  24   MR DEVERALL: Could I, through you, sir, ask Dr Jordan
  25     whether he knows whether that particular operation,

   1     which we can get on to in a minute, that particular
   2     operation the joint group agreed to had been done before
   3     by either of the surgeons?
   4   DR JORDAN: We are talking about 1992. Yes, that would be
   5     certainly our best option for dealing with the situation
   6     where the pulmonary arteries -- where there is a sort of
   7     Fallot type of situation but where the pulmonary
   8     arteries are disconnected, and I believe that that was
   9     regarded as the best option generally. There are, as
  10     I am sure you will become aware, alternative views, but
  11     that was -- yes, it had been done before, and it was not
  12     just a Bristol operation, if you see what I mean.
  13   MR DEVERALL: No, I was not suggesting that at all. I was
  14     asking had it been done before, and the second question
  15     was in a 1 year old.
  16   DR JORDAN: Yes, because I think if you are going to do this
  17     operation, you do it as soon as you reasonably can,
  18     otherwise you run into -- you leave yourself with
  19     a potential for running into a lot of problems later
  20     on. Our way of thinking is that the sooner the two
  21     pulmonary arteries are joined up together so that
  22     whatever way blood is getting into them goes into both
  23     of them, the better.
  24   MR DEVERALL: I do accept that. I was just specifically
  25     asking, since you say it had been done before and had

   1     been done at the age of 1, do you know roughly speaking
   2     how many times? Could you guess.
   3   DR JORDAN: No, I do not think it would be sensible to make
   4     a guess. Certainly, this was not a one-off decision.
   5   MR DEVERALL: My reason for asking, sir, is quite simple, in
   6     that it is actually a very difficult surgical technical
   7     manoeuvre to carry out, especially in a 1 year old.
   8   MR LANGSTAFF: One and a half by the time he comes to
   9     operation --
  10   MR DEVERALL: One and a half, yes, it is not as simple
  11     a procedure as it might sound. It is not an easy
  12     operation.
  13   MR LANGSTAFF: What are the particular difficulties with
  14     it?
  15   MR DEVERALL: It says in the particular instance the main
  16     pulmonary artery is very small, so that in itself is
  17     difficult. The main pulmonary artery leads on in
  18     a natural curve into the right pulmonary artery and the
  19     left, as you have heard here, comes off a rather long
  20     narrow low-placed duct. That would mean that the left
  21     pulmonary artery, where you wish to mobilise it to the
  22     main right, is at least a centimetre apart.
  23        In a bigger child, faced with that, you therefore
  24     have to mobilise in effect the left lung and pull it
  25     across to get the two to join together. Unless you

   1     decide to pull on the artery alone without all the other
   2     structures that surround it, which can be difficult. If
   3     you have a larger older child, you can always use some
   4     tube or material. I was asking from your experience,
   5     because speaking personally, it is not an easy
   6     operation, not to be embarked on lightly, and I think
   7     you know that.
   8   MR LANGSTAFF: The operation is, is it, an appropriate
   9     operation for this sort of condition?
  10   MR DEVERALL: I totally accept what Dr Jordan says: in
  11     pulmonary atresia, by the early 1990s, we all knew that
  12     the best way of getting the pulmonary artery structures
  13     to grow which is what the child needs for its long-term
  14     health is to enable blood flow to flow centrally and in
  15     a normal direction along those arteries. So I totally
  16     agree with the purpose. I was merely seeking to point
  17     out, and perhaps elucidate, whether there was a full
  18     appreciation of how difficult the operation can be.
  19   MR LANGSTAFF: So the purpose is appropriate; the technique
  20     is difficult. We have consensus on that, do we?
  21   DR JORDAN: I accept what Mr Deverall says. It is
  22     a surgical matter. I cannot say. I was trying to
  23     recall, I do not think I have actually been in theatre
  24     to see the surgeon doing this particular operation.
  25   MR LANGSTAFF: Can I then ask you to look at the operation

   1     note with us, Mr Deverall, to see what happens here?
   2   MR DEVERALL: What happens is exactly what I would have
   3     predicted: that it is difficult. The gap is large. The
   4     mobilisation procedure to get the left pulmonary artery
   5     to connect to the confluence of the right and main is
   6     difficult. The surgeon, having been able to sew part of
   7     the two together, describes there being tension on the
   8     anastomosis --
   9   MR LANGSTAFF: Can we look at this, MR 1732/26 at the top,
  10     eight lines down, where it says there was quite a bit of
  11     tension. Let us highlight that.
  12        "There was quite a bit of tension". If we read
  13     that sentence as a whole, we will see continuity between
  14     the main pulmonary artery and the left, which was the
  15     object, as you described it, which was established
  16     posteriorly by joining an end to end anastomosis, but
  17     there was quite a bit of tension.
  18   MR DEVERALL: Not only that, but it clearly was not possible
  19     to gain a circumferential anastomosis, in other words,
  20     the back wall was obliquely joined but then left a gap
  21     on the front which you could not get together, so into
  22     that had to put a non-viable synthetic patch to create
  23     the anastomosis, which is something which will not grow
  24     which was the sole original purpose of the operation.
  25   MR LANGSTAFF: In other words, the tension made this

   1     particularly difficult because you had to put a bit of
   2     artificial material in, non-living.
   3   MR DEVERALL: Yes. I do not blame the surgeon for doing
   4     that, he had to do that, but now you have an inadequate
   5     repair of precisely what you sought. It is not
   6     a criticism of the surgical manoeuvre, it is what
   7     I would have predicted happened.
   8   MR LANGSTAFF: It is a consequence of the underlying
   9     difficulty of the anatomy.
  10   MR DEVERALL: Yes.
  11   DR JORDAN: Can I venture into the surgical niceties, I do
  12     not want to take issue with Mr Deverall, but this was
  13     obviously in -- well, I should not say that, but the way
  14     that this was constructed, keeping the native pulmonary
  15     artery at the back and putting the patch just in the
  16     front of it, I would assume was done with the intention
  17     of leaving enough natural pulmonary artery to grow.
  18     I think that it is not a circumferential Goretex patch,
  19     it is a patch over the front, as I understand it
  20     correctly. Again, as a non-surgeon, I am sorry ...
  21   MR DEVERALL: The point I was trying to make is whenever
  22     a surgeon puts the word "tension" in, in relation to any
  23     operation in the body, there is likely to be
  24     difficulties. It is something any surgeon, general
  25     surgeon, orthopaedic surgeon, heart surgeon, the word

   1      "tension" is bad news.
   2   MR LANGSTAFF: So I understand it as a layman, if you are
   3     joining two tubes together, which are the vessels, and
   4     you are stitching them together, which is the
   5     anastomosis, if you have a pulling on one or other, then
   6     it will tend to pull the anastomosis apart, will it?
   7   MR DEVERALL: In the case of blood vessels, the anastomosis
   8     would tend to bleed because of damage to the wall of the
   9     blood vessel, and it appears from Mr Dhasmana's note
  10     that is exactly what happened. Then unfortunately, in
  11     order to control the situation in the operating room, he
  12     had to place further stitches. He does not precisely
  13     describe where, but in the sizes of the vessels we are
  14     talking about, we are now getting into a difficult area
  15     of not being quite sure whether you are undoing all the
  16     good you have done by having to place extra stitches.
  17        So I am not criticising, I am saying this is
  18     a difficult situation.
  19   MR LANGSTAFF: You are explaining, not criticising, I think
  20     is what you see your present observations as.
  21   MR DEVERALL: I think so.
  22   MR LANGSTAFF: Again, so I can pick that up in the note, to
  23     help the Panel, if we read down from where we are,
  24     reading about tension, we go down to "the patient was
  25     weaned off cardiopulmonary bypass with minimal problem,

   1     but there was considerable oozing from the mediastinal
   2     dissection and also from the PDA reconstruction suture
   3     line."
   4        That is the matter you have been describing.
   5   MR DEVERALL: Correct.
   6   MR LANGSTAFF: "A considerable amount of effort by use of
   7     a haemostatic agent and the insertion of a few stitches
   8     before bleeding was minimised and the chest closed in
   9     layers in our usual method."
  10        If bleeding was minimised, does that suggest
  11     possibly there may have been some bleeding or oozing
  12     continuing.
  13   MR DEVERALL: I think that is what that word means.
  14     "Minimised" to my mind means it was continuing, but at
  15     a much lesser volume. I think if the bleeding had
  16     stopped, I presume it would say that when the bleeding
  17     had stopped, the chest was closed.
  18   MR LANGSTAFF: He describes here, the third last sentence,
  19     "closing the sternum", does he not?
  20   MR DEVERALL: Yes.
  21   MR LANGSTAFF: Would you like to comment, given that there
  22     is some oozing possibly continuing?
  23   MR DEVERALL: I think some surgeons would have decided to
  24     probably leave the sternum open and merely close the
  25     skin, with the concern that the bleeding might recur or

   1     continue and it might be necessary: (a) to immediately
   2     re-explore the child's chest; or (b) (and I believe this
   3     might be relevant to our later discussion) to minimise
   4     the chances that any blood that did collect in relation
   5     to continuing bleeding occupying space -- I would like
   6     to use those words, because when we come back to discuss
   7     what "tamponade" means in the post-operative ventilated
   8     child, I would take exception with what Dr Jordan said
   9     earlier on about fluid surrounding the heart. So
  10     I deliberately said "occupying space".
  11   MR LANGSTAFF: We can have a healthy debate about that in
  12     a moment or two, but thus far, are we in consensus about
  13     what appears to be the position at the end of the
  14     operation: that from the operation note there is some
  15     oozing, one would think from the way the note is
  16     written, and the sternum has been closed; some surgeons
  17     might leave it open?
  18   DR JORDAN: I am not sure that what is described is anything
  19     other than what usually occurs after open-heart surgery
  20     and that is that there usually is some drainage from the
  21     operation site, and indeed, it may be quite
  22     considerable. So I just am not sure, really, as
  23     a cardiologist, "bleeding was minimised", whether that
  24     really means it was still troublesome, or whether it was
  25     reduced to the level one would expect after any

   1     open-heart operation.
   2   MR LANGSTAFF: It is something, if we are going to be clear
   3     about, we will have to take up with Mr Dhasmana, being
   4     his note.
   5   THE CHAIRMAN: But Mr Deverall can help us on what is being
   6     said as to it being normal to have bleeding after open
   7     heart surgery.
   8   MR DEVERALL: Yes. In order to conduct an operation using
   9     a heart/lung machine and all the tubes, one has to give
  10     drugs to prevent the blood clotting in that machine.
  11     The drug which is given is heparin. At the end of the
  12     bypass procedure, the effect of that heparin is
  13     reversed. That in itself takes some time. The accuracy
  14     and precision of the reversal procedure is not an
  15     absolutely precise science. In addition, the very fact
  16     you have connected a child, or any patient, to the
  17     heart/lung machine traumatises the components of blood
  18     so the clotting mechanism is now itself abnormal.
  19        So, yes, all patients who undergo heart surgery
  20     have a certain amount of bleeding post-operatively.
  21     That is why tubes are left around the heart to drain any
  22     blood that collects there.
  23        What concerns me, Dr Jordan, a little bit in this
  24     child is that the child was returned to the Intensive
  25     Care Unit at a quarter to 5 in the afternoon and at 45

   1     minutes later, it is said that there is oozing plus plus
   2     from the drains, plus plus, which --
   3   MR LANGSTAFF: Let us find that, because I think we ought to
   4     have that in front of us: 1731/33 the middle of the
   5     page: "oozing plus plus from drains".
   6   MR DEVERALL: Immediately, if that is not an uncommon
   7     situation, which all teams have to make decisions about,
   8     usually a decision is made to wait a little while and if
   9     there is a graded reduction in the amount of bleeding,
  10     you usually feel that everything is satisfactory and it
  11     will stop spontaneously.
  12        If you feel the bleeding is excessive, then either
  13     the chest is re-explored or possibly more frequently,
  14     a series of additional agents are given to try and make
  15     the blood clot better. In this instance, I notice that
  16     an additional dose of protamine, the drug which reverses
  17     heparin which I spoke about a few minutes ago, fresh
  18     frozen plasma, an extract from blood containing clotted
  19     factors, and platelet themselves, all three agents were
  20     used. I think to use all three agents in that situation
  21     in a child would make me think that the bleeding was
  22     significant. I cannot say more than that. We do not
  23     actually have measures of volumes.
  24   MR LANGSTAFF: We can pick that up at the bottom of this
  25     page. We see that at 23:00, and at the top of the next

   1     page we see the protamine. Is that what you had in
   2     mind?
   3   MR DEVERALL: Yes, and then reading through all the notes,
   4     the following morning, over 14 hours later, there is
   5     a comment in the notes, "bleeding settled at last", so
   6     I take it the bleeding did not stop immediately
   7     following the administration of these various agents.
   8        My reason for saying that is not to criticise that
   9     approach of trying to deal with bleeding, it is to try,
  10     at least to my mind clarify how much bleeding was going
  11     on. It seems to me to have been significant.
  12   MR LANGSTAFF: That is a question of interpretation of the
  13     notes. Dr Jordan, I will ask you in a moment if you
  14     shared that interpretation, or whether you want to give
  15     an interpretation. Dr Silove, do you want to come in on
  16     that?
  17   DR SILOVE: I agree, there was clearly a lot of bleeding
  18     post-operatively and they were taking all the right
  19     measures to try to stop the bleeding. At that stage
  20     there was no strong indication to re-explore the chest,
  21     I do not think, but it might have been considered.
  22        I just wonder, may I -- I do not want to spoil
  23     your thread, but I wonder whether we could just ask
  24     Mr Deverall for a moment what operative strategy he
  25     would have preferred to the one that was undertaken?

   1   MR LANGSTAFF: Certainly.
   2   MR DEVERALL: I agree with the fundamental premise with
   3     pulmonary atresia that one seeks to gain blood going in
   4     the correct direction down two pulmonary arteries which
   5     are joined up together.
   6        My own experience over quite a long period is that
   7     in that situation I would leave it until the child
   8     becomes somewhat larger because it becomes technically
   9     easier and one has a greater range of options
  10     available. That is purely a personal opinion. If the
  11     child needed surgery at this stage -- and I think she
  12     did and it was correct to so refer her -- then I think
  13     we would probably have done a shunt into the left
  14     pulmonary artery to enable it to grow maximally, so that
  15     you have the maximum options available at the next
  16     stage, the definitive corrective stage.
  17        That is a personal point of view. I am quite sure
  18     if you sat however many paediatric cardiac surgeons
  19     there are in the United Kingdom down in a row, we would
  20     split pretty evenly down the middle.
  21   DR SILOVE: Could I add to that, I was actually involved in
  22     the Clinical Case Note Review, a team of experts. There
  23     was a very distinguished surgeon with a lot of
  24     experience on our group and that was the approach he
  25     suggested should have been adopted. He considered that

   1     it was over-ambitious to have attempted the procedure
   2     that was planned. He felt there should have been --
   3     I am sorry, there is a typographical error in the
   4     Clinical Case Note Review. We have written down
   5     a "right BT shunt". He suggested that there should
   6     have been a left Blalock-Taussig shunt to allow for
   7     growth of the pulmonary artery and allow for growth of
   8     the child before trying to connect the pulmonary
   9     arteries up together.
  10   MR LANGSTAFF: So that confirms that Mr Deverall's approach
  11     is one which might be adopted.
  12   DR SILOVE: Yes.
  13   MR LANGSTAFF: Presumably you do not dissent from his view
  14     that it is a matter of taste for the two surgeons and
  15     there are two views on it.
  16   THE CHAIRMAN: Dr Jordan wanted to come in.
  17   DR JORDAN: I am surprised he said a "left shunt". I read
  18     that and I thought that is a misprint; he obviously
  19     meant a right, because, again -- we are getting into the
  20     options, but --
  21   MR DEVERALL: I only say a left and my colleague, I did not
  22     know, said the same thing, because it is dealing with
  23     the left that is the most difficult part of this
  24     operation. The bigger that it is, the better. You want
  25     to make it grow as big as possible, which makes the

   1     subsequent operation easy. That is my reason for saying
   2     left.
   3   DR JORDAN: The reason why I query it is that the left
   4     pulmonary artery was the one that was thought to be
   5     taking the most blood and in order to carry out the
   6     shunt, you have to clamp the pulmonary artery, as
   7     I understand it, and you have to close the ductus while
   8     you are doing it, so you may well be diminishing the
   9     blood flow, not by a half but by two-thirds or even
  10     more, if you do it on the left side.
  11        I am sorry, we are getting into the technical
  12     discussion that I might say goes on not infrequently
  13     over this sort of condition of pulmonary atresia, where
  14     the pulmonary arteries are not what they might be.
  15   MR LANGSTAFF: I do not want us to be as it were
  16     eavesdroppers in a private conversation. It is
  17     something you are entirely free to take up afterwards,
  18     obviously, but for our purposes, if I can come back to
  19     the issue of whether there may have been bleeding to
  20     a greater extent than one would normally expect
  21     following cardiac surgery, witness the way in which the
  22     records are entered, and going on the basis of the
  23     records, that would appear to be the case, would it, do
  24     you think?
  25   DR JORDAN: There is an "if" about this, and a "but", which

   1     is made clear, I think, if you go on to the bottom of
   2     the page we already have. There is a note by
   3     Mr Wisheart.
   4   MR LANGSTAFF:  It is "This boy has problems: (1) tendency
   5     to low arterial pressures ..."
   6   DR JORDAN: Yes. He has been given colloids -- starting
   7     through the third line down the entry on 10/1/92 -- and
   8     is now approximately plus 300. That is something in
   9     excess of a third of his total extracellular volume.
  10     In other words, he has been overtransfused. That makes
  11     any assessment based on the thinking at the time as to
  12     how much bleeding there actually was rather suspect,
  13     because I think it is clear what Mr Wisheart is saying
  14     is that you have overestimated the bleeding, you have
  15     actually considerably overtransfused this child, stop
  16     it.
  17   DR SILOVE: Could I just read what I think it says?
  18        "This boy has problems: (1) tendency to low
  19     arterial pressure which generally is associated with
  20     (2) severe hypoxia with saturations going down to 50 per
  21     cent."
  22        Then, as you say, he has been given colloid, and
  23     so on.
  24        A little bit further down on the page, it says:
  25         "Echo excludes pericardial collection", I will

   1     come back to that, "and CVP of central venous pressure,
   2     18 to 20, (i.e. high)."
   3        Central venous pressure of 18 to 20 is very high,
   4     actually, and there is clearly something going on. He
   5     is running low blood pressures, high central venous
   6     pressure. The echocardiogram, there is a more detailed
   7     report, if we could perhaps go to the BRI page 105 in
   8     this section. This was performed by the X-ray
   9     Department. They say, if we read down here, in the
  10     middle of the page, "left ventricle, contracts well"; so
  11     the left ventricle contracts well, so the heart is
  12     contracting well. Further down the page he says, "no
  13     pericardial effusion noted".
  14        I am sure they would do an echocardiogram to try
  15     to exclude pericardial effusion, because if we go back
  16     to page 34, it said, handwritten "echo excludes
  17     pericardial collection". That must have been the
  18     primary reason they decided to do an echocardiogram.
  19        One has to have the suspicion of cardiac tamponade
  20     when you have a CVP of 18 to 20 and low blood pressures,
  21     low arterial pressures.
  22        My problem is that the echocardiogram does not
  23     exclude a pericardial collection. They did not see
  24     a pericardial collection when they did the
  25     echocardiogram, but it would be very difficult to see

   1     a small amount, a relatively small amount, of blood,
   2     although it is a large amount for this child, it would
   3     be difficult to see a small amount of blood surrounding
   4     the heart causing compression on the heart so soon after
   5     an operation.
   6        My feeling is that if a cardiologist had been
   7     involved on the intensive care unit and there had been
   8     a discussion between the cardiologist and the surgeon,
   9     they would have discussed the question of whether there
  10     was a possible pericardial tamponade or collection of
  11     fluid, even though the echo had not shown it, and they
  12     would have said, "we must open this chest and have
  13     a look".
  14   MR LANGSTAFF: Can I stop you there, because I think there
  15     are a number of building blocks along the way, a number
  16     of points you are making, and they may not be consensus
  17     points, they may be controversial.
  18        The first point you make is, I think, that the
  19     association of low arterial pressure with high central
  20     venous pressure indicates, if one couples that with
  21     a left ventricle apparently working well, that there is
  22     some compression of the heart or the vessel, does it
  23     not?
  24   DR SILOVE: Yes. I should have said there are two
  25     alternatives: (1) compression of the heart;

   1     (2) ventricle failure. The fact they have said that the
   2     left ventricle is contracting well suggests that there
   3     is no ventricle failure.
   4   MR LANGSTAFF: Can I stop you there, because that is an
   5     essential building block in the argument which you are
   6     making. Is that a building block you would agree with,
   7     or not?
   8   DR JORDAN: I think you would look at it this way: there
   9     are, in terms of this child's haemodynamics, I do not
  10     think it is actually correct to say his blood pressure
  11     was low. If you look at the charts, they seem to have
  12     been aiming at a systolic pressure of 120, which I would
  13     have said is really generous for a child of this age.
  14     I think the lowest it ever got was about 100 systolic,
  15     which, for the age of a year, a child on a ventilator,
  16     would not cause me any particular worry, provided other
  17     things were okay and the child was perfusing well.
  18        So that is the first point. I think we are
  19     looking at this on the assumption that there appears to
  20     have been a problem with the cardiac output, and what
  21     I am saying is that my reading of the notes was that
  22     that was not the problem, and indeed, I think what
  23     Mr Wisheart wrote is consistent with his having the same
  24     view.
  25        But, yes, I mean the possibilities, if the venous

   1     pressure is high, in these circumstances, I would agree
   2     the things you have to consider are poor function of the
   3     ventricles, some obstruction somewhere in the
   4     circulation, and that obstruction may be in the form of
   5     tamponade, that is to say, compression of the heart
   6     preventing its filling and therefore preventing it being
   7     able to pump.
   8   MR LANGSTAFF: So you would really start the discussion with
   9     saying, you have a high CVP here; there has to be
  10     a reason for that. We can exclude ventricle failure,
  11     because there is not here, so there is some obstruction
  12     which might be compression.
  13   DR JORDAN: No, what I would say is that you actually have,
  14     if anything at this stage a somewhat high blood pressure
  15     and the whole thing may simply be that the child has
  16     been over-transfused, he has been given too much fluid,
  17     too much volume. As I say, my understanding is that
  18     that is Mr Wisheart's message -- I think it was
  19     Mr Wisheart who wrote that?
  20   MR LANGSTAFF: I think if we go overleaf, we will see it is
  21     his initials. Page 35, let us see his initials on
  22     that.
  23   DR JORDAN: Could I just say that your experts, and myself,
  24     are really doing this on the basis of what is written in
  25     the notes rather than seeing the patient, which I think

   1     both of us would agree is not absolutely ideal, but if
   2     you are asking us what we think about what is written in
   3     the notes, then I think we can give you a view of the
   4     possibility, but it is not the same as seeing the
   5     patient.
   6   MR LANGSTAFF: I am sure that must be appreciated by all.
   7     I invite you to give us the best you can, which I am
   8     sure you have been doing.
   9   MR DEVERALL: Could I ask a question which we cannot answer
  10     from the notes of this child, but just so that I can
  11     understand, this child was operated on in the Royal
  12     Infirmary?
  13   DR JORDAN: That is correct.
  14   MR DEVERALL: By Mr Dhasmana so the child is nursed in the
  15     predominantly adult Intensive Care Unit, correct?
  16   DR JORDAN: Yes. He is nursed in the Intensive Care Unit,
  17     about which I am sure the Inquiry has heard a lot of
  18     before.
  19   MR DEVERALL: I have only been here two days, so forgive
  20     me. The child is nursed by nurses from the Children's
  21     Hospital or from the adult hospital?
  22   DR JORDAN: They are employed in the adult hospital. They
  23     may or may not have had, from memory at this time,
  24     training in paediatric work.
  25   MR DEVERALL: So this is not a criticism of the individual

   1     concerned, and I do not know who was concerned, but the
   2     nurse looking after this child may or may not have had
   3     experience in looking after a sick child?
   4   DR JORDAN: We also have to remember it is the junior
   5     surgical staff.
   6   MR DEVERALL: I am coming to that. I am asking specifically
   7     whether the nurse would have been familiar with the
   8     volumes that Mr Langstaff has been referring to through
   9     reading Mr Wisheart's report. Is it possible that the
  10     nurse -- let me put it as speculation -- caring for this
  11     child during the first post-operative night was not
  12     trained in the care of young children?
  13   DR JORDAN: Yes, it is quite possible. What exactly one
  14     means by "trained" -- but not of training or experience
  15     that one would hope to have, let us put it that way.
  16     That is possible. I do not know.
  17   MR DEVERALL: So it is conceivable she would not be familiar
  18     with the sorts of volumes of infusion which you would
  19     perhaps expect if he was a 1 year old child as opposed
  20     to a bigger person.
  21   DR JORDAN: That, on my understanding, is quite possible,
  22     yes.
  23   MR DEVERALL: May I continue?
  24   MR LANGSTAFF: Yes.
  25   MR DEVERALL: If we can move on to the medical or surgical

   1     staff who are responsible for the care, Mr Dhasmana and
   2     his team, presumably are there in the immediate
   3     post-operative period until there is some stability.
   4     Who is responsible for the care during the night?
   5   DR JORDAN: It would be Senior House Officers who are
   6     surgical Senior House Officers, basically. That is my
   7     recollection of how it was in 1992, bearing in mind my
   8     somewhat limited involvement.
   9   MR DEVERALL: But by definition, they would have a variable
  10     degree of training in looking after any post-operative
  11     patient, let alone a small baby.
  12   DR JORDAN: Yes.
  13   MR DEVERALL: I noticed that the next morning we have
  14     Mr Wisheart's comments. There may have been all sorts
  15     of explanations, but as a generalisation, would it not
  16     be the normal practice for the surgeon who did the
  17     operation to see his patient on the following morning?
  18   DR JORDAN: Yes. My understanding is that it was. But it
  19     did, I think, sometimes depend upon the surgical
  20     programme. There were some operations, to the best of
  21     my recollection where surgeons would want to be in the
  22     theatre from the moment the anaesthetist started to
  23     induce the patient.
  24   MR DEVERALL: Again, please may I ask Dr Jordan to
  25     speculate -- this is not evidence, it is speculation: is

   1     it possible on occasions that the surgeon who did the
   2     operation would not necessarily communicate to his other
   3     colleague what events occurred in the operating room?
   4   DR JORDAN: It is speculation, and I am not sure it is not
   5     a question that is not better really asked directly to
   6     the two surgeons concerned. I can imagine circumstances
   7     where this might not happen, yes.
   8   MR DEVERALL: I am sorry.
   9   MR LANGSTAFF: Not at all. I am lost in admiration.
  10        The note Mr Wisheart makes at the top of page 35:
  11     he recommends no more colloid, and at line number 5, he
  12     is giving a diuretic, plainly trying to get rid of the
  13     additional volume.
  14        Can I ask about that? Dr Silove, would the
  15     additional volume which had been given in terms of
  16     colloid, needing a diuretic, have had an impact, do you
  17     think, upon the pressures which are recorded?
  18   DR SILOVE: That in itself could also cause the CVP to go
  19     up, as Dr Jordan, I think, has pointed out. So, yes, it
  20     could have had an impact. I think later on there was
  21     a note saying that the CVP had come down a bit, but it
  22     still remained high throughout, so far as I could make
  23     out.
  24   MR LANGSTAFF: So the point you would make about that is
  25     that for a surgeon who may not have known what had

   1     happened in operation, this was a reasonable
   2     investigation, or reasonable approach, was it?
   3   DR SILOVE: , I am sorry, which approach?
   4   MR LANGSTAFF: What Mr Wisheart was recommending here.
   5   DR SILOVE: The course of management was quite reasonable at
   6     that stage, but I still think that could have been tried
   7     for a short while and if it did not work pretty soon,
   8     I think the right approach would have been to explore
   9     the chest.
  10   MR LANGSTAFF: You make the point that here there is,
  11     because of the particular features which you identify,
  12     at least some suspicion of the possibility of
  13     compression or obstruction and one would wish to rule
  14     out the question of tamponade, as it appears was
  15     considered at the time.
  16        Why is it that you would say this echocardiogram
  17     that was done on 10th January, going back to the
  18     page before, page 34, why do you think this is
  19     a misinterpretation or may be misleading?
  20   DR SILOVE: Because an echocardiogram is not -- with
  21     echocardiography, you need several -- you probably need,
  22     I was going to say, several millimetres of fluid around
  23     the heart to be able to identify that fluid around the
  24     heart. If there is blood clot, then it will not be all
  25     around the heart, it will just be compressing in a more

   1     localising fashion, and you might not see that at all.
   2     I think echocardiography is more reliable for diagnosing
   3     tamponade in the early post-operative period.
   4   MR LANGSTAFF: Is that basically your views as well,
   5     Dr Jordan?
   6   DR JORDAN: Not quite. Again, I have to speak as someone
   7     whose involvement with continuous post-operative care of
   8     patients having open-heart surgery was somewhat limited,
   9     as I think you will realise. I agree with the premise
  10     that you must not, I think, say that an echocardiogram
  11     which does not show tamponade necessarily excludes it.
  12     I think you have to take it with other things. It is
  13     slightly unfortunate, I think, that Dr Murphy, the
  14     echocardiographer, who is a consultant radiologist, the
  15     other member of the team with Dr Wilde, that she simply
  16     said "good ventricles". It would be nice to know
  17     whether not only were they contracting well, but they
  18     were filling well, because one of the features about
  19     tamponade is the ventricles are small. This is really
  20     the basic problem: they to not get a chance to fill with
  21     blood. So a little more description on her part.
  22        I would think Dr Murphy was experienced enough,
  23     I mean, she did quite a lot of echos in the situation on
  24     the cardiac surgical ward post-operatively, would
  25     actually be experienced enough to comment on the fact if

   1     the ventricles were compressed, even if she could not
   2     actually see fluid. Again, I am in the position of
   3     trying to help you perhaps too much by saying what
   4     I think from knowledge of the person concerned and the
   5     situation that there might be more to be read into that
   6     report than is actually written there.
   7   DR SILOVE: I am sorry, on the typed report which we looked
   8     at, she had actually typed "LV contracts well", so here
   9     we have just handwritten "good ventricles". Presumably,
  10     it means the same thing.
  11   MR LANGSTAFF: I think the point Dr Jordan is making is that
  12     it is one thing to say "contracts well", you would also
  13     want to know whether they fill well, and you do not from
  14     the report.
  15   DR SILOVE: Yes, I think we are going to continue to dither
  16     on this question.
  17   MR LANGSTAFF: Can we let Dr Jordan come?
  18   DR JORDAN: I would make the point that there is a situation
  19     where the blood collects around the back of the heart
  20     particularly and that is therefore not immediately
  21     apparent as a complete sort of encircling area which you
  22     see as an area of very low echo density. Sometimes it
  23     is actually pushed up behind and actually obstructs the
  24     pulmonary veins, but I do not think that will be
  25     a situation at all likely from the sort of surgery that

   1     was carried out here.
   2   DR SILOVE: If I may just bring my own personal experience
   3     into this question of tamponade, we adopt the approach
   4     which I have suggested in our practice in Birmingham:
   5     the cardiologists are very closely involved. The
   6     cardiologists do echocardiograms within an hour or two
   7     of any patient returning from theatre. They do
   8     echocardiograms the next morning and if there is
   9     a patient who has a high CVP and there is any question,
  10     has this patient got tamponade, the echocardiogram is
  11     not done in order to look for pericardial fluid. The
  12     echocardiogram is done to check on whether the ventricle
  13     function looks good. If the ventricular function looks
  14     good, we say there is probably tamponade, or likely to
  15     be tamponade, it is worth having a look and the surgeons
  16     will open the chest.
  17        That is our experience, and it happens quite
  18     frequently.
  19   MR LANGSTAFF: I think we will move on. We have measured
  20     the extent of the opinions here.
  21   THE CHAIRMAN: I just wanted to ask one question for
  22     clarification, again. You were helpfully saying that
  23     sometimes knowing the person who has written the report
  24     one can read more into it than may be there on its face,
  25     but I think Mr Deverall was saying there might be people

   1     with less training or less familiarity who would
   2     necessarily read it on its face.
   3        Would that be a fair point?
   4   DR JORDAN: The echocardiograms done in these circumstances
   5     were done by Dr Wilde, Dr Murphy or, rather less
   6     frequently it has to be said, by the cardiologists.
   7     I think we were not only more experienced in
   8     echocardiography, but also aware of the sort of things
   9     Dr Silove and I have been discussing, which are really
  10     the limitations of the procedure.
  11   THE CHAIRMAN: I am perhaps not making my point clear,
  12     forgive me if I am not, but someone going to the records
  13     who is the trainee on duty -- the SHO or whatever on
  14     duty that night, may not be able to read into these
  15     reports -- this is what I am putting to you for your
  16     help -- the wisdom that you would bring because you know
  17     what might have been intended.
  18        Is that a fair point?
  19   DR JORDAN: Yes. I think it is to some extent. It is very
  20     tempting to say a cardiologist does not do an echo until
  21     he has done a clinical examination whereas a radiologist
  22     does an echocardiogram and writes it in the notes. That
  23     is a bit simplistic, but I think that is correct.
  24   DR SILOVE: I think what I am trying to highlight, really,
  25     is the difficulties that I can see the cardiologists

   1     must have had in Bristol in not being on the Intensive
   2     Care Unit as frequently as they would have been if the
   3     cardiac surgery had been done in their own hospital.
   4     I take Dr Jordan's point that echocardiograms were done
   5     on the Intensive Care Unit, but there was a thread of
   6     comments running through so many of the Clinical Case
   7     Note Reviews to the effect, no echocardiography
   8     post-operatively on ICU. We saw this as a comment time
   9     and again in the 80 cases.
  10   MR LANGSTAFF: There was one done here, plainly.
  11        Can I move forward from here? We know, because we
  12     have looked at the postmortem report already, that as it
  13     turned out, for whatever cause, there was
  14     intrapericardial blood found at postmortem around the
  15     area of the anastomosis. One hypothesis might be that
  16     that would have been a seepage or leakage from the
  17     anastomosis.
  18        If that had been the case -- again, I am asking
  19     you to work back -- would that have been the sort of
  20     leakage, do you think, to put pressure on the heart or
  21     the vessel so as to cause the signs that we have seen in
  22     the notes thus far?
  23   DR SILOVE: What I am saying is that it could have done.
  24     I am not saying it was the cause, but I am saying it is
  25     a possible cause that should have been excluded by going

   1     in and having a look.
   2   MR LANGSTAFF: Is that something you want to comment on?
   3   DR JORDAN: There is one point I think we need to clarify,
   4     and that is that, as I understand it, the pericardium
   5     was left open to both pleural cavities.
   6   MR LANGSTAFF: It would normally be, would it not?
   7   DR JORDAN: No, normally efforts are made in intracardiac
   8     operations not to allow too much communication with
   9     pericardial cavities, but my understanding in this
  10     case -- it is actually in Mr Dhasmana's operation
  11     note -- is that that because both of the pleural
  12     cavities had been opened into the pericardium, and this
  13     again does not entirely exclude tamponade occurring, but
  14     there is a way for the blood to leak out of the area
  15     around the heart where it is most likely to cause
  16     problems into the cavities around the lungs where there
  17     is more space, and although it can be serious, it is not
  18     quite as serious as having the same amount of blood
  19     around the heart.
  20        I would have said that there was an additional
  21     reason for, if you like, not being too concerned about
  22     the possibility of tamponade, and that is the particular
  23     way in which the pleura and the pericardial cavities
  24     were left. I am sorry, I am once again transgressing
  25     into surgery. What I am trying to do is to put myself

   1     in the position and saying, as Dr Silove was saying, we
   2     have to find a reason why the venous pressure is so high
   3     and if you believe it was low, the blood pressure is
   4     low, how can we be quite sure this child does not have
   5     tamponade, because it is the one thing that is
   6     considered to be very dangerous and yet very easily
   7     treatable in the post-operative period.
   8   MR LANGSTAFF: And the way to resolve that is to realise the
   9     possibility first, and then is it to open her up and
  10     have a look?
  11   DR JORDAN: If you cannot exclude it, I am sure both the
  12     experts would say, if you cannot confidently exclude it,
  13     there is only one thing to do and that is to open the
  14     chest, open the pericardium again.
  15   MR DEVERALL: Could I intervene, sir, please?
  16   MR LANGSTAFF: Certainly.
  17   MR DEVERALL: I have been trying to do some maths for you to
  18     put things into context. With some assumptions, the
  19     stroke output, the amount of heart blood the heart would
  20     put out in each beat in a baby of this size would be
  21     about a teaspoonful in comparison to our two
  22     tablespoonfuls of collected blood clot, about 4 to 5ccs
  23     per beat, so the amount of blood in the heart in total
  24     would be about half that 30 ml.
  25   MR LANGSTAFF: Thank you for that.

   1   MR DEVERALL: It was a point from earlier I was trying to
   2     clarify it.
   3   MR LANGSTAFF: The point Dr Silove was making was that if
   4     there had been the opportunity to have a more active
   5     cardiological presence on the ICU ward, is it likely, as
   6     he suggests it might have been, that the danger would
   7     have been perhaps highlighted more and the child might
   8     have been opened up and if it was the problem -- we do
   9     not know whether it was or not -- then rectify it?
  10   DR JORDAN: I think it depends on who else was there at the
  11     time. I think if you have someone like Mr Wisheart
  12     there, I doubt if the cardiologist would actually make
  13     a significant contribution. I am sure we would discuss
  14     it, but I am equally sure he would feel it was something
  15     that was his responsibility, and his responsibility
  16     alone to decide, unless the cardiologist would come in
  17     and say, "look, there is something I have found that
  18     explains it, hang on a minute". But in general terms,
  19     I think it is a decision that a consultant cardiac
  20     surgeon would make the decision without feeling he had
  21     to ring up the cardiologist to come and help him.
  22   MR DEVERALL: Sir, I am sorry, but having worked in
  23     a hospital where adult and children's patients are
  24     nursed on the same intensive care unit, in two different
  25     parts of the country, and may be you do not know the

   1     answer to this, which is fine, but if there was an
   2     necessity, or if it was thought that re-opening the
   3     chest might be useful in managing a child, would that
   4     take place in the ward or would there be a feeling that
   5     the child should be transferred to the operating room
   6     for that event?
   7   DR JORDAN: It depends on the circumstances. In my
   8     experience, when this was done -- under those
   9     circumstances that we have here and that is not what you
  10     might call an absolutely immediately life-threatening
  11     situation, I am sure they would have taken the patient
  12     back to the operating theatre to explore it.
  13   MR DEVERALL: So by definition and in following what you
  14     have already said about Mr Dhasmana possibly being
  15     otherwise involved and knowing about the availability of
  16     operating space, now in this child, we are now the next
  17     morning in an area overlapping with other operating
  18     events, so it is possible -- possible -- that an
  19     operating theatre would not have been available.
  20   DR JORDAN: They would have done it in the anaesthetic
  21     room.
  22   MR LANGSTAFF: Sir, would that --
  23   THE CHAIRMAN: I have one further question. You said to
  24     Dr Silove's observation about the benefit or otherwise
  25     of having a cardiologist in the Intensive Care Unit, if

   1     the surgeon was something like Mr Wisheart, he might
   2     have a conversation but he would feel it was his
   3     decision.
   4        Is that a comment which is, as it were,
   5     Mr Wisheart-specific, or is it a comment upon cardiac
   6     surgeons, in your experience generally.
   7   DR JORDAN: It is a comment on cardiac surgeons in my
   8     experience generally, but obviously in the last few
   9     years I have worked with a limited number. I do not
  10     know whether Mr Deverall would like to give you a view
  11     on that.
  12   MR DEVERALL: I think most cardiac surgeons would make the
  13     decision, but I would add a rider that if you are in
  14     doubt, it is very nice to have a hand on your shoulder
  15     saying "go on, open the chest".
  16   MR LANGSTAFF: Sir, on that note, can we leave that case,
  17     the case of Master Good, and perhaps have a short break
  18     before we proceed and learn what lessons there may be to
  19     be learned from the case of Ben Elliott?
  20   THE CHAIRMAN: Yes. Let us take 10 minutes, then and come
  21     back at 3.25.
  22   (3.15 pm)
  23               (A short break)
  24   (3.20 pm)
  25   MR LANGSTAFF: Dr Jordan, may I now turn to the case of Ben

   1     Elliott, and again, as with the other cases, it is
   2     a case on which we have full consent to refer to him and
   3     to the medical records.
   4        This was a boy born on 8th October 1989, who was
   5     diagnosed appropriately as suffering from pulmonary
   6     atresia and VSD.
   7        If I can go through the early history fairly
   8     quickly and come to the particular parts where there may
   9     be matters of interest for the Inquiry, he was seen by
  10     you in Bristol in October 1989, three days after birth.
  11     You gave him an echocardiogram and diagnosed the
  12     condition. The plan was to continue on prostin and that
  13     happened.
  14        There was subsequently an echocardiogram done by
  15     Dr Martin and the cardiac catheter on 13th October 1989,
  16     that is aged five days, by Dr Martin, which gave various
  17     measurements of the pulmonary arteries. He went for
  18     operation on 14th October 1989, at which there was
  19     a modified Blalock-Taussig shunt so that would be
  20     a Goretex tube.
  21        Thereafter, he was transferred back to Treliske in
  22     late October 1989, in stable condition. He was seen by
  23     you, I think, in clinic in Truro.
  24   DR JORDAN: That is correct, yes.
  25   MR LANGSTAFF: On a number of occasions, and in July 1990

   1     you planned him for the catheter list in October 1990.
   2     He had now been getting on for a year old. On 18th
   3     September 1990, just coming up to a year of age, he had
   4     a cardiac catheter and that is where I want to begin to
   5     ask you more detailed questions.
   6        We pick that up, I think, in the medical reports
   7     at MR 401/50. There is a description here of the
   8     report. If we look underneath "right ventricle", four
   9     lines down:  MR 401/51
  10        "The main pulmonary artery appears to have grown
  11     somewhat to a substantial size compared with the
  12     previous examination. The region of the proximal right
  13     pulmonary artery is not well seen and may well have been
  14     increased in size but this cannot be stated with
  15     complete confidence. A left-sided modified shunt to the
  16     left pulmonary artery is seen and this is associated
  17     with some narrowing of the left pulmonary artery at its
  18     site of insertion.
  19        "The previous communication to the left pulmonary
  20     artery is better seen on this examination, as is the
  21     opacification of the pulmonary artery itself. Again,
  22     the origin of the right pulmonary artery cannot be
  23     assessed adequately."
  24        It is summarised at the bottom of the page, the
  25     third line down:

   1        "The appearances have shown significant pulmonary
   2     artery growth since the previous examination, although
   3     there is still some uncertainty about the origin of the
   4     right pulmonary artery and there is some narrowing in
   5     the mid-left pulmonary artery."
   6        Just pausing there, the whole purpose of doing the
   7     Blalock-Taussig shunt would be in fact to enable the
   8     pulmonary arteries to grow and this would appear to have
   9     happened, did it.
  10   MR JORDAN: There are two reasons for doing it. One is to
  11     relieve the hypoxia, and the other is to encourage the
  12     pulmonary arteries to grow, yes.
  13   MR LANGSTAFF: There seems to have been a difficulty with
  14     the origin of the right pulmonary artery here. Were
  15     there any techniques available to you by which this
  16     might have been better imaged or where one might get
  17     a better idea of where the right pulmonary artery came
  18     from.
  19   MR JORDAN: In other circumstances, one might well have done
  20     a catheter and you would have to have done an arterial
  21     catheter to do this, to get into the shunt and actually
  22     make an injunction into the shunt or actually go through
  23     the shunt, but the reason why I do not think most
  24     cardiologists would attempt it is that this was
  25     a Goretex shunt and we know that if you put catheters

   1     down Goretex shunts, the inner lining they develop may
   2     come adrift, and I, and I think other cardiologists,
   3     would have had the unfortunate experience of doing this
   4     and blocking the shunt up and obviously putting the
   5     child into a critical condition.
   6        So the quick answer is, I am open to suggestions,
   7     but the other possibility that we might otherwise have
   8     considered, I did not regard as a safe option.
   9   DR SILOVE: I agree absolutely with Dr Jordan that I would
  10     not put a catheter down a Goretex shunt this child had
  11     had a left-sided modified shunt because there was an
  12     aberrant origin of the right subclavian artery and I am
  13     sure that is the absolutely correct operation to have
  14     done initially, but the catheter did enter the aorta.
  15     There was an aortogram. I just wonder if the catheter
  16     could not have been passed on into the left subclavian
  17     artery, to try to outline the shunt. I do not mean
  18     putting it down the Goretex, but an injection in the
  19     left subclavian artery would have had a better chance of
  20     opacifying the pulmonary arteries better.
  21   DR JORDAN: It is not of course purely a question of
  22     opacifying them. To some extent, it is a question of
  23     the angles at which you see them. I do not know whether
  24     the Panel who reviewed this case looked at the
  25     angiograms. I have not seen the angiograms and I am not

   1     sure whether it was a problem of the amount of contrast
   2     medium.
   3   DR SILOVE: Unfortunately it seems there was no angio
   4     available to them either. When I was asked to look at
   5     the medical records, there was no angio available to me,
   6     but it did occur to the Panel that reviewed it, and it
   7     occurred to me that perhaps an injection to the left
   8     subclavian artery might have shown the pulmonary
   9     arteries better.
  10        Basically, the blood flow going to the pulmonary
  11     arteries is almost all going down the shunt. The closer
  12     you are to the shunt when you do the angio, the better
  13     chance you have of showing the pulmonary arteries. That
  14     was the only point.
  15   MR LANGSTAFF: That was the only point you wanted to make on
  16     that?
  17   DR SILOVE: Yes.
  18   DR JORDAN: I would agree with exactly what he says: there
  19     is a possibility that if you had done this you would
  20     have got better pictures.
  21   MR LANGSTAFF: But equally, a possibility you might not have
  22     done?
  23   DR JORDAN: Absolutely. It is obviously not just a question
  24     of getting better pictures but getting more information
  25     out of it.

   1   DR SILOVE: I agree with that, there is no problem there.
   2   MR LANGSTAFF: The sort of information you want to end up
   3     with, if you are contemplating an operation, which
   4     plainly you were at this stage, would be to get an idea
   5     of the origin and location of the arteries, and their
   6     size, presumably.
   7   DR JORDAN: What you would like to know is the size and also
   8     whether there is any pressure gradient, but there is no
   9     way you will get a pressure gradient that I know of
  10     without wriggling your catheter down the Goretex shunt,
  11     which -- I think you have a measure of agreement -- is
  12     not a good thing.
  13   MR LANGSTAFF: So do we have, in the notes, actual
  14     measurements of the size of the arteries?
  15   DR SILOVE: From what I could find, the only measurements
  16     that were done were of the first cardiac catheter done
  17     in 1989. What we need to look at, were there any
  18     measurements done on this cardiac catheter which was
  19     done in 1990, September 1990. I could not find any
  20     record of any measurements of the pulmonary arteries.
  21     I think it is quite an important thing to do, if you are
  22     considering a corrective operation.
  23   MR LANGSTAFF: I think there is agreement upon the
  24     importance of it. I think the question is, if they had
  25     been done they would have been noted, presumably.

   1   DR JORDAN: There are two times when this is done.
   2     Sometimes the radiologist who wrote the report made
   3     measurements. The other thing was that if the surgeon,
   4     when we reviewed the angiograms, had concerns and asked
   5     for it, then it is possible to measure them actually
   6     while we are in the middle of doing our discussion.
   7     But, I agree, I cannot find any measurements. I am
   8     rather taken by the word "substantial", which to me is
   9     rather more generous than the term that is very often
  10     applied to the pulmonary arteries in the condition when
  11     you have tried to persuade them to grow. There is an
  12     indication of what -- one might almost say pleasure at
  13     the fact that they are large enough, implicit in that.
  14   MR DEVERALL: I think if I could interrupt and take issue,
  15     what it actually says there, "has a substantial growth
  16     of the main pulmonary artery". It goes on to say that
  17      "the origin of the right pulmonary artery cannot be
  18     assessed and that there is narrowing at the connection
  19     site of the Goretex graft".
  20        So I would take equal "pleasure", as you would in
  21     the growth of the main pulmonary artery, but the reality
  22     is that distal to that the situation may well have got
  23     significantly worse on both sides, compared to the
  24     figures which were quoted in the catheter done on the
  25     13th October 1989.

   1   DR JORDAN: I do not see why there should be any suggestion
   2     that they have got worse from that report.
   3   MR DEVERALL: All right, well --
   4   MR LANGSTAFF: Leave aside the question of "worst", I do not
   5     think we need to go into that because that would be
   6     really over-interpreting the notes, would it not?
   7   MR DEVERALL: While I accept your admonition, the surgeon
   8     has been in and has manipulated the left pulmonary
   9     artery with the Goretex graph. It is well known unless
  10     the operation is extremely well executed, you can end up
  11     narrowing the pulmonary artery at that point. It says
  12     so: "The pulmonary artery was somewhat narrowed at the
  13     site of the growth"; I am not dreaming this up, it is
  14     written in the notes.
  15   MR LANGSTAFF: The fundamental point appears to be there is
  16     actually no measurement of size. You are struck by the
  17     fact that the main pulmonary artery is referred to as
  18     substantial, which means it appears to be a good size,
  19     but there is no measurement so far as one can see of the
  20     left or the right.
  21   DR JORDAN: I agree, I have found no measurements.
  22   MR LANGSTAFF: When one is looking at it from a surgical
  23     aspect, how important is it to have the measurements?
  24   MR DEVERALL: It is very important. Surgeons correcting
  25     tetralogy-like lesions -- and this is another one in the

   1     same spectrum -- very early on, and I am talking about
   2     the late 1960s, realised a major determinant of the
   3     success of the operation was the size of the pulmonary
   4     arteries.
   5        In the 1970s, we all used what was called the
   6     McGoon formula, you added together the diameter of the
   7     left and right pulmonary arteries, described on
   8     13/10/89, and if they were equal to or greater than the
   9     diameter of the descending aorta you had a reasonable
  10     expectation all would be well, but it was sufficiently
  11     inaccurate for some tables to be constructed, which
  12     I know from other experiences Mr Wisheart and Dhasmana
  13     had in the operating room at least at the Bristol Royal
  14     Infirmary, the so-called Z tables, where the diameters
  15     of the right and left pulmonary artery corrected for
  16     body surface area are available for normal individuals,
  17     and then you can predict on the basis of what percentage
  18     of the normal size is measured as to what the
  19     post-correction right ventricular pressure will be and
  20     that was a huge advance in the management of tetralogy
  21     of Fallot, and was introduced to my knowledge about
  22     1975. I know from other notes that that was available
  23     to you in the operating room. I do not know whether it
  24     was available in the catheter lab.
  25   MR LANGSTAFF: You say "to you", you mean to the surgeon?

   1   MR DEVERALL: To my colleagues here in Bristol.
   2   MR LANGSTAFF: Can we go to the operation note, because
   3     after this catheter, he was seen I think by Mr Dhasmana
   4     and put on the waiting list; admitted on 8th March for
   5     operation; discharged because of respiratory infection.
   6     Readmitted on 31st May 1991, and came to operation on
   7     4th June 1991.
   8        I think there had been no further investigation by
   9     echo or angio which is reported in the notes between
  10     what we have just looked at and the operation.
  11   DR JORDAN: That is my understanding.
  12   MR LANGSTAFF: So if we go to the operation note which is
  13      213/23, this is a total repair operation. If we go to
  14     the findings, we can see that there what is found, "the
  15     left-sided shunt causing a little deformity, both
  16     pulmonary arteries comparatively narrow, especially the
  17     bifurcation" and it gives an indication of the size. It
  18     sets out the procedure.
  19        If we go overleaf to 24, described about four
  20     lines down "The main pulmonary artery was opened as the
  21     pulmonary valve was dysplastic".
  22        It goes on describing, just about the black dot on
  23     the right-hand side, "Though the pulmonary arterial
  24     orifices were enlarged at the bifurcation, the
  25     peripheral pulmonary arteries still appeared narrow" ...

   1        It goes on then to describe how though the patient
   2     was weaned off cardiopulmonary bypass the right
   3     ventricular pressure was suprasystemic. It sets out the
   4     pressures and says how that improved after an hour, but
   5     still the right ventricular pressure was systemic.
   6        We dealt earlier with the question of the systemic
   7     pressures and there it was different, but that is
   8     something which does not bode well, does it?
   9   DR JORDAN: It is considered desirable to have the right
  10     ventricular pressure below the systemic pressure.
  11     I think most of the figures that are used actually apply
  12     to what you might call a full-blown tetralogy of Fallot,
  13     whereas this, I think, would be regarded by most people
  14     as being pulmonary atresia, even though the
  15     investigation did show a very small way through the
  16     pulmonary valve.
  17        Again, you are asking me a surgical question about
  18     exactly what effect or what the surgeon is supposed to
  19     think under these circumstances.
  20   MR LANGSTAFF: Let me ask the surgeon. Perhaps if I can
  21     just again put in it lay terms, is the problem here that
  22     the right ventricle is having to pump the blood through
  23     arteries which are simply too small?
  24   MR DEVERALL: Yes. The ventricular septal defect, the
  25     communication between the two ventricles has been closed

   1     as part of the operative procedure. Therefore the right
   2     ventricle has no option but to seek to pump its content
   3     through the pulmonary arteries.
   4        What concerns me in the operation note, we have
   5     seen the estimation of the size of the pulmonary
   6     arteries even in the first catheter, if not the second
   7     catheter. Mr Dhasmana -- I assume it was Mr Dhasmana --
   8     says:
   9        "Though the pulmonary artery orifices were
  10     enlarged ... admitting only 7 Hegar", a Hegar is a metal
  11     instrument and the "7" refers to its circumferential
  12     size. Pi x d means the diameter of the pulmonary
  13     arteries was 2.3 ml, not only less than that predicted
  14     at the first catheter, but certainly shows no evidence
  15     of enlargement of the pulmonary arteries as a result of
  16     the first shunt.
  17        My only point in saying all this is that the
  18     findings at the operation and the size of the pulmonary
  19     arteries predicted that this child was likely to die
  20     post-operatively if the VSD was closed, and it was
  21     closed.
  22   MR LANGSTAFF: So what you are saying is that this operation
  23     on this child at this time could not have succeeded.
  24   MR DEVERALL: Sorry to use maths, but the Z tables which you
  25     have in the operating room would have told you that this

   1     child was likely to die if the complete correction was
   2     attempted.
   3   MR LANGSTAFF: That is because of the size --
   4   MR DEVERALL: The size of the pulmonary arteries.
   5   MR LANGSTAFF: Essentially, you have heard what Mr Deverall
   6     has to say. Do you want to comment on that; does that
   7     sound right to you?
   8   DR JORDAN: I have no knowledge of the size of Hegar
   9     dilators, so I do not think I can comment on what that
  10     means.
  11   MR DEVERALL: I can assure you, seven is the circumferential
  12     diameters.
  13   DR JORDAN: They used to be graded in inches. These are
  14     now millimetres, are they?
  15   MR DEVERALL: That is correct.
  16   MR LANGSTAFF: Dr Silove, I think, has to leave us at this
  17     stage. We have not quite, I think, finished and almost
  18     drawn the lessons of Ben Elliott that it has to show us,
  19     but perhaps this might be an appropriate moment to stop
  20     and invite Dr Jordan to come back tomorrow at 9.30, as
  21     had previously been arranged. We have the advantage of
  22     Mr Deverall here, and I anticipate that our next case
  23     will not take us very long. Then I can hand over the
  24     baton, as it were, or the microphone to Mr Maclean.
  25   DR JORDAN: Am I to understand we have finished with this

   1     case, because there was one comment --
   2   MR LANGSTAFF: You may want to make some comments and it is
   3     important we should hear and have those, but perhaps
   4     that could wait until tomorrow morning.
   5   THE CHAIRMAN: You are content to wait?
   6   DR JORDAN: Yes.
   7   THE CHAIRMAN: Thank you. I should not close today's
   8     proceedings without thanking Dr Silove, who has to wing
   9     his way elsewhere. Thank you very much indeed. The
  10     Panel greatly appreciate, again, your assistance. We
  11     are much in your debt.
  12        We reconvene, Dr Jordan, tomorrow at 9.30, so it
  13     is good afternoon to everyone.
  14   (3.50 pm)
  15   (Adjourned until 9.30 am on Thursday, 18th November 1999)
  16
  17
  18                I N D E X
  19
  20     MRS MARIA SHORTIS (sworn)
  21        Examined by MISS GREY ........................ 1
  22        Examined by THE PANEL ........................ 64
  23        Re-examined by MR LISSACK .................... 65
  24
  25     DR STEPHEN JORDAN (sworn)

   1        Examined by MR LANGSTAFF ..................... 69
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001