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 18th November 1999 The Bristol Royal Infirmary Inquiry oral hearings this week focus on the Directorate of Cardiology, United Bristol Healthcare NHS Trust (UBHT). Today we continued to hear from Dr Stephen Jordan, Emeritus Consultant Cardiologist, UBHT, retired 1993. Dr Stephen Jordan began his evidence today by continuing to comment on individual cases reviewed by independent experts as part of the Inquiry’s Clinical Case Note Review. He then went on to answer questions about evidence contained within his written statement. He discussed the decision made by the Supra-Regional Services Advisory Group to recognise Bristol in 1984 as a centre designated to provide infant and neo-natal cardiac surgery. He went on to describe discussions with the Welsh Medical Committee and the Welsh Office relating to referrals from South Wales to Bristol during the 1980s and 1990s and the decision to establish a paediatric cardiac service in Cardiff. Dr Jordan then responded to the issue of concerns raised by Welsh clinicians in 1986 about the quality of the Bristol service. He then talked about referrals for surgery made by the Bristol cardiologists outside Bristol and compared waiting times in Bristol against other units. Next he described meetings held between clinicians to discuss mortality and touched upon the use of audit to identify potential changes in practice. Dr Jordan was asked to comment on written evidence from referring clinicians about referral practice. He then discussed the issue of the split site and the limitations of providing a service from two hospitals and noted the funding implications of unifying the service. He concluded by discussing the impact of the criticisms made and concerns raised about the cardiac unit upon the clinicians involved. Mr Philip Deverall, retired Consultant Paediatric Surgeon, attended today’s hearing in his capacity as a member of the Inquiry’s Expert Group.

FULL TRANSCRIPT

   1               Day 79, Thursday, 18th November 1999
   2   (9.35 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Dr Jordan. Mr Langstaff?
   5        MR LANGSTAFF RE FURTHER LINE OF INQUIRY:
   6           OPERATIONS AFTER 1 MAY 1995
   7   MR LANGSTAFF: Sir, before I take up again on the case of
   8     Ben Elliott with Dr Jordan, may I just say a word about
   9     the matter which was raised yesterday by Maria Shortis
  10     in evidence when she offered a helpful line of inquiry
  11     to this Inquiry.
  12        We have done what can be done thus far to identify
  13     what the facts of the situation are and our inquiries
  14     are still continuing. At the moment we have identified
  15     that there are no more than 7 cases and probably
  16     a number less than that in which Mr Wisheart may have
  17     operated on a child after 1st May 1995.
  18        Again, present information suggests that in only
  19     one of those, that is the case of Andrew Peacock we have
  20     heard of, which was 1st May, did the child die and how
  21     appropriate the description of "child" is in some of the
  22     other cases is difficult to say because the age appears
  23     to be in the teens or may be in some cases just beyond
  24     the 16-year watershed. So we are having to look at the
  25     notes to identify that.

   1        It perhaps needs to be said because of some
   2     comment that there has been overnight that there was
   3     a protocol which did not preclude Mr Wisheart operating
   4     provided that was with the consent of the patient
   5     concerned or parent.
   6        Sir, perhaps I can say this: it is of course
   7     remarkably useful to have lines of Inquiry suggested.
   8     If there are others who have concerns as Mrs Shortis did
   9     which they would wish us to investigate, we are very
  10     happy to do that. That is what we are here for.
  11        It would be helpful perhaps to have those lines of
  12     Inquiry given to us as soon as possible so they may be
  13     inquired into thoroughly and the results presented
  14     comprehensively rather than my having as it were to
  15     indicate on almost a day by day basis how we are going
  16     with a particular line of inquiry. That is all I wanted
  17     to say about that this morning.
  18   THE CHAIRMAN: Thank you, Mr Langstaff. I am sure from our
  19     position we would echo that, save that sometimes it will
  20     be useful if lines of inquiry could be explored a little
  21     so as to establish what needs to be known or what is
  22     known before they are aired in such a public forum as
  23     this.
  24           DR STEPHEN JORDAN (RECALLED):
  25            Examined by MR LANGSTAFF:

   1   MR LANGSTAFF: Dr Jordan, I am sorry for cutting into the
   2     time we have today with that more administrative matter.
   3        We were talking about Ben Elliott yesterday and we
   4     had between us looked at the investigations beforehand,
   5     we had come to a view that in effect I think in the
   6     operation what was happening was that the arteries were
   7     too small to accommodate the blood flow, or at least
   8     that was the way we left it yesterday evening.
   9        You had a point you wanted to make which time
  10     precluded yesterday afternoon; do you remember what it
  11     was and would you like to elucidate that now?
  12   A. Yes, there are actually a couple of points, one of them
  13     is a more general one that I can perhaps leave to
  14     later. The particular point is that my understanding of
  15     the operation note is that it was comparing the right
  16     ventricular pressure with the systemic arterial pressure
  17     and I thought that in order to know what was the source
  18     of the obstruction to the flow into the lungs that was
  19     causing the right ventricular pressure to be so high one
  20     would actually need to measure the pressures at
  21     different points in the pulmonary arteries to find out
  22     where exactly the obstruction was.
  23        I think without that -- again, as before, I am
  24     straying on to things that are really surgical matters.
  25     I do not go to theatre to measure these pressures but

   1     had I been there that is information I would have wanted
   2     to know if there was going to be any discussion as to
   3     possible ways to improve the situation.
   4   Q. Again, is it one of those situations where, if there had
   5     been one site and the cardiologist was on site, he --
   6     I am saying "he" rather than "you" because it is
   7     a general proposition -- might have been called to an
   8     operation such as this to assist the surgeon and say
   9     "What do we do now because we have a problem?"
  10   A. I think what you have put is correct, yes. I mean you
  11     did say "might".
  12   Q. In effect the "might" becomes less probable because of
  13     the fact that there are two sites?
  14   A. Yes, I mean less probable. As I have indicated, it is
  15     not impossible, it was not impossible and it happened on
  16     occasions.
  17   Q. Before we leave Ben Elliott I do not know whether there
  18     is any further comment you want to make, Mr Deverall,
  19     before Dr Jordan's final comment on this?
  20   MR DEVERALL: No, what Dr Jordan has said is correct. The
  21     point I was trying to make yesterday is that the
  22     probable outcome in operations of this nature is
  23     improved if the pressure in the ventricle which is
  24     generating the pressure on the right side of the heart
  25     is lower than systemic and hopefully significantly lower

   1     than systemic, the lower it is the more the chances are
   2     that the child will have a very uninterrupted
   3     post-operative recovery.
   4        When the pressure is greater than 75 per cent of
   5     that in the systemic circulation and higher, there is an
   6     increasing probability that there will be major problems
   7     with morbidity and mortality.
   8        If the pressure is greater than that in the
   9     systemic circulation, the probability of major morbidity
  10     or mortality is greater than 50 per cent.
  11        What Dr Jordan says is quite right, why then is
  12     that pressure high? Because there is obstruction and
  13     that obstruction may lie at any level right out into the
  14     small vessels within the lungs, and what Dr Jordan is
  15     implying is that part of the assessment in that
  16     situation in the operating room is to see if there is
  17     a mechanical obstruction which can be relieved by
  18     further surgical plastic treatment of the pulmonary
  19     arteries and that would be a normal part of the
  20     evaluation of the particular situation which applied in
  21     Ben, I agree with what he is implying.
  22   Q. You wanted I think to make a final comment before we
  23     moved on to Ben Elliott to see what lessons the case of
  24     Verity Curnow may help us with?
  25   DR JORDAN: Staying with Ben Elliott for the moment.

   1     I think the point to make is that in this situation, the
   2     thing which has to be determined, and this is what would
   3     have been discussed at our joint meeting is: do you set
   4     out to correct the abnormality, in other words you open
   5     up the right ventricular outflow and make a good way
   6     through to the pulmonary artery and you close the
   7     ventricular septal defect, or do you say in advance
   8     "This may leave us with the sort of problem we know
   9     occurred there and we would aim to knock those
  10     ventricular septal defects, simply open up the right
  11     ventricular outflow, allow a further period for
  12     pulmonary arteries to grow and then go back later to
  13     close the ventricular septal defect.
  14        I am sure Mr Deverall will have something to say
  15     about his experience of this but I think most teams
  16     would say you do not get this right each time and that
  17     the surgeon has both met with the situation where he has
  18     taken the other alternative, that is to open up the
  19     outflow tract and leave the ventricular septal defect.
  20     Three days later the child will not come off the
  21     ventilator because there is an enormous flow through it,
  22     the pulmonary arteries are in fact big enough to take
  23     a very large amount of blood, very much greater than the
  24     normal amount and he then has to go back and do an
  25     operation to close the defect.

   1   Q. What you are saying I think is there is a difficult
   2     choice to be made but a lot depends, does it, from what
   3     you are saying on the size of the pulmonary arteries?
   4   A. I think however carefully, I know we talked about the
   5     question of measuring pulmonary arteries and of course
   6     none of us have seen the angio to know what those
   7     measurements might be, so I do not think you can advance
   8     the argument on either side on the basis of what those
   9     measurements might have been.
  10        What I am saying is that you have to assess it on
  11     the overall appearances, coupled of course, with what we
  12     call the haemodynamics, the measurements of pulmonary
  13     blood flow. Although it was not actually formally
  14     measured I think a rough assessment was that the
  15     pulmonary blood flow prior to this operation was in fact
  16     not far off normal and that is with an obstruction which
  17     was going to be relieved across the right ventricular
  18     outflow. Therefore a reasonable prospect that when that
  19     obstruction was removed, the pulmonary circulation would
  20     be able to cope with the cardiac output, the full
  21     cardiac output which was only going to be marginally
  22     above what it was prior to the operation, if I have made
  23     myself clear.
  24        In other words it is not only a question of
  25     looking at the size of the pulmonary arteries, it is

   1     also a question of studying the haemodynamics, the
   2     actual measurements we make at cardiac catheterisation.
   3        Can I finish because I think it is all part of the
   4     same theme. Again Mr Deverall may have a view on this,
   5     but of these two options and looking at what you may
   6     have to do if you have chosen wrongly, the situation
   7     here where you have elected to close the VSD and then
   8     found the pressure is too high can in fact be dealt with
   9     at the time of operation by re-opening the ventricular
  10     septal defect.
  11        It is slightly complicated here because in fact
  12     Mr Dhasmana had reason to believe from measurements he
  13     made that there was actually still a residual hole there
  14     anyway. The point I am making is that of the two
  15     options, if you like, the bailout situation is somewhat
  16     more straightforward with the option that was chosen in
  17     this case than if you choose the other option where you
  18     will not know until some time after the operation and
  19     therefore you have to do a further operation in order to
  20     put things right.
  21        I am sorry, it is complex subject, I may not have
  22     put it over very well.
  23        What I am simply trying to say is, to go back to
  24     the initial premise: that there are really two options
  25     in a marginal case, if you like, that you opt for:

   1     a total correction or you opt for just right ventricular
   2     outflow and you have to be aware that in quite
   3     a significant proportion of the cases that you submit to
   4     either of these operations, if you regard them as being
   5     marginal from the haemodynamics and the angiograms, that
   6     you will find at some stage, either in theatre or
   7     subsequently, that you have actually made the wrong
   8     decision.
   9   Q. Could I see in my own words whether I have understood
  10     that? Please forgive me if I am in error: there is
  11     a choice of two approaches, one is the total correction
  12     which involves patching the VSD. The second is
  13     concentrating on the right ventricular outflow which you
  14     would hope would eventually expand, enlarge the
  15     pulmonary artery so that the further correction, the VSD
  16     can be closed off at a later operation; those are the
  17     two choices?
  18   A. That is correct.
  19   Q. The question of which choice one makes depends upon
  20     a view as to the haemodynamics and that will necessarily
  21     involve as part of it the size of the pulmonary arteries
  22     because if they are too small to accommodate the flow
  23     from a total correction, the total correction is, for
  24     the reasons Mr Deverall has given, going to fail.
  25        You say if one takes that approach, the total

   1     correction approach and discovers in operation that it
   2     is not going to work for those reasons, that one can
   3     recreate the hole that one has sealed over, the hole of
   4     the VSD and you end up as it were with a situation
   5     which, although it is not ideal, is at least not going
   6     to have the same fatal consequences because you have
   7     relieved the attempt to put too much pressure through
   8     too small tubing. I am putting it very, very basically
   9     in terms; do I have it right?
  10   A. I think that is basically right.
  11   Q. You are pointing out, as it happened in this operation,
  12     faced with the problem he had of the blood flow from the
  13     right ventricle, trying to go through these tubes which
  14     are too small, that Mr Dhasmana assumed there was
  15     a small residual hole in the ventricular septum which
  16     there was not, I think?
  17   A. There was, yes. Sorry to interrupt but just to clarify
  18     this, he made that decision by measuring the oxygen
  19     saturation of the blood in, I think it was the left
  20     atrium where of course it is coming back from the lungs,
  21     it should be fully oxygenated and in the aorta where, if
  22     there is a mixture of blue blood getting into it, it
  23     would be lower and he found it was somewhat lower in the
  24     aorta.
  25   Q. But there was not in this case a controlled opening in

   1     the ventricular septum?
   2   A. He based his thought that there was a hole on that
   3     finding of the difference in oxygen saturations in these
   4     two samples.
   5   Q. Mr Deverall, do you want to come in on those options?
   6   MR DEVERALL: The last point is difficult to accept because
   7     if there is a significant hole between the two pumping
   8     chambers, incomplete surgery or deliberate, the
   9     pressures in the two ventricles are always equal and
  10     they were not, so that is another issue.
  11        Could I try to put this very complex -- I mean,
  12     little Ben had a most unpleasant condition; I would not
  13     wish anybody to think that the results even in the very
  14     best hands today are 100 per cent successful outcome,
  15     they are not, there is a series of complex judgments to
  16     be made. In my professional lifetime I have seen trying
  17     to manage little ones with this condition go from near
  18     100 per cent mortality to, in the very best hands, shall
  19     we say something of the order of a 90 per cent
  20     likelihood of survival with a reasonable quality of
  21     life.
  22        One, therefore, asks oneself the question, why has
  23     that occurred? It did not happen overnight, it did not
  24     happen in any one person's hands. It happened, I think,
  25     for three principal reasons: one is that there was an

   1     acceptance by surgeons and cardiologists that the more
   2     information that both had before making the decision the
   3     better. That is why I was referring yesterday to
   4     pulmonary artery sizes, estimations, mathematical
   5     probabilities, it sounds remote from emotional clinical
   6     decision making, but in fact it is the way forward.
   7        The second is that we have fortunately, and
   8     admittedly when Ben was operated on, we were at an early
   9     stage, developed a series of alternative mechanisms of
  10     assessing the results of our attempts to do the right
  11     thing, and I mean by that intra-operative
  12     echocardiography.
  13        Thirdly, as one of my teachers taught me, never to
  14     go to the operating room with a closed mind. By that
  15     I mean -- and this often takes place in the discussion
  16     with one's colleagues before you go in with a flexible
  17     approach, with a series of options available to you
  18     based on previous experience.
  19        You put all those three together and the results
  20     progressively become better, not suddenly one day on
  21     a Tuesday, but over a period of years.
  22        To try and put things fairly into context: 1991 we
  23     were somewhere along the process of that evolution.
  24   Q. Let us leave Ben Elliott now, if we may, and move to
  25     Verity Curnow's case. Do you have the records there,

   1     Dr Jordan?
   2   DR JORDAN: I do not have the clinical records, I have my
   3     brief summary of the chronology and the form from the
   4     clinical review.
   5   Q. If we first of all have a look at Medical Report 2374,
   6     page 37.
   7   THE CHAIRMAN: As regards which, as ever we say we have full
   8     consent.
   9   MR LANGSTAFF: Indeed we heard evidence at the start of the
  10     Inquiry from Mr Malcolm Curnow who is Verity's father.
  11     There are one or two matters he would raise through me
  12     in the course of the questioning. Go down to the bottom
  13     of the page. Let me put this in context: that is 30th
  14     December 1989. Verity was a little girl born on 22nd
  15     December, so at this stage she was 8 days old and she is
  16     transferred from her local district hospital. Is that
  17     your writing at the bottom of the page?
  18   A. It is my writing and my signature at the bottom
  19     right-hand corner.
  20   Q. This is just to pick up the diagnosis.
  21   A. Yes.
  22   Q. I think it is "small, somewhat dysmorphic baby"?
  23   A. Would you like me to read it? It is my writing,
  24     I should not have any difficulty to do so.
  25   Q. I was going to invite you to do so after I had tried and

   1     failed?
   2   A. "Small, somewhat dysmorphic baby. Small chin, small
   3     eyes, pointed ears, quite vigorous, grade 1 to 2
   4     cyanosis, normal pulses, no murmur, CX arch [chest
   5     X-ray], lungs, query oligaemic [that is with reduced
   6     amount of blood or sized blood vessels in them], "UCG
   7     [ultrasound cardiogram], pulmonary atresia, ventricular
   8     septal defect with overriding aorta, no pulmonary valve
   9     [that means no pulmonary valve seen], no main pulmonary
  10     artery or right pulmonary artery and no ductus.
  11        "Conclusion: pulmonary atresia with ventricular
  12     septal defect, probably bronchopulmonary collateral
  13     arteries will need catheter to establish this", that is
  14     the presence of bronchopulmonary collateral arteries.
  15   Q. And the catheter followed, I think. We can pick that up
  16     at page 108 in the same medical records. The summary at
  17     page 110, we see there those four conditions.
  18   A. That of course is Dr Wilde's angiographic report. There
  19     may or may not be a further report by me. Is it
  20     possible to scroll it down and see whether I have --
  21   Q. You have not actually said anything on that. If we go
  22     back to page 109, you do make comments.
  23   A. Yes.
  24   Q. It is "pulmonary atresia with moderate sized
  25     bronchopulmonary coronary arteries at very small central

   1     pulmonary artery"?
   2   A. Would it be possible for me, just reading the next
   3     sentence, to see what the aortic saturation which I have
   4     said was unrepresentative actually was, if we scroll
   5     back up again?
   6   Q. Yes, please.
   7   A. I think we are going down, scroll in the opposite
   8     direction and on to the next page, I am sorry. That is
   9     it. Yes, surprisingly high aortic saturation, that is
  10     obviously why I have commented.
  11   Q. It is very different, is it not, 95.5?
  12   A. Yes, but we see that some of the measured saturations
  13     were over 100 per cent which throws some doubt upon just
  14     how well the equipment was functioning at that time.
  15   Q. Were there problems with the equipment in January 1990?
  16   A. No. I do not want to go into the technicalities of
  17     this. What I would say is what the machine measures is
  18     not the oxygen saturation, it chucks up a figure which,
  19     if you are comparing samples in the same patient, is
  20     reasonably good at showing the differences, but it is
  21     not in fact an actual measurement of oxygen saturation,
  22     it measures something else in the blood.
  23   Q. I need not trouble you with the technicalities of that.
  24     Following catheterisation, I think there was a discharge
  25     summary at page 105. If we scroll down, please. Remove

   1     the address when it is going to be put on the Internet,
   2     please, but we have gone beyond that.
   3        We see there in the history as reported to the
   4     doctor --
   5   THE CHAIRMAN: We also have an address at the bottom; do we
   6     want to take that out?
   7   MR LANGSTAFF: That is the doctor's address. If you want
   8     that taken out, certainly: what we have here, you set
   9     out in typed form that which we saw from your original
  10     note, the catheterisation.
  11        You say "the pulmonary blood supply comes partly
  12     from branches arising from subclavian arteries, partly
  13     from the descending aorta, none of these are very
  14     large. The aortic arch is right-sided. There is" --
  15     and we go overleaf -- "filling of what appeared to be
  16     small central right and left pulmonary arteries through
  17     the collateral vessels, these are very small. Finally
  18     it was discussed with Mr Wisheart, it was felt the
  19     current size of the central pulmonary arteries precluded
  20     any attempt at shunting. It is actually unlikely these
  21     will grow but consideration will be given to a further
  22     catheter towards the end of the first year."
  23        At this stage was any further surgery planned?
  24   A. Not planned, no.
  25   Q. One of the messages one may take from this is, had the

   1     pulmonary arteries been bigger, a shunt might have been
   2     attempted?
   3   A. That was what was in a sense discussed with Mr Wisheart
   4     without any doubt.
   5   Q. How difficult a case was this?
   6   A. Difficult.
   7   Q. One of the matters raised by Mr Curnow in his evidence
   8     before us was that he was given, he says, no indication
   9     of the severity of Verity's condition at this stage.
  10     I do not know whether you remember talking to him; would
  11     you have talked to him or would Mr Wisheart have talked
  12     to him at this stage?
  13   A. I have to say as so often happens, I do not have any
  14     clear recollection of meeting with Mr Curnow or holding
  15     a discussion with him, therefore the best I can do is to
  16     refer to anything that I may have written in the notes
  17     and indicate what would have been my usual practice
  18     under these circumstances.
  19        I have to say, I do not wish to have a, if you
  20     like, even really a serious discussion with parents
  21     about their recollections as against my recollections
  22     because I realise this is an emotive subject and I would
  23     not in any way wish to get involved in an argument over
  24     that.
  25   Q. We see from page 103 -- this again will have to be

   1     edited before it goes on the screen. Let us have that
   2     up on the screen.
   3        What we have is a letter here from Mr McNinch who
   4     was the consultant paediatrician at Exeter.
   5   A. I am sorry to interrupt, could I go back over this
   6     business if we are going to do it chronologically?
   7     I think there is actually a note in the notes I made
   8     a note of about a discussion with the father. The note
   9     I have written down there was that I recorded "Father
  10     seen and 'aware of uncertainties in her future'".
  11   Q. The reason for my taking you to 103 to 104, this was not
  12     a letter you wrote but it was a letter to the general
  13     practitioner for the child in which Mr McNinch sets out
  14     his understanding of what you said to him from the
  15     discharge letter and communications.
  16        We see if we go down towards the bottom of the
  17     page:
  18        "I understand the catheter studies demonstrated
  19     absence of a main pulmonary artery, the lungs being
  20     supplied by a number of vessels presumably arising from
  21     the aorta. I understand that that anatomy is such that
  22     there is no pulmonary vessel large enough to attach
  23     a shunt, so at present no surgery is possible short of
  24     a heart/lung transplant which is barely feasible. The
  25     best hope is that Verity will grow up sufficiently and

   1     her vessels will enlarge sufficiently to allow surgery.
   2     In the meantime it is important she is kept as well as
   3     possible" and I can tell you without necessarily going
   4     overleaf, he promises that he will see her himself in
   5     two months and arrange for Dr Joffe to review her in the
   6     Exeter clinic; that would be his clinic, I suppose?
   7   A. It was either Dr Joffe or Dr Martin by then, I am not
   8     quite sure which, but it was not me, I did not on
   9     a regular basis do a week in Exeter.
  10   Q. At this stage she has a serious condition and there is
  11     a "wait and see" approach to see if anything can be
  12     done; is that a fair summary of where she was?
  13   A. Yes.
  14   Q. She comes back for a further admission and a cardiac
  15     catheterisation is performed again in July. She by now
  16     7 months of age. We can pick that up at page 94 to 95.
  17     Again if one goes overleaf to 95, unless there is
  18     anything you particularly want to see?
  19   A. Can I go through this in order?
  20   Q. Please.
  21   A. Can we scroll down? Thank you. If we carry on and then
  22     go overleaf, can we see the next page? Yes, I have
  23     finished reading.
  24   Q. The sentence I would like to focus on on page 95 is the
  25     third line down "The precise anatomy of this is not well

   1     seen", that is the precise anatomy of the left and right
   2     pulmonary vessels. "There is however faint filling of
   3     central hypoplastic true pulmonary arteries."
   4        As we know, having seen the notes, Verity went for
   5     operation on 12th September and the operation was
   6     discussed very shortly after this catheterisation. The
   7     decision of the operation was to go for a central shunt
   8     and to see what could be done.
   9        What I want to ask you about: it is plainly
  10     a matter of importance to the surgeon operating on
  11     a condition, particularly one as difficult as this, to
  12     have as precise a picture as possible, is it not?
  13   A. That is true, but there are difficulties in this
  14     particular condition, or there may be difficulties in
  15     this particular condition.
  16   Q. Was there anything more that might have been done, do
  17     you think, to make the anatomy more precisely known?
  18   A. I should perhaps explain really what one is setting out
  19     to show with this catheter. What one wants to know is
  20     whether there is a patent central pulmonary artery that
  21     is connected to both lungs and have some idea of the
  22     size of it. It does occur in this condition that you do
  23     the investigation up to this point and when you look at
  24     the angiograms you can see absolutely no sign of
  25     a central pulmonary artery at all. But that does not

   1     mean necessarily it is not there. The way of
   2     demonstrating it, which I think is actually mentioned as
   3     a possibility and I think I made a note about when we
   4     were going to do a catheter that we might have to do
   5     this, is to actually inject the dye, the contrast medium
   6     under force into one of the pulmonary veins and it then
   7     travels in the opposite direction to normal and you fill
   8     the pulmonary arteries, as we say "retrogradely".
   9        However, having shown there was a central
  10     pulmonary artery then for the purposes of what was being
  11     considered then that is actually adequate.
  12   Q. Picking up your reference to what had been proposed at
  13     one stage, was that a wedge injection?
  14   A. That was sometimes called a wedge injection, yes.
  15   Q. You actually thought that might be necessary back in
  16     January, I think, as a possibility?
  17   A. It was at the earlier catheter, yes.
  18   Q. It was after the earlier catheter, saying "with further
  19     studies we may need a wedge injection"?
  20   A. The reason for that is sometimes you may see the
  21     pulmonary artery initially if there is a very small
  22     amount of flow through the ductus, when you go back
  23     again the ductus may have closed and you do not get the
  24     flow into it.
  25        What I am saying is, and I am mindful of the

   1     criticism that I have read by the Panel who reviewed
   2     this, to say that it would have been nice basically to
   3     get better and clearer pictures, what I am saying is: my
   4     view and Mr Dhasmana's view when we reviewed this, was
   5     that the pictures we had done had shown the thing that
   6     he wanted to know; that is there was a central pulmonary
   7     artery and approximately what its size was.
   8   Q. What the reviewing panel appeared to think is that:
   9     accepting, I think what is common ground between you and
  10     them, that the best available picture obviously is what
  11     should be provided, that one could have got a better
  12     picture by for instance injecting contrast material into
  13     the collaterals. One possibility might be inflating
  14     a balloon below the collaterals and injecting above it.
  15   A. It is a pity we do not have Dr Silove here to give you
  16     his opinion about the technicalities of doing that. The
  17     answer is, it might have been. You could also have put
  18     a very much larger catheter in and a larger injection of
  19     contrast into the descending aorta. The technical
  20     problem, since we have got into this: once you start to
  21     blow the balloon up the flow of blood immediately starts
  22     to pull it away from where you want it to be. You can
  23     literally sit there for half an hour, three-quarters of
  24     an hour trying to keep the balloon in the right position
  25     to enable you to make the injection.

   1        This is a seriously ill cyanosed baby with a high
   2     haematocrit and one would be very mindful of the real
   3     dangers you were running through prolonging a catheter
   4     -- I must not say "unnecessarily", but prolonging
   5     a catheter after you had, what one might call, the
   6     minimum information necessary in order to make
   7     a decision about management.
   8   Q. You discussed the matter with Mr Dhasmana, as you say
   9     and his view was that what he needed to know was that
  10     there was some central artery to which he could connect
  11     the shunt.
  12        Can I ask Mr Deverall: from your perspective
  13     coming to a condition such as this, which is plainly not
  14     an easy one, what would you have wanted?
  15   MR DEVERALL: I note Dr Jordan and indirectly Mr Dhasmana's
  16     comment that they felt they had adequate information to
  17     make a decision and I respect that on the basis of the
  18     study that was done.
  19        I think it follows from an answer I gave to
  20     a previous question that in these extremely difficult
  21     situations the more information you have and the more
  22     accurate that information the more likely you are able
  23     to carry out a management plan more accurately and, by
  24     definition, with a greater chance of success.
  25        I did speak to Dr Silove yesterday in case the

   1     question was directed to me, which I am not qualified to
   2     answer. He said that he agreed with the group who
   3     examined the information in this little child that
   4     attempts should have been made to make the information
   5     even better than it was. I would agree with that.
   6        I think from the late 1980s onward, either
   7     selective injection of the collaterals, or retrograde
   8     wedge injection of the veins or balloon inflation of the
   9     aorta would be carried out routinely as a means of
  10     attempting to derive optimal information.
  11   Q. From the surgeon's perspective it is never going to be
  12     an easy operation; why would you need to know the
  13     additional information?
  14   DR DEVERALL: I think the surgeon has basically three
  15     options: he can either operate through the right chest,
  16     operate through the left chest or operate from the
  17     front, through the breast bone.
  18        There was evidence by the late 1980s and 1990s
  19     that if at all possible -- and we discussed this
  20     question yesterday -- one would attempt to secure
  21     a shunt procedure into the main pulmonary artery so that
  22     blood would flow in as near as normal as possible
  23     a direction thereafter and we have good evidence that
  24     that is the most likely way in which you are going to
  25     generate pulmonary artery growth in the two lungs.

   1        So, I think in 1990 most surgeons would have
   2     approached this condition through a midline stenotomy if
   3     they had a more than reasonable expectation of finding
   4     a significant sized main pulmonary artery which is why
   5     the necessity for the detailed studies. I do accept
   6     that carrying out investigations in -- this little one
   7     was 2.5 kilos at birth and I am very doubtful if she had
   8     grown very much in 6 months, so she was still a tiny
   9     cyanosed sick baby and I do accept that detailed
  10     investigations carry a risk but blind exploratory
  11     thoracotomy carries a greater risk.
  12   DR JORDAN: Can I please interject at that point: with due
  13     respect to Dr Deverall, he is misquoting what the Panel
  14     said. They did not say "it should have been done" or
  15     "ought to have been done"; they said "it might have
  16     provided further information", if my memory is correct.
  17   MR DEVERALL: I apologise, I did say the information was
  18     transmitted to me second-hand through Dr Silove, so
  19     I apologise.
  20   DR JORDAN: For completeness, "more detail" -- it has been
  21     altered actually -- "pre-operative angiography might
  22     have helped surgical decision-making" is the comment on
  23     there.
  24   MR LANGSTAFF: That is a hypothesis which I gather there is
  25     consensus on, it might have helped surgical

   1     decision-making. The issue we have been exploring is
   2     whether it should practically have been done. If
   3     everything has been said on that that needs to be said,
   4     can we move on.
   5   DR JORDAN: I am not sure it has been established how things
   6     would have been planned differently by Mr Dhasmana on
   7     the basis of what is now known of the anatomy, as was
   8     shown on the angiogram, if he just had rather better
   9     pictures because this is really the crux of the matter.
  10   MR DEVERALL: We are in a difficult area here, but if you
  11     read the operation note, and perhaps we should, my
  12     understanding of the interpretation of the studies was
  13     there was a main --
  14   Q. It is page 75, 76.
  15   DR JORDAN: Before we go from that could we note there is an
  16     approximate measurement of the internal diameter of the
  17     pulmonary artery.
  18   Q. That is on page 95.
  19   A. 2.7 millimetres which is rather exact for the sort of
  20     study that one is doing, but it puts it -- if
  21     Mr Deverall would agree -- in the ball park of the sort
  22     of size of anastomosis that surgeons by that time were
  23     doing under some circumstances for coronary artery
  24     disease and therefore potentially technically possible.
  25   MR DEVERALL: I think that is a very fair point. From the

   1     Panel's point of view, I should say that the average
   2     size of a coronary artery that surgeons are operating
   3     for coronary artery disease these days is 1.5 to
   4     2 millimetres in size. To make that possible with the
   5     human eye, most surgeons -- I imagine Mr Dhasmana in
   6     1990 -- would be using optical magnification.
   7   DR JORDAN: Absolutely.
   8   Q. Page 75, the operation note. We will have to edit this
   9     first, can we remove the top right-hand box.
  10   MR DEVERALL: I should perhaps say to slightly put things in
  11     a historical context: the carrying out of shunting
  12     operations, of these palliative procedures where an
  13     attempt is made to in some way or other connect the
  14     systemic and pulmonary circuits together have
  15     traditionally, almost mythologically always been carried
  16     out through the right or left chest.
  17        It might seem strange that going through the front
  18     of the chest for such a procedure was very rarely done.
  19     That is a historical thing to do with the way that these
  20     operations were developed. But in the late -- early
  21     1980s not exclusively, not all surgeons but many in this
  22     particular clinical circumstance had decided that
  23     approaches through the right or left chest left them in
  24     a very difficult limited option situation and were
  25     approaching this situation through a midline stenotomy,

   1     through the chest bone. That is why it was so crucial
   2     to know whether there was a main pulmonary artery or not
   3     because putting the shunt in depended on there being
   4     something there.
   5        My understanding of the management decision which
   6     was reached on the basis of the study we have been
   7     discussing, the one performed on 9th July, was that an
   8     attempt would be made to place a central shunt into the
   9     main pulmonary artery; that is what it says in the
  10     notes.
  11        My understanding of that would be that the surgeon
  12     would approach that from the front, as I have just
  13     said. I am not meaning this as a criticism, but
  14     Mr Dhasmana, for a reason, he made the decision to
  15     approach the child's surgery through the left chest
  16     which was the more conventional way still practised by
  17     many surgeons then and now, a rather smaller number but
  18     I am trying to be scrupulously fair to everybody
  19     concerned.
  20        However, having entered the left chest,
  21     Mr Dhasmana examined the anatomy and decided to do
  22     a central shunt. I can only tell you as a surgeon that
  23     to do a central shunt through the left chest is
  24     technically very difficult. You are not in control of
  25     the situation and I note that on attempting to open what

   1     he took to be the main pulmonary artery he was not able
   2     to complete a shunt because he could not define its
   3     lumen and there was significant bleeding. So even under
   4     the best circumstances the surgeon is now faced with an
   5     operation which is stable but difficult to unstable but
   6     difficult and you then seek to proceed as best you are
   7     able, which is what Mr Dhasmana describes in his
   8     operation note.
   9        I am a little bit -- I am not trying to be
  10     critical, I think it is an extremely difficult situation
  11     but I do not quite follow the logical thought processes
  12     which went on. I think had there been, had there been,
  13     more detailed -- better information about there being
  14     a main pulmonary artery -- which is why I am belabouring
  15     this perhaps a little too much -- it would have made
  16     that decision-making process easier and perhaps likely
  17     to be more successful.
  18   DR JORDAN: I do not want to make a major comment on that
  19     because I think it is something much more appropriately
  20     answered by Mr Dhasmana, he will tell you what his
  21     technique was and how he thought it compared with
  22     practices elsewhere in the country.
  23        All I can say is that both approaches were used
  24     during my time in Bristol, but I would not wish to say
  25     anything more than that. It is a matter very much of

   1     surgical expertise and planning and not for
   2     a cardiologist.
   3   Q. I think the point which may or may not arise when the
   4     Panel consider what has been said about Verity Curnow is
   5     whether, given the importance of the preoperative
   6     imaging of the arteries, whether that was a matter of
   7     significant importance because it might have dictated an
   8     approach in the operation which was or was not taken and
   9     it may very well have been, given the particular
  10     difficulties of Verity Curnow's case as the Panel
  11     themselves comment, that it may have made no difference
  12     to the ultimate outcome sadly. That is the point. The
  13     question I think is one of information and
  14     communication. I do not know if either of you want to
  15     say any more about that, do you?
  16   A. I would not wish to comment on Mr Dhasmana's method of
  17     approaching this.
  18   Q. There are a couple of other points I want to raise with
  19     you since we have heard evidence from Mr Curnow earlier
  20     in this Inquiry. If I can take you first to page 84 in
  21     the notes, down at the bottom of the page. You are
  22     writing to the parents afterwards because they passed
  23     a letter on to you following the death of Verity. You
  24     set out in the paragraph above just going off the top of
  25     the page --

   1   A. Could I see where it starts just to remind myself?
   2   Q. Certainly. As you read down, perhaps if you would tell
   3     me when you want the screen scrolled down further.
   4   A. Yes.
   5   Q. Once you are ready we can go overleaf.
   6   A. Okay.
   7   Q. The first paragraph I think need not trouble you very
   8     much, it is a question of possible future vacancies and
   9     problems and the points you may want to pick up from
  10     this, I think at the second last paragraph where you
  11     were responding in an offer to raise money for equipment
  12     for the Intensive Care Unit made by the Curnows. You
  13     are offering a meeting if the parents would like that.
  14        Can we go back to page 84, the bottom of the page,
  15     it is the paragraph which begins with the words:
  16        "As you know, we felt that although the prospects
  17     looked generally poor, we should make the attempt as
  18     I and all my colleagues felt that her outlook without
  19     some attempt at operation was extremely poor and we
  20     could be fairly certain that she would not have managed
  21     to survive another six or twelve months without some
  22     sort of intervention."
  23        Is essentially what is being said there that you
  24     and Mr Dhasmana, the treating clinicians, felt something
  25     had to be attempted because the otherwise the prospects

   1     were extremely bleak for Verity and even though there
   2     was not a necessarily obvious chance of success with an
   3     operation, something had to be tried; is that the
   4     flavour of it?
   5   A. She was actually referred back to us because she was
   6     becoming increasingly cyanosed even compared with the
   7     time I last saw her in outpatients. She was actually
   8     sort of sent back to us earlier than we had planned to
   9     repeat the investigation, it was actually I think done
  10     in about 7 months. Yes.
  11        Yes, she was very blue. All the notes there
  12     indicate she was extremely cyanosed. That is
  13     prognostically, I am afraid, a very bad thing if you
  14     cannot do something about it.
  15   Q. What Mr Curnow tells us is that he had not appreciated
  16     before her operation how serious the condition was.
  17     I am not going to ask you about that because you have
  18     already indicated that you would rely upon what is said
  19     in the notes and I suspect you may, in this paragraph,
  20     reflect on the words "as you know" which are written to
  21     him, no doubt a contemporaneous recollection of what you
  22     may or may not have said as you saw it. That is
  23     a matter for the Panel to make of what they will.
  24        Can I ask you about this: was the condition that
  25     Verity had something which might have been amenable to

   1     a heart/lung transplant or not?
   2   A. In theory, yes, in practice no. I think I would need to
   3     find out from a centre that was doing heart and lung
   4     transplants; this time I think it was probably only
   5     Harefield Hospital in children, and I do not think they
   6     were actually doing them under the age of a year but
   7     I am not exactly sure about that.
   8        But the answer is: in theory, yes; in practice,
   9     what are the chances of her having a successful heart
  10     and lung transplant assuming that I referred her to,
  11     say, Harefield Hospital. They are small for two
  12     reasons: the first is that there are not a lot of
  13     donors, if I may refer to impersonally, in this age
  14     group at all.
  15        Secondly, doing a heart and lung transplant in
  16     these particular circumstances is fraught with
  17     considerable difficulties. Again I do not know what the
  18     Harefield experience is, but in the literature where it
  19     has been attempted, in considerably older patients it
  20     has to be said in the States there has been very
  21     troublesome bleeding from collateral vessels coming into
  22     the lungs from outside.
  23        All I can say is that if she had been referred to
  24     a centre that in theory were offering heart and lung
  25     transplants, as I say like Harefield, I think they would

   1     have said "This is really not at all a good prospect and
   2     we would anyway think it highly unlikely that we would
   3     actually have donor organs becoming available during the
   4     period we actually have before it becomes too late".
   5   Q. When Dr Martin gave evidence he mentioned that in
   6     a number of case complex --
   7   A. Of course he worked at Harefield himself.
   8   Q. That is a slightly different point -- of complex
   9     pulmonary atresia and VSD, that there may be a referral
  10     out from Bristol to another centre; was this something
  11     you ever did?
  12   A. Yes. This is the third out of four cases as it happens
  13     that refer to what you might call variants of pulmonary
  14     atresia with a ventricular septal defect. We did on
  15     occasions send usually, not the patient but the
  16     angiograms to someone at Great Ormond Street and say
  17     would they give us a view on this.
  18   Q. Did you do that in this case?
  19   A. No, because I think we knew what the answer would be,
  20     that is: "The only possibility with this child is to do
  21     a central shunt. The collateral arteries are very
  22     small, they are entirely disconnected, none of them
  23     appear to have stenosis on so they are almost certainly
  24     working at systemic arterial pressure. I could go on
  25     and it becomes very technically difficult even for this

   1     technically difficult subject.
   2        The quick answer to the question is: I, and
   3     I think my colleagues, would not have considered there
   4     was any point in that because we would have known the
   5     answer would have come back by return of post, so to
   6     speak.
   7   Q. There is one further comment --
   8   A. To be honest the only difference is we might have had an
   9     answer saying "I think the chances of making a central
  10     shunt are pretty small and we would not be very keen to
  11     try it", but I think most centres dealing with this
  12     condition would have one attempt to establish
  13     the central shunt in the hope that it would be
  14     successful.
  15   Q. The further comment that the reviewing panel makes is in
  16     relation to post-operative care. There is a query
  17     Mr Curnow has over the decision to extubate in the early
  18     post-operative period and the degree of fluid overload.
  19        I do not know whether that is something I should
  20     raise with you. Do I take it you were not involved
  21     directly?
  22   A. I would have been in the sense that this was done at the
  23     Children's Hospital; this was not an infant -- at least
  24     I do not think so. No, I am virtually certain this was
  25     at the Children's Hospital.

   1   Q. Can you help, then, whether this was a case in which the
   2     extubation was perhaps too early at 3 to 4 hours?
   3   A. On principle a child or an infant having a Blalock shunt
   4     we would expect to extubate, unless there was some other
   5     reason, as soon as he or she was stable on the ITU.
   6        The answer is: I do not know where they get that
   7     from but we would hope to be able to extubate at this
   8     stage if there were no indications to continue it. If
   9     I can just go on a little bit from that: this was not
  10     a baby who had been on cardio-pulmonary bypass so she
  11     was not likely to have the pulmonary complications which
  12     follow that which can take a little time to develop.
  13        She had lungs which were, if you like, light
  14     rather than stiff because they had very little blood
  15     going through them, and her haemodynamic condition had
  16     actually been sort of stable during the operation.
  17     I cannot see the point of that quite honestly, I mean
  18     that is as a general point.
  19   Q. I do not want to take time on this case, because the
  20     central points I wanted to illustrate was the question
  21     of the information available to the surgeon and that we
  22     have explored. So I do not want to deal with the other
  23     aspect in any detail.
  24        Can I finally ask you one question which arises
  25     from the four cases we have been looking at --

   1   THE CHAIRMAN: Before you do, Mr Langstaff, does Mr Deverall
   2     have a view on the transplant?
   3   MR DEVERALL: I am not a transplant expert, sir. At the
   4     time in question the only centre in the world with
   5     claimed survival in this situation was the Lomalinda
   6     Institute in Los Angeles, to the best of my knowledge
   7     the babies did not survive very long.
   8   MR LANGSTAFF: Looking at the four cases we have looked at,
   9     this last one is a closed case, the other three were
  10     open cases; was there ever between 1984 and 1995
  11     intra-operative echo available at the BRI.
  12   DR JORDAN: Sorry, what was the last time, when I retired
  13     are we talking about?
  14   Q. Between 1984 and 1993 when you retired?
  15   A. The answer to that question is: we did, like a few other
  16     people, attempt to carry out surface echocardiography in
  17     the operating theatre. It was messy, there was no doubt
  18     it jeopardised sterility which is obviously important.
  19     Again, I do not know whether Mr Deverall may like to
  20     comment on how he viewed having people with non-sterile
  21     instruments in close proximity to his operating sphere
  22     but, shall I pause there and see whether he wants to
  23     comment on that?
  24   MR DEVERALL: It is another example of how sometimes one has
  25     to change one's notions. Yes, at about that time

   1     I guess there was a little bit of resentment but now
   2     I think you would routinely see direct cardiac
   3     echocardiographic probing by the surgeon with the
   4     cardiologist at his shoulder in difficult situations,
   5     almost eager to lean over and secure the instrument.
   6        No, I am being a little bit joking and that is
   7     perhaps not appropriate. Yes, there was a necessity to
   8     go through a complete thought change in terms of one's
   9     willingness to have foreign instruments in one's
  10     operating field. I cannot even say in my own case when
  11     I realised I had to accept that without even thinking,
  12     but it was in the 1990s some time.
  13   DR JORDAN: The other question refer to trans-oesophageal
  14     echocardiography. The BRI did have a trans-oesophageal
  15     probe I think from about the middle or beginning of
  16     1991, I am not absolutely certain but it was an adult
  17     one and would not I think have been suitable for the
  18     sort of size patients we have been discussing.
  19   MR LANGSTAFF: Would you have wanted to have one?
  20   A. Yes, indeed -- it was one of the first things I did
  21     after I retired, but it did happen. After I retired
  22     I had the opportunity to raise money with the Bristol
  23     and South West children's heart circle to provide a
  24     paediatric trans-oesophageal echo probe.
  25   Q. Whilst you were in post was any effort made by you or

   1     any other cardiologist to secure that equipment?
   2   A. Yes, it is 25,000 pounds worth for a single probe and
   3     you probably need at least two and that money does not
   4     come easily from what we call Exchequer sources, what we
   5     called Exchequer sources.
   6   Q. Do you remember when those attempts were made?
   7   A. No.
   8   Q. Roughly?
   9   A. I think trans-oesophageal echocardiography generally
  10     became available about sort of 1991 so it would have
  11     been from then onwards. I do not think I want to bore
  12     the Panel by telling them the processes one had to
  13     actually go through, but it was a very protracted
  14     process to get any new piece of equipment and you had to
  15     know you wanted it three years before.
  16   THE CHAIRMAN: Dr Jordan, far from being boring, it is
  17     absolutely critical that we understand that. If you
  18     feel able to set that out in writing for us it would
  19     help, that is precisely what we need to understand.
  20   MR LANGSTAFF: As the Chairman has indicated, that is
  21     probably best responded to in writing after today.
  22     There is nothing more I want to ask you that arises from
  23     the cases.
  24        Again, sir, perhaps I should repeat as I did when
  25     we began looking at the cases which arose from the Case

   1     Note Review, the purpose of doing it is to identify and
   2     use individual cases to see whether they are truly
   3     examples of the themes which, it is said by the experts
   4     who have done those reviews, arise out of those cases in
   5     their view. The purpose has not been to resolve
   6     individual cases in the same way as one would in a court
   7     of law when considering other issues.
   8   THE CHAIRMAN: Absolutely, and it has been very helpful in
   9     the process we have engaged in, Mr Langstaff.
  10   DR JORDAN: May I make a comment? The comment is a general
  11     one, that is: I had of course advanced warning of the
  12     four cases that were going to be discussed in some
  13     detail. I had understood that I was going to be asked
  14     my reaction to the comments made by the Panel which of
  15     course I had seen before I came here. I must admit to
  16     having been slightly thrown by some of the things that
  17     I was asked which, despite the assurances did seem to me
  18     rather more what I had -- not accustomed to -- had
  19     experience of in other spheres where there was
  20     a tendency to pick on individual items, sometimes in
  21     isolation, and explore these with a view to
  22     demonstrating that a fault had occurred.
  23        Particularly in that context I would say that on
  24     two occasions I think I had to ask to be allowed to
  25     speak to the results of the joint discussions that we

   1     had had rather than relying upon things that had been
   2     writing in catheter reports or, for example, my
   3     preliminary views on an echocardiogram or something like
   4     that. I think I would like to stress the fact, if you
   5     like the working document, the thing which really
   6     determined what we were going to do and what our feeling
   7     was about the anatomy, the physiology was actually our
   8     review very often with all six of the people concerned,
   9     that is three cardiologists, two surgeons and
  10     a paediatric cardiac radiologist present as well.
  11        There is no doubt we were somewhat slack, I have
  12     to admit, in recording a very detailed note of our
  13     discussions there and also in correcting, if you like,
  14     some of the things that occasionally got into catheter
  15     reports and preliminary echo reports and were
  16     subsequently not agreed.
  17        I would just emphasise again that was really our
  18     sort of point of take off for making decisions and
  19     I would not regard things recorded in the cardiac
  20     catheter report for example which was usually typed out
  21     before we actually had the meeting as being a definitive
  22     statement on our final view of what, for example,
  23     angiograms showed.
  24        The other point is with regard to questions I have
  25     been asked about surgical matters. I mean I have from

   1     time to time said that I regarded something as well
   2     outside my sphere of knowledge or expertise, but I think
   3     I was pressed on a few occasions really to give an
   4     opinion on something which would much more appropriately
   5     have been dealt with in a discussion with the surgeon
   6     concerned. I hope I have not in any way misled the
   7     Inquiry by giving what one might call an amateur view on
   8     that.
   9   MR LANGSTAFF: In relation to the last point, may I say for
  10     the record that it has to be respected and I am quite
  11     sure the Panel will respect the fact that you have come
  12     to us as a cardiologist and not as a cardiac surgeon and
  13     that any comment which I may have persuaded you to make
  14     in that respect has to be read subject to the very heavy
  15     qualification you have just given. That of course is
  16     accepted and I would hope -- this again is for a wider
  17     audience -- that any further clinician to whom cases are
  18     put would say, as you have on occasions said: "This is
  19     not my particular field".
  20        You will understand, I hope from the perspective
  21     of the Inquiry, that it is helpful to see a case in the
  22     round involving not only the area where you can as an
  23     acknowledged expert give your view, but also those areas
  24     where it may necessarily have to be taken up with
  25     somebody else because one has, I think, to form a view

   1     of the whole rather than look simply at a part. That is
   2     the reason why I invited you to comment on areas which
   3     may have fallen outside your strict discipline.
   4        If it has caused you discomfort, I am sorry for
   5     that.
   6   DR JORDAN: It is not a question of discomfort, I am afraid
   7     I am just too easily led to put my finger on something
   8     that I am not an expert on, that is it.
   9   THE CHAIRMAN: Our expertise is sitting in Mr Deverall's
  10     chair and we do not look to you for expertise in that.
  11   MR LANGSTAFF: Sir, may I invite a break before Mr Maclean
  12     continues the questions to be put to Dr Jordan? Can
  13     I thank Mr Deverall for his attendance, not only today
  14     but also yesterday, and for the contributions he has
  15     made on the surgical aspects which we have touched on
  16     for the reasons I have just outlined.
  17   THE CHAIRMAN: I join you and I am sure everyone joins me in
  18     thanking Mr Deverall. Your contribution has been
  19     extremely helpful and we are very much, as ever, in your
  20     debt. Thank you Mr Deverall.
  21        Shall we take a break for 15 minutes until about
  22     11.10.
  23   (10.55 am)
  24               (A short break)
  25   (11.15 am)

   1             Examined by MR MACLEAN:
   2   MR MACLEAN: Dr Jordan, you were one of the few consultants
   3     from whom the Inquiry has heard, or will hear, who was
   4     a consultant at Bristol throughout the period that the
   5     Inquiry is concerned with, save that you retired in
   6     1993. You were therefore a consultant at the time of
   7     designation of Bristol and other centres as
   8     supra-regional centres for neonatal and infant cardiac
   9     surgery?
  10   A. That is correct.
  11   Q. Are you able to help the Panel with the process by which
  12     the centres in general, and Bristol in particular, came
  13     to be designated as a supra-regional centre for neonatal
  14     and infant cardiac surgery?
  15   A. My recollection is obviously somewhat hazy, because this
  16     goes back now at least 16 years to when I first got
  17     involved in this process, and I can obviously only sort
  18     of speak from my personal involvement.
  19        I first heard of the idea of supra-regional status
  20     for some form of paediatric cardiology in, I think it
  21     was 1983, through Mr Wisheart.
  22   Q. You say "cardiology"?
  23   A. I beg your pardon, well, cardiac surgery, yes.
  24     Paediatric cardiac surgery. Mr Wisheart told me that he
  25     had heard that there had been meetings at the, as it

   1     then was, Department of Health and Social Security, the
   2     DHSS, concerning this question and that proposals had
   3     been put up for some sort of supra-regional funding, but
   4     that Bristol had not been included in these proposals.
   5   Q. Just pausing there, Dr Jordan, did you understand what
   6     the concept of supra-regional services meant at that
   7     time?
   8   A. I quickly did, yes. I obviously learned more about it
   9     at meetings that I went to subsequently, at the DHSS.
  10   Q. Let me keep quiet and allow you to develop the story.
  11     There was a short-list that Bristol was not on
  12     initially?
  13   A. That is correct. Mr Wisheart, I believe, and I think
  14     possibly with Dr Joffe being involved slightly more than
  15     myself, bearing in mind that at that time I was sort of
  16     split between adult and paediatric cardiology, that they
  17     really contacted the Department of Health and Social
  18     Security and said, basically, you know, we were
  19     interested in this and we were somewhat surprised that
  20     some other centres which were smaller or took patients
  21     from smaller areas had been included, and Bristol had
  22     not.
  23   Q. Do you know which centres were on this initial list?
  24   A. I cannot give you a definitive view, but from our
  25     particular point of view, the one thing that stood out

   1     was that Southampton had been suggested as a centre, and
   2     of course they in a sense were our newest neighbours.
   3     This seemed slightly odd at first reading, because we
   4     believed that we had a larger catchment area, to use the
   5     commonly employed phrase.
   6        The next thing that happened -- that I can recall
   7     at any rate -- was the DHSS invited representatives from
   8     all centres doing cardiac surgery to come to a small
   9     number of meetings that were held at the DHSS, where the
  10     proposals were discussed, advice was given to the DHSS,
  11     professional advice, on what effects supra-regional
  12     funding or the concept of supra-regional funding might
  13     have on the service in general, that is, in round terms,
  14     whether there would be advantages to it or
  15     disadvantages, and how they weighed out.
  16        I think I went to two meetings -- there may have
  17     been more than that. I have to say that the advice that
  18     I remember from this most strongly was that there was an
  19     emphasis on firstly fewer centres with larger numbers of
  20     patients to each centre; on surgeons in each centre
  21     being particularly concerned with paediatric cardiac
  22     surgery; and there was, I think, some mention of
  23     information, mainly from the United States, about the
  24     effect or the relatively better results that occurred in
  25     the larger centres compared with the smaller centres.

   1   Q. Just pausing there, at this time how many paediatric
   2     cardiac surgeons were there in Bristol?
   3   A. At that time, there was only Mr Wisheart, he was really
   4     the only one carrying out a reasonably full range of
   5     paediatric cardiac surgical operations, to include
   6     things like tetralogy of Fallot, then going from the
   7     Mustard operation to the Senning operation, that sort of
   8     thing.
   9   Q. But he was by no means exclusively a paediatric cardiac
  10     surgeon?
  11   A. No.
  12   Q. You mentioned the emphasis on the numbers, if you like,
  13     of paediatric cases that were being done. What did you
  14     understand the concept to be at that stage? Had it been
  15     defined to neonatal and infant work, or was it more
  16     broadly defined?
  17   A. The discussion was certainly more broadly defined, and
  18     it included the question of restricting complex and what
  19     one might call "emerging" operations on older patients
  20     as well.
  21   Q. As we know, that did not come to pass, that particular
  22     notion. Do you know how and why it came about that
  23     there was this focus on neonatal and infant cardiac
  24     surgery?
  25   A. I can only speculate, but I think the general feeling in

   1     the profession was that this was particularly important,
   2     apart from anything else, because operations on small
   3     babies quite often needed to be done relatively soon.
   4     With the older patients, there was certainly at that
   5     time a certain amount of passing patients from one
   6     centre to another, if it was thought that there was
   7     a surgeon with a particular expertise in any particular
   8     operation.
   9   Q. So what did you understand the criteria to be which
  10     would ultimately be used to select the relevant centres?
  11   A. My understanding was that it was based on the number of
  12     open-heart operations of any sort carried out on
  13     infants, that is under the age of a year.
  14   Q. And the idea would be, the more one is doing, the
  15     better?
  16   A. The idea was, I believe -- I am not absolutely certain
  17     about this -- that there was a minimum number that
  18     a centre was expected to do in order to qualify for
  19     supra-regional funding. What became clear, I think, as
  20     the discussions progressed, and I had not appreciated
  21     this originally, was that the emphasis as far as the
  22     DHSS was concerned, was on the monetary side of it.
  23     That is to say: how do we relieve districts, as they
  24     then were, or regions, of this not inconsiderable sum,
  25     the cost of carrying out operations for patients who are

   1     not in their own district, or not in their own region.
   2     They were really considering the other aspects, that is
   3     to say, the question of the larger centres having better
   4     results in round terms, more to reassure themselves that
   5     anything that they decided from a monetary point of view
   6     would not be criticised as being detrimental to patient
   7     care.
   8   Q. Just focusing on the numbers for a moment, there was
   9     some regard had to the number of neonatal or infant
  10     cases done?
  11   A. Yes.
  12   Q. You mentioned there being some form of number which
  13     a centre ought to be doing in order to qualify. Do you
  14     remember what that number was?
  15   A. To the best of my recollection, the one that was
  16     suggested originally was a minimum of 50, and it was
  17     subsequently reduced to 40, although I think the advice
  18     that was given to the DHSS was that numbers were likely
  19     to be better in centres doing 100 or more a year.
  20   Q. Just to be clear what we mean, that would be 40 or 50 or
  21     100 open-heart operations on neonates or infants?
  22   A. Yes. Any child under 1 year of age.
  23   Q. And open operations?
  24   A. Open operations only.
  25   Q. Per year, per annum?

   1   A. Per year, yes.
   2   Q. That was one of the criteria. Do you remember any
   3     others?
   4   A. I think really it seemed to end up being more or less
   5     the sole criterion. There were other things that were
   6     indicated that I have not dealt with which were regarded
   7     as being desirable, and that the whole unit was
   8     operating within a paediatric environment, and also,
   9     although I cannot remember clearly how this discussion
  10     went, but I am fairly sure there was the need to
  11     integrate the investigational side of it, that is the
  12     cardiology with the cardiac surgery.
  13   Q. In what sense? What do you mean by "integrate"?
  14   A. That it should be one unit doing both investigations.
  15     What you call "one unit" is obviously open to
  16     discussion, but the situation still existed at that time
  17     that there were some centres which were doing cardiac
  18     surgery with a minimum amount actually of paediatric
  19     work, in hospitals quite remote from the
  20     cardiologists -- a lot more remote than the BRI is from
  21     the Children's Hospital.
  22   Q. Bristol at that time did not have neonatal and infant
  23     cardiac surgery carried out in a paediatric environment?
  24   A. Not the open-heart surgery, no.
  25   Q. It did not have a dedicated paediatric cardiac surgeon?

   1   A. No.
   2   Q. Can we look at UBHT 62/56? This is a return to the
   3     Supra Regional Services Advisory Group. If we scan down
   4     the page, we see in the left-hand column, "1983 to 1984
   5     actual".
   6   A. Yes.
   7   Q. It is the fourth entry, number of operations performed,
   8     open-heart, 3. Then there are three stars beside that.
   9        If we scan down a little more, we see that is
  10     information supplied by Mr Wisheart's secretary on
  11     21st May 1984.
  12        The Panel heard I think when Mr Wisheart gave
  13     evidence that depending whether one takes a financial
  14     year or a calendar year, there were either three or four
  15     open-heart operations carried out at the start of this
  16     period. Does that accord with your recollection: the
  17     number of open-heart operations on neonates and infants
  18     in Bristol in 1983/84 was less than a handful?
  19   A. I cannot have a clear recollection as far back as that.
  20     I think that my impression is that three was an
  21     unusually low number, and that on either side of that,
  22     the numbers were higher, but I do not know whether that
  23     information is available.
  24   Q. Let us see if it is. Can we look at DOH 4/28, please?
  25     That, Dr Jordan, gives you a greater run of cases. You

   1     see for 1983 the figure of 4. You are right that that
   2     is a lower figure than the years either side, but if we
   3     look at that table, we have to get, do we not, to 1989
   4     before we see the figure of 40 open-heart cases on
   5     under 1s?
   6   A. Yes.
   7   Q. If we go to the basket of factors that the DHSS was
   8     considering, you mentioned -- tell me if I have
   9     forgotten any -- the paediatric environment, the number
  10     of cases, the question of having a surgeon who did
  11     paediatric work, presumably the more the better. It
  12     might seem that Bristol --
  13   A. Can I just stop you? I was not asked, I think, to give
  14     a comprehensive list. There are others, and in
  15     particular of course the question of having a reasonable
  16     geographical spread of these centres.
  17   Q. If none of factors we have so far discussed it would
  18     appear were satisfied by Bristol in 1983/84, what is
  19     your impression of why it was that the DHSS was
  20     nonetheless satisfied that Bristol was appropriate to be
  21     designated as a centre?
  22   A. My guess is that it was because of its geographical
  23     position. And also the fact that in the discussions it
  24     was clear that there was an intention to increase the
  25     numbers.

   1   Q. In Bristol?
   2   A. In Bristol. By that time also we had already got the
   3     planning for, if not the start of, the catheter lab at
   4     the Children's Hospital and we were, of course, already
   5     at that time working on the question of building at the
   6     Children's Hospital to allow all cardiac surgery to be
   7     carried out at the Children's Hospital. Okay, it may be
   8     it is on the basis of promises, but those were, as far
   9     as I can recollect, factors that were put.
  10   Q. That last promise was kept, if you like, in October
  11     1995 which is when the surgery finally moved to the
  12     Children's Hospital.
  13   A. If that surprises the Panel, can I just say as an aside
  14     that my contract when I was appointed in 1969 said that
  15     I should have beds in Phase III of the rebuilding of
  16     Bristol Royal Infirmary, and Phase III has not
  17     occurred. So I am afraid in some ways, that is not
  18     unusual, and I am sure we will get on to the question of
  19     what efforts were being made during the intervening
  20     period from 1983 to -- 1995, was it?
  21   THE CHAIRMAN: For clarification, Dr Jordan, you just
  22     referred to there being promises made to integrate the
  23     services. Do you mean "promises" or do you mean that
  24     "it is our intention in Bristol to do the best we can
  25     to proceed in that direction"?

   1   A. My recollection of the situation is that in 1983 we had
   2     very clear plans that had been drawn up -- I mean, this
   3     includes commissioning of architects and actually
   4     spending money on it. This was done by the Avon Area
   5     Health Authority. The trouble was, of course, the Avon
   6     Area Health Authority was abolished in 1984 and those
   7     plans were essentially withdrawn and the process started
   8     over again with Bristol & Weston Health Authority.
   9   Q. I think, Dr Jordan, I appreciate it is a long time ago,
  10     but those who represent the present Health Authority are
  11     anxious to point out that the Avon Area Health Authority
  12     ceased to exist actually on 1st April 1982?
  13   A. Thank you. I am afraid it shows my recollection is not
  14     what it might be.
  15   Q. So your recollection would be that that authority, which
  16     was abolished a little earlier than you initially
  17     suggested, did have some plans?
  18   A. Yes. I mean, quite when the Bristol & Weston Health
  19     Authority -- I think it was the one that took over
  20     responsibility, together, of course with the South West
  21     Regional Health Authority. It was on and off
  22     continuously. I think I attended meetings with three
  23     sets of architects drawing up different plans, none of
  24     which ended up by being the plans which were eventually
  25     adopted and implemented in 1995.

   1   THE CHAIRMAN: Thank you, that is helpful. The reason for
   2     my question was, I am seeking to understand what it was
   3     that passed between Bristol and the Advisory Group, so
   4     as to persuade the Advisory Group that Bristol should be
   5     an appropriately designated centre.
   6        I am sure that everyone understands that
   7     assurances are given all things being equal, and that is
   8     why I was enquiring about your word "promised" rather
   9     than "these are our plans and all things being equal we
  10     are aiming towards that", or was it stronger than that?
  11   A. I really cannot help the Inquiry with any clear
  12     information about that. Mr Wisheart may be able to.
  13     I think he is more directly concerned, and of course the
  14     other thing is that I suspect he will have kept all his
  15     documentation. I am afraid when I retired mine went out
  16     in order to make room for my successor's filing system.
  17   MR MACLEAN: Can we then move to the impact that designation
  18     as a supra-regional centre had? Can we go to --
  19     I cannot remember which of your witness statements it
  20     is, but it is WIT 99/17, the one dealing with Issue B,
  21     and it is B2. By all means have a look at the entire
  22     paragraph, but can I indicate the passage I am
  23     interested in is the last two or three lines, when you
  24     say:
  25        "It [which is designation] also provided

   1     a stimulus for Bristol to move towards earlier diagnosis
   2     in surgery in which it was lagging behind other centres
   3     worldwide and in the UK."
   4   A. Yes, I have read that.
   5   Q. Why was it that Bristol was "lagging behind" other
   6     centres in the UK?
   7   A. I think the main reason is that ever since I was
   8     appointed in Bristol, facilities generally for cardiac
   9     surgery, that is, adult and paediatric cardiac surgery,
  10     lagged far behind the centres elsewhere. It was
  11     a continuing problem. I do not know what the situation
  12     is now, but it was still a problem right up to the time
  13     that I stopped doing adult work in about 1990.
  14   Q. You say "equipment". Does that embrace physical
  15     machines, or is it a question of manpower as well, or
  16     what?
  17   A. I am sorry, we are talking about the whole concept, but
  18     particularly the stumbling block was the facilities for
  19     cardiac surgery. That is space, wards, beds --
  20   Q. And operating time?
  21   A. Well, operating theatres. I think well before the time
  22     this Inquiry is looking at, we moved away, at any rate
  23     for open-heart surgery, from the times when theatres
  24     were shared with other people and it was actually the
  25     number of theatres that were available.

   1   Q. We know that the cath' lab at the Children's Hospital
   2     was opened I think in 1987?
   3   A. 1987 I think, that is right, yes.
   4   Q. You have told us that was something that was in the
   5     planning?
   6   A. Yes.
   7   Q. At about the time that Bristol was designated?
   8   A. Yes.
   9   Q. In what way did designation as a supra-regional centre
  10     provide a stimulus to move towards earlier diagnosis in
  11     surgery?
  12   A. I think it really concentrated all our minds on what
  13     other people were doing, and not only, you know, the
  14     desirability of earlier operations, but also the
  15     feasibility of operating earlier for some conditions.
  16   Q. But the direct incentive provided by designation would
  17     be the money provided top-sliced from the Department of
  18     Health if an operation was carried out before a child's
  19     first birthday?
  20   A. That is the incentive to the planners and the
  21     administrators, yes. I mean, all it meant as far as we
  22     were concerned was that if we were proposing to try and
  23     increase the throughput of cardiac surgery, we were able
  24     to say to the administrators that, "Look, you know, if
  25     we can do this, it is not actually going to cost you

   1     more money", because this, as I am sure has become
   2     clear, is what was always happening. The moment that
   3     you wanted to expand something, you had to justify it,
   4     you had to cost it, and the initial reaction was always,
   5     "Where is the money going to come from?"
   6        Here was something where we could actually say,
   7     "If we do this, money is going to come here".
   8   Q. So those who would be responsible for financing
   9     developments in Bristol, the Regional Health Authority,
  10     would have to approve the proposals; is that right, and
  11     in the case of open-heart operations in children
  12     under 1, it was not costing them anything because the
  13     money was coming direct from the Department of Health?
  14   A. That is a correct statement, yes.
  15   Q. So you could say to the usual exchequer sources, as you
  16     put it earlier, "If we increase the numbers from X to Y
  17     on open-heart operations for under 1 it is not going to
  18     cost you anything because the Ministry is going to send
  19     the money"?
  20   A. It might not have been put that way, but we were trying
  21     to expand the total number of open-heart operations, and
  22     this, if you like, was a financial window that we could
  23     use on the Regional Health Authority and the District
  24     Health Authority.
  25        I mean, can I make it clear, in case anyone has

   1     misread the meaning of that statement, I am not saying
   2     that we deliberately operated on children who either did
   3     not need operations or could have had their operations
   4     later on, we did not deliberately operate on them
   5     because we, or someone else, would get money for that.
   6     That is not what is intended by that statement. It had
   7     a dual purpose as far as I was concerned that it
   8     concentrated people's minds on what was possible and,
   9     indeed, what was desirable, and secondly, it gave us
  10     a small amount of leverage with the authorities in terms
  11     of expanding facilities.
  12   Q. When you say "authorities", you mean whom? You mean the
  13     local authorities in Bristol?
  14   A. The local authorities, the District Health Authority and
  15     the Regional Health Authority, and at different times,
  16     I am sure that the Inquiry knows more now about the
  17     organisation of these various bodies, because I have
  18     largely forgotten it, but it did shift from Region to
  19     Area, when area was abolished it was back to Region but
  20     with some split to the district, as far as I remember,
  21     and then, of course, when Trusts came in, the Region
  22     went out -- indeed, the regions disappeared completely
  23     of course shortly afterwards.
  24        So it was a continuing process.
  25   Q. Can we look at BCS 1/17, please? This has been supplied

   1     by the British Cardiac Society, of whom the Inquiry
   2     heard some time ago. We see from the cover -- that is
   3     the front page -- "Staffing in Cardiology in 1988, Fifth
   4     Biennial Survey".
   5        If we go to page 19, I think it is the bottom of
   6     the page, if we look at table 2, please, Dr Jordan,
   7     I want to look particularly at Wales, which you will
   8     find in the penultimate line, and at the South West,
   9     which is a little bit above. (Pause).
  10        We see from that in 1988 there were two paediatric
  11     cardiologists in the South Western region.
  12   A. That is what it says there, yes.
  13   Q. Those would be, one assumes, yourself and Dr Joffe?
  14   A. I should say that Douglas Chamberlain and I invariably
  15     had difficulties over what they should put me down as,
  16     because in 1988 I was still officially half an adult
  17     cardiac cardiologist and half a paediatric cardiologist,
  18     but I think the general agreement was that I should be
  19     classified as a paediatric cardiologist, because as you
  20     will see, there are no halves or quarters or anything in
  21     this table.
  22   Q. And there is no-one else who could be classified as
  23     being a paediatric cardiologist in the South West region
  24     at that time?
  25   A. That is correct, yes.

   1   Q. So those two must be you and Dr Joffe?
   2   A. Yes, I am sorry, I have no problem with that.
   3   Q. I did not think there was anything between us. Wales
   4     has no paediatric cardiologists, we see that from the
   5     tables, at this time. To what extent did Bristol, at
   6     this time, see Wales as being -- or part of Wales
   7     perhaps as being within its "catchment area", to use
   8     your expression?
   9   A. That is a very big question. We are talking about
  10     1988. The quick answer to the question is that we did
  11     see by that time a number of paediatric patients,
  12     paediatric cardiology and cardiac surgery patients from
  13     South Wales.
  14        Is that a good enough answer?
  15   Q. We will come to looking at Wales in a little more detail
  16     later, but at the moment, I just want to explore with
  17     you the extent to which Wales was seen as falling within
  18     Bristol's catchment area. I think your answer, in
  19     general at this stage, is in part it was seen as falling
  20     into Bristol's catchment area?
  21   A. It would depend very much on whom you asked, I think, at
  22     that time. Cardiff was very anxious, over a number of
  23     years, not to lose, if that is the right word, South
  24     Wales to Bristol. I think the Panel have already heard
  25     quite a bit of information from members of the Welsh

   1     Office and there was a sort of constant form of
   2     discussion, much of which took place between Andrew
   3     Henderson, Professor of Cardiology in Wales and myself.
   4   Q. Let me stop you there. I do not want to persuade you to
   5     say something, looking at this diagram, which you do not
   6     want to say without looking at the detail of it, so can
   7     we just look at some of the Welsh material? Can we look
   8     at WO 1/254?
   9        We see the date, 27th November 1986. If we scan
  10     down the page, please --
  11   A. I am sorry, could I read all of it, because I think
  12     there are some things that may be relevant.
  13   Q. I want to show you first of all who wrote the letter.
  14     If we go to page 255, and then we will go back to the
  15     beginning.
  16        It is written by Dr Prosser. One of the ccs was
  17     yourself.
  18   A. Yes.
  19   Q. Can we go back to 254 and read as much of this letter as
  20     you wish. (Pause).
  21   A. I have got to the bottom, if you could scroll up? Thank
  22     you. (Pause). Yes, we can turn over, thank you.
  23     (Pause).
  24   Q. We see in that paragraph the list of places in Wales
  25     that Bristol was already serving?

   1   A. Yes.
   2   Q. So that is a letter to the Chief Medical Officer of
   3     Wales, Dr Crompton as he then was, which was very
   4     supportive for forging closer links with Bristol.
   5        Do you recall a visit in 1986 to Bristol by
   6     representatives of the Welsh Office, the Chief Medical
   7     Officer and some other people from the Welsh Office?
   8   A. I have no clear recollection of it. I have been made
   9     aware more recently, and reminded that such a visit took
  10     place.
  11   Q. Can we look at WO 1/263, please? This is a note which
  12     I think you have seen recently, of the visit that was
  13     made by the Welsh delegates to Bristol.
  14        I am not going to ask you to read all of this
  15     document, Dr Jordan, but if we go to page 265, to the
  16     second paragraph, the paragraph beginning "During the
  17     visit ...", dealing with surgery, if we can scan down
  18     the page a little, you see in the second line of that
  19     paragraph:
  20        "Both consultant paediatric cardiologists and one
  21     of the consultant surgeons accompanied us while
  22     inspecting the Bristol Children's Hospital."
  23   A. I see it, yes.
  24   Q. That is why I suggest that there is contemporaneous
  25     evidence of you having met the delegates from Wales.

   1        It would appear from this document that you and
   2     I assume Dr Joffe, and one of the surgeons, went around
   3     the Children's Hospital, but it would not appear that
   4     there was a cardiologist involved in a tour of the
   5     Bristol Royal Infirmary?
   6   A. I am sorry, I cannot help you with that.
   7   Q. Can we go to page 266? Can I ask you to read that first
   8     paragraph, beginning " ... any figures ...", but
   9     beginning with the sentence "We did however raise ...",
  10     to the end of the paragraph?
  11   A. Yes, I have read the first paragraph.
  12   Q. Can you help us with any discussion, either at this
  13     meeting or otherwise, from delegates from the Welsh
  14     Office, asking Bristol about the question of the outcome
  15     of results at Bristol?
  16   A. I have no recollection of it, I am sorry. I mean,
  17     I have a recollection of much more informal discussions
  18     with individuals, but I cannot, I have to say, remember,
  19     myself, what was said at that meeting. I cannot
  20     remember the meeting at all.
  21   Q. You mentioned earlier Professor Henderson, Andrew
  22     Henderson?
  23   A. Yes.
  24   Q. He was a cardiologist in Cardiff?
  25   A. He was the Professor of Cardiology, yes. There is

   1     a slight distinction, I am sorry. He was, he is retired
   2     now.
   3   Q. He was known to you?
   4   A. He had been the Senior Registrar in Bristol at the time
   5     I got my consultant appointment, from memory.
   6   Q. So you were old colleagues?
   7   A. Yes. I mean, we are contemporaries, and we used to meet
   8     up quite regularly.
   9   Q. What was his attitude to Bristol providing paediatric
  10     cardiac services to children from Wales?
  11   A. I have a recollection of discussing this on a number of
  12     occasions with him, most of which were sort of
  13     discussions that we might have, say, at a Cardiac
  14     Society meeting when we were sitting down having a cup
  15     of coffee or something like that, but there was actually
  16     one more formal meeting where he asked me to come and
  17     meet him in the University Hospital of Wales, and
  18     I think I went there from one of my clinics in the far
  19     west of Wales.
  20        Certainly at that meeting, and at other meetings,
  21     we discussed if you like the possibilities of liaison or
  22     linkage between Cardiff and Bristol in relation to
  23     paediatric cardiac surgery and paediatric cardiology,
  24     and various options were discussed. Again, I mean, this
  25     is informally; we did not produce minuted documents or

   1     anything like that.
   2   Q. What were the difficulties that stood in the way of
   3     Bristol providing a service for the Welsh children?
   4   A. I suppose high on the list must be the amour-propre or
   5     whatever the Welsh translation is of the Welsh people.
   6     I have to say, he is not a Welshman, but he was well
   7     aware that there was a lot of local feeling that, like
   8     so many things, this should be provided within the
   9     Principality.
  10        The other problem that we discussed in some
  11     detail, because, as a Professor, and responsible
  12     particularly for training, it concerned him, was his
  13     concerns about paediatric cardiology in a sense going
  14     completely from Cardiff. I should say, at this time,
  15     although the chart that we looked at before did not
  16     record any paediatric cardiologists, there was actually
  17     I think his senior lecturer and one of the consultants
  18     who did investigations on children in Cardiff. There
  19     was really no cardiac surgery, but there was some
  20     cardiology.
  21        His particular worry was the question of training
  22     posts, of which they had quite a number in Cardiff at
  23     that time, Senior Registrar posts in cardiology, because
  24     one of the requirements was that Senior Registrars in
  25     cardiology had to have exposure to paediatric as well as

   1     adult cardiology -- I mean a limited amount, but --
   2   Q. That would explain what Professor Henderson was
   3     concerned about Cardiff potentially losing, if you like?
   4   A. That was one of the things we discussed, yes.
   5   Q. What about the difficulties, if there were any in
   6     Bristol, logistical or otherwise, to Bristol providing
   7     the service for the Welsh children?
   8   A. It must be clear, we are not actually talking about the
   9     whole of Wales, we are talking about South Wales. For
  10     geographical reasons, I do not think it was ever
  11     envisaged that patients from North Wales would go either
  12     to Cardiff or Bristol. They basically went to Liverpool
  13     and some from the central department to Birmingham.
  14     I am talking about South Wales, which is in terms of
  15     population, the major part of it.
  16        There was certainly discussion about either the
  17     children all coming to Bristol or alternatively, a sort
  18     of compromise situation whereby they investigated
  19     patients in Cardiff and they were then sent to Bristol,
  20     or the majority of them would be sent to Bristol, for
  21     surgery. That was one of the options that was
  22     considered that would still allow them to retain
  23     paediatric cardiology for teaching purposes.
  24   Q. But again, we are looking at it as it were from the
  25     Welsh angle?

   1   A. Yes.
   2   Q. What were the bars to Bristol providing this service?
   3     Was there anything to stop Bristol throwing open its
   4     doors to the South Wales children?
   5   A. By that time, we had already, I think, had the majority
   6     of the paediatricians in South Wales sending their
   7     patients to Bristol, so it would have been an increase.
   8     Clearly we would have had to look at the implications in
   9     terms of additional beds and so on. There were certain
  10     negotiations with the Welsh Office, I cannot remember
  11     the outcome of them, but for the Welsh Office actually
  12     to pay Bristol essentially for the running costs of
  13     something like one intensive care bed or something, to
  14     cover the additional costs in relation to the patients
  15     who came from South Wales.
  16   Q. In the end, the Welsh Office decided, did it not, to
  17     send South Wales children to Bristol as part of the
  18     supra-regional service, and not to establish or plan to
  19     establish in Cardiff a paediatric service which would
  20     embrace those very young children?
  21   A. My understanding -- and I am sorry, things changed over
  22     the years and my recollection is hazy. My recollection
  23     is that they decided not to do anything to stop the
  24     under 1s coming to Bristol: I mean, anything active.
  25     I do not know how far you want me to take this, but as

   1     it is well known, there was a lot of debate. I think
   2     the Royal College of Physicians was asked to intervene
   3     and either set up or provide a Chairman for a Working
   4     Party, and they came to another conclusion, of course,
   5     which was that Cardiff should have a unit and that new
   6     staff should be appointed. That became effective at
   7     just about the time of my retirement.
   8   Q. Yes. Can I just show you briefly -- I do not want to
   9     delve into this in too much detail, WO 1/273. It is
  10     a meeting you were not at. It is a meeting of the Welsh
  11     Medical Committee on 21st January 1987. I just want to
  12     show you what was decided by the Welsh Medical
  13     Committee.
  14        If we go to page 273, we see that the guest
  15     speakers included Professor Henderson. I think the
  16     first page must be 272.
  17        If we go to page 272, there is the first page.
  18        Can we go to page 279? Professor Henderson, if we
  19     scan down the page, said ... you can read what he says.
  20        He had been surprised to learn on 20th October
  21     1986 that there could be problems concerning infant
  22     cardiac surgery and said that Bristol seemed to a number
  23     of clinicians not to be offering the very best possible
  24     service.
  25        At that time, were there any reasons that you were

   1     aware of which might justify that statement?
   2   A. I do not know the source of the information that
   3     Professor Henderson appears to be putting out there.
   4     I have to say that I think the main source of his
   5     information was me.
   6   Q. That is why I am asking.
   7   A. Do you wish me to go into, in general terms, what I said
   8     to Professor Henderson about the situation in Bristol?
   9   Q. I want to explore with you whether or not there were any
  10     reasons to think at that time that Bristol was not
  11     offering the very best possible service and if there
  12     were, what the problems were, whether it was waiting
  13     lists or the surgeon or the cardiologist, or whatever it
  14     might be?
  15   A. Shall I address that? Firstly in general terms, we had
  16     the hypothetical argument, basically, with me saying "If
  17     you are thinking of setting up a paediatric cardiac
  18     surgical service, a full service in Cardiff -- and,
  19     I mean, let us face it, although economically it might
  20     not be considered a good thing this side of the Severn,
  21     different considerations apply over there -- but if you
  22     are thinking about it and you want to know how your
  23     service is likely to differ from that in Bristol, we can
  24     start at the very extreme, if you like, and can I say to
  25     you that Bristol is undoubtedly the best centre in the

   1     country, if not in the world and therefore if you set 
   2        up a centre in Cardiff, it is unlikely it is going
   3     to match the results in Bristol, and therefore patients
   4     are going to continue to come over to Bristol." That is
   5     one of the ways we have looked at the problem.
   6        I said to him, as far as I was concerned, I did
   7     not feel in a position to say that that was the case, in
   8     other words, that Bristol was so outstanding that there
   9     was absolutely no possibility that they would be able to
  10     run a service that was comparable to it.
  11        We did certainly, I recall, discuss the fact that
  12     we were having difficulty over the business of firstly
  13     appointing another paediatric cardiologist -- was this
  14     in 1988? I cannot remember.
  15   Q. This was a meeting in January 1987.
  16   A. Right, so I do not think that had come up. We were
  17     actually at that time expecting to appoint a third
  18     paediatric cardiologist.
  19   Q. That turned out to be Dr Martin in due course?
  20   A. It did, but in fact as I think is known, we did not
  21     succeed in making an appointment the first time we
  22     attempted it, which I think was at the end of 1987, from
  23     memory.
  24        But firstly, you know, we needed more help with
  25     the paediatric cardiology, but we were hoping to get it;

   1     secondly, overall we needed more facilities for cardiac
   2     surgery, and we were working on that. Thirdly, we were
   3     still not, as it were, assured of having a combined unit
   4     situated at the Children's Hospital at that time.
   5        So those would have been the things that I would
   6     have discussed with him in terms of, if you like, the
   7     downside of relying on Bristol.
   8   Q. Can we go to page 286, please, still in the same
   9     meeting, just to show you what was decided by the Welsh
  10     Medical Committee?
  11   A. I take it the Welsh Medical Committee is an advisory
  12     committee, they do not decide anything, they actually
  13     advised the Welsh Office.
  14   Q. The advice in the meeting was taken by the relevant
  15     minister.
  16        If we scan down to find the relevant passage at
  17     the very bottom, it is the quotation from the bottom
  18     paragraph. That is what they decided. We see in the
  19     last sentence of that first paragraph --
  20   A. I am sorry, can I read it through in its entirety so
  21     that I get it in context?
  22   Q. The relevant sentence is the last one of the penultimate
  23     paragraph. (Pause).
  24   A. Yes, okay, I have got as far as that sentence now.
  25   Q. Can I take you to UBHT 133/29? We have moved on

   1     a little. This is now 3rd August 1987. You recognise
   2     this letter, I think, Dr Jordan? It is a letter that
   3     you and Dr Joffe and Mr Wisheart and Mr Dhasmana all
   4     signed. Do you remember?
   5   A. I do not remember it, I am afraid. Can I read it all
   6     through, or do you wish me to look at one particular
   7     part of it?
   8   Q. It is a rather long letter. I am more than happy for
   9     you to read it all through in due course, but can
  10     I perhaps go to the guts of it?
  11        This is a letter written by the four of you, and
  12     it is in the wake of a television programme which had
  13     been shown on Welsh television on 16th June 1987. You
  14     might not remember the precise date, but do you remember
  15     there being a television programme?
  16   A. A television programme that I think was entitled "And
  17     meanwhile our children are dying"; is that correct?
  18   Q. If we go over the page, UBHT 133/30, to the top of the
  19     page, there is a reference to the Bristol paediatric
  20     unit being subjected to "a campaign of vilification, the
  21     word is chosen advisedly, which we find quite
  22     extraordinary and very sad ..."
  23        Then you see what is said.
  24        At the bottom of that page, if we scan down, in
  25     that paragraph that we can now see:

   1        "We too felt obliged to seek publication of
   2     a letter in the Welsh press indicating that the
   3     allegations made against Bristol regarding surgical
   4     results are totally false. A summary of the results in
   5     Bristol in the period 1994-1986 compared with national
   6     figures for 1984, the latest available, is enclosed ..."
   7        I do not want to focus any more on the detail of
   8     the letter. If we go to HA(A) 119/44, and have a look
   9     at that.
  10   A. Do you want me to focus on anything in particular?
  11   Q. First of all, where would the UK figures be taken from?
  12   A. I would presume that they came from the United Kingdom
  13     Cardiac Surgical Register.
  14   Q. We can see from these figures, for example, in
  15     open-heart surgery over 1 year, in Bristol for those
  16     three years, the mortality was 7.9 per cent; the UK for
  17     1984, 6.9 per cent; for under 1 years, 26.5 per cent as
  18     against 21.8 per cent.
  19        We see the total number of patients under 1 year
  20     for those three years in Bristol was 49?
  21   A. Yes.
  22   Q. If we go just back to the letter very briefly,
  23     UBHT 133.31 --
  24   A. I am sorry, before we go way from there, can I just have
  25     a moment, because I am simply looking at the number of

   1     open-heart operations for the UK in relation to that,
   2     because we are running at an eighth of the total number,
   3     if my calculations are right.
   4   Q. No, because Bristol's figures are over three years.
   5     Bristol takes three years to do 49 patients. The UK did
   6     431 --
   7   A. Yes, okay.
   8   Q. Can we go to UBHT 133/31? This is the end of the
   9     letter. If we just scan down the page a little, I am
  10     looking for the reference to "steady improvement". Do
  11     you see in the paragraph which is now at the top of the
  12     page, there is a reference to the "steady improvement in
  13     the results achieved". Do read the paragraph,
  14     Dr Jordan.
  15   A. You want me to read the paragraph starting at the top
  16     of the page?
  17   Q. If you wish, but all I want to focus upon is the
  18     reference to "steady improvement in the results
  19     achieved".
  20   A. It is pretty heavy stuff, is it not? I do not think
  21     that is my style, but still.
  22   Q. My next question was, if we scan down the page we will
  23     see the four signatures there.
  24   A. I am sure I signed it, yes.
  25   Q. Do you remember who drafted this letter? Do you

   1     recognise the style?
   2   A. I cannot remember, but I do not think it is my style.
   3     I tend to be a little more subtle with these things,
   4     I am afraid.
   5   Q. Might it be Dr Joffe's style?
   6   A. It might be, or it might be Mr Wisheart's. I do not
   7     think it is Mr Dhasmana's, either. Dr Joffe and
   8     Mr Wisheart could well have been responsible for the
   9     text of that letter.
  10   Q. You see, feelings were running high, obviously, on both
  11     sides; that is plain, is it not?
  12   A. Yes.
  13   Q. If we go to UBHT 209/11, this is a letter from Dr Joffe
  14     to Mr Gray, about the Welsh question, if I can put it
  15     like that.
  16        I just want to take you to the third
  17     paragraph there, where Dr Joffe says:
  18        "Failing this, I believe further action should be
  19     taken against the compiler of the report ..."
  20        So Dr Joffe is taking a robust line, it might be
  21     said.
  22        Can I show you now your letter at 209/7? It is
  23     the last paragraph I want to focus on there. You are
  24     taking a less robust approach, which rather ties in with
  25     what you have just told us. You say:

   1        " ... unlike the majority of my colleagues ..."
   2        Does it follow from what you have told us a moment
   3     ago that perhaps Mr Dhasmana might have been, like you,
   4     rather less robust than perhaps the other two
   5     signatories of the letter?
   6   A. I am not sure I would really want to speak for him at
   7     all. I mean, I am simply putting my view, which is that
   8     it should not be construed as saying that I disagreed
   9     with the comments. In fact, I have said there, my view
  10     was, and I repeatedly stated this, that if you are
  11     subject to adverse criticism, that to -- how shall I put
  12     it -- have a public debate about this, let alone going
  13     into the law courts -- I have to be careful what I say
  14     here, but let us say that things are used selectively in
  15     the law courts sometimes and the selective reporting
  16     could actually, you know, be something that it would be
  17     difficult to refute. In general, my understanding of
  18     the sort of history of doctors suing papers or
  19     television companies for libel was that it cost an awful
  20     lot of money and did not actually achieve anything in
  21     the long run.
  22   Q. Now can I turn to something else --
  23   THE CHAIRMAN: May I just go back to the letter for
  24     a moment, Mr Maclean? Could you help me with the four
  25     signatories, the reference?

   1   MR MACLEAN:  UBHT 133/29 is the start of it.
   2   THE CHAIRMAN: I think it is the top of the second page.
   3   MR MACLEAN: Page 30?
   4   THE CHAIRMAN: I am told it is the next page.
   5     [UBHT 133/31].
   6        May I take you to lines 8 or 9, the actual status
   7     of the facilities: "better than most in our view".
   8        Your evidence to us today, Dr Jordan, perhaps only
   9     half an hour ago, was that the facilities for cardiac
  10     surgery in the generality lagged behind those in other
  11     centres for the whole of the time of your holding tenure
  12     at the hospital.
  13        How are those two propositions to be reconciled?
  14   A. It is terrible to have to say it, because I am
  15     a signatory to this letter, but I am not exactly sure of
  16     the actual facilities.
  17        One thing that I remember was the programme dealt
  18     with facilities for parents and support facilities, and
  19     I think that that may well be what Dr Joffe, if he
  20     indeed was the author -- and Mr Wisheart -- had in mind
  21     at that time. I accept that another view on that is
  22     that it is inaccurate in particular with regard to the
  23     fact that we had a split site for the surgery.
  24   MR MACLEAN: Just before we leave the letter, in the same
  25     paragraph, just after the reference that the Chairman

   1     has taken you to, to the facilities, we see the
   2     reference to surgical results "which are at least equal
   3     to those achieved by other paediatric units."
   4        As you recall, what ability did clinicians have at
   5     this time to obtain data on the results of other
   6     centres?
   7   A. My recollection is that -- this is all a reference to
   8     the UK Cardiac Surgical Register. I cannot think of any
   9     other sort of widespread source of information. That
  10     information was made available to participating
  11     surgeons, actually some time, I think there was usually
  12     about two or three year gap --
  13   Q. That would be one's own data?
  14   A. No, the overall numbers and results I think for the
  15     country as a whole were made to the surgeons.
  16   Q. Do you remember the letter, the results that we looked
  17     at, comparing Bristol's results over three years to the
  18     register in one year, do you remember, 1984/86 against
  19     1984?
  20   A. Yes.
  21   Q. The register eventually, after the passage of time, made
  22     available to each centre the total results for all the
  23     centres in the country, and, as I understand it, each
  24     individual centre, obviously, would have known its own
  25     results because they had submitted it to the register in

   1     the first place, but the register did not send, for
   2     example, to Bristol the results of Great Ormond Street
   3     or the Brompton, or Newcastle; it simply sent the annual
   4     return figure.
   5        Does that accord with your understanding?
   6   A. That is my understanding. Also, they did not send them
   7     to Bristol in general. They did not send them to the
   8     cardiologists; they went specifically to the surgeon who
   9     completed the return, as I understand it, in confidence.
  10   Q. So is this right: that the cardiologists were not sent
  11     even the country-wide data, because that went to the
  12     surgeons?
  13   A. That is correct.
  14   Q. But the surgeons would be sent only country-wide data,
  15     not centre by centre data?
  16   A. That is also my understanding.
  17   Q. So what is the basis for the claim that surgical results
  18     were at least equal to those achieved by other
  19     paediatric units?
  20   A. My understanding is that they are comparing them with
  21     the average results from other units.
  22   Q. Because that was the only comparison there was?
  23   A. Exactly.
  24   Q. With the national register?
  25   A. Exactly.

   1   Q. I am sure in the course of the day you will have an
   2     opportunity to look at this letter which may be an
   3     important one and it may be we will want to come back to
   4     it later, but in the meantime, can I go to something
   5     else?
   6        I want to turn to the question of the auditing of
   7     results.
   8        We know that there were pre-operative planning
   9     meetings before surgery took place, and you have
  10     emphasised those in your response to Mr Langstaff
  11     earlier.
  12        Can we look at UBHT 188/167? You mentioned in
  13     your remarks at the end of Mr Langstaff's questioning
  14     that no very full notes were kept of the
  15     multidisciplinary meetings.
  16        Is this an example of the output of one of those
  17     planning meetings?
  18   A. I would not want to give you a single example if I was
  19     trying to give an impression of what we did at this
  20     meeting. If this was a perfectly straightforward -- let
  21     me just say, about the most straightforward condition is
  22     an atrial septal defect in a four year old child.
  23     I think that is the sort of report that we might well
  24     have done on the basis that there really was nothing
  25     much to argue about.

   1        On the other hand, there were clearly other ones,
   2     and we have seen examples, where the discussion was to
   3     some extent recorded there, although there was much more
   4     emphasis on the final decision than there was on the
   5     discussion, which might go on for half an hour,
   6     altogether.
   7   Q. It says at the top of this one, which is only an example
   8     and I do not choose it for any particular reason "Joint
   9     Paediatric/Surgical Meeting."
  10        These meetings would be attended by surgeons,
  11     cardiologists, and I think you said earlier,
  12     radiologists?
  13   A. I am just looking at the date and wondering how we were
  14     having a meeting on a Thursday, whether we rearranged
  15     something, because they were normally Wednesdays and
  16     Mondays. That may be a typing error, but --
  17   Q. I do not propose to work out now whether 29th January
  18     1987 was a Thursday --
  19   A. I am sorry to distract you.
  20   Q. If you were to attend these meetings, obviously surgeons
  21     and cardiologists, and radiologists I think you
  22     suggested earlier, Dr Wilde perhaps?
  23   A. Yes.
  24   Q. Did anaesthetists attend these meetings?
  25   A. Sometimes. Not frequently.

   1   Q. Did Dr Masey attend them more frequently than other
   2     anaesthetists?
   3   A. I think the two I recall going were Dr Burton and
   4     Dr Masey.
   5   Q. Why did they attend and others did not?
   6   A. I think it is a question of, you know, when they were
   7     appointed, and that the ones who had been there longer
   8     tended to, if you like, have a closer association with
   9     the cardiologists and what they were doing than those
  10     who were appointed a bit later on.
  11   Q. If the other anaesthetists did not attend, would there
  12     be such meetings which would sometimes take place
  13     without an anaesthetist?
  14   A. Oh, indeed, yes.
  15   Q. So their anaesthetic input into these meetings was
  16     not --
  17   A. I am sorry, could I just comment on this? I am not sure
  18     whether this one actually comes from the Children's
  19     Hospital or from the BRI, because it was fairly --
  20     I mean, if it was January 1987, I am not sure we
  21     actually had the catheter lab open. I am just a little
  22     bit uncertain.
  23   Q. Perhaps I ought to have chosen another one.
  24   A. Yes.
  25   Q. We see a reference to the BRI cath' file. There is

   1     a copy to go to the BRI cath' file.
   2   A. In that case it would have been the BRI, it would have
   3     been before we opened the catheter lab at the Children's
   4     Hospital.
   5   Q. Let us focus on the anaesthetists at these meetings.
   6     Their input was not vital to these meetings?
   7   A. I think I would agree with that as it stands, yes --
   8     desirable, but not vital.
   9   Q. When Dr Masey or Dr Burton did attend, what did they
  10     bring to the meeting that was not otherwise there?
  11   A. I think they obviously liked to know in advance the
  12     sort of patients that they were likely to have to
  13     operate on. From memory, I think it is sort of unusual
  14     that an anaesthetist would have a lot of input. The
  15     only exception, I think, was when we were discussing
  16     patients with pulmonary hypertension, in which there
  17     might well be a need for some sort of specific
  18     post-operative treatment.
  19   Q. We will see that a little later.
  20   A. Yes.
  21   Q. These are not audit meetings; these are pre-operation
  22     planning meetings.
  23        When Dr Martin took up his post, he took the lead,
  24     did he not, in the cardiological audit programme?
  25   A. He was given it, but -- he accepted it, yes.

   1   Q. Can we go to UBHT 61/126? This is a note of an audit
   2     meeting of 19th March 1990, and you see the attendees.
   3   A. Yes.
   4   Q. At this meeting, amongst other things, were reviewed the
   5     results for the under 1s for 1989.
   6   A. Yes.
   7   Q. If we scan down the page, there is a discussion of
   8     children with VSDs and there is a discussion then of the
   9     Senning operation:
  10        "The Senning results were good, 10 patients
  11     underwent Senning repair with one death. The death was
  12     again associated with post-operative pulmonary vascular
  13     hypertensive problems, possibly related to multiple
  14     pulmonary embolism from SVC thrombosis. The merits of
  15     changing the necklines were more often discussed or the
  16     use of Doppler ultrasound to look at their SVC flow. No
  17     definite policies were recommended at this stage."
  18        If we go over the page, skipping over the SVC
  19     discussion, "Future direction", the third paragraph:
  20        "We should aim to perform Senning operation at
  21     between 8 and 9 months of age, rather than 10 to 12
  22     months as at present."
  23        How would that desirable aim be achieved? How
  24     does one go about shortening the period between
  25     diagnosis and surgery?

   1   A. The first thing is that it was our normal practice to
   2     carry out a pre-operative cardiac catheter in patients
   3     who were being lined up for a Senning operation, so the
   4     first thing would be that that would be carried out
   5     earlier, because, as I think has become clear, there
   6     were continuing problems with the waiting list and it
   7     was easier to do the catheter earlier and hope that the
   8     waiting list period would not lengthen, than to actually
   9     try and shorten the surgical waiting list, basically.
  10   Q. So the catheter by this time is, at 1990, discussing 89
  11     cases, the catheter would be done at the Children's
  12     Hospital?
  13   A. Yes.
  14   Q. Because the cath' lab was up and running?
  15   A. Yes.
  16   Q. If there was then surgery to follow as a result of the
  17     findings of the catheter investigation, and that surgery
  18     was open-heart surgery, which it would be for the
  19     Sennings operation, it would be conducted at the BRI?
  20   A. That is correct.
  21   Q. So then the patient enters the waiting list?
  22   A. Yes.
  23   Q. The waiting list was controlled by whom?
  24   A. The surgeons.
  25   Q. You say in your witness statement -- which I think you

   1     have in front of you in hard copy form, have you?
   2   A. Yes.
   3   Q. It is page 41, or numbering, the top of the page,
   4     WIT 99/41.
   5   A. No, I do not have a copy.
   6   Q. Here it is on the screen, the very bottom of the page,
   7     dealing with Issue E. You suggest that the surgeon is
   8     the only one who controlled the waiting list?
   9   A. I think for practical reasons, that is correct, yes.
  10   Q. Let us assume that this decision has been taken to try
  11     to reduce the period between diagnosis and surgery for
  12     the Sennings operation if 1990, which we have just seen
  13     it was.
  14        The cardiologist could conduct the catheter
  15     earlier and there was no particular waiting list
  16     difficulty with that?
  17   A. That is correct. I mean, from memory, from fairly
  18     shortly after we got to the Children's Hospital, we had
  19     effectively got the waiting list down to negligible
  20     proportions.
  21   Q. So the clog in the system was the waiting list for the
  22     open-heart surgery?
  23   A. That is correct.
  24   Q. And that was in the hands of the surgeon?
  25   A. That is correct.

   1   Q. What could the surgeon do? How could he achieve the
   2     earlier operation? What would the repercussions of that
   3     be?
   4   A. The mechanism of the waiting list is not simply a list
   5     of patients who are put on top and taken off at the
   6     bottom, or vice versa, so the surgeon would have
   7     a waiting list and I am sure that they kept separate
   8     waiting lists for children and adults, which, from
   9     memory, was kept as, you know, small cards with the
  10     details on.
  11        The surgeon would enter on it either something
  12     like "To be done preferably January or if not, February
  13     at the latest", you know, in the year 2000 if we were
  14     dealing with it now. If there was really no urgency, or
  15     very little urgency, he would simply put it on the
  16     waiting list and say, you know, "When there is a space
  17     available".
  18   Q. It would ultimately be down to the surgeon, then, to say
  19     "Case X really does now have to be done", and time will
  20     certainly have to be found for it?
  21   A. I am sure the surgeons would tell you about this in more
  22     detail, but for practical purposes, if they were looking
  23     at December's waiting list, they would, at the beginning
  24     of November, have gone through all the cards and
  25     selected the patients for December.

   1        The problem with that is that when they selected
   2     all the patients for December, they would find there
   3     were twice as many patients as they had spaces for, so
   4     inevitably, some of those went over to the next time.
   5     I mean, "twice as many" is perhaps an exaggeration, but
   6     that was not infrequently the situation. In other
   7     words, if you like, the expression of intent that went
   8     on the card, on the surgical waiting list, was not
   9     always borne out in practice.
  10   Q. We will see perhaps a little later some discussions that
  11     you had with referring paediatricians elsewhere.
  12     I think perhaps in Plymouth, who were referring their
  13     patients to Southampton?
  14   A. Yes.
  15   Q. Is that right?
  16   A. Yes.
  17   Q. We can turn up the document in due course, but I think
  18     it is right that you had a discussion with
  19     paediatricians in Plymouth about the merits or demerits
  20     of referring their patients to Bristol as against
  21     Southampton?
  22   A. Yes.
  23   Q. Southampton, if I have understood it correctly, had no
  24     or very short waiting lists compared to Bristol?
  25   A. The information I was given by the paediatricians in

   1     Plymouth was if a patient was seen by one of their
   2     paediatric cardiologists in outpatients, requiring
   3     a catheter and presumably an operation, they will be
   4     admitted within about three weeks for the catheter and
   5     they will have their operation next week. That is what
   6     they described to me as being a typical situation.
   7     Whether, you know, it always quite worked like that,
   8     I cannot say, but that was the information given to me.
   9   Q. And that was about this sort of time, three years or
  10     thereabouts before your retirement?
  11   A. Yes. We had this discussion on odd occasions, but, yes,
  12     I mean, there was certainly a discussion about 1989/90,
  13     something like that.
  14   Q. So were the Bristol children who were facing the long
  15     waiting list at Bristol referred to Southampton where
  16     there were very short waiting lists?
  17   A. Is the question, were they? No, they were not.
  18   Q. Would that not have been a more sensible way of
  19     proceeding?
  20   A. It is like all of these things: it is sensible in that
  21     it deals with the immediate problem. What then happens
  22     when Southampton builds up a waiting list because they
  23     have been sent twice as many patients as they can cope
  24     with?
  25   Q. What would be the bars, the disincentives for you and

   1     Dr Joffe in sending a patient to Southampton, say?
   2   A. Can I say, I have absolutely no criticisms of the
   3     surgery in Southampton, so let us get that out of the
   4     way. That is not a bar.
   5        Firstly, it would almost inevitably mean a longer
   6     journey for the patients and their parents. Secondly,
   7     there would then be problems of communication between
   8     the surgeons there and the patients: where do they
   9     follow them up? If it was a patient who came from
  10     Haverfordwest in South Wales, they would not want to be
  11     sending one of their teams out to Haverfordwest just to
  12     see one or two patients.
  13        There were those sort of logistic problems,
  14     basically, that it seemed to us desirable to avoid, if
  15     they could be avoided.
  16        Having said that, I did refer patients not to
  17     Southampton but to other hospitals for specific reasons,
  18     and obviously we had to make the best that we could of
  19     those particular objections.
  20   MR MACLEAN: We may want to come back to some of that
  21     later. I am sorry for being distracted, but we were
  22     discussing whether or not this would be an appropriate
  23     moment to have a break of perhaps half an hour or
  24     thereabouts?
  25   THE CHAIRMAN: Yes, shall we do that, thank you, Mr Maclean,

   1     and reconvene, therefore, at 1.10?
   2   (12.40 pm)
   3            (Adjourned until 1.10 pm)
   4   (1.15 pm)
   5   THE CHAIRMAN: Forgive me, Dr Jordan, I kept us waiting.
   6     It is my fault. Mr Maclean?
   7   MR MACLEAN: Dr Jordan, we were looking at the example of
   8     the audit meeting, do you remember, of 19th March 1990?
   9     We dealt amongst other things with the Sennings
  10     operation.
  11        That would be an example, would it, of one of the
  12     typical audit meetings Dr Martin organised after he was
  13     appointed?
  14   A. I think actually that was not a terribly typical one, in
  15     that most of the meetings were concerned with a much
  16     more detailed review of an individual condition or
  17     problem. So it was unusual for the meetings to actually
  18     concentrate on what you might call "overall results"
  19     across the spectrum.
  20   Q. There were a couple of different meetings in which
  21     results were reviewed, was there not? One was the
  22     clinical pathology meetings that Professor Berry
  23     attended to review any deaths that occurred in the
  24     previous month?
  25   A. Yes, that is right.

   1   Q. Secondly, this would on occasion, a few times a year,
   2     meetings in somebody's house, one or other of the
   3     clinicians' house, to discuss broader topics?
   4   A. Yes, broader topics, not specifically audit, I think.
   5   Q. Is that right? Those are the other fora for discussing
   6     outcomes generally?
   7   A. Yes. Apart from producing papers for meetings and that
   8     sort of thing, I mean, scientific meetings.
   9   Q. If we go to WIT 99/19, your witness statement,
  10     paragraph 4, you make a reference there to "holding
  11     regular but infrequent informal meetings in somebody's
  12     house."
  13   A. I am sorry, which issue are we dealing with, because my
  14     copy is not annotated in the same way as yours.
  15   Q. Dealing with Issue B, Dr Jordan. This is a paragraph in
  16     which you refer to these meetings that took place in
  17     somebody's house; yes?
  18   A. Yes.
  19   Q. At the end of the paragraph, you say:
  20        "These meetings were not minuted."
  21        I think generally speaking that was the case. But
  22     we do have a note of one of those meetings. I want to
  23     show you that note. It is UBHT 61/146.
  24        I am not suggesting to you that these are formal
  25     minutes of the meeting, but it is a note, somebody's

   1     note, after a meeting that took place on 28th July 1991
   2     at Mr Wisheart's house.
   3        You see the topics that were discussed under the
   4     heading "Agenda". Among the topics were pulmonary
   5     hypertension, tetralogy of Fallot, AVSD and age at
   6     operation.
   7        If we scan down the page, under "Introduction" --
   8   A. I am sorry, can I be told in advance whether I am
   9     documented as having been present at this meeting?
  10   Q. There is no mention in this note of any cardiologist
  11     having contributed to the meeting. There is no record
  12     on this note of who did or did not attend the meeting,
  13     but you will see as we go through, who is recorded as
  14     having spoken. It would not appear, on the face of it,
  15     that you were present at this meeting.
  16   A. Right, because I was going to say, we were not usually
  17     reluctant to make the odd comment, as cardiologists.
  18   Q. I should tell you, it would appear this note was
  19     compiled by Dr Bolsin.
  20        Can I take you to the paragraph under
  21     "Introduction"? Remember, this is July 1991. It is
  22     the reference in that first paragraph:
  23        "Mr Wisheart said he thought that the tables", we
  24     see which tables they were, "then demonstrated that the
  25     problem which had thought to have been reaching crisis

   1     proportions in the Bristol unit, when put in context,
   2     was actually not as serious as had been thought.
   3        "Dr Bolsin said that he thought that the data in
   4     the tables in which the Bristol mortality was higher
   5     than the average for two years prior, vindicated the
   6     vigilance of the anaesthetic staff in recording their
   7     mortality data. This point of view was supported by
   8     Dr Burton, Dr Masey and Dr Monk."
   9        If we deal with this point now, before your
  10     retirement, did you ever see any data from Dr Bolsin
  11     which he, Dr Bolsin, had compiled about paediatric
  12     cardiac surgery in Bristol?
  13   A. No.
  14   Q. Does that answer apply either directly from Dr Bolsin
  15     himself, as well as indirectly from others?
  16   A. I saw no data at all. I was unaware at the time, up to
  17     the time of my retirement that he had actually ever
  18     produced any data.
  19   Q. And you do not recall anyone mentioning such data
  20     existing to you during your time in-post?
  21   A. As I have put in my statement, the only possible
  22     connection with this is the fact that I think it was
  23     Dr Bolsin introduced Dr Black to me and said he
  24     understood that I had some information on a computer at
  25     the Children's Hospital; could Dr Black have a look at

   1     it. I think I took Dr Black up and showed him what the
   2     information was. I am not aware of Dr Black ever having
   3     used this. That is the only possible connection that
   4     I can recall between myself and Dr Bolsin in terms of
   5     collecting data and auditing data.
   6   Q. There is a reference there to reaching "crisis
   7     proportions" in the Bristol unit. Can you think of
   8     anything that might have been happening at this time --
   9     this is July 1991 -- that might justify the description
  10     of a problem which was "reaching crisis proportions", or
  11     "thought to have been reaching crisis proportions", but
  12     actually was not as serious as was thought?
  13   A. These are minutes that have been agreed and taken and
  14     signed as a correct record by the people who were there;
  15     is that right?
  16   Q. There is no evidence of that being the case, Dr Jordan.
  17   A. And you tell me that they were made by Dr Bolsin?
  18   Q. That is my understanding, although he will give evidence
  19     next week and may or may not confirm that.
  20   A. So this is purely, as I understand it, therefore,
  21     Dr Bolsin's own impressions of this meeting, not
  22     necessarily agreed by anyone who may have been there,
  23     which did not include me, I think.
  24   Q. That may well be the case. That is why I am asking you
  25     whether you have any knowledge of anything at about this

   1     time, July 1991, which might justify the comment that is
   2     made there about there being a problem which was thought
   3     to have been reaching crisis proportions but was not as
   4     serious as had been thought?
   5   A. I was not aware of anything that could remotely be
   6     described as "assuming crisis proportions". I mean, the
   7     term "problem" is not specific. I suspect, if I still
   8     had access to, you know, information that I filed at
   9     about that time, there might have been the odd crisis
  10     about something or other, but I am not aware of anything
  11     that related to cardiology or cardiac surgery at that
  12     time.
  13   Q. We saw from the agenda that this meeting discussed,
  14     amongst other things, age at operation. We will see
  15     that again in a minute.
  16        A discussion of the appropriate age of a child at
  17     operation would be something in which the cardiologist
  18     would have an important role to play?
  19   A. Yes.
  20   Q. So whether or not the cardiologists were present at this
  21     meeting, the topics which were discussed at this meeting
  22     would be the sort of topics into which the cardiologists
  23     would expect to have an input?
  24   A. I think that is correct, yes.
  25   Q. If we go, then, please, to page 149, this is under the

   1     heading "Tetralogy of Fallot". Dr Masey, a consultant
   2     anaesthetist, is suggesting that it might be possible
   3     that cardiologists could be involved with tetralogy of
   4     Fallot cases, particularly in the elucidation of the
   5     coronary artery anatomy.
   6        "Mr Dhasmana said he had reviewed specific deaths
   7     with the paediatric cardiologist and had found in some
   8     cases that the information provided was just not good
   9     enough, with specific reference to the pulmonary artery
  10     anatomy, and the coronary anatomy ..."
  11        Do read on to the end of the paragraph, if you
  12     want.
  13        Was there a specific paediatric cardiologist who
  14     dealt with tetralogy of Fallot cases?
  15   A. No, it would have been any of the three of us.
  16   Q. There is no reason why any particular one of you,
  17     Dr Joffe or Dr Martin, should get any particular case?
  18   A. No, not at all.
  19   Q. And any one of you dealt with tetralogy of Fallot cases
  20     over a period of time?
  21   A. That is correct.
  22   Q. Do you remember any discussion with Mr Dhasmana about
  23     the matters referred to in the note?
  24   A. Not at that time at all. We had discussions
  25     considerably earlier than this, and I think it would

   1     have been perhaps 1984/85 which followed a specific case
   2     where there had been a problem at operation over the
   3     coronary artery anatomy. It was decided at that time
   4     that we would make a policy of ensuring that the
   5     coronary artery anatomy was demonstrated at the cardiac
   6     catheter and angiogram, which we were still doing as
   7     a routine in Bristol right up to the time of my
   8     retirement.
   9        I say that because a lot of other centres were
  10     doing their operations purely on the basis of
  11     echocardiography, I think, by then.
  12   Q. That is what I was going to ask you: what was the
  13     diagnostic technique which was relied upon at operation
  14     at this time --
  15   A. I am sorry, at catheterisation, are we talking about,
  16     angiography?
  17   Q. What procedures were carried out pre-operatively in
  18     Fallot's patients in Bristol at this time?
  19   A. The normal investigation for tetralogy -- this would
  20     certainly apply from the time of the catheter lab at the
  21     Children's Hospital, so that is 1987 -- was that we
  22     would do a catheter to measure pressures, take oxygen
  23     saturations in the normal way. We would do angiograms
  24     in the left ventricle and the right ventricle. If those
  25     did not clearly show the coronary artery anatomy, we

   1     would also make an injection into the ascending aorta
   2     specifically to look at that, and perhaps incidentally
   3     to check whether there was a patent ductus, which we
   4     occasionally had.
   5        So those were the investigations that we were
   6     certainly carrying out routinely by then. I might say,
   7     one of the other problems that is not mentioned here,
   8     which came up from time to time, and is a well-known
   9     hazard in tetralogy, is the question of additional
  10     defects in the lower part of the ventricular septum.
  11     For that reason, once we had the equipment to carry out
  12     multiple views of the left ventricle, we always did this
  13     as a routine.
  14   Q. Which equipment was that?
  15   A. This is the cineangiography equipment. At the BRI we
  16     only had one plane. At the Children's Hospital we had
  17     two planes, so you could put one injection in and get
  18     two sets of pictures looking in different directions at
  19     the heart.
  20   Q. In, as we have seen, this is July 1991, was there any
  21     piece of equipment or diagnostic technique which you as
  22     a Bristol cardiologist would have wanted to have had for
  23     Fallot's patients at this time but did not have?
  24   A. In terms of pre-operative diagnosis, I do not think so.
  25     I mean, nothing that was essential. There were some

   1     instances where trans-oesophageal echocardiography to be
   2     carried out immediately after completion of the repair
   3     might have been useful, but those were fairly small
   4     numbers and as has already been said, we were working
   5     towards getting that equipment eventually.
   6   Q. You had that discussion with Mr Langstaff earlier.
   7   A. I am just saying, I am surprised at this paragraph. As
   8     you tell me, this is Dr Bolsin who is neither a cardiac
   9     surgeon nor a paediatric cardiologist, making a note on
  10     this, and I frankly do not know what is being got at, if
  11     you like, in the paragraph. I have not actually seen
  12     the document before.
  13   Q. What about the previous paragraph? What do you make of
  14     the paragraph beginning "Dr Masey ..."?
  15   A. I thought we were involved.
  16   Q. Who else would be involved in the elucidation of the
  17     coronary artery anatomy?
  18   A. I do not know what is meant by this.
  19   Q. You find that paragraph difficult to comprehend?
  20   A. I find both those paragraphs difficult to comprehend,
  21     quite honestly. We were already doing considerably more
  22     than a number of centres were doing in 1991 in terms of
  23     investigation, and this was after discussion with the
  24     surgeons. I mean, we do not have the benefit of
  25     Mr Deverall here, but he might well have told you, well,

   1     the coronary artery anatomy is apparent to the surgeon
   2     when he opens the chest anyway, and any reputable
   3     surgeon will check whether there are multiple VSDs. As
   4     I say, there were some people who were operating without
   5     angiography, and I think, interestingly enough, it was
   6     passed over, but one of the criticisms made of one of
   7     the earlier cases was that we were doing unnecessary
   8     angiograms.
   9   Q. If we move down the page, please, Dr Jordan, it is the
  10     last passage in the paragraph. We have to perhaps go
  11     about six lines into the paragraph. You see the
  12     reference to Mr Wisheart?
  13   A. Yes.
  14   Q. The "he" all the way through the rest of the
  15     paragraph would appear to be Mr Wisheart. For example,
  16     eight lines from the bottom of the paragraph:
  17        "He suggested the surgeon should approach the
  18     cardiologists about more detailed demonstration of
  19     coronary anatomy in tetralogy of Fallot and also the
  20     pulmonary artery anatomy. They should also consider
  21     whether these patients should be operated on earlier,
  22     when the left ventricle was capable of taking the
  23     systemic workload."
  24        How would the cardiologists be in a position to
  25     have a more detailed demonstration of the coronary

   1     anatomy and the pulmonary artery anatomy than was then
   2     the case?
   3   A. I do not see this as being a possibility. I mean,
   4     I have dealt with coronary artery anatomy. The
   5     pulmonary artery anatomy, we were again taking multiple
   6     views at what might seem rather peculiar angles, to make
   7     sure we did see the anatomy of the pulmonary arteries.
   8        I might say, this is not always necessary. It is
   9     only necessary in those cases where there is thought to
  10     be a narrowing at the origin of one or other of the
  11     pulmonary arteries, and you sometimes need additional
  12     views in angiography in order to look at this, but this
  13     was something that we had in hand well before this time.
  14   Q. Is it right that there was a notion at this time that
  15     Fallot's cases might be operated on rather earlier than
  16     they had been before?
  17   A. There was a debate about it. The last evidence that
  18     I saw, which admittedly came from the States, was that
  19     even as late at 1995, the actual mortality from doing
  20     elective operations for tetralogy was still higher in
  21     infancy than over the age of a year.
  22        That was one side of it.
  23        The other side was that there was a concern that
  24     if left too long, the ventricles became what was called
  25     muscle-bound, but this related to the period when

   1     operations were not routinely done much before the age
   2     of 8 or 9, or something like that, and I do not think
   3     that there was really anything to suggest that there was
   4     a difference in terms of this particular aspect in
   5     patients operated on at the age of, say, 6 months, as
   6     compared with those that were operated on at the age of
   7     18 months.
   8   Q. Can we go over the page, please? There was a discussion
   9     at this meeting, so it would seem, of the AVSD
  10     condition. This is a condition which is not uncommon
  11     with Down's syndrome children; is that right?
  12   A. Of the atrioventricular septal defects that are seen,
  13     four-fifths occur in Downs syndrome and the condition
  14     occurs in about 25 per cent of all babies with Downs
  15     syndrome, if you want the statistics.
  16   Q. The particular problem with these children is that the
  17     pulmonary vascular disease, which is progressive, occurs
  18     quite early?
  19   A. That is a problem, yes.
  20   Q. And that when that is, as it were, superimposed on to
  21     the abnormality in the heart, then there can be quite
  22     rapid progressive pulmonary vascular changes in these
  23     children?
  24   A. Yes, that is correct.
  25   Q. That is essentially the argument for early operation on

   1     AVSD children?
   2   A. Yes.
   3   Q. I think -- we do not have to go to the paper, but there
   4     was a well-known paper by May, Brawn and others from
   5     Melbourne in about 1990 which demonstrated good results
   6     from the AVSD correction and one of the factors was
   7     early operation?
   8   A. You have the advantage of me. I have not looked at that
   9     paper recently. I am quite prepared to accept that this
  10     was the general view in 1991, that early operation was
  11     better than leaving the operation.
  12   Q. You were not at this meeting, but you see that
  13     Mr Wisheart is recorded in this note as referring to the
  14     Melbourne and recent Great Ormond Street experience, and
  15     it may be that Mr Wisheart has in mind the May, Brawn,
  16     et cetera, paper from Melbourne?
  17   A. I have since discovered there was apparently a meeting
  18     dealing entirely with this problem. I am not sure
  19     whether it is actually before or after. It probably
  20     must have been at around that time, I think, 1991,
  21     referred to I think as the "friendly" meeting.
  22   Q. Where Mr Brawn presented the results?
  23   A. So I understand. I was not at the meeting. It was
  24     a cardiac surgical meeting.
  25   Q. I think that is right. It was about this time. Anyway,

   1     the point is that these patients should be operated on
   2     at a younger age. This proposal was accepted by the
   3     meeting.
   4        What was the position in Bristol at this time, in
   5     terms of the age of operation of AVSD patients?
   6   A. As I remember it, this was about the time that we had
   7     actually done an audit of which there do not seem to be
   8     any papers still in existence, but actually on the
   9     management of AVSDs, and I think from memory, we by that
  10     time had operated on 16. There had been four deaths,
  11     and I think 13 out of the 16 had been patients with
  12     Down's syndrome.
  13        Those were patients who had been operated on over
  14     perhaps about three, four, five years. Up until then
  15     they included some who were over the age of the year,
  16     but I think one of the conclusions we arrived at was
  17     that even by the age of a year, which was by that time
  18     our sort of point to try and get the operation done by
  19     and I think most other centres as well that we knew of,
  20     that this meant that some of these patients had already
  21     got a greater than desirable degree of hypertensive
  22     pulmonary vascular disease.
  23        So I think at about this time, as a result of an
  24     audit meeting, we had already decided we should aim for
  25     operation by about six months of age rather than by 12

   1     months of age.
   2   Q. Was that aim realised?
   3   A. No.
   4   Q. Why not?
   5   A. The main problem was the surgical waiting list, and our
   6     trying to get the catheter done as close as possible to
   7     the time when the patient was actually going to get
   8     operated on, because clearly the surgeon wanted
   9     up-to-date information and it was going to be most
  10     useful if we did it that way. But, on the other hand,
  11     that might mean, if they were still waiting three or
  12     four months on the waiting list, if we had to allow for
  13     that and them getting the operation by six months, we
  14     would be investigating them at perhaps only six or eight
  15     weeks old and the findings then would not be
  16     representative of what the surgeon would find.
  17        So we were still trying to investigate them
  18     between sort of four and five months in the hope that
  19     they would, you know, get accelerated on the waiting
  20     list. But this really was not borne out, and indeed,
  21     I subsequently noted that I think the last patient
  22     I ever referred with an AVSD for operation in about
  23     December 1992 actually did not get her operation until
  24     June or July of the following year, which would have
  25     been get getting on for about six months later.

   1   Q. The age of the child when you would refer would
   2     typically be what?
   3   A. I think when it is referred, I am speaking from memory,
   4     but I think it would have been about four or five
   5     months, something like that.
   6   Q. So I appreciate that is one example from memory, but
   7     taking that as an example, that child would be nine
   8     months, maybe slightly more, by the time of the
   9     operation?
  10   A. Yes. I think it was actually nearly 12 months, from
  11     what I recall, but I cannot be absolutely certain about
  12     that.
  13   Q. I do not want to ask you any more about that particular
  14     note, Dr Jordan --
  15   THE CHAIRMAN: May I ask one question? If we could go back
  16     to the previous page, please, Mr Maclean. [UBHT 61/149]
  17     Is an explanation for Dr Masey's observation that she
  18     was suggesting that there be cardiologists available
  19     during the operation, or available to those carrying out
  20     surgery?
  21   A. If she is talking purely about the coronary artery
  22     anatomy, no, because once the chest is opened the
  23     surgeon can see the coronary artery anatomy far better
  24     than we can demonstrate it. It is in front of his
  25     eyes. He knows exactly where it is in relation to where

   1     he is going to make his incision in the right
   2     ventricle. As I say, I really cannot understand any of
   3     that particular section.
   4   Q. This is asking you to speculate, and you may not wish
   5     to: it might be about having the advantage of the help
   6     of cardiologists, but it is merely expressed wrongly at
   7     the end, "coronary artery anatomy", rather than
   8     something else?
   9   A. I did wonder that. One of the things I was particularly
  10     interested and given the opportunity would like to have
  11     pursued was actually the business of the function of the
  12     heart muscle, particularly in patients with tetralogy of
  13     Fallot immediately after surgery. Without going into
  14     details, it seemed to me, from some of the
  15     echocardiograms that I had done, that there was
  16     a misconception about what was happening and also about
  17     the beneficial or other effects of treatment that might
  18     be given under these circumstances.
  19        So I think if we left off the bit after the comma,
  20     I would agree with that. I would love to have been
  21     involved with the post-operative management and
  22     particularly with the echocardiograms.
  23   MR MACLEAN: Dr Jordan, you say one of the things you would
  24     have been interested in, given the opportunity and would
  25     like to pursue, and then you gave that explanation,

   1     which you did rather briefly and perhaps might read on
   2     the transcript as being rather opaque.
   3        Do take the time now, if it is something you are
   4     particularly interested in, to explain to us what it was
   5     about the post-operative situation that you have in
   6     mind?
   7   A. The thing that interested me particularly was that we
   8     might have the situation post-operatively, that is in
   9     the Intensive Care Unit, of a baby or child who had an
  10     operation for repair of tetralogy of Fallot, whose
  11     cardiac output, let us say, and perfusion of the body,
  12     was less than optimum and the main way of treating this
  13     at the time was to give these drugs that are known as
  14     inotropic drugs, those that make the heart contract much
  15     more forcefully than normal.
  16        On the echocardiograms that I did on some of these
  17     patients, there appeared to be no problem with the heart
  18     actually contracting, it was contracting very well.
  19     What it was not doing was relaxing and of course that is
  20     equally important, because if the ventricles do not
  21     relax when they have finished contracting they do not
  22     fill properly, there is not enough blood for them to
  23     pump out. There are technical terms for this, but it is
  24     another reason why cardiac output might be less than
  25     satisfactory.

   1        Had I been more involved, I think one of the
   2     things I would have liked to look into was how much of
   3     this was due to the drugs that the patient was receiving
   4     and how much was, if you like, unrelated to that, and in
   5     particular, whether some drugs were more likely to cause
   6     this particular problem than others.
   7        This was discussed with the surgeons and
   8     anaesthetists and I think the best we got was for them
   9     to change over from dopamine to dobutamine, which we
  10     were able to show produced rather less of this effect in
  11     as it were shutting the heart down and making it very
  12     small and unable to fill itself properly.
  13   Q. The post-operative echocardiograms that were done on
  14     open-heart patients at the Bristol Royal Infirmary were
  15     not typically done by you or by Dr Joffe or Dr Martin?
  16   A. I think on the whole more were done by the
  17     radiologists. If the surgeons wanted one, they would
  18     usually ask the radiologists to do it, mainly because
  19     the radiologists during the day at any rate, they knew
  20     where to find him.
  21   Q. They were in the same building?
  22   A. It was not a question of being in the same building. As
  23     you have heard, the cardiologists were all over Wales
  24     and the South West and Wessex, and I think they did not
  25     really feel that it was terribly useful to try and chase

   1     around when they could make a phone call to Dr Wilde's
   2     secretary and know he could be in the next room and have
   3     the message passed to him.
   4   Q. I am afraid this is jumping back to where we were, but
   5     it is something I should have asked you about earlier.
   6        Were you ever aware of a bid for capital funding
   7     that was made to the Supra Regional Services Advisory
   8     Group by Bristol in 1992?
   9   A. I cannot recall being aware of it; let us put it that
  10     way. I doubt if anything like that happened entirely
  11     without my knowledge. This was at the end of --
  12   Q. 1992.
  13   A. It would be much more likely to have been Dr Joffe
  14     because by that time it was well known that I was
  15     retiring and there was not much point in my getting too
  16     involved in the processes that were likely to go on well
  17     after my retirement.
  18   Q. Can I show you JDW 3/142?
  19        This says:
  20        "Dear Colin,
  21        "We were requested by Mr Owen (Supra-regional
  22     Services) to apply for capital allocation for 1993/4.
  23     The deadline was very short so I have submitted the
  24     enclosed as a preliminary bid. A detailed submission
  25     will need to be prepared in due course (? by when)",

   1     and then initials. Do you recognise those initials?
   2   A. That is HSJ, Dr Joffe.
   3   Q. It is copied, you see, to Mr Nix?
   4   A. Mr Nix -- you know who Mr Nix is; I cannot help with
   5     Mr Cameron -- and of course Mr Wisheart.
   6   Q. There was a short application for capital funding made
   7     at that time which the Panel saw, I think, when
   8     Mr Wisheart gave evidence. Does that ring any bell at
   9     all?
  10   A. I am afraid it does not, no.
  11   Q. Do you recall that capital funding was not initially
  12     available under the supra-regional scheme but became
  13     available in, I think, about 1987?
  14   A. I cannot recall that, no.
  15   Q. Were you aware, in 1992, of there being a Working Party
  16     of the Royal College of Surgeons of England and Wales
  17     looking into the question of the continued designation
  18     of neonatal and infant cardiac surgery?
  19   A. I cannot remember it. I think it is highly unlikely
  20     I was aware of it at that time. I really did not have
  21     any dealings with the Royal College of Surgeons in
  22     general terms, apart from their President, who was
  23     actually a friend of mine.
  24   Q. Which one was that?
  25   A. Sir Terence English. I think he was the President at

   1     that time.
   2   Q. How did you know him?
   3   A. Well, I mean, he and I were contemporaries and we met
   4     up on a number of occasions. I have also met him when
   5     he came to Bristol, which he did on a number of
   6     occasions when we advertised the post which Mr Wisheart
   7     was actually appointed to, and as I say, we were
   8     contemporaries, it was a fairly small field, we kept in
   9     touch. I also was in touch with him occasionally about
  10     cardiac transplantation -- this is in adults.
  11   Q. Did you and he ever discuss the question of
  12     supra-regional services?
  13   A. No.
  14   Q. Did you ever discuss Bristol's relative performance in
  15     cardiac surgery?
  16   A. No.
  17   Q. You presumably became aware that a decision had been
  18     taken by the Supra Regional Services Advisory Group by
  19     the Department of Health to de-designate neonatal and
  20     infant cardiac services?
  21   A. I became aware of it. It was after my retirement
  22     though.
  23   Q. It took effect after your retirement, yes. It took
  24     effect in April 1994, I think, but the decision was
  25     taken in the latter part of 1992?

   1   A. I am really not sure. I knew that there was some
   2     discussion about it. I do not think I was ever aware
   3     that the decision had been made to stop designation as
   4     a supra-regional centre, only that there was
   5     a discussion as to whether it was effective.
   6   Q. Did you ever remember becoming aware that all the
   7     centres were being de-designated?
   8   A. Yes, but only after I retired.
   9   Q. What did you understand the reason to be for the
  10     de-designation of the centres?
  11   A. No-one told me. I deduced, because in a sense it was
  12     not working because other centres were doing the work
  13     that were not designated centres, that they wanted to be
  14     on the same footing as the centres that were designated,
  15     from the financial point of view. The Supra Regional
  16     Services Advisory Group or whatever it was did not like
  17     the idea of really broadening their remit, and rather
  18     said that they had scrapped the idea. That was my
  19     understanding of it.
  20        That was my understanding of what was being
  21     discussed at about the time I retired. Whether it went
  22     a different way from that in the end, I just do not
  23     know, I am afraid.
  24   Q. Let us go to something else, Dr Jordan. Can we look at
  25     UBHT 61/165? We will see the whole page in just

   1     a moment, but first of all, let us focus on the date:
   2     3rd June 1992. Perhaps you could just identify for me
   3     who else was present? We can certainly read
   4     Mr Dhasmana, Drs Jordan, Joffe and Martin.
   5   A. Dr Bu'Lock was a Registrar in cardiology. Dr Dyson
   6     I think was a paediatric Registrar. Sister Wakeley was
   7     the Sister in charge of the cardiac catheter laboratory,
   8     and Mrs Vegoda was the support worker.
   9   Q. If we scan down the page so we can see the bottom
  10     part --
  11   A. Interestingly, you will have noted the writing changes.
  12     It is my writing at the top and this is Dr Martin's,
  13     I think, actually.
  14   Q. You see "Audit topic/criterion reviewed, results of
  15     arterial switch operation (by JPD)":
  16        "Findings and observations, mortality for TGA TVSD
  17     switch similar to reported results particularly if
  18     consider is early experience", I think that is what it
  19     actually says.
  20        Then "Higher mortality for multiple VSDs", and
  21     does it say "and when in hospital for long time prior to
  22     switch"?
  23   A. I think so, yes.
  24   Q. "Action taken/clinical changes instituted: (1) persevere
  25     with arterial switch for TGA and VSD; (2) continue

   1     programme of switch for TGA and IVS", intact ventricular
   2     septum?
   3   A. Yes.
   4   Q. "(3) aim for earlier repair when possible; (4) careful
   5     search for multiple VSDs and coarctation."
   6        Do you remember this meeting?
   7   A. I cannot remember it, no, I am afraid. I am sorry if
   8     this is getting monotonous, but I have to be honest.
   9   Q. We will come back to this a little later, but the
  10     arterial switch operation, this is June 1992. What we
  11     are here discussing is the arterial switch operation for
  12     transposition with VSD. That is at the top of the page,
  13     under "Findings and observations". That is to be
  14     distinguished, is it not, from the other type of
  15     transposition which was referred to in number (2) under
  16     "Action Taken", which is so-called "simple
  17     transposition"?
  18   A. I think the division comes after "Results of arterial
  19     switch operation", in other words, the topic is all
  20     sorts of arterial switch and the observation next
  21     applies basically to, as you say, transposition with VSD
  22     and, yes, as is implied, possibly coarctation.
  23   Q. Before the institution of the arterial switch operation,
  24     what operation was given to patients with TGA and VSD?
  25   A. It varies. There were two possibilities: you could in

   1     fact carry out something like a Senning operation plus
   2     repair of the ventricular septal defect, plus, as was
   3     usually necessary by then, deband the pulmonary artery
   4     and anything else that needed to be done, so a Senning
   5     operation plus other things. But there was also the
   6     possibility to do what has been referred to as the
   7     Rastelli operation, which basically means not correcting
   8     the arterial transposition but rerouting the blood from
   9     the left ventricle internally through the VSD and into
  10     the aorta, which of course originates from the right
  11     ventricle, and putting a conduit from the right
  12     ventricle to the pulmonary artery. That is the Rastelli
  13     operation as applied to this particular condition.
  14   Q. Which of those alternatives had Bristol been pursuing
  15     before it started doing the arterial switch?
  16   A. Before we started doing the arterial switch it was the
  17     Rastelli procedure. Earlier on the other one was used
  18     on a few patients.
  19   Q. You say "earlier on". When?
  20   A. It is difficult to say, but I think not within the remit
  21     of this investigation: early 1980s, we gave up.
  22   Q. So by the time the arterial switch came along, the
  23     established procedure was the Rastelli?
  24   A. Yes, I think that is true.
  25   Q. For the cases of intact ventricular septum with

   1     transposition before the days of the arterial switch,
   2     the alternative was the Senning or Mustard, was it?
   3   A. Yes. In Bristol it was the Senning operation by that
   4     time.
   5   Q. And the Senning operation had been carried out by
   6     Mr Dhasmana and Mr Wisheart, had it?
   7   A. That is correct.
   8   Q. We will have to come back to the switch in due course,
   9     but just arising out of this document, under the heading
  10     "Action Taken", number 2:
  11        "Continued programme of switch for TGA and IVS."
  12        How long had that programme been running by this
  13     time?
  14   A. I think the first one was done about the beginning of
  15     1992, but I would need my mind refreshing, if it is
  16     available.
  17   Q. I am reminded that it is March 1992. That would seem --
  18   A. That fits in with my general recollection, yes.
  19   Q. Number 3:
  20        "Aim for earlier repair when possible."
  21        Would that apply to both transposition cases?
  22   A. I think, yes, it would. I am not quite sure in the
  23     sense that if you are going to do an arterial switch for
  24     transposition with intact ventricular septum, you cannot
  25     do it, so I cannot quite see the applicability of that

   1     comment.
   2   Q. It has to be done in the first week or so of life?
   3   A. Well, four or six weeks at the absolute outside,
   4     I think.
   5   Q. The other condition, transposition of the VSD: when was
   6     Bristol operating on those children?
   7   A. At what sort of age?
   8   Q. Yes, that is right.
   9   A. I think it was usually between the first and the second
  10     year of age. It might occasionally be longer. I should
  11     perhaps explain that if you are doing the Rastelli
  12     operation you are putting in a conduit. It was
  13     mentioned by Mr Deverall that, whatever it is made of,
  14     it will not grow, and therefore if you do the operation
  15     too early you cannot put in a reasonable sized conduit;
  16     you are going to have to re-operate much earlier. So
  17     there are some advantages to leaving it. On the other
  18     hand, of course, these are quite blue children who have
  19     considerable risks in terms of their lives and also of
  20     complications, particularly stroke if they are not
  21     operated on fairly early, and there is also the
  22     consideration that we touched on slightly in relation to
  23     the tetralogy. The ones who have been banded, which is
  24     of course the majority of these, tend to get rather
  25     muscle-bound hearts, which may not be good for them.

   1        So the compromise, if you like, is to operate as
   2     early as you can, but still be able to put in
   3     a reasonable sized conduit that you will not have to
   4     replace perhaps for the next five or six years at any
   5     rate.
   6   Q. The first heading under "Action Taken" is "Persevere
   7     with arterial switch for TGA and VSD."
   8        "Persevere" might suggest that things have been
   9     a bit of a struggle so far. Would that be a fair
  10     deduction?
  11   A. There was certainly an appreciable mortality to this,
  12     but it was all along very similar or rather better than
  13     mortality for doing a Rastelli type of operation.
  14   Q. If we could come back to the switch later, shortly after
  15     this meeting, which was 3rd June 1992, there was an
  16     article which was not the first article, about Bristol,
  17     in Private Eye.
  18        Can we look at SLD 2/5, please? It is on the
  19     left-hand side, the paragraph that the Panel might be
  20     familiar with, which begins with the word "Gorgeous".
  21        You see at the bottom of that column there is
  22     a reference made to Bristol, mortality rate for the
  23     arterial switch being 30 per cent.
  24   A. Yes.
  25   Q. At the GMC hearings, various witnesses were asked about

   1     this, but can I just read you what Mr Wisheart said? He
   2     said that the result of the Private Eye article -- this
   3     one, I think -- was, and I quote, "that the audit
   4     process was very seriously set back and really did not
   5     occur thereafter for quite some time."
   6        Dr Martin said that the format of audit that we
   7     have seen the example of in the last page I showed you
   8     ceased after the Private Eye articles.
   9        Do you remember there being this article in
  10     Private Eye a few weeks after this audit of the switch
  11     operation?
  12   A. I recall Mr Wisheart mentioning to me that there had
  13     been an article. Is this actually the 8th May one?
  14   Q. No, if we look up the page, this is 3rd July. If we go
  15     back to page 3, SLD 2/3, this is the one which was
  16     published on 8th May. This, we think, is the first one
  17     and the July one we think is the second one.
  18   A. I might say, my memory for dates is not that good, but
  19     8th May is my birthday, so it would stick with me. So
  20     okay, they are talking about something different and not
  21     the arterial switch.
  22   Q. That is right. It is the July one which specifically
  23     refers to Bristol's arterial switch data. I think the
  24     conclusion that was drawn, was it not, was that there
  25     had been some sort of leak to Private Eye, either from

   1     directly among those who were present at that meeting on
   2     3rd June, or from somebody else who knew the figures
   3     that were discussed there, which led to the article in
   4     Private Eye?
   5   A. I mean, my recollection, such as it is, is that there
   6     was certainly concern, as I understood it on
   7     Mr Wisheart's part, that someone had obviously been
   8     talking to Private Eye and the fact that they may or may
   9     not have got their information correct. I mean, the
  10     rest of it is factually incorrect, as I am sure you are
  11     aware. But that certainly caused him concern.
  12        The best recollection that I have about its effect
  13     on audit, I certainly do not think we stopped doing
  14     audit. I think we really possibly for the moment
  15     confined it to sort of cardiological problems because of
  16     course some of the audit meetings I was concerned with,
  17     that I am talking about, would have been basically, you
  18     know, cardiological things like, for example, the
  19     results of non-surgical occlusion of ductus arteriosus,
  20     the results of dilation for pulmonary stenosis. Those
  21     were certainly topics that were covered, and it may be
  22     that sort of topic continued, but I cannot recall there
  23     being a decision that we simply stopped audit as
  24     a result of it, or, indeed, you know, that I was
  25     actually aware that it was thought that an audit meeting

   1     was the source of any data that Private Eye were
   2     publishing.
   3        Incidentally, I did not see either of the Private
   4     Eye articles until a couple of months ago. I do not
   5     read Private Eye. I was just aware that there had been
   6     an article, at any rate.
   7   Q. But you do remember that your source of knowledge that
   8     there had been articles in Private Eye was Mr Wisheart
   9     and he was concerned about it?
  10   A. Yes.
  11   Q. And specifically his concern was that there had been, in
  12     some shape or form, a leak?
  13   A. Yes.
  14   Q. He was anxious that that should not be repeated.
  15   A. I think that is a reasonable assumption, but my
  16     recollection of it more is that he was obviously upset
  17     by it, and my main reaction to it was to make a note
  18     that I personally had to be a bit careful about what
  19     I said to the surgeons, because I was not averse to
  20     expressing my views occasionally on things, and clearly,
  21     if they were in a sensitive mood, I did not want to
  22     upset things further.
  23   Q. They were feeling a bit delicate?
  24   A. If you like to put it that way, yes.
  25   Q. Do you know what the source of Private Eye's information

   1     might have been?
   2   A. I know the speculation. I have absolutely no knowledge
   3     of my own, though, at all.
   4   Q. It was not you?
   5   A. No; it was not me.
   6   Q. Mr Wisheart's reaction to the publication of the article
   7     in Private Eye: was it the fact that there was a leak
   8     from within the hospital that upset him, or was it the
   9     fact that there was a criticism about cardiac surgery
  10     specifically?
  11   A. Much more the latter. I mean, the impression I got was
  12     that he was saying, you know, "I thought we had got away
  13     from this sort of Welsh nonsense from a few years ago,
  14     and here is someone starting it up all over again".
  15     That was the sort of impression that I got of his
  16     attitude to it.
  17   Q. Did it indicate a degree of intolerance of criticism, do
  18     you think?
  19   A. No, I would not say that. I mean, we are all intolerant
  20     to criticism, but not one that I would remark upon, let
  21     us put it that way.
  22   Q. You have mentioned once or twice the fact that you and
  23     Dr Joffe would be out at clinics typically throughout
  24     the South West of England and Wales?
  25   A. Yes.

   1   Q. You deal with it in your statement. You say that the
   2     practice at the outreach clinics would be to have
   3     between 12 and 15 patients per hour listed; is that
   4     right?
   5   A. Yes. That was commonly the case. We tried to keep the
   6     numbers down, but they were always putting in extra
   7     ones.
   8   Q. These clinics would last all day, would they, wherever
   9     you were?
  10   A. Yes, I suppose typically the clinic in Truro, for
  11     example, I would actually start at half 8 which meant
  12     getting up and leaving Bristol at half 5 or so. The
  13     clinic itself would go on usually until about 7, 7.30.
  14     I would have to do a certain amount of clearing up
  15     afterwards, and then get myself back to Bristol, usually
  16     via one of the fish and chip shops on the way for
  17     sustenance.
  18   Q. So these were long days?
  19   A. They were long days. They were not the end of the day,
  20     either, because it was not infrequently the case that
  21     I would either have a call when I was down there to say,
  22     "When you come back to Bristol, can you pop into the
  23     Children's Hospital", occasionally into the BRI, and see
  24     someone, and I would have to continue even after I got
  25     back to Bristol.

   1   Q. So in the course of such a clinic, you can easily see
   2     100 patients, perhaps?
   3   A. I think 100 is a bit of an exaggeration. The Truro
   4     clinic included some time for doing echocardiography, so
   5     the numbers would not be that great, but I recall, when
   6     Dr Hayes came here, I actually went down with her for
   7     the first clinic, because it was one place where she did
   8     not know any people and we actually sat there in two
   9     separate rooms seeing patients until 7 o'clock, so
  10     heaven knows what time I would have got away if I had
  11     been there on my own.
  12   Q. A typical pattern would that be a paediatrician would
  13     refer a case to you or Dr Joffe, or one of your other
  14     colleagues?
  15   A. There were two ways, really, that the patients got to
  16     us. One was because we saw them with a paediatrician in
  17     one of the joint clinics, or the other was the emergency
  18     admissions, because they would ring whichever of us was
  19     taking calls and say "I have a problem, can I send it
  20     up?"
  21   Q. And then, if there was any question of further
  22     investigation and perhaps surgery in due course, the
  23     decision as to which centre to refer the patient to for
  24     surgery in theory lay with the cardiologist?
  25   A. In theory, yes. I mean, up to that point we really

   1     controlled what happened to the patient, up to the point
   2     when we had done the investigations. It did not always
   3     apply. We might well discuss it with the surgeon
   4     beforehand, to say, you know, "We have this patient,
   5     here is the echocardiogram, what further do you want?
   6     Do you want us to do a cardiac catheter? Do you want us
   7     to do another echocardiogram? Are there particular
   8     things you want to know?"
   9        So it was not uncommon for a surgeon to have been
  10     involved before the investigations were complete.
  11   Q. And the surgeon would be either Mr Wisheart or
  12     Mr Dhasmana?
  13   A. That is right, yes.
  14   Q. Can we look at RE F1/17? This is a letter to the
  15     Inquiry. I will show you who it is from if we go over
  16     the page, page 18, from Dr Lenton. Is he somebody who
  17     is known to you?
  18   A. No. I mean, Bath was not one of the places where I did
  19     a clinic, Dr Joffe did that. I am not sure Dr Lenton
  20     was actually working there, because even though I did
  21     not do the clinics, if they were referring patients
  22     I would talk to them on the phone. He is actually
  23     community paediatrician. I did not think they had their
  24     first community paediatrician until about 1993 in Bath
  25     so --

   1   Q. It does not matter technically. Let us go back to the
   2     first page.
   3        What I want to take you to, if we scan down the
   4     page a little?
   5   A. I am sorry, could I go back to the beginning and just
   6     read it through, because I am -- I do not want to hold
   7     things up.
   8   Q. Can I tell you the point I want to make, and if you want
   9     to go back and read it after that, I will be happy for
  10     you to do so.
  11        If you go to the bottom of the page, he says, four
  12     lines from the bottom:
  13        "In the absence of comparative data, I would not
  14     have considered referring to another centre for
  15     a particular suspected clinical problem [he means in
  16     Bristol]. Once referred to Bristol for assessment, it
  17     was automatic that the surgeons would operate in Bristol
  18     rather than transferring the child elsewhere."
  19        That is the point I need to explore. We do not
  20     need to read the letter.
  21   A. Okay, I am happy to take it from there.
  22   Q. To what extent is that an accurate statement of the
  23     state of affairs?
  24   A. It is over 99 per cent accurate.
  25   Q. What would cause a case to be in the 1 per cent?

   1   A. There are a number of reasons. I mean, I/we did refer
   2     patients to other centres. I think the commonest reason
   3     was when we had doubts about the diagnosis or the
   4     problem of diagnosis together with the actual
   5     management, and merely wanted a second opinion, if you
   6     like, there were some operations at different times, not
   7     very many by the time I retired, that were only done in
   8     a few centres. For example, replacing the aortic valve
   9     by taking the patient's pulmonary valve and using that,
  10     and then putting a homograft in the aortic area.
  11     I believe that is now done in Bristol, but it was not,
  12     I think, done during my time. So that would be an
  13     example of a procedure that was known to be done
  14     elsewhere and not available in Bristol.
  15        I mean, I can continue. I did actually, I think,
  16     make a list of these and I think it ran to about 10
  17     possibilities. There were other things. There were
  18     social reasons, and I suppose the other important group,
  19     really were the parents who were unhappy with the advice
  20     that they were given, and said, you know, "Can we go and
  21     see someone else and see what they have to say about
  22     it?"
  23   Q. You gave an example in your statement of parents who had
  24     perhaps lost a child already?
  25   A. That was another example.

   1   Q. That would be one example?
   2   A. Yes.
   3   Q. But it was comparatively, absolutely rare?
   4   A. Yes.
   5   Q. And you say the statement of Dr Lenton is 99 per cent
   6     accurate.
   7        I could show you the evidence that we have of the
   8     various outreach clinics that were conducted either by
   9     yourself or one of your colleagues, but perhaps it is
  10     not necessary to go through them exhaustively. Is it
  11     right that you yourself conducted clinics in, for
  12     example, Carmarthen, Haverfordwest, Cheltenham, Swindon,
  13     Taunton, Truro and a number of other places?
  14   A. Yes. Cheltenham, not latterly: that was Dr Martin. But
  15     a lot of places, yes.
  16   Q. Can I just show you one or two examples of the evidence
  17     that we have of the referrals? Can we go to REF 1/122?
  18     This is dealing with Newport. It deals with the
  19     question of Dr Leslie Davies, who had previously carried
  20     out a clinic at the Royal Gwent Hospital. He had
  21     unfortunately died.
  22   A. Yes, I knew Les Davies and I knew what had been going
  23     on.
  24   Q. If we go to the second page of this letter, I hope you
  25     will be able to read this. We see the reference in the

   1     third line:
   2        "Dr Steve Jordan started a regular clinic with us
   3     from that time, i.e. 1981/2. Therefore, from this time
   4     all the children and babies with heart problems were
   5     seen by Dr Jordan and consequently most if not all of
   6     those requiring surgery received this in Bristol. In
   7     1991, a full paediatric cardiology and cardiac surgery
   8     service was established in Cardiff. As we understood at
   9     the time, the reasons for doing this were largely
  10     'political'.
  11        "It was felt that establishing such a service
  12     would enhance general cardiology training in Cardiff,
  13     but there was also considerable public pressure to
  14     establish a unit in Wales so that children in Wales
  15     would no longer need to travel 'abroad' for their
  16     treatment! We in Newport saw no reason to change our
  17     arrangements immediately and continued to use Bristol
  18     until the Spring of 1993, when Dr Jordan retired, and we
  19     thought it opportune and more convenient to switch to
  20     Cardiff for paediatric cardiology and paediatric cardiac
  21     surgery ..."
  22        Is that a reasonable summary of the development of
  23     the Cardiff centre?
  24   A. I think he has the date wrong, because I do not think
  25     they were actually up and running even for cardiac

   1     investigation until towards the end of 1992, but I may
   2     be wrong. It certainly happened, yes.
   3   Q. I think that may be right as a matter of timing, but the
   4     substance of the reasons that are given there are
   5     substantially those you gave to me this morning?
   6   A. The reasons for --
   7   Q. -- on the one hand training in Cardiff being
   8     a consideration, and the political aspects of it as
   9     well, with a small "p"?
  10   A. Yes. I think that is not a bad explanation of the
  11     situation he gives there.
  12   Q. Can we look at REF 1/128 --
  13   A. I am sorry, but before we go off that, Dr Caudery signed
  14     that.
  15   Q. Yes.
  16   A. I think it is worth pointing out that I think Dr Caudery
  17     at that time was Chairman or President of the Welsh
  18     Paediatric Association and they were the people who
  19     had -- well, some of them had at least supported the
  20     idea of having a new unit in Cardiff. We discussed
  21     this. I think he admitted to a certain amount of
  22     embarrassment that he was still sending his patients to
  23     Bristol when in theory the body of which he was the
  24     Chairman or the President had apparently supported the
  25     establishment in Cardiff.

   1   Q. We have evidence of the fact that in a number of places
   2     in Wales clinics were conducted some years ago by
   3     a Dr Halliday-Smith from the Hammersmith Hospital?
   4   A. Yes, that is right.
   5   Q. She retired?
   6   A. Yes.
   7   Q. And Bristol took over a number of her clinics?
   8   A. That is correct, yes. I think particularly one that
   9     I dealt with in the East Glamorgan General Hospital.
  10   Q. We have also seen reference to Dr Leslie Davies once or
  11     twice. When he died, Bristol again picked up some of
  12     his work?
  13   A. Yes. It was already starting to come before Dr Davies'
  14     death, because what there was of paediatric cardiac
  15     surgery at that time in Cardiff had stopped before then.
  16   Q. If we go over the page, we will see whom it is this
  17     letter is from: I think from a Dr Griffiths from
  18     Abergavenny? Anthony Griffiths?
  19   A. I did not do a clinic in Abergavenny.
  20   Q. I just want to show you this letter because it is not
  21     untypical of the letters from the paediatricians. At
  22     page 128, it is that main paragraph beginning "I was
  23     appointed ..."
  24        If you see in the middle of the paragraph:
  25        "10 to 12 years ago, we contacted the Bristol team

   1     and their paediatric cardiologists would come out and
   2     run a combined cardiac clinic with us. Over the years
   3     we have had three paediatric cardiologists from Bristol,
   4     initially Dr Joffe, then Dr Jordan and more recently,
   5     Dr Robin Martin. The service for children with cardiac
   6     problems improved dramatically. Patients were seen
   7     promptly and those requiring operation had their surgery
   8     within a very acceptable timescale. I was not aware
   9     myself of any problems with the surgery at Bristol, and
  10     the results from our point of view were good."
  11        So Abergavenny, at least, thought the Bristol
  12     service was a dramatic improvement on what had gone
  13     before.
  14        Just before we have a short break, Dr Jordan,
  15     there is a couple more of these paediatricians letters
  16     I want to take you to. Perhaps I can leave that until
  17     after the break. Slightly out of order, I just want to
  18     deal with one small point.
  19        Can I take you to MR 1636/41, please? This is an
  20     extract from the medical record -- just taking those
  21     details out -- of a patient called Samantha Rickard.
  22     There is full consent for this point to be dealt with --
  23     indeed, it is being dealt with at the express request of
  24     the parent of the child.
  25        Can I take you to the bottom right-hand corner?

   1     Can I ask you to read what is said there, Dr Jordan, and
   2     in particular, the paragraph numbered (3).
   3        We see the date of this is December 1991. The
   4     questions that arise are these: ultrasound in the
   5     operating theatre would appear not to have been used on
   6     this occasion. The first question is whether you can
   7     help us with why not? If that is a question you cannot
   8     answer off-the-cuff and you need to look at the medical
   9     records, then we would invite you perhaps at your
  10     leisure to do so and to come back to us?
  11   A. Can I just say that I have actually looked at the
  12     medical records, although not in the last few weeks.
  13     I have been asked to look at them for another purpose,
  14     so I have some knowledge, other than what is here,
  15     within my recent memory.
  16   Q. Can I just indicate the second question? The second
  17     question is: if it had been available, would that have
  18     been what equipment would have been used to provide such
  19     a service?
  20        Are those questions you can help me with now?
  21   A. Yes, I can help you with, if you like, the logistics
  22     that was sorted out. This was actually done, I think,
  23     at 9.12.91. My recollection is, of course, we did not
  24     have our equipment at the Children's Hospital then; that
  25     did not arrive until the end of 1993 or the beginning of

   1     1994.
   2        The BRI had a trans-oesophageal probe. It does
   3     not specifically state that, I note, it just simply says
   4     "ultrasound", so it may be what I made an oblique
   5     reference to this morning: use of the sort of probe that
   6     goes on the front of the chest which can just about be
   7     used in the operating theatre, but it has to be swathed
   8     in sterile drapes and that sort of thing.
   9   Q. The trans-oesophageal --
  10   A. That does not.
  11   Q. -- equipment at this stage in the BRI was the adult
  12     probe that you referred to earlier?
  13   A. It was the adult probe, and I think it is highly
  14     unlikely that that would be of an appropriate size, but
  15     I have to say, trans-oesophageal echocardiography was
  16     something I had no personal experience of. I went and
  17     saw other people manipulating the probe, but that was
  18     Dr Wilde and Dr Martin, and it was a skill I felt there
  19     was really little point in my acquiring, in view of the
  20     fact that I was not to use it very long.
  21   Q. Dr Wilde, did you say?
  22   A. Dr Wilde.
  23   Q. We see in this note the reference is to "Please inform
  24     Dr Wilde at the time of planning so he has good notice."
  25   A. Yes. It would have been at the time the BRI was set up

   1     anyway.
   2   Q. It would not have been done by a paediatric
   3     cardiologist, normally, it would have been done by the
   4     radiologist at the BRI?
   5   A. It would have been done by the radiologist, yes. I have
   6     to say, I am trying to remember how many times by then
   7     we might have used trans-oesophageal echocardiography in
   8     theatre. There might have been one or two patients, but
   9     I do not have that recollection. It might be possible
  10     to obtain the information from Dr Wilde's department,
  11     but I do not think I can help you.
  12   MR MACLEAN: It may be that that is something we can come
  13     back to. If there is another appropriate source to
  14     trace that point, perhaps we can do so in writing in due
  15     course, either with you or with whoever else is
  16     appropriate.
  17        Sir, would it now be appropriate to take a short
  18     break, before I deal with the remaining points for
  19     Dr Jordan?
  20   THE CHAIRMAN: Yes, indeed, but I am anxious for us all to
  21     understand why we are looking at particular cases. They
  22     are to demonstrate general themes. We have explored the
  23     theme of the existence of appropriate equipment in
  24     operating theatres this morning, and we have learned
  25     a great deal about it. We cannot, as you know, in this

   1     Inquiry investigate each and every case to determine
   2     what may or may not have happened in that particular
   3     case. We can, and must, and have, explored the general
   4     themes which are of importance to us which these
   5     illustrate, as you say.
   6        We will now break until about 5 to 3.
   7   (2.50 pm)
   8               (A short break)
   9   (3.00 pm)
  10        CHAIRMAN'S STATEMENT RE REVIEW OF CASES
  11   THE CHAIRMAN: Mr Maclean, pursuing the point I made before
  12     the break, forgive me, Dr Jordan, if I digress for
  13     a moment: the Panel has sought to make it clear on
  14     a number of occasions why we are looking at cases. It
  15     is to review the totality of cases so as to allow
  16     general conclusions to be drawn and we have always made
  17     it clear that it is not within our terms of reference to
  18     explore the details of a particular case. But that is
  19     not to say that we do not take account of every case,
  20     nor, speaking as human beings as well as as members of
  21     a Panel, of course we feel about every case and we are
  22     concerned about every case and we are concerned about
  23     parents who have followed or are involved in this public
  24     Inquiry. It is merely to say that, as a Panel observing
  25     our terms of reference, we cannot go into the particular

   1     details, but we do not devalue any case or any person by
   2     doing that.
   3        We remember, as I have said before, every time we
   4     come in through the doors of this hearing chamber, that
   5     there are people and there are babies and there are
   6     professionals, all of whom are very concerned with
   7     everything we say and what we will do. I hope that
   8     helps everyone.
   9   MR MACLEAN: Dr Jordan, we were dealing before the break
  10     with the question of referrals from various places in
  11     the South West of England and from Wales.
  12        In your statement at WIT 99/35, Issue D, page 1 of
  13     your Issue D statement, if we go to the foot of the
  14     page, heading D2, D2 is, as it says there, "The judgment
  15     or impression by referring paediatricians or other
  16     clinicians of the paediatric cardiac surgical services
  17     provided by the BRI."
  18        You say "I do not have any direct evidence in this
  19     issue. However, I cannot recall, during my time as
  20     a consultant, that any paediatricians in the regions
  21     expressed concerns about the service provided."
  22        It is right, is it not, that the cardiac unit at
  23     Bristol produced an annual report from the late 1980s
  24     onwards?
  25   A. My recollection of this has been helped by the fact that

   1     I have found a copy of what I think was the first annual
   2     report we produced, which was for 1987. I think that
   3     was stimulated by the fact that of course that was the
   4     first year that we had a catheter laboratory at the
   5     Children's Hospital and really had anything physically,
   6     if you like, that could be called a paediatric cardiac
   7     unit.
   8        We did try and produce an annual report -- not
   9     actually quite of the same size as that one --
  10     subsequently.
  11   Q. For whose consumption was the report produced?
  12   A. The consumption was basically internal and it went
  13     I think to the management of the Children's Hospital and
  14     to the various people concerned; that is a fairly wide
  15     number of people, not just the cardiologists, the
  16     cardiac surgeons, it would include people like Sister
  17     Wakeley, I think the secretaries had a copy, that sort
  18     of thing.
  19   Q. It was not disseminated externally? It was not sent,
  20     for example, to referring paediatricians?
  21   A. I think we did actually send the one in 1987 out much
  22     more widely. I think we just wanted to do a bit of
  23     advertising then, but my recollection is that we did not
  24     send subsequent ones out.
  25   Q. You say in the paragraph here that you cannot recall

   1     during your time consultant paediatricians in the region
   2     expressing concern, and so on.
   3        I appreciate that is obviously your recollection
   4     when you wrote the statement. Can I perhaps jog your
   5     memory? Can we have REF 1/41? This is a letter to the
   6     Inquiry from the Royal Cornwall Hospital in Truro; do
   7     you see that, at the top of the page?
   8   A. Yes.
   9   Q. Go over the page. You will see there is a letter signed
  10     by Graham Taylor?
  11   A. Yes.
  12   Q. You know Mr Taylor?
  13   A. Yes. He was one of the paediatricians that I used to do
  14     joint clinics with in Truro.
  15   Q. Looking at the summary of his letter to the Inquiry, by
  16     all means have a look at that paragraph. The bit I want
  17     to focus on, Dr Jordan comes in the last half dozen
  18     lines or thereabouts beginning with the sentence "I also
  19     became aware ..."
  20   A. Yes, I have read the sentence.
  21   Q. Does that ring any bell?
  22   A. Not really. We used to have sort of what one might call
  23     general discussions and I cannot recall Dr Taylor
  24     standing out from other paediatricians that I did
  25     clinics with as particularly pursuing any sort of

   1     discussion of this sort. He does say "on a number of
   2     occasions" which sort of surprises me slightly.
   3        All I can say is that we did discuss very
   4     generally not only our plans but also our results and to
   5     some extent the discussion included a "warts and all"
   6     approach to it so it may well be I had actually, you
   7     know, talked about things that were of concern to us as
   8     well.
   9   Q. What would the "warts" have been?
  10   A. The fact, for example that we still had not, right up to
  11     the time that I retired, got the cardiac surgery moved
  12     up the road. That is of particular importance to
  13     paediatricians because paediatricians are really very
  14     keen on the idea that children should be looked after in
  15     a paediatric environment.
  16   Q. Any paediatrician who had been referring to Bristol over
  17     a number of years would have known there had always been
  18     the split site, so that would not have been a cause for
  19     fresh concern in the early 1990s?
  20   A. Certainly I think Graham Taylor would have known.
  21   Q. It would appear from this letter that he received, as he
  22     puts it "reassurance that the situation was under
  23     review"; it would seem that has come from you,
  24     Dr Jordan?
  25   A. Yes.

   1   Q. What situation would have been under review at that
   2     stage?
   3   A. I am sorry, I do not think I can really help you with
   4     a specific situation.
   5   Q. Might it be a reference to the type of discussion we saw
   6     earlier on, 3rd June 1992 meeting and a decision as to
   7     whether or not to persevere with the arterial switch
   8     operation?
   9   A. I do not think that would normally have filtered down to
  10     Truro, you know, the results of that meeting.
  11   Q. But in terms of the "warts and all" discussion with the
  12     paediatrician about what is going on in Bristol, the
  13     discussion of particular procedures would be part of
  14     that discussion, would it?
  15   A. I think it would only be if I was specifically asked.
  16     Bear in mind that if we are dealing with transposition
  17     with intact intraventricular septum, how many
  18     paediatricians were we dealing with, they would see one
  19     case in every five years or something like that.
  20        I do not think it is reasonable to suppose that
  21     Dr Taylor specifically had a problem over his patients
  22     or indeed from any information that he would have got
  23     from what I might call reliable sources.
  24   Q. The point you are making is: each paediatrician would
  25     statistically only see each particular complex

   1     abnormality fairly rarely?
   2   A. Exactly. I think it would be --
   3   Q. It would be a general perception they would have rather
   4     than specific procedures?
   5   A. Yes, I think it would be very difficult for
   6     a paediatrician to form a view on his own about, for
   7     example, what our success rate was in neonatal arterial
   8     switch operation.
   9   Q. We discussed this a little bit earlier: in terms of
  10     having comparative data available. We know about the
  11     register, the Society of Cardiothoracic Surgeons
  12     Register?
  13   A. Yes.
  14   Q. And you described earlier how as you understand it each
  15     surgeon's own data was sent to that surgeon
  16     confidentially and the national data was also made
  17     available to the surgeons as well?
  18   A. That was my understanding, yes.
  19   Q. Nothing was actually sent to you as a paediatric
  20     cardiologist?
  21   A. No.
  22   Q. But you had access to the results from the register, did
  23     you?
  24   A. Only through the surgeons. My understanding is they
  25     were sent the results, saying "This information is

   1     confidential please do not disclose it -- please do not
   2     discuss it with anyone else".
   3   Q. Your understanding --
   4   A. That is my understanding.
   5   Q. Your understanding was that that prohibition extended to
   6     a discussion as between surgeon and cardiologist?
   7   A. Let me put it this way: no, I can never recall
   8     Mr Wisheart or Mr Dhasmana coming along to a meeting and
   9     saying "Here is this table that I have received from the
  10     UK Cardiac Surgical Register, let us sit down and look
  11     at the figures"; he never produced the returns as such.
  12   Q. We have seen in some of the letters earlier, do you
  13     remember we looked at that table which compared
  14     Bristol's performance over three years with the register
  15     in one particular year?
  16   A. Yes, but that table did not come from the UK Cardiac
  17     Surgical Register.
  18   Q. The detail in it?
  19   A. Yes.
  20   Q. For 1984, the national figures were the figures from the
  21     register?
  22   A. Yes, that is right. But I mean we did not actually see
  23     the crude returns on their sort of headed notepaper, if
  24     you like.
  25   Q. If someone said to you "Dr Jordan, how does Bristol

   1     compare with the national average?" you would have said
   2     "I have to check with the register to see what the
   3     national figures are"; is that right?
   4   A. No, I had absolutely no access to the register at all.
   5   Q. You would say "I am terribly sorry I cannot help you"?
   6   A. Yes, I would have said that "I can compare it by
   7     discussing it with Mr Wisheart or Mr Dhasmana who do
   8     have access to it". Am I being obtuse, I am sorry?
   9   Q. It sounds like a rather obtuse process, if you do not
  10     mind me saying so, that national figures are produced
  11     for paediatric cardiac surgery to which paediatric
  12     cardiologists consider themselves to have no direct
  13     access?
  14   A. That, as I say, is my understanding of it and the only
  15     exception, I think that one year they produced an
  16     article in one of the journals really to demonstrate how
  17     the system was working but not to concentrate on the
  18     actual results.
  19   Q. Can we have a look at UBHT 55/69? Let us scan down this
  20     page. There is a list there of staff at the Bristol
  21     Royal Infirmary. We see you, Dr Joffe and Dr Martin.
  22     We are obviously now dealing with 1989 or subsequently,
  23     because Dr Martin has been appointed?
  24   A. Yes.
  25   Q. Can we go to page 81? This is an extract from one of

   1     the annual reports. We see it deals with 30 day
   2     mortality for Bristol over a five-year period, 1984 to
   3     1988 and for 1989 as against UK figures for 1988; is
   4     that right?
   5   A. This is 1984 to 1988.
   6   Q. And 1989 separately?
   7   A. Is this from the document I refer to which is the 1987
   8     report?
   9   Q. It is from a later report.
  10   A. I beg your pardon, yes, it goes up to 1989, yes.
  11   Q. That is right. Published, I think, in 1990, but looking
  12     at the results for Bristol first of all over the
  13     five-year period; that is the first two columns. Then
  14     for 1989 that is the next two columns; totally them, the
  15     next two columns, and then comparing them with the UK
  16     figures for 1988 in the last two columns.
  17        Those figures in the last two columns, UK 1988:
  18     they would have come from where?
  19   A. I think they would have come from the UK Cardiac
  20     Surgical Register.
  21   Q. The table shows, does it not, that for the under 1 year
  22     old category of patients, for the five years 1984 to
  23     1988, Bristol's mortality was 30.1 per cent; do you see
  24     that?
  25   A. Yes.

   1   Q. For 1989, moving across the same line, 40. Do you
   2     remember earlier on I showed you a table showing how
   3     many open heart operations on under 1s were done at
   4     Bristol; do you remember?
   5   A. Over a number of years, yes.
   6   Q. Over a long number of years, and I think I commented
   7     when we saw that table that 1989 was the first year that
   8     Bristol had reached 40 cases. The mortality then was
   9     37.5 per cent.
  10        The total over the six years 1984 to 1989 was
  11     32.2 per cent and the percentage mortality in the UK for
  12     the single year 1988 was 18.8 per cent.
  13   A. Yes, I follow that.
  14   Q. This would be data which was published in the annual
  15     report for that particular year; yes?
  16   A. This is the Children's Hospital paediatric cardiology
  17     and cardiac surgery report; is that right?
  18   Q. That is my understanding.
  19   A. Yes, okay.
  20   Q. So it would be published, as it were, in the name of all
  21     the clinicians who worked in the cardiac field, would
  22     it?
  23   A. If you say it is part of an annual report, yes. I mean,
  24     it would have been similar to the other one, yes.
  25   Q. If there was data from the UK present as there is in

   1     this table, that must have come ultimately from the
   2     surgeons; is that right?
   3   A. Yes.
   4   Q. Because only they held it?
   5   A. Yes.
   6   Q. So it is reflecting in Bristol's case that which took
   7     place at the Children's Hospital as well as the Bristol
   8     Royal Infirmary because the open heart surgery took
   9     place at the Bristol Royal Infirmary?
  10   A. Yes.
  11   Q. You would have known what this data showed, would you
  12     not, because you would have read your own annual
  13     reports?
  14   A. I may even have produced it, I am not sure.
  15   Q. So you did have effectively access to the national
  16     comparative data indirectly by looking at your own
  17     annual report?
  18   A. Yes, I am sorry if there is a misunderstanding.
  19     Either I or Dr Joffe, whichever of us produced this
  20     report would have got it from the cardiac surgeons.
  21     Yes, we would have seen it.
  22        What I was saying earlier, let us be clear about
  23     this, is that I did not have direct access to it. If
  24     I wanted information I had to go to one of the surgeons
  25     and say "Is it all right for you to let me have the

   1     information, this confidential information?" which
   2     basically I mean they would do. But this was not in
   3     general information that I felt we were at liberty to as
   4     it were splash around the whole of the South West.
   5   Q. When a paediatrician hypothetically said to you,
   6     "Dr Jordan, what is the position as between Bristol and
   7     the rest of the country?" -- I put this to you a few
   8     minutes ago and I suggested your answer would be that
   9     you could not help them -- in fact is it the position
  10     that you could help them if you could show them this
  11     type of data but you did not do so because you did not
  12     consider that would be appropriate because the national
  13     data was confidential?
  14   A. I would have given them a general report related --
  15   Q. You could have sent them this report, for example?
  16   A. Yes, as I say, my understanding is that this was not
  17     data that was supposed to be passed on.
  18   Q. Hypothetically, if Bristol's mortality data were twice
  19     as good as opposed to, on the face of it, twice as bad
  20     as the UK for 1988 -- I say that because the line we
  21     have been looking at, mortality UK 18.8; for Bristol
  22     over the six years 37.5, which is roughly 2 to 1 -- I am
  23     sorry, the comparison between 1989 and 1988 would be
  24     37.5 as against 18.8?
  25   A. I would have felt able, if someone said, "Can you give

   1     me a rough breakdown of how you stand in relation to the
   2     whole of the UK?", I would have been quite happy -- and
   3     I may well have done this -- to say "According to the
   4     figures that are actually reported to the UK register.
   5     I think, as you know, it is not actually comprehensive,
   6     there are a number of units that did not supply their
   7     data, but if you want to know how we stand, the answer
   8     is -- the worst side of it is our mortality for open
   9     heart surgery under the age of 1 year was higher than
  10     the national average and the figures, whatever they are,
  11     the totals over a year were similar and the totals for
  12     closed heart surgery were rather better."
  13        I would not have had any objection or any
  14     difficulty in making that sort of statement if I had
  15     been asked "How do we stand as far as figures are
  16     concerned?"
  17   Q. Was that ever a discussion you had with referring
  18     paediatricians like Dr Taylor in Truro, for example?
  19   A. I cannot specifically remember saying to him anything
  20     like that.
  21   Q. Dr Taylor, in his letter we were looking at a moment ago
  22     at REF 1/41 and 42, specifically dated his concerns to
  23     the early 1990s, at "rumours", as he put it: they were
  24     not his direct concerns, they were rumours that he was
  25     aware of that all was not well at Bristol.

   1        If there were rumours about outcomes of surgery
   2     then, from the table we have just looked at which must
   3     have been produced shortly after 1989, they would appear
   4     on the face of it to be food for rumours in respect of
   5     the results of open heart surgery for those under 1 year
   6     of age?
   7   A. If you break it down as far as that, yes. I do not know
   8     how he would have got hold of this information quite
   9     honestly unless we sent it to him, I cannot remember
  10     exactly, but I do not think we did send it regularly
  11     round to everyone.
  12   Q. Would he or people like him have known there was an
  13     annual report produced?
  14   A. Probably not.
  15   Q. And hence would not have asked for one?
  16   A. I think that is likely, yes.
  17   Q. We have looked at the reference to "under review",
  18     remember "situation under review", and I think you told
  19     me you could not remember specifically what you might
  20     have said.
  21        What about "no cause for concern"? If there are
  22     rumours that all is not well and one is told there is
  23     a review going on, one might think that was on the face
  24     of it cause for concern which may or may well not be
  25     well-founded?

   1   A. He says "under review". I would not interpret that as
   2     meaning that someone is undertaking a systematic review,
   3     if that is the thrust of the question.
   4        These are very general terms. He says "no cause
   5     for concern". I am never going to turn round to someone
   6     during the whole of the time I worked in Bristol and say
   7     "I have absolutely no cause for concern about what is
   8     happening". There are always concerns, but as you know
   9     the heading of another section of this did make the
  10     distinction between what might be sort of general
  11     feelings that things were not as good as they could be
  12     and much more serious concerns.
  13   Q. Many of the paediatricians make the point that they
  14     would get feedback on the unit at Bristol from the
  15     parents of children to whom they had referred to Bristol
  16     who might come back and say "the nurses were wonderful"
  17     or whatever it might be.
  18        But in terms of information from Bristol there
  19     would be this type of conversation between you and the
  20     paediatrician when you went to the clinic perhaps; yes?
  21   A. There might well be, yes.
  22   Q. Apart from that type of verbal interaction between the
  23     referring paediatrician and the visiting paediatric
  24     cardiologist, what other sources of information would
  25     the referring paediatrician have about the quality of

   1     the care at Bristol, assuming they had an interest in
   2     finding out?
   3   A. I cannot think of any ones otherwise. I think it has to
   4     be put in the context that the amount of work that
   5     a peripheral paediatrician would put in, when dealing
   6     with children with congenital heart disease, would be
   7     really quite small in relation to his overall workload,
   8     the point being -- I would be surprised if sort of out
   9     of the blue they decided that was something that they
  10     would want to pursue, to look for data-backed results.
  11   Q. The corollary of that would be that the referring
  12     paediatrician, who would not see all that many complex
  13     congenital heart cases compared to other cases that he
  14     or she might come across, would rely in very large part
  15     on the expertise of paediatric cardiologist in making
  16     the appropriate decisions once a referral to that
  17     cardiologist had been made?
  18   A. Yes, I think it would be very exceptional not only in
  19     our unit or in other sort of arrangements throughout the
  20     country for a paediatrician to send a patient to
  21     a paediatric cardiologist and say "I am sending you this
  22     patient but I want him operated on by so and so or
  23     I want him sent to such and such a hospital"; I do not
  24     think that was part of the sort of picture when I was
  25     working, at all.

   1   Q. The paediatrician would say "This is a cardiac case, we
   2     need a cardiologist. The cardiologist is the expert",
   3     refer the patient to your hands and trust the
   4     cardiologist to make the appropriate decisions
   5     thereafter?
   6   A. I think that is a reasonable assumption, yes.
   7   Q. In the latter part of the 1980s before Dr Martin had
   8     been appointed there was only yourself and Dr Joffe as
   9     paediatric cardiologists, excepting the qualification
  10     that if one looked at your contract you were not
  11     a paediatric cardiologist at all originally?
  12   A. I was appointed a cardiologist in the days when there
  13     was not a distinction between paediatric cardiologists
  14     and adult cardiologists.
  15   Q. And for some years did do a degree of adult work as
  16     well?
  17   A. Yes.
  18   Q. The fact that there were two of you only doing clinics
  19     elsewhere, to what extent did that have an effect on
  20     your ability to be the consultant cardiologist of the
  21     particular patient undergoing surgery in Bristol to be
  22     on the spot, if you like?
  23   A. It obviously had quite important effects that we all
  24     spent quite a considerable part of our time away from
  25     Bristol. It would certainly have an effect.

   1   Q. You would have had junior staff, presumably, supporting
   2     you as a consultant?
   3   A. No. I mean there were no junior staff really who could
   4     take on our work when we were not there. If we are
   5     talking about that sort of support.
   6        We had junior staff who would look after the
   7     general care of the patients as they would any other
   8     paediatric patient in a Children's Hospital, but --
   9   Q. The lack of junior staff, was that something that
  10     concerned you and Dr Joffe and later Dr Martin?
  11   A. Yes.
  12   Q. There was an attempt, was not there -- perhaps more than
  13     one attempt, you can tell me -- in about 1990/1991 to
  14     obtain approval for a Senior Registrar post in
  15     paediatric cardiology?
  16   A. That was not the first attempt but perhaps the one we
  17     felt had the most chance of success.
  18   Q. How long had you been pressing, if that is the right
  19     word, for a senior/junior staff in paediatric
  20     cardiology?
  21   A. For a Senior Registrar. It goes right back to before
  22     when Dr Joffe was appointed, but the problem is: this
  23     was a small speciality, it was known that at one time
  24     there were trained people unable to get posts, but then
  25     even when the thing went entirely the other way, there

   1     was a considerable reluctance to grant manpower
   2     approval. This was the stumbling block, basically.
   3     We were perpetually up against this problem, that we
   4     kept our ear to the ground, and when it looked as though
   5     the manpower restrictions were being lifted, we
   6     hurriedly got together an application. But then, of
   7     course, it was a time when there were money constraints
   8     and we were told "Yes, you can only have a Senior
   9     Registrar if you get rid of one of your consultants",
  10     that was the sort of standard response to it.
  11   Q. So there were financial constraints from -- these were
  12     the days before Trusts?
  13   A. Yes.
  14   Q. Where would the financial constraints come from?
  15   A. There were budgets for staff; there was what might be
  16     called a "cautious" expansion in consultant staff
  17     throughout the 1980s, but they were always something
  18     like -- well, typically in a given year there might be
  19     two or perhaps three new consultant posts -- this is
  20     throughout what became UBHT eventually -- and there
  21     might be perhaps 40 or 50 applications for posts. This
  22     was in terms of funding.
  23   Q. There were other problems as well, were there not,
  24     blocks in the way of appointing a Senior Registrar?
  25     I think you probably recall the visit made in February

   1     1991 to Bristol by a Dr Elliott Shinebourne?
   2   A. I know there was a visit, I cannot remember the exact
   3     date, but it would have been about then.
   4   Q. Dr Shinebourne was a paediatric cardiologist from the
   5     Royal Brompton Hospital?
   6   A. Yes.
   7   Q. The purpose of his visit was to consider approving the
   8     Bristol Children's Hospital for the Senior Registrar
   9     post in paediatric cardiology?
  10   A. Yes, that is right. He came presumably on behalf of the
  11     Joint Committee on Higher Medical Training.
  12   Q. One assumes so, yes. What was the outcome of his
  13     decision?
  14   A. It was turned down.
  15   Q. What was your understanding as to the reason?
  16   A. My recollection is that they had no problems with the
  17     investigational side but they did not like the fact that
  18     there was no open heart surgery on the same site, that
  19     is the Children's Hospital and there was no involvement
  20     or there was no planned involvement in post-operative
  21     care which they considered was an essential part of
  22     training.
  23   Q. There is no reason particularly why you should,
  24     Dr Jordan, have considered the evidence Dr Shinebourne
  25     gave at the GMC hearings. He said there "The paediatric

   1     cardiologists in Bristol were pretty much divorced from
   2     post-operative care", which I think one sees reflected
   3     in your statement?
   4   A. Yes, it needs a qualification and I am prepared to spend
   5     as long on it as you wish.
   6   Q. That was one of his two main concerns: one was the split
   7     site for surgery and the other was a lack of involvement
   8     in post-operative care.
   9   A. Yes.
  10   Q. The hypothetical Senior Registrar in paediatric
  11     cardiology who might be appointed, when he or she came
  12     to the hospital Dr Shinebourne's concerns would be they
  13     would not be properly exposed, if you like, to the
  14     surgery and to the post-operative care?
  15   A. That is correct.
  16   Q. I think this is a direct quotation: Dr Shinebourne said
  17     at the GMC that he thought the Bristol consultant
  18     cardiologists, which at this time would be you and
  19     Drs Joffe and Martin, were running a service under, as
  20     he put it, "a tremendous disadvantage"?
  21   A. In what particular respect, or was that just general?
  22   Q. My understanding is that was his conclusion having
  23     visited for this approval purpose; there were three
  24     consultants by that stage with no backup from Senior
  25     Registrars; that he was not prepared to approve for the

   1     reasons we have explored which meant the service was
   2     consultant led --
   3   A. Consultant provided, if I may interject.
   4   Q. -- consultant provided, which was something that would
   5     put a great strain on Paediatric Cardiologists.
   6   A. Yes, I would not disagree with him on that.
   7   Q. That is a description you recognise?
   8   A. Yes.
   9   Q. The question of the split site perhaps we can take
  10     reasonably shortly. Can I take you to UBHT 159/44.
  11     This document is stamped, as you can see in the top
  12     right-hand corner, 7th September 1990. Do you recognise
  13     this document?
  14   A. I have seen this particular document before, yes.
  15     I cannot tell you its provenance, though, I am afraid.
  16   Q. It is your document, is it not?
  17   A. I produced it, yes.
  18   Q. Can we look at page 45? We have seen this, I think, in
  19     the evidence of Graham Nix previously. Perhaps we do
  20     not therefore need to go through it in as much detail as
  21     we might otherwise do.
  22        At the top of the page:
  23        "Currently closed heart operations are carried
  24     out at the Children's Hospital, but for open heart
  25     operations all children have to be admitted to the Royal

   1     Infirmary, where they are cared for in a non-paediatric
   2     environment. This is against all current thinking on
   3     the management of children in hospital, and the
   4     fragmentation of the service makes for considerable
   5     difficulties with staff of all types. No other centre
   6     in the UK has open and closed surgery split between the
   7     two sites in this way."
   8        Skipping a paragraph:
   9        "An additional factor is that an amalgamation of
  10     all the children's heart services in the Children's
  11     Hospital site would allow a much needed increase in
  12     adult cardiac surgery at the BRI."
  13        Those are two different points, are they not? The
  14     first point is a concern that children are not being as
  15     well cared for under the split site regime as they would
  16     be without it; the second point is that to end the split
  17     site would allow an expansion of adult work at the BRI;
  18     that is right, is it not?
  19   A. That is right.
  20   Q. The Panel have seen various working party documents and
  21     so on from the latter part of the 1980s which looked at
  22     the question of the split site of open heart surgery for
  23     children. It is now well-known that the split site in
  24     fact did not end until October 1995. Can you tell us,
  25     Dr Jordan, from your perspective, what the reason was

   1     that the apparently concerted effort at the end of the
   2     1980s, from the clinicians themselves, to demand or ask
   3     for an end to the split site, why that was unsuccessful?
   4   A. Just to correct you, this had started at least at the
   5     beginning of the 1980s, just at this particular period.
   6   Q. I am willing to accept that. I want to focus on the end
   7     of the 1980s when there were various Working Party
   8     reports and this document was produced and so on, and
   9     the split site was not in fact ended.
  10   A. This of course was about the time that Trusts came into
  11     being. I do not want to waste time by going into too
  12     much detail, but it does actually have a relevance to
  13     this.
  14   Q. I do not think you are wasting time, Dr Jordan.
  15   A. The Trusts came into operation I think in April 1991?
  16   Q. That is right.
  17   A. For a year before that, that is starting April 1990, we
  18     had sort of shadow Trusts. Everything was worked out in
  19     exactly the same way as it was going to be the following
  20     year but no money actually changed hands, if you like,
  21     and no one actually physically signed contracts and so
  22     on.
  23        For the year before that, that is the year
  24     beginning 1st April 1989, we were busy drawing up the
  25     shadow contract for the following year. We were

   1     instructed to do this on the basis of the workload for
   2     the previous two years and on the strict understanding
   3     that one thing that would not happen would be any, if
   4     you like, expansion of workload in relation to the new
   5     Trust status. I mean this was part, as I recall it, of
   6     the general "aura" of the new status: that although it
   7     was going to sort of start off with the ability to
   8     change everything, the promise was it was not going to
   9     actually change suddenly and therefore it would be
  10     related directly to what was going on before.
  11        Furthermore, there was I think a sort of promise
  12     that there would be no change not only in 1991 to 1992
  13     but in 1992 to 1993.
  14        In other words, we were locked into a situation
  15     where anything that you came up with which said "we want
  16     to change what we are doing", it was nearly always
  17     saying "we want to spend more money and we want to
  18     expand something", but anything you wanted to change was
  19     really hit on the head because we were told, "Sorry, we
  20     have to organise the service according to these rules
  21     that are being laid down and they do not allow us to
  22     expand or increase any of the services".
  23        So it was a particularly difficult time as far as
  24     I was concerned in a speciality where there was -- not
  25     just paediatric cardiology, I mean adult cardiac surgery

   1     was very considerably underprovided for at the same time
   2     and it was still just about one of my concerns, that we
   3     were really being told "freeze all your ideas and go
   4     away for five years and then we will start thinking
   5     again".
   6   Q. There had been a considerable investment in cardiac
   7     services throughout the 1980s and a very considerable
   8     expansion in the number of cases, both paediatric and
   9     adult, that had been undertaken?
  10   A. Yes, but my understanding is that Bristol overall --
  11     this is including adult and paediatric cardiac
  12     services -- fell below the average and in fact I think
  13     the South West and East Anglia vied for the doubtful
  14     honour of being the region that had the lowest amount of
  15     throughput of cardiac surgery generally. I imagine
  16     there are some statistics that will be available to show
  17     this. Obviously I do not have them, but that was,
  18     I think, common knowledge.
  19   Q. Why was that the case, that the relative prioritisation
  20     of cardiac services was lower here than it was in most
  21     other places?
  22   A. There were a number of sort of historical reasons. It
  23     started off small. We were actually very fortunate in
  24     that the first expansion arose purely by chance because
  25     we pinched what was going to be the nurse's sick bay for

   1     a cardiological expansion, that was about 1972, 1973,
   2     1974. There was then a working party after Terence
   3     English had come down and said exactly what he thought
   4     of the provision for cardiac services in Bristol. That
   5     took about six years to report, by which time things had
   6     moved on elsewhere. This was the period of rapid
   7     expansion of coronary artery surgery in particular and
   8     it just really continued to be the case that although
   9     there were these expansions, I quite agree, they never
  10     quite caught up.
  11   Q. It may be you cannot help us, it may be after your time
  12     as a consultant had ended: what was your impression of
  13     the reason why the split site was ended when it was?
  14   A. I do not think I can answer that question, I was not
  15     there.
  16   Q. I have a few more topics I want to deal with and then we
  17     can draw to a close, Dr Jordan.
  18        Can I deal first of all with the question of the
  19     switch operation again, in a little more detail?
  20        We discussed earlier the two different categories
  21     of transposition cases, so-called simple transposition
  22     and the transposition with VSD, and we established that
  23     the latter of those, the established operation was the
  24     Rastelli procedure and for the former it was the
  25     Senning, in Bristol at the relevant time?

   1   A. Yes.
   2   Q. Why did Bristol start doing the arterial switch
   3     operation on non-neonates at the end of the 1980s; whose
   4     idea was it?
   5   A. For the non-neonatal switches?
   6   Q. The non-neonatal switches which were begun at the end of
   7     the 1980s -- 1988, I think it was.
   8   A. I think it was part of a general discussion in relation
   9     to what we knew of what other centres were doing, but
  10     there obviously was some sort of coordinated activity
  11     about this because I know it was decided that these
  12     would all be done by Mr Dhasmana rather than shared
  13     between the two surgeons. But the thinking of it really
  14     was that -- you know the Rastelli operation had problems
  15     there were well recognised, in particular the need to go
  16     back and replace conduits and so on, and as soon as it
  17     was clear that other centres were doing it, that seemed
  18     to be the right approach. Bear in mind that similar
  19     operations had been done for truncus and for pulmonary
  20     atresia with ventricular septal defect. The operation
  21     is sometimes referred to a Rastelli for that, but it is
  22     actually not strictly speaking true -- Donald Ross
  23     invented that one, but it is the same operation.
  24        It is the same operation, basically putting
  25     a conduit from the right ventricle to the pulmonary

   1     artery, so it was something that had been done and was
   2     now generally regarded as being a reasonable operation
   3     but with problems, and the arterial switch appearing as
   4     a much better operation.
   5   Q. Mr Dhasmana was keen to start doing the arterial switch
   6     operation, was he?
   7   A. I think so, yes.
   8   Q. He said at the GMC that it took him, as he put it:
   9     "about a year" until 1988 to persuade you and Dr Joffe
  10     of the wisdom of this course?
  11   A. I cannot recall that, but I would not argue with it.
  12     We, I think, would want to think fairly seriously about
  13     a change like that.
  14   Q. If I suggested that your attitude was one of cautious
  15     support to the idea, would that be fair?
  16   A. I cannot recall what I felt like 14, 15 years ago but
  17     that would, I think, be something I would not argue
  18     with.
  19   Q. That was Mr Dhasmana's expression at the GMC?
  20   A. Yes.
  21   Q. The existing operation was recognised as having
  22     problems, the Rastelli procedure, and the decision was
  23     taken to start doing the arterial switch. By whom was
  24     that decision therefore taken?
  25   A. This is the non-neonatal arterial switch?

   1   Q. We are going to come to that distinction in a minute.
   2     The first arterial switch operation done in Bristol in
   3     1988 was done after the agreement of whom?
   4   A. Clearly it would have had to have the agreement of the
   5     cardiologist who referred the patient. I cannot
   6     remember at this stage whether it was me or Dr Joffe.
   7     It would have been decided, we were not really holding
   8     our joint meetings in quite the same way then, I cannot
   9     sort of recall at that stage as it were our holding
  10     a meeting to decide on this. I do not think I can help
  11     you terribly with this.
  12   Q. A consensus had been reached that this is what would be
  13     tried, had it?
  14   A. I am sure there would have been a consensus, that was
  15     the way we worked.
  16   Q. Why was the operation -- this may be a simple question
  17     -- done on non-neonates alone?
  18   A. There were two sides or two reasons to that. The first
  19     is that the operation that was being done, or the
  20     patients in whom it would have been appropriate to do
  21     a switch operation in the neonatal period were being
  22     operated on very successfully with the Senning
  23     procedure.
  24   Q. This would be the so-called simple transposition cases?
  25   A. Simple transposition.

   1   Q. With the intact ventricular septum?
   2   A. Yes, that is right.
   3   Q. So no linkage of blue blood and red blood so the trial
   4     was not going to last long unless the operation was done
   5     quickly; it had to be done in the first period?
   6   A. That is actually not the reason why it had to be done in
   7     that period, if I can just explain. We could reasonably
   8     hope to keep a baby with simple transposition alive for
   9     9 to 12 months by doing a thorough balloon septostomy,
  10     if I may use the term, in other words making as big hole
  11     as big as we could, and the results of that were good in
  12     the sense that few patients ran into trouble or died
  13     during the period in which they were waiting to have
  14     their Senning operation.
  15        The reason why you cannot do an arterial switch in
  16     simple transposition after about 4 to 6 weeks is that
  17     the left ventricle adapts itself to behaving like the
  18     right ventricle, in other words, its wall thins out, it
  19     is incapable of generating the necessary pressure; that
  20     is the reason why there is a time limit.
  21   Q. So the initial arterial switch was done only on those
  22     patients who would otherwise have had a Rastelli
  23     procedure, not in those who would otherwise have had the
  24     Sennings procedure which continued as before?
  25   A. By and large that is correct, yes.

   1   Q. What was the outcome of the non-neonatal arterial switch
   2     for the TGA and VSD cases?
   3   A. My recollection is it was similar, or at least that the
   4     actual 30-day mortality rate was very similar to that of
   5     the Rastelli operation but that we had achieved what
   6     hopefully would be a lifelong cure and not the need to
   7     subject the child to further surgery as a matter of
   8     course.
   9   Q. So the results appeared to be similar. There would be
  10     no need for a further corrective operation and so it
  11     appeared as though the decision had been a wise one?
  12   A. Yes, that was our feeling.
  13   Q. What would be the course of events? Once a decision was
  14     taken "We will now do the arterial switch for TGA and
  15     VSD cases, we will now do that where previously we only
  16     did the Rastelli, for the next patient who came in
  17     through the door with TGA/VSD, how would the matter be
  18     presented to the parents of the child?
  19   A. TGA/VSD we are talking about still?
  20   Q. We are talking about a child who would previously have
  21     been operated on with the Rastelli procedure, the
  22     Bristol clinicians have now decided that "we will do the
  23     arterial switch", Mr Dhasmana will do the operation.
  24     What happens when the next patient comes through the
  25     door suitable for the Rastelli operation or for the new

   1     arterial switch operation, what are the parents of that
   2     child told?
   3   A. I would imagine they are told something like this: that
   4     there are two ways of dealing with this problem. The
   5     first thing always is to say "This is a very complicated
   6     problem, it is going to need a major operation. There
   7     are two possible operations we can do. The one we have
   8     done most in the past is one where we do such and such"
   9     and describe the Rastelli operation, "but there is an
  10     alternative operation which we think may be more
  11     suitable and the general view of the surgeons and the
  12     cardiologist is that that would be the most appropriate
  13     operation for your child".
  14   Q. What would be said about the success rate? Obviously
  15     for the first case there would be no direct success or
  16     failure rate; what would be provided by way of
  17     justification for this unit and this surgeon doing this
  18     operation on this child?
  19   A. That obviously is a difficult question and all one can
  20     do is to use any information that is available from
  21     other sources as to how they get on when they change
  22     from one operation to another. It is not something
  23     clearly where one can quote a mortality.
  24   Q. That would be the results of other centres?
  25   A. As I say, let me break off that argument a moment and

   1     say: from my own point of view I find this whole
   2     business of emphasis on giving parents an exact figure
   3     for the mortality for an operation rather strange and it
   4     did not seem to relate to the real world in which
   5     I worked at the time. It may well be the situation in
   6     1999 is entirely different, but I was much more prone to
   7     use terms like "This is a major operation, there are
   8     going to be considerable risks, but on the other
   9     hand..." and you know, describe what the advantages
  10     are.
  11        In other words it was not my practice unasked to
  12     say to the parents "I am going to tell you what the
  13     statistics are with regard to the chance of your child
  14     surviving this operation".
  15   Q. In terms of statistics from other centres, I think we
  16     have already discussed this a couple of times, there was
  17     not any reliable published comparative data showing the
  18     comparison between Bristol or any other centre and other
  19     individual centres?
  20   A. The statistics on this occasion would consist of what
  21     either we heard formally at meetings of people
  22     presenting results or what was discussed over coffee at
  23     the same sort of meetings with clinicians there.
  24   Q. There might be papers published by centres who were
  25     anxious to broadcast to the relevant professional

   1     community?
   2   A. Papers usually are sort of given as presentations
   3     first. You would probably hear of it more quickly by
   4     going to something like a British Cardiac meeting or
   5     surgeons going to one of the Cardiac Surgical meetings.
   6   Q. Typically centres would be more anxious to write papers
   7     and give lectures and presentations on their successes
   8     as opposed to their failures?
   9   A. That is true, yes.
  10   Q. The switch operation was then carried out. After
  11     Bristol decided to provide the arterial switch operation
  12     for the TGA/VSD patients, do you remember if any of your
  13     patients underwent the Rastelli operation?
  14   A. I do not think I can answer that. I think it was
  15     generally a policy to continue, but there could have
  16     been some where for a particular reason a Rastelli
  17     operation was considered more suitable. I cannot recall
  18     whether it happened but of course one of the things that
  19     comes into this equation is the question of coronary
  20     artery anatomy. It would still I think be up to the
  21     surgeon to say whether he thought the patient should be
  22     offered an arterial switch operation or a Rastelli
  23     operation.
  24   Q. We know the arterial switch operation took place between
  25     1988 and 1992 in Bristol before it was extended to

   1     neonates; is that right?
   2   A. Yes, that is correct, yes.
   3   Q. How did it come about then that the decision was taken
   4     to undertake a neonatal switch operation?
   5   A. It was something that was really under consideration and
   6     discussion for certainly a year if not longer before
   7     then and I have to say I think that the changeover was
   8     if anything slightly hampered by the fact that the
   9     results of the Senning operation appeared to be not very
  10     much better than the Mustard operation but that our
  11     results seemed to be at least as good as anyone else was
  12     producing.
  13   Q. You are being slightly modest, are you not? Bristol
  14     results for the Senning operation were very good?
  15   A. Yes.
  16   Q. Compared to the national average?
  17   A. Yes.
  18   Q. Dr Masey I think used the expression "very favourable".
  19   A. Yes.
  20   Q. That was the position throughout the period up until the
  21     beginning of the neonatal switch programme; is that
  22     right?
  23   A. Yes.
  24   Q. So for the neonatal switch for those patients who would
  25     previously undergo the Sennings procedure, we did not

   1     have this factor of the alternative operation, having
   2     recognised difficulties that we did have in the case of
   3     the Rastelli operation?
   4   A. We did not have the problem that it had a relatively
   5     high early mortality. We did have the problem that it
   6     was not a corrective operation, which I think was sort
   7     of equally important in our thoughts.
   8   Q. The Sennings operation had been undertaken by both
   9     surgeons, had it?
  10   A. Yes.
  11   Q. Mr Dhasmana had either from the very beginning or very
  12     quickly become the arterial switch surgeon for the
  13     non-neonates?
  14   A. It was a deliberate policy, it did not come about by
  15     chance.
  16   Q. Why was it he and not Mr Wisheart?
  17   A. The younger surgeon -- he had had some experience of
  18     this fairly recently in Birmingham, Alabama where he had
  19     spent a year. Again I cannot remember the exact details
  20     of it but he wanted to do it, Mr Wisheart was happy for
  21     him to do it, he had had some experience of this
  22     operation elsewhere.
  23   Q. The problem if you like of the Sennings operation
  24     therefore was not that Bristol's results were not good,
  25     in fact on the contrary, they were good, very good. The

   1     perceived problem with it was that it was not a fully
   2     corrective operation?
   3   A. That is correct.
   4   Q. And that it might not last the patient a lifetime; it
   5     was anticipated it would not in fact?
   6   A. Yes.
   7   Q. And a further operation would be necessary?
   8   A. Yes, well, might not be possible.
   9   Q. What were the perceived advantages of the arterial
  10     switch?
  11   A. The main perceived advantage was that it was
  12     a corrective operation. By that time -- we are straying
  13     again into surgical territory, but if I could say that
  14     there were considerable problems early on with attempts
  15     at the switch operation both in neonates and in older
  16     patients and the problems particularly related to the
  17     coronary arteries and their reimplantation, keeping them
  18     patent and also to the reconstruction of the pulmonary
  19     artery was often necessary so that a lot of the early
  20     patients -- I am not talking about ours, I am talking
  21     about elsewhere -- had coronary artery problems.
  22        In fact the first patient to have an arterial
  23     switch operation in this country was actually a patient
  24     from Bristol. It was not actually done in Bristol but
  25     I knew about him and his problems, but there was that

   1     and the problem of the pulmonary artery and some
   2     patients needing a further operation to reconstruct the
   3     pulmonary artery.
   4        The point was, if you like, things were moving and
   5     we were moving to the situation where the problems with
   6     the arterial switch operation seemed to be being ironed
   7     out, this is not by us, but generally, and therefore it
   8     was looking much more attractive as a long-term
   9     prospect.
  10   Q. Was the idea that Mr Dhasmana should do the first
  11     neonatal switch operation on his own as the only
  12     consultant surgeon in the operating theatre or was he
  13     going to have some assistance?
  14   A. My recollection is that he was going to arrange to have
  15     someone to come and assist him with the first two or
  16     three, something like that.
  17   Q. Did that happen?
  18   A. To the best of my knowledge it did not happen, no.
  19   Q. Why not?
  20   A. I do not know exactly. I believe that the operation was
  21     actually postponed for technical reasons, shortage of
  22     beds or something like that, but I am not fully
  23     conversant because that is obviously something
  24     Mr Dhasmana would have been involved in organising.
  25     I obviously was not in a position to ring up a cardiac

   1     surgeon and get him down.
   2   Q. To what extent did the non-neonatal switch results
   3     between 1988 and 1992 provide a basis for the decision
   4     to start the neonatal switch?
   5   A. The fact that this appeared to be both possible and to
   6     have results that, as far as we knew, were comparable
   7     with other centres who were doing this on the same sort
   8     of patients, Mr Dhasmana had managed to do that.
   9     I might say I went to theatre to actually watch him do
  10     one of these operations, purely out of curiosity,
  11     I wanted to see what it was like. But I came away,
  12     I have to say impressed with the neatness of his
  13     surgery. We already had experience.
  14        The difference between the neonatal arterial
  15     switch and the other one, the ones we had been doing, on
  16     the sort of good side if you like, the encouraging side,
  17     was that these did not have a requirement to close
  18     ventricular septal defects or reconstruct the pulmonary
  19     artery which had been banded or something like that so
  20     there was less to do for the surgeon.
  21        Again I am talking in surgical terms but obviously
  22     these were things that were discussed with the
  23     cardiologist, so I am quite prepared to go on along that
  24     theme.
  25        The problem was that this was still a fairly

   1     complicated and lengthy operation that was going to have
   2     to be carried out in small babies so we had over the
   3     years, one or two years up until then, had to really
   4     sort of balance these two things to decide when would be
   5     a reasonable time to actually start moving towards the
   6     neonatal switch operation.
   7   Q. Again, once the decision had been taken that the
   8     neonatal switch operation would be done in Bristol by
   9     Mr Dhasmana, what would be said to the next patient's
  10     parents who turned up with a simple transposition, you
  11     previously would have without any further thought --
  12   A. Can I go back one stage before I answer that question?
  13     I think there is a sort of assumption that we put a wall
  14     down and said "Up to now we have done a major balloon
  15     septostomy and kept our patients and done a Senning, now
  16     we are going to move forward and do this". It was not
  17     exactly like that.
  18        Basically it was "We feel we are in a position to
  19     do this and when we discuss patients with relatively
  20     uncomplicated transposition when they come to us, we
  21     will consider this as a possibility". Obviously at the
  22     end of the day it is the surgeon who will decide what he
  23     is going to do.
  24        It was not a case that we said to Mr Dhasmana
  25     "From now on you will not do any Senning operations,

   1     you will only do neonatal arterial switch operations".
   2   Q. Can you help us with what would be said to the parents
   3     of the child?
   4   A. Yes. My best recollection of what I said in effect was
   5     that, rather similar to starting off what I would have
   6     said about a normal neonatal arterial switch operation,
   7     the severity of the condition and obviously it is
   8     important that the parents realise once you are starting
   9     to talk about an operation with important risks that you
  10     are also talking about an operation on a child who
  11     otherwise is not going to survive. That is the first
  12     thing that is said.
  13        The second thing is to say that there are actually
  14     two ways of dealing with this condition. We will be
  15     discussing with the surgeon, this is if I had not
  16     already discussed it with the surgeon, that "There is
  17     one operation which can be left for some time and in our
  18     hands has very good immediate results, but the operation
  19     which would actually correct the condition is a much
  20     more major operation and it would have to be done fairly
  21     soon while your baby is still very small".
  22   Q. What would be said about the relative risks of mortality
  23     in that arterial switch procedure?
  24   A. As I have said before, I was not one to write figures on
  25     a piece of paper, I know the surgeons did on occasions,

   1     but I would have used terms like "major risk" and so
   2     on.
   3        Again, had I been pushed I would have said at that
   4     time "I think that the risks of doing a neonatal
   5     arterial switch operation in our hospital with this
   6     surgeon with his previous experience in a relatively
   7     uncomplicated transposition are going to be similar to
   8     the risks that would have occurred in the older patients
   9     with the more complicated form of anatomy".
  10   Q. I think it is right to say that the first five neonatal
  11     switch patients all died?
  12   A. Yes, I am afraid that is correct.
  13   Q. Would that statement you have just outlined you would
  14     have made have applied to the sixth set of parents?
  15   A. This again takes us back to the thing that you may feel
  16     I am hedging over and that is the application of
  17     statistics. What we are dealing with with any of these
  18     children or babies is an individual that we have to look
  19     at as an individual. It is no more true to say that
  20     because the last patient died the coin is going to come
  21     down the same way or the other way statistically.
  22   Q. That is if one thinks that the outcome is a matter of
  23     chance?
  24   A. This is what statistics are about really, are they not,
  25     I do not think we really want to get into that

   1     discussion at this time in the afternoon.
   2        My view is that statistics really have a limited
   3     value in telling you, firstly how you should make
   4     decisions and, secondly, how you should put the matter
   5     to the parents. Let us say we look at patient number 6:
   6     "this is a baby who has no other abnormalities outside
   7     the heart, he has isolated transposition, he is
   8     a reasonable size, say, he is 3.5 kilograms, he is not
   9     acidotic, we have done our balloon septostomy, he is
  10     quite comfortable on his prostaglandin drip. We have
  11     done an angio on him and we know his coronary artery
  12     pattern is normal, he does not have any other
  13     conditions, then I think those are the factors one would
  14     consider in deciding what advice we should give to the
  15     parents and also in terms of the advice they would
  16     actually get.
  17   Q. How did you react to the early results for the neonatal
  18     switch?
  19   A. I was very upset.
  20   Q. How did Mr Dhasmana react?
  21   A. He was also upset.
  22   Q. We know by December 1992 Mr Dhasmana had decided to go
  23     to Birmingham?
  24   A. Yes.
  25   Q. To observe Mr Brawn performing a switch operation?

   1   A. I think the idea was more than one, but I am not
   2     absolutely sure about that. In the event he did go to
   3     Birmingham, yes.
   4   Q. For the day with Dr Masey and perhaps a perfusion
   5     technician, I think we were told last week?
   6   A. You know more than I can recollect about the event.
   7   Q. You did not go to Birmingham?
   8   A. I did not go to Birmingham, no.
   9   Q. Mr Dhasmana went subsequently to Birmingham, I think,
  10     perhaps after you had retired you were still doing
  11     outreach clinics in the summer of 1993?
  12   A. It could be.
  13   Q. You would have retired by then?
  14   A. Yes.
  15   Q. Dr Joffe did not go to Birmingham in December 1992
  16     either, did he?
  17   A. To the best of my knowledge he did not, no.
  18   Q. Or Dr Martin?
  19   A. No.
  20   Q. Mr Dhasmana was anxious for the Paediatric Cardiologists
  21     to go to Birmingham, as well, was he not?
  22   A. I cannot recall -- I would have liked to go I must say,
  23     I am a curious person and I spent quite a lot of time in
  24     the operating theatre minding someone else's business.
  25     I cannot recall that he actually pressed me. If he had

   1      -- bearing in mind that in a few months time I was
   2     going to be retiring -- and he was saying who should
   3     come out of the Paediatric Cardiologists, I do not think
   4     I would have nominated myself, but I would have been
   5     quite happy to go if I had been available.
   6   Q. Dr Joffe and Dr Martin would have been perhaps more
   7     obvious candidates?
   8   A. I think purely from the point of view of, as I say, my
   9     impending retirement which would have made such a visit
  10     not particularly valuable to me. I must say I would
  11     think it would be very interesting. As I say, I have
  12     been in theatre and have watched Mr Dhasmana do an
  13     arterial switch operation and I would have been
  14     interested to see someone else doing it. I am not sure
  15     it would have actually helped in subsequent management
  16     of patients. It would be different obviously for
  17     perfusionists and anaesthetists, they are actually
  18     concerned in it, it is one situation where I think the
  19     cardiologist would not really have any place other than
  20     as a fly on the wall.
  21        The diagnosis is absolutely cast iron, the surgeon
  22     knows what he is going to do, the cardiologist is not
  23     going to be in the operating theatre other than just to
  24     perhaps give him a bit of back up.
  25   Q. Did you ever consider referring an arterial switch

   1     patient to a surgeon other than Mr Dhasmana?
   2   A. Any of the patients we are talking about, are we?
   3   Q. Let us take the neonates?
   4   A. Taking the neonates. There was always this
   5     consideration, if you like, for any patient. What you
   6     are there to do is to do what is best for the patient
   7     under the circumstances and that is a possibility that
   8     would occur. I have to say I think we were much more
   9     concentrated on what was the appropriate operation in
  10     Bristol really. Unlike some of the other conditions
  11     that I have referred to it was a procedure that we
  12     considered could technically be done in Bristol.
  13   Q. Dr Jordan, can you go to WIT 99/23. If we see the
  14     second half of this page. This is your own witness
  15     statement and you say in what is now the middle
  16     paragraph that you had:
  17        "Absolutely no knowledge that Dr Bolsin was
  18     undertaking a secret audit or was expressing his views
  19     to medical staff in management".
  20        You did not know about that until Mr Hill from the
  21     BBC visited you a couple of years after you had retired;
  22     is that right?
  23   A. That is right, yes. It should be "News West" not
  24     "Points West", sorry about that.
  25   Q. Perhaps not the most crucial change any witness has

   1     made.
   2        Can we go to page 26, please, still your witness
   3     statement, top of the page. This is dealing with
   4     Issue B. You say "There was certainly a degree of
   5     loyalties between cardiologists and cardiac surgeons.
   6     We were all concerned about the effects of the
   7     criticisms which had been voiced".
   8        Help me, Dr Jordan, with what you are referring to
   9     there in terms of timescale and which criticisms was
  10     voiced by whom?
  11   A. The particular times were when the Welsh programme came
  12     on and when in fact Mr Wisheart told me there had been
  13     something about him in Private Eye basically. These are
  14     the criticisms that I am talking about.
  15   Q. Dr Jordan, thank you very much for answering those
  16     questions. There may be some questions from the Panel.
  17     I understand from behind that there is no
  18     re-examination.
  19        Before the Panel ask you any questions they may
  20     have, you have an opportunity now to say anything else
  21     that you wish to say if there is anything I have missed
  22     or have not covered properly or got wrong, whatever, or
  23     anything else you want to say to the Inquiry. There are
  24     one or two points from your discussion with Mr Langstaff
  25     earlier, there was one point going to be followed up

   1     perhaps in writing; is there anything else you want to
   2     say now?
   3   A. No, I do not think I have any burning issues to discuss
   4     as you indicate and I am glad of the opportunity to
   5     reflect on it and if necessary to send further evidence
   6     in writing.
   7   MR MACLEAN: Do have a look at today's transcript which will
   8     be available by tomorrow and reflect on that and you can
   9     obviously make such comment as you wish.
  10        Are there any questions from the Panel?
  11             Examined by THE PANEL:
  12   THE CHAIRMAN: Just one question from me, Dr Jordan. if an
  13     observer having heard your evidence formed a picture
  14     that you were someone who, recognising that there were
  15     some problems in Bristol, fought within Bristol to
  16     effect change while outside quietly suggested or warned
  17     people off; would that observer have any right to hold
  18     that view?
  19   A. There is some truth in it. I will perhaps give you an
  20     example: shortly before I retired I had discussions with
  21     cardiologists in South Wales, I think this has sort of
  22     been obliquely referred to. Basically they were
  23     obviously considering whether they should continue to
  24     send patients to Bristol and take on a new cardiologist
  25     from Bristol, there was going to be a change anyway and

   1     they were being offered, in fact being encouraged to use
   2     the service in Cardiff instead.
   3        The thing I said to all of them, and I used very
   4     similar words but not necessarily identical ones were
   5     "You have asked my advice and what you are asking is
   6     really what is best for our patients. If I thought that
   7     the centre in Bristol was absolutely the best centre in
   8     the UK and there was no way that anyone else was going
   9     to produce comparable or better results, I would say to
  10     you, 'Do not try an untried unit in Cardiff'. Frankly,
  11     I do not think I am in a position to say that to you and
  12     therefore you will have to make up your mind whether you
  13     want to try a new unit or stick with Bristol."
  14        I think that is the sort of, if you like, comment
  15     I made which indicated that I was not going to go around
  16     blindly saying "Bristol is wonderful, keep on sending
  17     your patients there".
  18   THE CHAIRMAN: Thank you very much. Miss O'Rourke?
  19   MISS O'ROURKE: No, thank you, sir.
  20   THE CHAIRMAN: Thank you, Dr Jordan. You have been patient
  21     with us for a long day today and part of a day. We have
  22     learned a great deal, thank you very much for coming to
  23     talk to us.
  24        As Mr Maclean said, there may be things when you
  25     have gone through the transcript that you would think we

   1     ought to see or know of. I remember one particular
   2     exchange concerning equipment.
   3   DR JORDAN: Yes, I have made a note of that, sir.
   4   THE CHAIRMAN: That would be particularly helpful but if
   5     there are other things as well I am sure, having had
   6     conversations with those who help you, you will be able
   7     to respond to us. For today, thank you very much
   8     indeed.
   9   MR LANGSTAFF: Before I announce what is to happen next
  10     week, may I mention, as our protocol is, the
  11     representative of any person who is giving evidence may
  12     the next day, if he or she wishes, make an application
  13     to make a short statement placing that evidence in
  14     context or commenting upon the issues that may arise
  15     therefrom.
  16        Mr Lissack would wish to make an application to
  17     say something orally. It can be done in writing as you
  18     know, but it can be done orally on application and he
  19     tells me, despite the hour, it is unlikely to detain the
  20     Inquiry long if leave is given.
  21   THE CHAIRMAN: Yes, of course. Mr Lissack?
  22     MR LISSACK: STATEMENT ON BEHALF OF BEREAVED PARENTS
  23   MR LISSACK: Yesterday morning you heard the evidence of
  24     Maria Shortis and her evidence was the first to be heard
  25     from any bereaved parent in Block 6. It provides

   1     a useful opportunity for me to make these few comments,
   2     if I may.
   3        The end of the evidence is now in sight. That is
   4     a view that fills some with fear. As Maria Shortis has
   5     chosen to immerse herself in the issues which spring
   6     from the loss of a child, so others have been unable to
   7     do so.
   8        The toll this Inquiry has taken and will continue
   9     to take on the participants is considerable, as the
  10     Panel recognises, but all the participants will and must
  11     move on.
  12        The moving on will undoubtedly be most difficult
  13     for the parents who face the very real possibility that
  14     this Inquiry that they fought so hard for for their dead
  15     or for their injured child, will pass without the name
  16     ever being mentioned.
  17        I have explained, and they know that, firstly, the
  18     primary source of evidence before this Inquiry is
  19     written.
  20        Secondly, the Clinical Case Review is there to
  21     serve a purpose.
  22        Thirdly, the Inquiry is not the forum to
  23     investigate their child's operation.
  24        Fourthly, anonymity or not mentioning a name does
  25     not equate with insignificance; indeed, the contrary is

   1     true.
   2        But for many those realities are all the harder to
   3     bear. I fully appreciate that the Inquiry has
   4     a complete grasp of the humanity of this tragedy and the
   5     tragedy is equal and in each case each parent will deal
   6     with it differently. Some, like Maria Shortis, have
   7     retained an outward appearance of composure that others
   8     may envy. Some have not.
   9        Some, indeed most, prefer the anonymity
  10     scrupulously applied by the Inquiry. Others, like Helen
  11     Rickard or Maria Shortis, prefer to talk openly about
  12     the death of their child.
  13        The Inquiry may be assured that we will continue
  14     to work for the single purpose of assisting it in its
  15     difficult work. From time to time we may yet seek the
  16     Inquiry's indulgence. On those rare occasions I know
  17     you will be tolerant of that.
  18   THE CHAIRMAN: Mr Lissack, that is a very helpful set of
  19     comments. We are all grateful to you. Thank you very
  20     much indeed.
  21          MR LANGSTAFF: PROGRESS REPORT RE
  22          APPLICATION TO RECALL WITNESSES:
  23   MR LANGSTAFF: Two matters before we break for the week.
  24     The first is to report briefly upon the progress of the
  25     application which was made on an earlier occasion by

   1     Mr Lissack for the recall of Professor Berry and
   2     others. As I told you earlier, the Inquiry had written
   3     seeking information. We have now received today
   4     a response in some detail which requires some
   5     consideration over the next few days and I am sure that
   6     once we and the Secretariat have looked at it you and
   7     the Panel would wish to consider it.
   8           RE: TIMETABLE FOR NEXT WEEK:
   9   MR LANGSTAFF: Next week we have the evidence of Dr Stephen
  10     Bolsin.
  11        If I may mention so there is no misunderstanding,
  12     on Monday we start at 10.30. On Tuesday we start at
  13     9.30 as we do on each of the other two days, but on
  14     Tuesday there will be something of a short day; by
  15     reason of particular prior commitments which have been
  16     known about for some time, we will not be sitting beyond
  17     about 1.00 on that day.
  18        Until 10.30 on Monday then.
  19   THE CHAIRMAN: Yes. Thank you, Mr Langstaff. I thank
  20     everyone for helping us, again a long day, and I say
  21     good afternoon to everyone.
  22   (4.30 pm)
  23     (Adjourned until 10.30 am on Monday, 22nd November 1999)
  24
  25

   1
   2                I N D E X
   3
   4
   5     MR LANGSTAFF re further line of inquiry:
   6        Operations after 1 May 1995 ................. 1
   7
   8     DR STEPHEN JORDAN (recalled):
   9        Examined by MR LANGSTAFF .................... 2
  10        Examined by THE PANEL ....................... 188
  11
  12     CHAIRMAN'S STATEMENT re review of cases .......... 139
  13
  14     MR LISSACK:
  15        Statement on behalf of bereaved parents ..... 190
  16
  17     MR LANGSTAFF:
  18        Progress report re application to recall
  19          witnesses ............................... 192
  20
  21        Re timetable for next week .................. 193
  22
  23
  24
  25

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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001