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Daily transcripts
Hearing summary
22nd November 1999
The Bristol Royal Infirmary Inquiry oral hearings this week centre on
the evidence of Dr Stephen Bolsin, former Consultant Anaesthetist, United Bristol
Healthcare NHS Trust (UBHT) and currently Director of Anaesthesia, Geelong Hospital,
Geelong, Victoria, Australia.
Dr Stephen Bolsin began his evidence today by answering a series of
introductory questions about his role in auditing the Bristol service, conclusions he drew
and actions he took to draw his concerns to colleagues within and outside the Trust. He
went on to talk about the consequences of his actions in terms of his clinical career in
Bristol and the UK,and commented on discussions he had with UBHT management and
representatives of the British Medical Association (BMA) regarding compensation. Dr Bolsin
next described national guidelines for audit activity, organisation of audit in Bristol
and audit data collected. Dr Bolsin then began to answer more detailed questions. He
described his experience of paediatric cardiac surgery before coming to Bristol and
commented that operation times were longer in Bristol. He referred to a personal review he
undertook after his first year which noted that adult and paediatric mortality figures
could be better. He then told the Inquiry about the establishment of joint audit meetings
attended by surgeons, cardiologists and anaesthetists. He went on to describe a letter he
sent prior to the approval of Trust status, to Dr John Roylance, former Chief Executive,
UBHT, in which he identified concerns about infant mortality for patients undergoing
cardiac surgery. He outlined the response to the letter from various clinical colleagues.
Dr Bolsin recounted the discussions of an anaesthetic audit meeting in 1990 which focussed
on the switch programme and the decision of the anaesthetists for a request to be made to
the surgeons for an open review of the procedure to be undertaken. He concluded by
describing an evening multidisciplinary audit meeting held in 1991 at which he took notes
and prepared minutes which were subsequently withdrawn at the request of colleagues. The
meeting considered that Bristol had a higher mortality for certain procedures.
Dr Bolsin’s evidence continues tomorrow morning at 9.30 a.m.
|
FULL TRANSCRIPT
1 Day 80, 22nd November 1999
2 (10.35 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Mr Langstaff.
5 MR LANGSTAFF: Good morning, sir. Sir, today we, as indeed
6 throughout the rest of this week, we have the evidence
7 of Dr Stephen Bolsin.
8 Dr Bolsin, would you stand, please, to take the
9 oath?
10 DR STEPHEN BOLSIN (SWORN):
11 Examined by MR LANGSTAFF:
12 Q. Dr Bolsin, thank you for coming from Australia in order
13 to give your evidence to us and for relieving us of the
14 need to take it by video link.
15 A. Thank you for inviting me.
16 Q. Your full name?
17 A. Stephen Nicholas Clevely Bolsin.
18 Q. You have given us two statements for the purposes of
19 this Inquiry, together with a number of comments on
20 other statements. Can we have on the screen, please,
21 WIT 80/1? Is this the start of your first statement?
22 A. Yes, that is true.
23 Q. If we go through to page 7, do we see there that you
24 sign it and date it 14th April of this year?
25 A. Yes.
0001
1 Q. That dealt with issues B and H from the issue list.
2 At page 106, is this effectively your main
3 statement to us?
4 A. Yes.
5 Q. Which, including a glossary of terms, goes on to
6 page 144?
7 A. Yes.
8 Q. The statement as such ends at page 132. That is not
9 signed, nor is it dated, but nonetheless, this is your
10 statement, is it?
11 A. Yes.
12 Q. You are represented today by Mr Ryan, who sits behind
13 me?
14 A. Yes.
15 Q. Tell me, do you adopt the contents of those statements
16 as your evidence to the Inquiry?
17 A. Yes.
18 Q. Is it right that there are a number of typographical
19 errors? Let me pick one, for example. If we go to
20 page 80/3, and go down to (i), we see a Professor there
21 who is described as Professor "wrench leaning" and that
22 should be Professor Angelini?
23 A. I am sorry about that.
24 Q. That is a graphic example of one of a number of
25 typographical errors. Perhaps you would like to say
0002
1 a word about how that came about?
2 A. I was using a voice recognition dictating system in
3 order to rapidly produce this statement, and I thought
4 that I had checked this statement over effectively, but
5 obviously there were some things I missed out and
6 I apologise for that. I explained last night I was
7 actually quite sad I let a document of this quality out
8 with my name underneath it, and I apologise for that.
9 Q. In respect of both of your statements, how accurate and
10 reliable do you think is your recollection of dates?
11 A. It is to the best of my knowledge. I had some
12 documentation and certainly at least one diary for one
13 year, which I was able to fall back on and which
14 I submitted to the Inquiry. There may be some dates
15 which are incorrect or uncertain, and where I have been
16 uncertain of dates, I have indicated that in the
17 transcript, in that I might have said it occurred in the
18 winter of such-and-such a year, or late in such-and-such
19 a year, and that is because I have not been able to
20 accurately identify the date of that meeting.
21 Q. Apart from typographical errors, and apart from some
22 accepted potential unreliability as to dates, is there
23 any specific alteration you would wish to make to one or
24 other of your statements?
25 A. No.
0003
1 Q. Before I leave just the tidying-up process at the start,
2 we have had a comment from the Department of Health that
3 Dr Ashwell and Dr Doyle, to whom you refer, were senior
4 officers in the employment of the Department of Health
5 and not of the UBHT, as you describe them in your
6 statement. That is obviously right, is it not?
7 A. Yes.
8 Q. So, subject to those corrections, may we take your
9 statements as true and accurate?
10 A. Certainly, yes.
11 Q. Are they, do you think, complete?
12 A. Yes.
13 Q. What I want to do, before we go through your statements
14 in some detail, because of course we will adopt our
15 usual pattern at this Inquiry which is to take your
16 statement as read, and therefore not require you to go
17 through each and every chapter of it; it is, as it were,
18 your evidence and it is in and anyone who is interested
19 may read it, and report it as such.
20 Let me see first of all, if I can have some "Yes"
21 or "No" answers to a number of general points so that we
22 can see where we go, and each them, I think, we will
23 probably examine at rather greater length over the next
24 couple of days or so.
25 A. Yes.
0004
1 Q. Am I right in concluding that you never asked
2 Mr Dhasmana, Mr Wisheart or any of the paediatric
3 cardiologists performing paediatric cardiac surgery to
4 show you data of outcomes?
5 A. The "Yes" or "No" answer to that is no, you are not
6 right in assuming that, because -- do you want me to
7 explain?
8 Q. Is the answer that you did do so?
9 A. Yes.
10 Q. Whom did you ask, of those I have mentioned?
11 A. At the audit meetings --
12 Q. No, not when, whom?
13 A. The people who were present at the early audit meetings
14 would have received requests from me at that meeting --
15 Q. Would have, or did have?
16 A. Did receive requests for audit data to be provided to
17 continue the audit process that we had begun at one of
18 the meetings, and I think the minutes are scanned into
19 the Inquiry's database.
20 Q. So you made a request at an audit meeting for data and
21 that data was not forthcoming?
22 A. Yes.
23 Q. The second general point -- again, a "Yes" or "No", if
24 we can: is it right that you had no personal contact --
25 personal as opposed to written contact -- with
0005
1 Dr Roylance until after the incident involving Joshua
2 Loveday?
3 A. I believe that I have a record of a meeting with
4 Dr Roylance late in 1994, which would have been prior to
5 the Loveday operation and I think that is referenced in
6 some of the statements that I have looked at in the last
7 few days.
8 Q. So not until then, late 1994?
9 A. Yes. That would have been the personal contact.
10 Q. The third general question, general point: is it right
11 that you never directly, or personally, showed the data
12 which you had collected and analysed, together with
13 Mr Black, to any of Mr Dhasmana, Mr Wisheart, Dr Joffe,
14 Dr Jordan, Dr Martin, at least before February 1995?
15 A. Yes, that is true.
16 Q. Next, is it right that although you were a member at
17 least for a time of the Trust Audit Committee, the
18 Central Audit Committee of the Trust, you never raised
19 any inability to get figures at any of the meetings of
20 that committee?
21 A. Yes, that is also true.
22 Q. Next, is it right that there were a number of meetings
23 of anaesthetists, of cardiac services, and of those
24 engaged in paediatric cardiac surgery or cardiology, at
25 which you could, if you had wished to do so, have shown
0006
1 and explained the data which you and Dr Black had
2 collected? I am not suggesting you were ever invited to
3 do so, I am saying you could have done so if you had so
4 wished?
5 A. I could have done that, yes, if that had been an
6 appropriate action on my part.
7 Q. We will come to why and qualifications, but it is really
8 just to establish something that we can regard as
9 factual and move forward. That is the purpose of these
10 introductory questions.
11 You had a view of Mr Dhasmana, did you, as someone
12 who was deeply caring?
13 A. Yes.
14 Q. Who could be found at all hours in the ICU?
15 A. Yes.
16 Q. Who, when it was put to you by his counsel at the GMC
17 that he was someone who would go one mile and more on
18 behalf of the patient, you readily agreed?
19 A. Yes.
20 Q. Someone whom you found very self-critical?
21 A. Yes.
22 Q. And on one occasion, I think, in 1992, when he was
23 being critical in discussion with you of himself, you --
24 A. Can I just correct that? He was expressing doubts about
25 his continuing with some paediatric cardiac surgical
0007
1 operations.
2 Q. Thank you. You have told him that he was the best
3 cardiac surgeon in the South West?
4 A. What I specifically said was that he was the best
5 paediatric cardiac surgeon in the South West region, and
6 he was the best of two, but another part of that meeting
7 was that I said he should concentrate on the operations
8 for which he had good outcomes and should not undertake
9 the operations for which he did not have good outcomes.
10 Q. You were encouraging him not to do the switch which was
11 the operation you are referring to, but you were, in
12 1992, encouraging him to continue operating on other
13 children?
14 A. No, I was encouraging him to do the operations that he
15 could do with good outcomes. I did not actually define
16 the operations that he should do; what I said was that
17 he should do the operations for which he had good
18 outcomes.
19 Q. Was it the effect of that meeting that, with the
20 exception of the switch, you were encouraging him to
21 continue as a paediatric cardiac surgeon?
22 A. I think at that time I did not know --
23 Q. No, it is a "Yes" or "No".
24 A. I am sorry, you will have to repeat the question. I am
25 sorry.
0008
1 Q. Were you, at that time, with the exception of the
2 switch, encouraging Mr Dhasmana to continue as
3 a paediatric cardiac surgeon?
4 A. Can I give more than a "Yes" or "No"? It will be
5 a brief answer.
6 Q. Start with a "Yes" or "No" and qualify it.
7 A. Yes, I was encouraging him to continue as a paediatric
8 cardiac surgeon with those operations for which he
9 believed his outcomes were good.
10 Q. So far as Mr Wisheart is concerned, did you share an
11 interest with him in rugby?
12 A. Yes.
13 Q. And in cricket?
14 A. Yes.
15 Q. And did you talk or chat about that in the course of
16 your clinical time together?
17 A. We certainly did, yes.
18 Q. Was he then pleasant and easy to work with when you
19 worked on his lists?
20 A. It was easy to talk to him about rugby and cricket, yes.
21 Q. Was he as a person, leaving aside the quality of the
22 surgery, easy and pleasant to work with?
23 A. Yes.
24 Q. In June 1992, I think, you demonstrated for the benefit
25 of local television a new device, did you not?
0009
1 A. Yes.
2 Q. What was that device?
3 A. It was an implantable Doppler device for measuring blood
4 flow in the aorta, so measuring the performance of the
5 heart.
6 Q. This was cutting-edge?
7 A. Yes, it was the first time it had been used in this
8 country.
9 Q. And the surgeon who performed the operation, which was
10 filmed, was whom?
11 A. Mr Wisheart.
12 Q. So in June 1992, you and he effectively collaborated,
13 no doubt with your suggesting in the first place, but
14 his acceding to the suggestion that you should
15 demonstrate cutting-edge technology in paediatric
16 cardiac surgery for the benefit of local television?
17 A. Yes.
18 Q. Can we look on the screen, please, at JDW 6/461? This
19 is a letter dated 11th April 1991. The initials at the
20 top will tell you it comes from you.
21 A. Yes.
22 Q. Can we scroll down just a little bit? What you are
23 talking about there is mortality data for patients
24 undergoing cardiac surgery in Bristol, who have been
25 allocated a pre-operative BBC score.
0010
1 Can I put this in context? You became involved
2 at some stage shortly after your appointment -- it may
3 have been before -- with the Association of
4 Cardiothoracic Anaesthetists, did you?
5 A. Yes.
6 Q. And you were the first member to be given a role in
7 co-ordinating audit nationally?
8 A. Yes.
9 Q. Did you then have a particular interest in audit and
10 audit processes?
11 A. Yes, I did in adult cardiac surgery.
12 Q. And you no doubt encouraged others to share that
13 interest?
14 A. Yes.
15 Q. And am I right in thinking that you arranged with the
16 unit here in Bristol to carry out an audit, a risk
17 stratified audit, of adult patients?
18 A. Yes, that is true.
19 Q. So in 1991 -- let us just go back up for a moment to the
20 data: 11th April 1991; can we go down again -- you were
21 actively involved in pursuing an audit programme in
22 respect of adults to see what the results were, given
23 the risk stratification?
24 A. Yes.
25 Q. You say, towards the middle of the page, that Andy Black
0011
1 was making an analysis of the data, so you were working
2 with him on this?
3 A. Yes.
4 Q. And five lines up from the bottom:
5 "James Wisheart has also seen this data and is
6 interested in the outcome."
7 Was that right?
8 A. Yes, I believe so.
9 Q. If we go to page 459, 12th April 1991, you are writing
10 to James Wisheart about a decision to publish data
11 dealing with outcomes. This is then an audit process
12 which you were engaged in with the support of
13 Mr Wisheart?
14 A. Mr Wisheart knew about it and was not opposed to it,
15 yes.
16 Q. He expressed his interest, you said?
17 A. Yes.
18 Q. So he knew what you were doing, expressed an interest in
19 it and in knowing the results and you were able, were
20 you, to conduct that audit entirely openly in so far as
21 the unit was concerned?
22 A. I assumed it was conducted openly. Actually the
23 research was undertaken by Rob Ray, a Senior Registrar
24 visiting from Australia, and he went round and collected
25 the data and we entered it into the computer, but
0012
1 everyone knew what we were doing, yes.
2 Q. Can we go back to the first of those documents we looked
3 at, page 461? Scroll right down to the bottom, please.
4 You copied that to Mr Wisheart.
5 Can I move from that to ask you, you make the
6 point in your statements that Mr Wisheart, as you saw
7 it, obstructed the audit which you wished to carry out
8 of paediatric cases?
9 A. Just to correct you there, it was not an audit that
10 I wished to carry out, it was an audit that I believed
11 should be carried out.
12 Q. I am sorry, obstructed the audit process in respect of?
13 A. He failed to undertake a full and open review which is
14 what I had been asking for for several years in
15 Bristol.
16 Q. Is there one occasion of which you can give chapter and
17 verse where Mr Wisheart actually obstructed such an
18 event happening, rather than failed to produce figures
19 which you would have wished him to produce?
20 A. If threatening somebody who has --
21 Q. No; "Yes" or "No", and then you may qualify it.
22 A. You have to qualify "obstructed".
23 Q. You tell me, because the words are words which come from
24 your statement, which is why I am asking.
25 A. I would have included in "obstruction" telling a junior
0013
1 anaesthetist who had suggested to the CEO or the
2 District General Manager of a group of hospitals that
3 there was a problem in paediatric cardiac surgery in the
4 under 1 year old age group, telling him that he should
5 not proceed with that type of activity in future, could
6 be construed as obstruction. I probably have done in my
7 statement. You might want to call it something else.
8 Q. So when you talk about his "obstructing", it is that
9 incident that you have in mind, is it?
10 A. I think that there was another incident when I produced
11 minutes of one of the informal evening audit meetings
12 and I was told that they were not acceptable outside of
13 the meeting. So that not at the time, when the minutes
14 were being considered to be accepted at the meeting,
15 before the next meeting was arranged I was told: "these
16 minutes will not be circulated, this is not how we do
17 things, I do not want you keeping minutes again". That
18 to me could be construed as obstruction. I probably
19 brought that in as "obstruction" in my statement.
20 Q. We have been told by Mrs Masey that it was her who said
21 that to you, and we have been told by Mr Wisheart and
22 from comments he has made that he did not say that to
23 you. Are they right or are they wrong?
24 A. I think Dr Masey is right, she did say it. Mr Wisheart
25 may be wrong. I believe he also said that to me as
0014
1 well.
2 What surprised me was that here was a concerted
3 attempt by two members of the meeting, not to correct
4 the minutes when they are presented at the next meeting,
5 which is the usual way things are done, but actually to
6 say "You are not to circulate these or keep minutes
7 again".
8 Q. Next, again, going through a number of points fairly
9 quickly because we will come to an opportunity to expand
10 on the chronology, am I right in thinking that you would
11 not, yourself, have anaesthetised a patient if you
12 thought that the patient would be at risk, particular
13 risk, in the operation which that patient was going to
14 undergo?
15 A. Yes, I believe in general terms that would be my view.
16 Q. Did you continue to be prepared to and in fact did
17 anaesthetise patients in operations which Mr Wisheart
18 conducted as surgeon after the Joshua Loveday operation?
19 A. I would have anaesthetised adult patients. I think at
20 that stage I was not anaesthetising paediatric cardiac
21 surgical patients, and in fact, just to add information
22 to that, when Dr Pryn and Dr Davies joined the unit,
23 I moved my days of anaesthetising cardiac surgical
24 patients --
25 Q. Again, the answer is "Yes"?
0015
1 A. Yes.
2 Q. The audit which you and Andrew Black prepared dealt,
3 amongst other things, with the operation known as VSD?
4 A. Yes.
5 Q. Is it right that, whether we call the audit an "audit",
6 or I think you have called it a "review" at the GMC --
7 A. Yes.
8 Q. -- when you rather disclaimed the word "audit" for it,
9 but it does not much matter. There were figures?
10 A. Yes.
11 Q. Were those figures when it came to VSD in fact in error?
12 A. They were, yes.
13 Q. To the tune of 500 per cent?
14 A. I think we come to that, "lies, damned lies and
15 statistics". There were some errors. Another way of
16 looking at it would be to say we collected something
17 like 3,000 data sets on 286 patients and we got six or
18 seven of the fields wrong, so exactly how you look at it
19 lies somewhere between the spectrum you have put and the
20 spectrum I have put.
21 Q. If one focused on VSDs, so this is a conclusion of the
22 report analysis, is it right or is it wrong to say that
23 the result, as produced by the analysis, was 500 per
24 cent wrong?
25 A. That is a factual statement.
0016
1 Q. The results which you showed were really quite bad for
2 mortality in that operation, were they not, on any
3 comparative view?
4 A. This is the VSD operation?
5 Q. Yes, the VSD.
6 A. Yes, they were very worrying.
7 Q. This Inquiry, as you know, has conducted a careful
8 statistical analysis and the Panel will understand if
9 I describe the results as "preliminary" or "provisional"
10 because that is the way they have been presented to us
11 thus far and those who may wish to criticise or argue in
12 respect of those statistics are yet to have the full
13 opportunity to do so.
14 A. Yes.
15 Q. But on the face of those statistics, the VSD operation
16 is one of those where it appears the Bristol unit was
17 actually very much in line with units elsewhere up and
18 down the country in the results it was achieving, if not
19 better than those units.
20 A. Good.
21 Q. So far as you are concerned, do you accept that is
22 probably the case?
23 A. Yes. I think when Andy and I reviewed the data in
24 the meeting, I think probably in February 1995, we
25 withdrew the VSD data and stood by the other conclusions
0017
1 that we had come to.
2 Q. Again, you will forgive me, I hope, for making or asking
3 a number of general questions at the beginning, to set
4 the framework for your evidence.
5 When you left the UBHT, you went to your present
6 post, did you, in Australia?
7 A. Yes.
8 Q. You have been invited on a number of occasions to
9 lecture about your experience, because you have gained,
10 if that is the right word, a certain amount of public
11 interest as being the person responsible for bringing
12 the Bristol situation to light.
13 A. Yes. I think I have gained a lot of experience in
14 dealing with these types of problems, and the health
15 care system that I am working in is very keen to learn
16 those lessons.
17 Q. If we take a look at your statement -- I will come back
18 to that, actually.
19 In a lecture which you gave at Melbourne in March
20 of this year, you said that there had been, you thought,
21 200 unnecessary deaths. Do you recall saying that?
22 A. No.
23 Q. Let me, in that case, tell you the passage that I have
24 and identify it rather more closely for you. This is
25 Friday, 19th March of this year at the Naval and
0018
1 Military Club in Little Colin Street, Melbourne, the
2 Chairman being the Honourable Justice Kellam, a talk
3 called "The Whistle-blower in Medicine", presented by
4 yourself to the Medico-legal Society of Victoria.
5 A. Yes.
6 Q. The transcript that I have tells me that this is said --
7 I will read it out because I am afraid I do not have it
8 on the screen, so I will take it slowly:
9 "Unfortunately -- and this leads to a legal
10 engagement -- the paediatric cardiologist and the
11 paediatric cardiac surgeons were being funded by
12 a system which gave them a million pounds a year and
13 latterly 2 million pounds a year to run their paediatric
14 cardiac surgery service. Had they stopped referring
15 patients to their service, they would have lost the
16 money. The solicitors are now very actively looking
17 into the possibility that the compensation that the
18 parents should be getting is not just the #7,500 for the
19 death of a child, but is actually aggravated or punitive
20 damages because there was a pecuniary interest behind
21 the continuing of the service. Under those
22 circumstances, when you are into punitive damage, there
23 is no top limit. So if you consider 200 cases of
24 children who have died unnecessarily in a unit that was
25 gaining pecuniary advantage from continuing, then the
0019
1 top amount for the compensation suddenly blows out
2 enormously."
3 That is recorded as being your words. Do you
4 think you said that?
5 A. I think the 200 figure there was related to a reference
6 that was in the BMJ which was in 1998 -- I cannot give
7 you the full reference -- in which they say 200 sets of
8 parents have since come forward, so it would have been
9 in relation to the number of sets of parents that have
10 come forward rather than the number of -- I forget the
11 phrase you quoted there, "unnecessary deaths".
12 Q. "200 cases of children who have died unnecessarily".
13 A. I think I was referring to the 200 sets of parents who
14 have come forward.
15 Q. Because plainly, on anything you actually know about the
16 unit, 200 unnecessary deaths would probably be more than
17 the total number of deaths from paediatric cardiac
18 surgery in the entire time that you were at the unit,
19 would it not?
20 A. I would not know what the number of deaths was in the
21 unit while I was there, but I was aware of the fact that
22 200 sets of parents were reported to have come forward
23 in the BMJ.
24 Q. So you were relying on the report of others there?
25 A. I was relying on the report published in a medical
0020
1 journal, yes.
2 Q. In an article, I think it is -- it may be another one
3 of your lectures -- you have spoken about there being
4 50 cases of unnecessary deaths, and 50 cases of brain
5 damage.
6 Again, is that figure right or is that almost
7 certainly excessive, do you think?
8 A. I think the 50 cases of brain damage is a similar figure
9 and it is actually the same article in the British
10 Medical Journal and is reported as those number of
11 parents have come forward with children who suffered
12 brain damage. So all I am quoting from is a report in
13 the British Medical Journal, which as far as I know has
14 not been corrected.
15 Q. Is that an article in which you say you think you have
16 probably only seen a quarter of the picture?
17 A. I am sorry; I say that I have only seen a quarter of the
18 picture? No, the article I am referring to is produced
19 in the news section of the British Medical Journal and
20 deals with some of the statistics that have fallen out
21 of the GMC and the Public Inquiry into Bristol which
22 says that so far 200 sets of parents have come forward,
23 and 50 sets of parents of brain-damaged children have
24 also come forward.
25 Q. If you were to look at that from your own memories of
0021
1 time at the unit, is that perhaps an exaggeration? I am
2 not ascribing this to you, because you are saying this
3 is something I am reporting from elsewhere, but it is
4 bound to be, is it not, something of an exaggeration.
5 Or is it?
6 A. I cannot tell you what the number of deaths in Bristol
7 was, because that information has not been shown to me.
8 Q. I am focusing on brain damage.
9 A. I cannot tell you what the number of brain-damaged
10 children in Bristol was because that information has
11 never been shown to me. All I can do is comment on
12 a report which so far as I can see has not been
13 corrected in the British Medical Journal.
14 Q. I will give you a moment to think about it. Do you
15 think from anything you know actually about the number
16 of children, the way in which the operations went and
17 your own involvement in the outcomes -- because, after
18 all, being an anaesthetist you were responsible, amongst
19 others, for intensive care, were you not?
20 Can you think that that figure could possibly be
21 right?
22 A. If I believed that the figure was wrong, I would not
23 have passed it on.
24 Q. That is jumping ahead to the next question. What I am
25 asking you is, could you possibly believe that it was
0022
1 right, or might be right?
2 A. I think there was certainly a possibility that that
3 figure was right, yes.
4 Q. Can I ask you to look at your statement, please?
5 WIT 80/1. Can we go down to Issue B1(b)? It is
6 essentially the same point, I think, that was made in
7 the extract that I read to you from the Melbourne
8 lecture. You say in the fifth line down:
9 "I believe that to have suspended an arterial
10 switch programme in this competitive environment would
11 have cost the unit a considerable amount of top-sliced
12 funding."
13 This is not a "Yes" or "No" answer, this gives
14 you an opportunity to say a bit more. We will come back
15 to the matters I have been dealing with, because I do
16 not want to cut you short.
17 A. Okay.
18 Q. But what is the basis for saying that?
19 A. I think it is a conglomerate experience. There were
20 several reasons why supra-regional paediatric cardiac
21 surgical designation was important, one of which was the
22 funding reason, and we know that some of the catheter
23 facilities were provided through that funding mechanism.
24 I also remember having a discussion with my
25 director of anaesthesia, Chris Monk, again which
0023
1 I mention in my statement, at which we were talking
2 about whether there should be a stop to the activity of
3 the unit, certainly for the high risk operations, and
4 that we should examine our results and then move
5 forward. The analogy that was used was, this was
6 a train that occasional passengers were falling off, but
7 the train had to keep moving and the train had to keep
8 moving in order to attract the funding. That was one of
9 my concerns about the subjugation of patient safety to
10 reasons of funding and continued activity in high risk
11 areas.
12 Q. So what you are relying on, basically, is what you have
13 inferred from what other people have said to you?
14 A. Yes. I did not have letters from the Department of
15 Health or anything like that, but my impression in this
16 unit was that the commitment of the staff was to keep
17 doing things that they felt were important for
18 designation irrespective of the risk to the patient, and
19 that concerned me.
20 Q. You yourself did not have a particular financial role to
21 play? You were not involved in the financing of the
22 department, personally?
23 A. No.
24 Q. So the belief, really, is this right: that it is an
25 attempt to explain to yourself and to understand why it
0024
1 should be that there were those who wanted to continue
2 with the operation, but it seemed to you obvious that
3 that should not happen?
4 A. Well, no. Being slightly more specific, if I may, this
5 was a Director of Anaesthesia who was in touch with the
6 Chief Executive and other members of the Hospital Board
7 who was telling me quite late on in the process that the
8 reason for keeping the train going was for funding
9 reasons.
10 This essentially put into perspective all of the
11 things that I had experienced in the preceding few
12 years, which was an enormous difficulty and an enormous
13 sensitivity in getting people to examine the outcomes of
14 high risk activity in this unit.
15 My time had been spent trying to get an open
16 review to say which operations are risky and we should
17 not be doing them, which ones are fine and we should be
18 doing them, and obviously the VSD was one we should have
19 been doing.
20 I got no real response from anybody at any level,
21 and I think one of the reasons was, if they had actually
22 undertaken that review, it would have demonstrated that
23 they could not do, let us say, the switch operation and
24 Leicester would have come in and said "We can do it.
25 Can we have their funding, please?"
0025
1 Q. Most of your time as anaesthetist was spent
2 anaesthetising adults, was it?
3 A. No, my emphasis changed around 1993. If you remember,
4 I applied for the job in Oxford in 1992 because I did
5 not want to be associated with the high mortality rate
6 paediatric cardiac surgery in Bristol.
7 Q. Can I come back to that and just ask you the question
8 that was going to arise from it --
9 A. Well, no, it changed, because in 1993, up until then,
10 I had been doing two potential days of paediatric
11 cardiac anaesthesia a week. In 1993 I dropped my
12 Monday, which was Mr Wisheart's day when he always did
13 a child, and I did days when I was much less likely to
14 be undertaking paediatric cardiac anaesthesia.
15 Q. The question was going to lead on to this question,
16 which you can still comment on, I think: so far as the
17 adult work was concerned, is it the case that the
18 department was under pressure because there was more
19 adult work to be done than there were beds available and
20 the waiting lists got longer and so on?
21 A. Yes, I think there were always pressures to perform.
22 Q. So it might be said from that that if one were taking an
23 overall financial perspective, from the point of view of
24 the management, that if there were less children's
25 operations done, the space would simply be filled by
0026
1 more adults, of which there were a number waiting to be
2 done and therefore there would be no financial downside
3 to doing less children's operations.
4 Might that be right, or not?
5 A. I think that certainly could be true, but if children
6 under 1 year were funded by the Department of Health,
7 you could undertake a certain number of operations free
8 of charge.
9 Q. Free of charge?
10 A. Supra-regional paediatric cardiac surgical designation
11 meant that operations carried out on the under 1s were
12 funded by the Department of Health direct, not through
13 Region or through contracts.
14 Q. But the hypothesis that I think I was putting to you,
15 simply for your comment, simply to explore, because
16 I think you may not be the right person to explore the
17 details of finances with --
18 A. I suspect you are right.
19 Q. -- and I do not want to put you in a position which is
20 unfair to you, but I think the hypothesis would be that
21 the child under 1, not over 1, the under 1 child is
22 funded directly by the government because it was
23 a supra-regional centre, at least in 1994. The adult is
24 funded through the contract with the purchaser unit?
25 A. Yes.
0027
1 Q. And those contracts, we are told, provided for a certain
2 core number and if you go beyond that core number you
3 get a "bonus" -- I am putting it in very bad terms --
4 for each additional case that one does, so the funding
5 would still be there although it comes through
6 a different route. I think that is the point that may
7 be made back to you.
8 I do not know if that is something you want to
9 come back to, and we will come back to it at a later
10 stage.
11 A. Yes, that is fine.
12 Q. In your statement you say nothing, I think, about any
13 Masonic influence in Bristol. When you first I think
14 had a draft of your statement, you were intending to say
15 something about that.
16 Am I right on both those counts?
17 A. Yes. I withdrew a section on Freemasonry in my first
18 statement, or draft statement.
19 Q. So do we take it that you make no allegations in respect
20 of Freemasonry operating in Bristol to the disadvantage
21 of the children?
22 A. I think it would be very difficult for me to produce
23 evidence that that had occurred.
24 Q. So you took the responsible course, as it were, you are
25 saying; you felt there might be allegations to be made,
0028
1 you had no evidence to sustain it and therefore you did
2 not pursue it?
3 A. Yes.
4 Q. You did the same, I think, in respect of the merit
5 awards which were made or not made to consultants such
6 as Mr Wisheart, Professor Angelini and so on, because
7 that is not in your final statement, but it was,
8 I think, something you had intended at one stage to say.
9 Do you want to pursue any comments in respect of
10 those, or not?
11 A. The only comment I would have is that Gianni Angelini
12 told me in his second year that he had been threatened
13 by Dr Roylance that if he continued to raise his
14 concerns about --
15 Q. Shall we leave that; if he is reporting to you what has
16 been said to him, it was not a conversation you were
17 part of?
18 A. No.
19 Q. So you cannot give us direct evidence of it?
20 A. No, but he did --
21 Q. If it becomes important to explain why you did
22 something, that somebody else said that to you, then we
23 will take it as evidence, but otherwise we have had
24 Professor Angelini, we will have Dr Roylance back again,
25 and so we can ask them who were involved in the
0029
1 conversation directly about it. But thank you, anyway.
2 A. Okay.
3 Q. Finally, before I come to matters on which we may be
4 a bit more expansive, in October 1995 you produced
5 a report which we see at UBHT 52/170. That is your
6 report produced for the Chief Executive and Chairman of
7 the Trust?
8 A. Yes.
9 Q. In that report do you accept -- if you want to see it,
10 I will take you there -- that you gave the date of
11 16th January 1995 for the meeting on the night before
12 the operation on Joshua Loveday?
13 A. I could not comment on that. If it was put down as the
14 16th, I suspect it was wrong.
15 Q. Well, yes. Perhaps you ought to see it. Can we turn
16 overleaf, please and go on, please? [UBHT 52/176].
17 It is the first line on page 176. Plainly the
18 date is wrong. It goes back to the questions I was
19 asking you about your recollection for dates. It is
20 really this: here in October 1995 you are looking back
21 to January, the events of which must have been even
22 clearer then in your mind than they are now, although
23 you have obviously been over those events in a number of
24 different fora since.
25 Why was it that we have Wednesday, 16th January
0030
1 rather than 11th January?
2 A. It is a week out. I cannot explain that, I am afraid.
3 Q. Because the thing about the data, it is not just
4 a Wednesday in January, it is a specific date. Were you
5 relying on a diary or what, for that?
6 A. I think this would have been produced from memory and
7 I would have been relying on my memory of whether it was
8 the second or third week after Christmas. It would have
9 been as vague as that.
10 Q. So you actually gave a specific date, even though you
11 could not really remember the specific date at the
12 time?
13 A. No. I mean, I think that this document had been checked
14 over by -- I had asked a lot of people to review it for
15 accuracy and what have you, and I was possibly relying
16 on other people to pick up that kind of inaccuracy, and
17 I apologise unreservedly for getting it wrong.
18 Q. The reason I draw your attention to it is that obviously
19 others will have to evaluate how accurate dates are,
20 particularly when you give them specifically with
21 a particular day of the week, date in the month and
22 month. This is perhaps a stark example of inaccuracy,
23 as it happens?
24 A. I think it is -- I mean, it is qualified by the sentence
25 afterwards, in that it is referring to a specific
0031
1 Wednesday before an operation on the last arterial
2 switch that was undertaken, so it is very easy, and I am
3 sure you have been able to accurately pinpoint the
4 meeting that we are talking about. So I am not sure it
5 has a heinous crime.
6 Q. I am not suggesting that it is a heinous crime, please
7 do not misunderstand me. It is with a view to helping
8 the Panel form a view when we come to particular dates
9 and sequencing, which may or may not be a matter of
10 dispute, but we need to have a view as to how far your
11 statement, your memory, is or is not accurate or may be
12 unreliable.
13 As to that issue, as to events that happened, that
14 may be different, but that is the point.
15 A. Yes.
16 Q. Can I turn to something rather different? It really
17 takes you away from the beginning of your period of time
18 at the Bristol hospitals to the time that you left the
19 Trust.
20 When you left the Trust, did you go, as it were,
21 with a statement, a ringing endorsement from Mr Ross, of
22 the way in which you had conducted yourself over the
23 previous few years?
24 A. Mr Ross sent me a couple of communications, one of which
25 would fit the description that you have just given,
0032
1 "a ringing endorsement", and I think he then wrote back
2 and expressed the disappointment of the Trust Board
3 about my behaviour, which was contradictory to the
4 letter that he had sent me when I was still working at
5 the hospital.
6 Q. Can we look at GMC 4/113? This is the endorsement
7 letter, is it --
8 THE CHAIRMAN: Forgive me for interrupting. We are quite
9 anxious always to take any identifying criteria out, so
10 we will take it off the screen for a moment and put it
11 back on when we have removed it.
12 MR LANGSTAFF: Forgive me for wanting to jump ahead.
13 "The Chairman [Mr McKinlay] and I felt we should
14 put on record our belief that your actions in recent
15 years have been motivated throughout by a concern for
16 the best interests of patient care. The records
17 available to us confirm that you did raise your concerns
18 internally within the Trust in the first instance, and
19 only when you felt they were not being adequately
20 recognised did you raise them outside the Trust."
21 That is what the Chief Executive is saying to you
22 openly at this stage.
23 You were off to Australia. When did you take up
24 your present post?
25 A. It was 1st March 1996.
0033
1 Q. Before you left, you had applied, I think, to, amongst
2 other places, Nottingham, had you?
3 A. Yes.
4 Q. That was shortly after the Joshua Loveday operation?
5 A. Yes, I think it was the first half of 1995.
6 Q. You did not get that particular post, and you expressed
7 the view then you were committed to staying in Bristol?
8 A. Yes, for the time being.
9 Q. I want to go into it later, but for present purposes,
10 relations between Mr Dhasmana, Mr Wisheart and yourself
11 were such that adjustments, leave aside why it happened,
12 were made to the anaesthetic "cover" that they had for
13 operations and the three of you went into a counselling
14 programme, did you?
15 A. Yes.
16 Q. With the consent of each of you?
17 A. Yes, we all had to sign a consent form, and also a form
18 to say that we would not disclose any of the contents of
19 the meetings outside the meetings.
20 Q. And you were happy to do that?
21 A. Yes, I felt that if that is what the Trust felt was
22 appropriate, then I was happy to go along with that.
23 Q. Did that appear to be a constructive and positive move?
24 A. I think that what it confirmed was that Mr Wisheart and
25 Mr Dhasmana and I were coming from different ends of the
0034
1 same spectrum in looking at this problem.
2 Q. So was it a positive, constructive move?
3 A. It is difficult to say. I do not think it achieved much
4 in the way of positive results, but it was one way of
5 trying to resolve differences of opinion. I am not sure
6 that getting psychiatrists in to resolve differences of
7 opinion was necessarily an appropriate step, but it was
8 one that was proposed by the Chief Executive.
9 Q. Did you withdraw from the programme, the counselling?
10 A. I suspect when I had obtained my appointment in
11 Australia, I probably would not have seen that it was
12 necessarily good use of my time to continue in the
13 programme.
14 Having said that, we had already had one combined
15 meeting. I think the goal of the programme was to get
16 the three of us together to try and work out what the
17 differences of opinion were. It was quite obvious at
18 that meeting that there was still a gulf between us, and
19 I am not sure that was ever going to be dealt with.
20 Q. Suppose you had not got the post in Australia: you would
21 have stayed on working at Bristol?
22 A. Yes. I think I had decided, having received the advice
23 that I had from the Chief Executive and one or two
24 others, that I personally did not want to work for an
25 organisation that did not want me to work for them, and
0035
1 I was looking for opportunities to leave. I also
2 applied for a post in Southampton, which I did not get,
3 so I was actively looking for posts outside Bristol.
4 Q. Here one would have thought, on the basis of the GMC
5 letter, that the Chief Executive was wanting you to work
6 for them, but you say there was another letter which
7 said the opposite?
8 A. Yes. I received that in Australia.
9 Q. But at this time, at any rate, whilst you were in
10 England, your view was, was it, that the Chief Executive
11 was prepared to commit himself to paper, saying
12 basically that you were wanted and needed?
13 A. Can I just have a look at the date of this letter,
14 please? [20th February 1996].
15 Okay, at this point I have already obtained an
16 appointment in Australia. I am within probably two or
17 three days of leaving the country, and I asked at one of
18 the series of meetings that is mentioned in the letter
19 whether Mr Ross believed that he would be able to
20 produce for me a letter of a sort of personal reference,
21 because I had spoken to Mr Ross about the problems of
22 paediatric cardiac surgery and explained that I felt
23 that there had been a serious problem, and that that had
24 led to friction between myself and previous members of
25 the Trust Board.
0036
1 I asked him whether he would be prepared to
2 produce a document suggesting that actually I had done
3 the right thing in terms of patient care, and he was
4 prepared to produce this document.
5 At that point, I would, within 10 days, be taking
6 up a new appointment in Australia.
7 Q. Can we look at UBHT 21/214? Go down to "Chief
8 Executive's Remarks".
9 This is earlier in the year. We can see a report
10 of the conciliation process, which it was hoped would
11 reach a conclusion by the next Board meeting in July.
12 It is there dealt with and plainly if it had gone to
13 board level, they are looking for conciliation between
14 the three of you, on paper at any rate.
15 Can we move on to UBHT 21/5? Can we move down,
16 please? It is a new report produced by Dr Bolsin which
17 had not been circulated outside UBHT:
18 "Mr Ross had sent a copy to Dr Scally, and
19 Dr Bolsin had agreed that any further contacts with the
20 Department of Public Health would be through Dr Scally.
21 Dr Bolsin had been offered a job in Australia and had
22 requested compensation for what he considered to be
23 constructive dismissal."
24 Can I get the chronology right? You had been in
25 the Bristol Royal Infirmary working away. You applied
0037
1 to Nottingham, you had applied to Southampton, you had
2 applied to Australia and been accepted. Once you were
3 accepted, after you were accepted, you then asked for
4 compensation for constructive dismissal; is that right
5 or wrong?
6 A. I think it is a very brief summary. I actually went to
7 Mr Ross and said that I thought that the threats that
8 were made to my employment by members of the Trust Board
9 and senior Executive of the hospital had led me to
10 believe that I was not a valued member of the team at
11 the UBHT, and as a result of that, I had taken the
12 decision I did not want to work for an organisation that
13 did not want me to work for it.
14 Under those circumstances, I believed that they
15 might want to consider the possibility of offering some
16 degree of relocation allowance or disruption to life
17 allowance which was what I had been involved in in
18 taking up my post in Australia. He undertook to review
19 it. He did not say "Don't be stupid, it is absolutely
20 absurd", he said "It is a reasonable request and we will
21 have a look at it".
22 Q. So putting it in terms of compensation for constructive
23 dismissal is overstating it completely, is it?
24 A. Mr Ross is the Manager and he has put it into
25 a managerial context, to try to summarise it for the
0038
1 Board. Yes, that is probably what he said.
2 I think there is another important point here on
3 the screen, which is that Mr Wisheart pointed out "the
4 conciliation process had come to an end but would not
5 produce a commonly agreed statement".
6 So there was still a measure of disagreement
7 between the people involved in the conciliation
8 process. It seemed it had come to an end, not that
9 I had necessarily withdrawn from it.
10 Q. The point he makes, commenting upon your statement is
11 that he says you withdrew from it. That is what he puts
12 through me to you.
13 A. Right, but he has not put it to the Board at the time.
14 Q. It depends. Obviously that has to be explored. Thank
15 you for pointing it out. Your own recollection is that
16 you did not withdraw from the programme?
17 A. My recollection is that we had one meeting in which we
18 all came together and there was still such a measure of
19 disagreement --
20 Q. That there was no point in going forward?
21 A. It was concluded that the two psychiatrists said, "We
22 are going to have to go away and have another think
23 about this, because we do not think this is necessarily
24 going to produce perhaps what was required", which was
25 an agreed statement. There was still a lot of
0039
1 disagreement between us all.
2 Q. One meeting only?
3 A. There was one combined meeting at which James, Janardan
4 and I, with Neil Moore and I think Dr O'Connor, there
5 was one meet at which we all met, otherwise we had been
6 meeting separately with the psychiatrists.
7 Q. So one combined meeting, otherwise a number of separate
8 meetings?
9 A. Yes, a series.
10 Q. Back to the question of constructive dismissal, the
11 Manager's words for what was taking place: the way you
12 put it is that you say "I am going really because
13 I would have stayed if it had not been for the fuss and
14 bother there has been over what has happened". I am
15 putting this in my own words and asking how accurate it
16 is. "You are requiring me to dislocate, the effect has
17 been dislocating my life, my family has to move, there
18 are expenses involved, will you pay?" That was the
19 flavour of it, was it?
20 A. Yes. I think underlying that was somebody who believed,
21 when they moved to Bristol in 1998, that they had
22 achieved a perfect scenario. They were in a University
23 teaching hospital, they were undertaking specialties for
24 which they had been trained in the country for which
25 they had trained and wanted to put a lot back into the
0040
1 specialty, and because of the events that had gone on in
2 that hospital and because of criticisms that had been
3 raised of me, despite the comments of subsequent Chief
4 Executives that this was done in the patients' best
5 interests, I had believed that this hospital did not
6 want me working for it. And I felt that while I was not
7 prepared or did not particularly want to go through an
8 industrial process with the BMA and whoever else might
9 be involved, I wanted Hugh Ross to consider whether he
10 wanted, in some way, to recompense me for the problems
11 that I had brought to light for the improvement in the
12 service that had been achieved through that and for the
13 change that it had brought on not just me but my family.
14 Q. If one goes to a manager and says, "Look, you know and
15 I know that I am being paid a consultant's salary, but
16 I would like some money because I think that you would
17 like to give it to me for what I have achieved and done
18 and because I am going", one can anticipate that the
19 Manager might say, "Well, I understand the moral force
20 of your argument, but I am a manager and you have to
21 give me justification for it".
22 Did you give him any other reason than, as it
23 were, recognition of what you had done for him paying
24 you money.
25 A. No. I think what I asked him for was some measure of
0041
1 compensation for what I had been forced to do, which was
2 not just to leave the hospital, because I had applied
3 for jobs outside the UBHT after I had been threatened
4 that I would not be supported if there was a problem in
5 terms of my employment, and I had actually found that
6 I had had to take a post in Australia rather than being
7 able to get jobs in other hospitals.
8 Q. Did you give him any reason, other than that, as to why
9 he might wish to recommend to the Board that they made
10 you an ex gratia payment?
11 A. No, he undertook on that basis to consider my viewpoint.
12 Q. So you never threatened to go to the press if you did
13 not get an ex gratia payment, putting it crudely?
14 A. No.
15 Q. You had contact, did you, at this time with someone
16 called Sean Cusack?
17 A. Yes, Sean Cusack was the Industrial Relations Officer at
18 the BMA in Bristol.
19 Q. You were a member of the BMA?
20 A. I was, yes.
21 Q. So he was your representative, was he, in industrial
22 relations matters?
23 A. I had seen him for -- I am trying to think when I first
24 saw him, actually. I had seen him after David Coates,
25 who was the Place of Work Accredited Representative for
0042
1 the BMA, had come to me with very serious concerns about
2 the threat that John Roylance had given him about my
3 employment. I am sorry, wrong. I had gone to Sean
4 Cusack when my job contract had changed and I had been
5 asked to do general surgery instead of cardiac surgery
6 on a Thursday.
7 Q. So you were talking to him in 1995, anyway?
8 A. Yes.
9 Q. And he took matters up on your behalf, did he?
10 A. I think he wrote or he sent me a copy of a letter he
11 wrote to Chris Monk.
12 Q. Did he, so far as you know, take matters up on your
13 behalf with the Trust?
14 A. Not as far as I know, no. I think he also obtained
15 a legal opinion on my industrial position.
16 Q. Can we have a look, please, at BMA 1/28? This is an
17 internal memo. I do not think you have seen this
18 before. Can we scroll up again, please? It is BMA, 8th
19 March 1996, which is just after the memo we have seen in
20 February, anticipating your departure to Australia. It
21 is to Dr Armstrong from Sean Cusack, the Industrial
22 Relations Officer at Bristol.
23 A. Yes.
24 Q. Can we scroll down, please, the third paragraph?
25 "Dr Stephen Bolsin, the anaesthetist who was
0043
1 instrumental in bringing the previously high mortality
2 rate for paediatric cardiac surgery in Bristol to light,
3 finally emigrated to Australia last week. In November
4 he produced a confidential report", we have seen part of
5 that, the one with 16th January in it, "giving his
6 version. In January the new Chief Executive, Hugh Ross
7 held a press conference at which he expressed confidence
8 in the present high standard in paediatric cardiac
9 surgery and he regretted there had not been an earlier
10 investigation into the concerns raised by the staff.
11 It became clear at this point that the Trust is facing
12 legal action with the families..."
13 Then it says this:
14 "Dr Bolsin has been trying to mount a claim for
15 constructive unfair dismissal against the Trust for
16 a significant sum of money, but the advice from both
17 myself and the Legal Department is that he is unlikely
18 to succeed and that he should not proceed."
19 Pausing there, that is the way he, the Industrial
20 Relations Officer to whom you had had recourse,
21 puts it. Is that, then, the way in which you recall
22 putting the matter to him in the conversations before he
23 gets the legal advice that that is unlikely to succeed?
24 A. I am sorry, is this how I was putting it to Hugh Ross,
25 or to Sean?
0044
1 Q. This is Sean Cusack, reflecting what you had been trying
2 to do?
3 A. Yes.
4 Q. He was on your side, your Industrial Relations Officer,
5 the person you were talking to about your problems with
6 the Trust?
7 A. Yes.
8 Q. Is it right, then, that you had been trying to mount
9 a claim for constructive unfair dismissal for
10 a significant sum of money?
11 A. I think that after the advice that he got from the Legal
12 Department, then that became very much -- I mean, it was
13 a non-starter on the basis of the legal report that he
14 had got.
15 Q. So you had raised it and it became a non-starter?
16 A. Yes, I had asked him whether I had a case for unfair
17 dismissal. He said, "We will have to get some legal
18 advice" and he then got legal advice, and when we
19 discussed that, it became apparent that there probably
20 was not a case.
21 Q. Can we read on:
22 "However, Dr Bolsin has been using the threat of
23 such action to try and extract, from the Trust,
24 financial compensation."
25 So he appears to be saying, on legal advice, that
0045
1 he has told you that you do not have a hope, putting it
2 bluntly, legally, but nonetheless, you are saying to the
3 Trust, "Look, I have this claim here, pay me some
4 money".
5 Is that the way that it was?
6 A. I do not remember actually saying to Hugh Ross that
7 I think I have got a claim, because at that point
8 I would have had the advice from Sean Cusack.
9 Q. You see, if one puts that second sentence together with
10 the Trust minute saying he is claiming constructive
11 dismissal, and Sean Cusack's expressed view, which is
12 that despite the advice he is giving, you are still
13 saying to the Trust, "Look, you constructively dismissed
14 me, pay me some money", that that was still being raised
15 as a threat. Was it or was it not?
16 A. I would not have thought so. The way you could resolve
17 that would be to look at the date of the advice that was
18 given to Sean from the Industrial Relations Office at
19 the BMA, and then to look at the dates of the meetings
20 I had with Hugh Ross and Ian Stone, and also the date of
21 the minute you have of the Board meeting, because
22 I suspect it was an evolving process. I may at one
23 stage have said to Hugh Ross, "I think you should
24 consider a claim for constructive dismissal". He may
25 then have had a Board meeting at which he reported
0046
1 that. I would then have gone on and got the advice from
2 Sean Cusack and the Industrial Relations Office, which
3 said, "Actually, you do not have a claim", in which case
4 that would then have sort of foundered, as it were. So
5 it would not then have been raised again.
6 Q. So point number 1, perhaps, is that it means that the
7 minute we looked at, which you described as a manager's
8 reaction, somewhat inappropriately, to what you were
9 suggesting, was actually the way you were putting it at
10 that time?
11 A. Yes. It may have been my early raising of --
12 Q. -- of constructive dismissal?
13 A. Yes, of potential constructive dismissal.
14 Q. Can we go on down in this paragraph:
15 "Dr Bolsin has also recorded an interview for the
16 Channel 4 Dispatches programme, scheduled to be screened
17 on 26th or 27th March. I do not know the substance of
18 the interview, but I understand there may be further
19 allegations about the mortality rate of survivors of the
20 switch operation which would be damaging to the Trust
21 and in particular to Mr James Wisheart, the Medical
22 Director, who was one of the two surgeons involved.
23 Dr Bolsin has told me that he has not yet authorised the
24 interview for broadcast and that whether he does or not
25 depends upon the reactions of the Trust Board to his
0047
1 request.
2 "In short, if Dr Bolsin can be convinced that
3 there is no further risk to patient safety and that he
4 feels he has been properly compensated for the damage
5 done to his career, he will not feel the need to go
6 public."
7 Is that a faithful report of what you said to Sean
8 Cusack was your position?
9 A. I do not think so, because the authorisation is made at
10 the time of the filming, so that -- well, you go into
11 a filming saying, "Well, yes, you can produce what you
12 want, show it to me."
13 Having said that, I also remember that there was
14 a meeting at Heathrow Airport between some Channel 4
15 legal advisers and myself, dealing with the issue of
16 whether the programme was going to go ahead or not.
17 So at either point, there were other factors that
18 were actually going to come to bear on whether this
19 programme was screened or not.
20 Q. Let me be blunt about this, Dr Bolsin: the suggestion
21 which Sean Cusack is making there in that internal
22 memorandum in the BMA is that you were saying to the
23 Trust, "Pay me some money and I will keep quiet; I will
24 not go public. If you do not pay me enough, I will."
25 Is that the position?
0048
1 A. No, I do not think that was the position that I was
2 taking with Hugh Ross and Ian Stone, who were the two
3 people that I was negotiating with. What I was saying
4 was, "I think I deserve to be compensated, and I think
5 you should be having a look at this". They were
6 saying, "Well, okay, we will have a look at it."
7 The interesting thing is that if we go back to the
8 mention of the item at the Trust Board, we see no
9 mention of what Sean Cusack is saying in the last
10 sentence, that the Trust Board have yet to decide their
11 reaction, "but the Chief Executive takes the view ..."
12 They do have mention of a specific item, which is
13 constructive dismissal, but there is no mention of any
14 of the other items that Sean has mentioned here with
15 respect to publicity.
16 Q. There is in fact no secret: the Trust did in fact make
17 you an ex gratia payment.
18 A. No, the Trust has never made me an ex gratia payment,
19 no.
20 Q. I am sorry, I thought they had done, I beg your pardon.
21 A. Where did you get that information from?
22 Q. Forgive me. The suggestion here, you see, that Sean
23 Cusack is making, is that you were putting a gun to the
24 head of the Trust and saying, "Pay up or I will go
25 public". Are you saying that is not anything like the
0049
1 position?
2 A. If I can expand on that, actually what Sean is saying
3 here is that I was holding two guns to the Trust's
4 head. He is saying I was holding the gun of
5 constructive dismissal to the Trust's head and that was
6 raised at a Board meeting. He is then also saying that
7 I was holding this other gun of publicity, or whatever
8 else it might be, and that was also going on at the same
9 time. That was not mentioned at the Trust Board meeting
10 and I think if I had been doing that, I would have
11 expected that to have been raised at a Trust Board
12 meeting, because, as far as Sean is concerned, and one
13 must assume he is reasonably well informed here, the
14 Trust Board was supposed to be deciding on it.
15 So if I was supposed to have been holding all
16 these guns, then, I mean, that is not the way I saw the
17 request that I was making. The request that I was
18 making was a perfectly human request for compensation
19 for disruption to career and family life.
20 Q. I am going the leave it now, we have been through this
21 quite enough, but can I just have a look at GMC 4/112?
22 A. Can I just follow up my question to you? Where did you
23 get the information I was made an ex gratia payment,
24 because I find that an absolute fabulous remark.
25 Q. Will you look at the middle paragraph here? It is
0050
1 a letter to you. Let us look at the date. 31st January
2 1996, from Hugh Ross. The middle paragraph:
3 "We then turned to your departure. I confirmed
4 [this is Hugh Ross] that I had taken advice and that it
5 would be in order for the Trust to make an ex gratia
6 payment to you if it felt that to be appropriate.
7 I will consider the matter further together with
8 a letter from the Trust regarding your role nearer the
9 time of your departure ..."
10 A. The letter came, but certainly the ex gratia payment was
11 never mentioned.
12 Q. Well, it is mentioned in the letter.
13 A. I am sorry, it is.
14 Q. I think what you are saying is that insufficient regard
15 may have been had by me, or by anyone reading the
16 letter, to the words which follow: "ex gratia payment to
17 you if it felt that to be appropriate"?
18 A. Yes.
19 Q. In other words, it has the legal power to do so; it is
20 therefore a matter simply of choice whether it does so?
21 A. Yes.
22 Q. And you say it did not choose to do so?
23 A. It chose not to, certainly.
24 Q. So one would be misled by reading this letter as saying
25 they were actually going to make you an ex gratia
0051
1 payment, because they did not?
2 A. Absolutely, yes.
3 Q. The other interesting part of this letter, which you may
4 want to comment on, is that it appears that there was
5 discussion about publicity?
6 A. Yes, I think the interesting thing there is that that is
7 not raised in the paragraph about ex gratia payments.
8 There is a very clear distinction in this letter between
9 publicity in TV programmes and any ex gratia payments.
10 To me, that was certainly the way the meetings were
11 discussed. We did talk about publicity because there
12 was an enormous amount of publicity at this stage, and
13 that was certainly a paragraph in the letter, but it was
14 in no way linked to ex gratia payments. That was
15 certainly never made.
16 I think this letter confirms that, and that Sean
17 Cusack may, at a distance, have been perhaps putting 2
18 and 2 together and making 5.
19 Q. Reporting your conversations with him inaccurately, is
20 what you would say?
21 A. Yes, okay.
22 Q. It would have to be that, would it not?
23 A. Yes. I think he was putting 2 and 2 together and making
24 5, but you are the barrister, so ...
25 Q. You are giving evidence; it is not for me to give the
0052
1 evidence. I only ask the questions.
2 A. Yes, I think he was letting things run away -- his
3 imagination was running away with him.
4 MR LANGSTAFF: It is probably about time I stopped asking
5 questions at least for a short while and we have our
6 first break.
7 THE CHAIRMAN: We will take a break now for 15 minutes until
8 just after a quarter past 12.
9 (12 noon)
10 (A short break)
11 (12.20 pm)
12 MR LANGSTAFF: Can I turn to a completely different but
13 still introductory topic before we get on to the
14 chronology, and go through some of the episodes you tell
15 us about in greater detail?
16 A. Yes.
17 Q. Can I explore some of the issues that surround figures
18 and their interpretation by again taking if I may
19 a stark example. Can we have a look at UBHT 126/51.
20 Your thesis throughout, after you began to collect
21 data and you began to analyse it, was that the data
22 showed by comparison of one surgeon with another that
23 the results were so different, and so different from
24 what one might have expected elsewhere in the United
25 Kingdom, that those surgeons ought not to have been
0053
1 doing those operations, again I put it crudely; is that
2 broadly right or not?
3 A. No, I think it is important to emphasise that the data
4 I had raised concerns in my mind that we should actually
5 undertake a full review and then decide what we should
6 and should not be doing. So I was not saying that "This
7 person should not do this". What I was saying was "The
8 evidence is we are not doing this very well and the only
9 evidence is the evidence I am producing. What we need
10 to do is get green evidence from the unit, authoritative
11 evidence and on that basis we make decisions".
12 Could I say that is corroborated in the switch
13 letter where we talk about "an open and thorough review"
14 before we do any more switches.
15 Q. Can I scroll down the page. Do you recognise this
16 document?
17 A. Yes.
18 Q. We are told it was produced by Dr Pryn and it was
19 circulated at the time of the meeting before the
20 operation on Joshua Loveday. Can we come down. He sets
21 out under the "Mortality" heading, looking at initials
22 there, those must be the initials in respect of
23 anaesthetists, are they?
24 A. Yes.
25 Q. If one were to look at the figures -- shall we look at
0054
1 the "SB" line; that is you, is it not?
2 A. Yes.
3 Q. If we highlight that across the page: is it in fact the
4 case that in 100 per cent of the neonatal switch
5 operations which you did there was a mortality?
6 A. Yes.
7 Q. That in 80 per cent of the non-neonatal arterial switch
8 operations there was mortality?
9 A. Yes.
10 Q. If one were to do any form of comparison of the crude
11 figures, 83 per cent in respect of your mortality as
12 compared to 50 per cent for Dr Monk, 43 per cent for
13 Sue Underwood, 35 per cent for Sally Masey, one would
14 conclude that you were twice as unsuccessful as
15 Sally Masey or Sue Underwood on the basis of those
16 figures?
17 A. Yes.
18 Q. I suspect one might argue that all other things were
19 equal, cardiologists and surgeons. That I expect you
20 would agree with me would be a totally misleading way of
21 looking at figures such as this, would it?
22 A. I think what these figures demonstrate is that you have
23 to now go and try and find out what it is about SB that
24 is appearing to be a risk factor for adverse outcome.
25 I think that that kind of data for me means you then
0055
1 have to go and look at the results in context and say
2 "What was happening here?" In fact I believe the
3 reason I had a high mortality in the non-neonatal
4 switches was because I did the early ones because at one
5 point only Sally Masey and I were undertaking
6 anaesthesia for the non-neonatal arterial switch and
7 that may be an explanation for it, it may not, we may
8 have to look for other explanations, but I think the
9 important thing is that you have embarked upon the
10 process of examination of the results and that is the
11 crucial point about this kind of data.
12 Q. If one were looking at that kind of data alone and
13 Dr Masey and Dr Underwood, they have both obviously done
14 a much greater number of operations than you did?
15 A. Correct.
16 Q. You doing six in total. You say there may be reasons
17 why the mortality is higher in your case than those.
18 One would not get those reasons from the figures
19 themselves, would one?
20 A. Not necessarily, no.
21 Q. So the figures would need to be interpreted?
22 A. Yes.
23 Q. If one were looking at this as an exercise in statistics
24 one would have, would one, to put confidence intervals
25 around the 83 per cent shown for you in order to compare
0056
1 it with others?
2 A. I think if you were looking at this as an exercise in
3 statistics, yes, you would want to be doing those kinds
4 of complex things, looking at confidence intervals and
5 deciding how certain you could be about the nature of
6 differences between those figures.
7 If you were looking at this as an exercise in
8 trying to find out if concerns were justified or whether
9 there was any need to have concerns in the first place,
10 then this is a perfectly good starting point and with
11 this you can then go into an open and thorough review
12 and you can then produce the more detailed data you are
13 talking about with confidence intervals.
14 This is really the starting point, this is the
15 jumping-off point for a review of a programme. This is
16 what we had been requesting, certainly I had been
17 requesting for probably five or six years in Bristol.
18 Q. Again jumping ahead and asking a general question to see
19 if there is a general point here, in the data which you
20 and Dr Black collected, was there any confidence
21 interval around the figures in the crude data?
22 A. If you produce confidence intervals then you are making
23 a comparison and you have to say "This is representative
24 of a population and this is a sample from that
25 population". We did not want to do that. What we were
0057
1 saying was "Here is a rate, here is another rate,
2 chi-squared does not give you confidence intervals,
3 chi-squared just gives you a statistical likelihood of
4 one group being different from another and we said that
5 was what we would do and that is how we undertook our
6 analysis, it was not detailed statistically enormous.
7 Andy Black was a statistician, it was one of his
8 interests apart from anaesthesia and he said "There is
9 an indication here that there is a probable reason for
10 us to be concerned about this data". What we said was
11 "With this data we must go and get the review".
12 Q. Is the answer "No, but there is a good reason why we did
13 not have confidence intervals"?
14 A. There is a good reason, there was a good statistical
15 reason --
16 Q. But the essential answer is "no"; there was no
17 demonstration on the figures that you produced of, as it
18 were, the limits to which results might be due to
19 chance?
20 A. Yes; sorry, do I mean "Yes" or "No"?
21 Q. If you are agreeing with me I think we can express it
22 that way; do you agree with the question that I put?
23 A. I agree with you that we had not put confidence limits
24 in, no, we thought they would be misleading.
25 Q. Again if one looks at the crude data -- you appreciate
0058
1 I have highlighted this line simply because it makes the
2 point fairly starkly -- results which may appear on the
3 face of it in a small number to be starkly different may
4 have an explanation such as the one you were giving from
5 your own knowledge: "these are early operations
6 therefore the results will look worse", something along
7 those lines?
8 A. Yes.
9 Q. In order to get such an interpretation or information
10 which adds to the investigation one has to ask the
11 people who have intimate knowledge of the facts and the
12 details that matter, does one?
13 A. One does not necessarily have to. One has to involve
14 them in the process whether that is directly or
15 indirectly, the answer is "Yes" they have to be
16 involved.
17 Q. You appreciate these are as it were general issues which
18 I am touching on rather than exploring deeply at this
19 stage.
20 A. Yes.
21 Q. The Royal College of Surgeons of England produced, did
22 it, guidelines in respect of audit in 1989 in March
23 which would have been extant at the time or shortly
24 after the time you took up your appointment in Bristol.
25 Shall we have a look at WIT 48/118? You have seen these
0059
1 passages before when you were asked questions about this
2 at the GMC.
3 Do you agree with what the Royal College of
4 Surgeons of England and Wales said under 3 there in
5 respect of audit meetings as at 1989 and thereafter
6 until the guidelines were updated, that audit meetings
7 should "be absolutely confidential to the audit group".
8 Do you agree with that?
9 A. Yes.
10 Q. 2: "Be full, frank and truthful discussions of clinical
11 and administrative problems"; do you agree with that?
12 A. Yes.
13 Q. "Be educational and constructive"; do you agree with
14 that?
15 A. Yes.
16 Q. "Result in agreement to act or recommend action to
17 improve clinical results"?
18 A. Yes.
19 Q. "Never be a witch hunt"?
20 A. Yes. Can you define for me what an audit meeting is?
21 Q. You answer the questions and if you have a point to make
22 about that by all means we will make sure you have
23 the chance to make it.
24 Can we scroll down to 4, "Confidentiality". What
25 it says under that heading is:
0060
1 "Open discussion cannot take place unless its
2 confidentiality to the group is absolute. If this basic
3 principle is not respected, mutual trust will be lost
4 and the consequences may be disastrous"; do you agree
5 with that?
6 A. Yes.
7 Q. "The importance of anonymity cannot be over-emphasised.
8 It should be remembered that any patient or relative (or
9 their legal representative) is entitled to demand access
10 to the relevant clinical (but not audit) records;
11 Hospital Management will have access to the general
12 conclusions of clinical audit meetings. However,
13 neither consideration should stand in the way of the
14 clinical audit programme."
15 Again, do you agree with that?
16 A. Presumably the "anonymity" there is the anonymity of the
17 patient record as opposed to the anonymity of the
18 proceduralist involved.
19 Q. It is opaque. I think it appears -- it is not for me to
20 interpret, you have to leave it as it stands.
21 The point you are making is that it can be read in
22 more than one way. You read it in the way of patient
23 anonymity?
24 A. Yes.
25 Q. When the articles were published in Private Eye in 1992,
0061
1 that I imagine, we have been told, became something of
2 a topic of conversation in the Trust?
3 You are nodding and I have to say that to make
4 sure it gets down as a "Yes" in the transcript.
5 A. Yes.
6 Q. What in your view was the effect of the publications in
7 Private Eye in 1992 upon any audit process that was then
8 going on in cardiac surgery?
9 A. I do not remember any specific effect. The audit
10 meetings that were being carried out then were occurring
11 on a Friday lunchtime as I remember which coincided with
12 one of my clinical commitments and so I was not able to
13 get to many if not any of those meetings.
14 Q. What about paediatric cardiology, any audit process that
15 was going on in paediatric cardiology?
16 A. I was not attending meetings or audit meetings in
17 paediatric cardiology, not on a regular basis.
18 Q. Not on a regular basis?
19 A. You are going to have to help me here.
20 Q. Tell me how I can help you and I will do my best.
21 A. I attended one meeting on a Monday morning which was
22 probably 1989 or 1990 but I do not remember attending
23 very many other of those morning meetings, I do not
24 remember attending any of the lunchtime meetings which
25 I think were the ones that had specific cases
0062
1 discussed. I did attend some of the evening meetings
2 which were in people's homes and were no agenda
3 unminuted. I am not sure, bringing those in, whether
4 they actually conformed to the "audit meetings should"
5 section of what is on our screens at the moment.
6 Q. Again, just so we know we are talking about the same
7 thing, or meaning the same thing by question and answer:
8 what do you understand by "audit meetings"?
9 A. I think the audit meetings we were having in the
10 Department of Anaesthesia were an agenda'd, minuted
11 audit meetings at which actions were agreed and then
12 reviews of the processes after the actions had been
13 taken were then undertaken. So it was a continuous
14 looping through of the audit process and we all knew
15 what was going to be audited in advance. We all knew
16 that we would then be looking at what results the audit
17 had produced and we all then agreed we would undertake
18 a review of the process.
19 Q. Does that mean that, critical to the way that you look
20 at what an audit meeting is, is the presence of minutes?
21 A. Yes, I think an agenda and minutes and confirmation to
22 the structure that you have shown me here which was
23 derived by the Royal College of Surgeons, that kind of
24 process is crucial.
25 Q. The reason I ask you is: it might be said it is just the
0063
1 same for 4, 5, 6 clinicians, 10 clinicians perhaps, who
2 know each other well or work together who get together
3 to discuss, in what is recognised as something of
4 a formal meeting, a particular problem, come to
5 a conclusion and the conclusion is let us say "There is
6 a problem" or "We can do this better, let us try this"
7 and so they then come back, 2, 3 months later and say
8 "We have tried it and it seems to work".
9 That is something which could be done without
10 minutes but it represents exactly the audit loop you are
11 discussing, does it not?
12 A. I think in practise it is working in those terms,
13 I think that whether you have the evidence then that you
14 have actually achieved the audit loop is the crucially
15 important point. Have results improved and if they
16 have, are you collecting them?
17 Q. The important thing for patients' safety is that the
18 process should be gone through, is it not, rather than
19 that the process should be minuted? I appreciate
20 minuting is evidence it has been gone through, but leave
21 aside questions of evidence, the important thing for
22 patients' safety is the process, is it not?
23 A. I think it is very difficult to undertake audit on the
24 process of memory, I think you have to have some written
25 documentation.
0064
1 Q. When you were asked in the GMC about the --
2 A. Can I just say that that is supported by item 5 on our
3 screens which says "a record of audit meetings should be
4 kept and should include", so the meetings you are
5 suggesting of colleagues not keeping minutes --
6 Q. I am not suggesting, I am asking how the one corresponds
7 to the other, that is all.
8 A. My answer would be: according to the Royal College of
9 Surgeons if you are not keeping records as in item 5
10 here, then I am not sure you are entitled to call it an
11 audit meeting.
12 Q. I think there are probably two views on that. Looking
13 at it, it talks about "a record of audit meetings" which
14 might be taken to presuppose that a record is not an
15 intrinsic part of the definition, you have an audit
16 meeting and you then have a choice as to whether you
17 record it or not, the guidance says (quite rightly) you
18 should. That does not mean to say it is not an audit
19 meeting if you do not record it; do you follow the other
20 argument?
21 A. Yes.
22 Q. Let us not get into semantics.
23 A. Let us not.
24 Q. When you were asked about Private Eye and you were
25 associated yourself in 1995 with Private Eye as being
0065
1 the person who had provided information or had
2 information reported in the 1992 editions, you said
3 this:
4 "To have your name associated with (A) audit and
5 (B) cardiac surgery in a satirical magazine in the way
6 it was, was not helpful and very damaging to your
7 position as the national audit coordinator of the
8 association of cardiothoracic anaesthetists."
9 The question was then put to you:
10 "It gives both you and audit a bad name. It
11 makes one more reluctant to go about the process if one
12 thinks one's figures are going to be published in
13 a satirical magazine as you observe" and you replied
14 "Absolutely".
15 Did you mean that?
16 A. Yes.
17 Q. You were then pressed a little on the possible effect of
18 Private Eye upon audit meetings. Can we have a look at
19 GMC transcript 6/86. We are going to pick it up at
20 GMCT 6/85. This is the question:
21 "You recognised that an article such as this,
22 [that was the 1992 one] would undoubtedly cause
23 clinicians considerable disquiet?
24 Answer: Absolutely, yes."
25 Go over the page:
0066
1 "The one thing they do not promote is overaudit of
2 one's figures?
3 Answer: Exactly, yes."
4 Then the next question and answer:
5 "Question: Do you think in any way that articles
6 such as these explain a perceived unwillingness to
7 divulge figures to you?
8 Answer: I think from after May 1992 they may
9 explain or they may be part of an explanation of
10 people's unwillingness, but it does not explain an
11 unwillingness to produce results prior to that."
12 When I asked you a moment ago about the effect of
13 Private Eye on audit meetings, I think you did not make
14 any particular comment. It seems I think at the GMC you
15 thought or you were persuaded or you agreed with the
16 question at any rate that it made people in the
17 department more unwilling to produce results. Thinking
18 about it, is that right or is that wrong?
19 A. No, I think it is right. In fact I have confirmation of
20 that recently from Mr Dhasmana's statement where he said
21 that he thought I had possibly unintentionally been the
22 conduit for information getting to Private Eye and he
23 had actually addressed that issue with me at the time,
24 he asked me and I had said "No, I was not involved".
25 Q. Two questions merely arise from this. One is: we have
0067
1 seen that the Royal College guidelines on audit which
2 stress confidentiality and obviously if figures which
3 were talked about in an audit meeting hit the press,
4 there would be a breach of that guideline on the face of
5 it. You are agreeing?
6 A. Yes.
7 Q. That would explain, at least in part, the unwillingness
8 of those who might otherwise have contributed to the
9 meetings or minuted the meetings to go on contributing
10 or minuting in the way they had done before?
11 A. Yes.
12 Q. You appear to be saying to the GMC at this stage that
13 that looks as though that is probably part of what
14 happened at Bristol following the 1992 articles from
15 Private Eye?
16 A. Yes.
17 Q. That is an attitude which, as I read what you were
18 saying to the GMC you had some sympathy with from your
19 own comments about not wanting to have your name
20 associated with a satirical magazine and so on?
21 A. Yes.
22 Q. Can you tell me why it should be in your view correct or
23 understandable, reasonable for individuals when their
24 results are put in the press to their disadvantage to
25 say to themselves "Now that this has been bandied around
0068
1 in public I am not going to deal with audit any more,
2 I am going to clam up on results, not minute them, not
3 discuss them", when one might have thought the
4 alternative response would be to say "Because they are
5 saying this about me in the press and getting it wrong
6 or it might be misleading, all the more reason to
7 collect results, publish them and promulgate them and so
8 on"; do you follow the point?
9 A. Yes, I think I do, yes.
10 Q. The former is the attitude which you understand and
11 I think impliedly endorse by your own approach to
12 publicity in Private Eye?
13 A. Yes.
14 Q. Why should not the latter be a more appropriate
15 reaction: "These are results, they have got out in the
16 public domain, let us sort it out by being even more
17 open, frank, thorough, et cetera"?
18 A. I suppose at that point you have two routes you can go
19 down. You can go down one route which says: "We will
20 not ever allow this to happen again" and you can go down
21 the other route which says: "Actually we do not have
22 a problem with this and we are now going to make sure
23 that this information is never available for people to
24 produce because we are going to put it in the public
25 domain straightaway".
0069
1 Q. Or "We do have a problem with this but we are going to
2 put it in the public domain"; what about that?
3 A. I think that is a theoretical option but I do not think
4 it was one I would have associated with the attitudes in
5 the BRI at that time.
6 Q. And your own attitude?
7 A. My own attitude was that we wanted to conduct an
8 anonymous national audit of adult cardiac surgical
9 procedures in the UK and in order to get that concept
10 across we had to guarantee the anonymity of the data we
11 were collecting. That was for the profession to
12 participate and the profession had to participate.
13 Q. From a personal point of view, appreciating we are
14 looking back here to 1992, you were solidly, were you,
15 taking the first approach: saying "Any breach of
16 confidentiality is something which is only going to set
17 the audit process back understandably" and the
18 alternative of responding to it by being more open
19 really in 1992 is not realistic or sensible for that
20 time?
21 A. No, I think the alternative view of saying "We will now
22 deal with this by being extremely open" would have been
23 visionary at that time.
24 Q. From what you are saying (very frankly), it is not
25 a vision which you personally had at that time, whatever
0070
1 your views may now be?
2 A. No, I think at that point because I wanted to set up the
3 national system and I had had discussions with 35
4 contributors from adult cardiac centres in the UK, one
5 of the things they were all committed to was the
6 confidentiality of the process.
7 Q. This is the last rather general question on the audit
8 process. When you gave your oration in Melbourne, the
9 one we have already looked at, "The Whistle Blower in
10 Medicine", you were asked, so the transcript tells me,
11 this question. I will read it to you; again I am sorry
12 I cannot show it to you on the screen. If you want me
13 to go over it again I will do:
14 "I am Margaret Tangen. I am a physician. Even
15 with your data you faced an entrenched power base. What
16 advice would you give to someone in your situation who
17 is confronting this for the first time?"
18 Your answer as recorded is this:
19 "I think you have to do all the things that you
20 would expect to do. You should confirm that the data is
21 correct. You should then discuss it with the colleagues
22 in your speciality area. I think you should then take
23 it to the director of your department or if necessary
24 the academic leaders of the department and I think you
25 then take it across with their backing to the second
0071
1 professional group. I think what you would normally
2 find is that that group was actually aware of the
3 problem and only needed to be nudged in order to take
4 some action, but if they did not then I think that
5 group, you should be able to expect that group to deal
6 with it."
7 That is the answer you are recorded as giving and
8 my first question is: does it sound right to you? By
9 all means if you need to have a look and study this
10 later on then you will be able to do so. Can I go
11 through the elements of your reply with you?
12 You appreciate the question is: what does someone
13 do in this situation, what advice do you give having
14 been there? You say -- these are my words "The proper
15 way of dealing with it is ..."
16 First, you should confirm that the data is
17 correct?
18 A. Yes.
19 Q. Is that right?
20 A. Yes.
21 Q. Secondly, you should then discuss it with the colleagues
22 in your speciality area; is that step number 2?
23 A. Yes, could I take you back to the question because I am
24 not sure how concrete the concerns were in the question.
25 Q. If we look at WIT 80/382 we may find we now have it
0072
1 scanned in, we have. I will give you a moment to read
2 it.
3 A. Yes.
4 Q. That is the question. The answer, going through one by
5 one: "you should confirm the data is correct". You
6 agree that. Point number 2: "you should then discuss it
7 with the colleagues in your speciality area"; is that
8 the second step to be taken?
9 A. Yes.
10 Q. Third step: "then take it to the director at your
11 department or if necessary the academic leaders in the
12 department"?
13 A. Yes.
14 Q. "Fourthly, that you would then take it across with their
15 backing to the second professional group"?
16 A. Yes.
17 Q. The comment "I think what you would normally find is
18 that that group was actually aware of the problem and
19 needed to be nudged in order to take some action."
20 Pausing there, that is presumably because they share the
21 same professional interest in the welfare of the
22 patient?
23 A. Yes.
24 Q. Turn over. "But if they did not then I think you should
25 be able to expect that group to deal with it."
0073
1 A. Yes.
2 Q. Can we call that, because we may need to make reference
3 to it later, the "blueprint for action"?
4 A. Yes, certainly. Should we give it a number just in case
5 there are other blueprints for action?
6 Q. Let us call it that for the moment. If we get into
7 trouble with blueprints or redprints, whatever, we will
8 come back to it.
9 The very last general point before I take you
10 through some of the chronology to which you deferred us.
11 Do you regard the outcome of paediatric cardiac
12 surgery as essentially dependent upon a team process?
13 A. Yes, I think the process is certainly one of teamwork.
14 Q. May it be misleading, do you think, to focus upon the
15 surgeons' skills or expertise alone?
16 A. I think it is one of the things that you would have to
17 examine if you were concerned about the outcomes of
18 a paediatric cardiac surgery programme.
19 Q. You are not quite answering my question: would it be
20 wrong to regard the outcome as dependent upon surgical
21 skill alone?
22 A. No, it is certainly not "alone", though, emphasising
23 that word, then the answer is "No".
24 THE CHAIRMAN: I think the answer would be "Yes" actually,
25 it would be wrong. I do not want to put words into your
0074
1 mouth, but just for clarification.
2 MR LANGSTAFF: I think that is what you meant to say, is it
3 not?
4 A. I agree with the concept it is not --
5 THE CHAIRMAN: Please start again and say exactly what you
6 wish.
7 MR LANGSTAFF: Put it in your own words for us.
8 A. The skill of the surgeon, was that one of the phrases
9 you used?
10 Q. Yes.
11 A. The skill of the surgeon is not the sole determinant of
12 the outcome of the paediatric cardiac surgical
13 programme.
14 Q. Where one has a split site as there was at Bristol is
15 that likely do you think to make a difference in terms
16 of outcomes?
17 A. It is difficult to say. I think the clinicians involved
18 in the service had a dual responsibility for two sites
19 and that sometimes meant they could not be accessible
20 for decisions on one site because they were operating or
21 had clinical commitments at the other site and I think
22 that did detract from time to time from the service we
23 were able to offer the patients in the BRI.
24 Q. Was it something which you particularly with your
25 responsibilities for intensive care may have noticed, do
0075
1 you think a drawback that the intensive care ward as one
2 shared as between adults and children?
3 A. Yes, I think there were drawbacks, but whether they
4 impacted on outcomes, I think it is difficult to make
5 the comment that they -- there may have been points at
6 which you said "this outcome has been produced by this
7 shared accommodation".
8 Q. If one were to take a general view: is it or is it not
9 desirable, in the interest of outcomes, for paediatric
10 patients to be nursed in intensive care with other
11 children only or in a mixed adult paediatric intensive
12 unit, what would your answer be?
13 A. I do not want to avoid answering the question, but
14 I just think that using the word "outcomes" there is too
15 broad a phrase. If the outcome you were looking at
16 could be the satisfaction of the parents of the children
17 in the mixed ward then I suspect the outcome would be
18 unfavourable because they would prefer to have their
19 child nursed with other children. If the outcome is
20 mortality or serious morbidity there, I suspect, is less
21 evidence to suggest that children looked after in
22 a mixed ward have worse outcomes but I do not know of
23 any data to confirm that.
24 Q. You know of no data but your hunch is, what?
25 A. I suspect the specialised units produce better results
0076
1 in most countries in the world, so that a specialised
2 unit would be expected to have better outcomes.
3 Q. Again you may not know the data in respect of this, if
4 you compare a unit with a large throughput in terms of
5 numbers of patients having broadly the same type of
6 operation, albeit that every operation is inevitably
7 different just as every patient is different, with
8 a smaller unit, with a small throughput, say under 50
9 surgical open heart cases per year on children, what
10 would you expect, generally speaking, to find as
11 a difference in outcomes between the two units, if
12 anything?
13 A. I would expect the smaller unit to have the worse
14 outcomes. I think that data was confirmed by Yadistak
15 in the early 1990s. Can I expand on that for
16 edification rather than the answer?
17 Hannan and Kilbin in New York State demonstrated
18 that there was a specific number of coronary artery
19 bypass graft operations that a surgeon needs to do in
20 a year in order to have a statistically significantly
21 lower mortality than other surgeons. That number is
22 115. One of the notions that I had developed during
23 this time was that for every procedure that a cardiac
24 surgeon undertakes, there is a minimum number that he
25 has to do to achieve the optimum mortality. So it could
0077
1 be mitral valves, it could be aortic valves, it could be
2 aortic root replacements, it could be coronary artery
3 surgery. If you add on top of that all of the gamut of
4 paediatric cardiac surgery, then it is very easy to see
5 you can actually define a job description in which you
6 are dictating mediocrity. You will never have
7 excellence from that surgeon because he will never be
8 able to do the number of operations to achieve the
9 lowest mortality.
10 Q. I thank you for the phrase "dictating mediocrity".
11 Turning to the question of organisation of the
12 intensive care unit, again a general point: are you one
13 of those who in the 1990s (perhaps still is) in favour
14 of intensive care units being managed by an intensivist?
15 A. Certainly it is not a model that in the UK we have moved
16 to with any rapidity, but in 1986/1987 I was working as
17 a locum consultant Senior Registrar on an Intensive Care
18 Unit managed by intensivists and I am sure they provided
19 a better service than anaesthetists.
20 Q. By providing a better service, again you may know of no
21 evidence for this, would you expect the outcomes for
22 children as between a unit which had no intensivist and
23 one which did have an intensivist to be better in the
24 latter?
25 A. Yes.
0078
1 Q. I am going to come to the history, the chronology and
2 try and identify with you what dates we can put to which
3 events and what happened and the various challenges that
4 there are from the various different participants to
5 some of those events, as you will appreciate.
6 Before we embark on that, I think there was
7 something which you wished to say generally before we
8 deal with the history and the events at Bristol, bearing
9 in mind they may be distressing to many to listen to.
10 A. Yes, thank you for that opportunity.
11 I wanted to say that we will be talking about
12 mortality rates and we will be talking about numbers of
13 deaths and excess deaths. I wanted to say that
14 I sympathised enormously with the parents who have been
15 through the situation of children undergoing open heart
16 surgery and complex paediatric cardiac surgery and also
17 with those parents of children who did not survive and
18 I wanted to let them know that for me they were all
19 individual children who had families, I am very sorry
20 for what happened to them.
21 Q. Would you like to take a break?
22 A. No, I am okay.
23 Q. If you want a break at any time, Dr Bolsin, please just
24 ask. What you tell us about in your statement is your
25 arrival in Bristol, never having held a consultant post
0079
1 before, but having had experience at the Brompton,
2 amongst other things, of the surgery performed by
3 Mr Christopher Lincoln.
4 A. Yes.
5 Q. How many open heart operations do you think you had
6 actually watched in training up to that stage?
7 A. Paediatric or adult or both?
8 Q. Paediatric.
9 A. Paediatric, it would have been scores I would have said,
10 it was a very busy unit and the trainees were encouraged
11 to go and watch the interesting cases and we would have
12 seen -- I mean Mr Lincoln used to operate on five or six
13 paediatric cases a day and we would have been exposed to
14 them and we were there full-time five days a week.
15 Q. Can we have a look at UBHT 61/11. At the end of your
16 first year did you produce an annual report on your
17 work?
18 A. Yes.
19 Q. It is described as the first, was there ever a second?
20 A. No.
21 Q. Why was that?
22 A. I did not have time actually. After this I became the
23 ACTA, the National Audit Coordinator for ACTA and I just
24 never had time to collate the data again, it is probably
25 a bit like the blueprints.
0080
1 Q. Here you are saying that the purpose of the report is to
2 critically review your first year in post and you
3 describe there the background, your coming to Bristol.
4 Can we scroll down to the bottom? It appears you did
5 about a third roughly of paediatric cases and two-thirds
6 therefore adult?
7 A. Yes.
8 Q. You say your "confidence in this subgroup [the
9 paediatrics] has grown considerably during the year, but
10 I had much to learn especially in ICU management".
11 That is partly why I asked you about the number of
12 cases you had seen with Mr Christopher Lincoln. You
13 were feeling your way a bit, were you, at this stage?
14 A. I was feeling my way in a new unit, I think. Bristol
15 did things slightly differently to the Brompton and
16 I was learning those aspects of the care and the
17 management. I think the reason ICU management is
18 highlighted here is because of the protracted stay of
19 the patients in intensive care. This was something
20 I was not used to at the Brompton so I had to pick up
21 this particular aspect in some detail.
22 Q. Can we go over the page to page 12 and scroll down. The
23 first line on the screen:
24 "The adult mortality is acceptable but should be
25 addressed ..."
0081
1 What were you saying there?
2 A. I think I had documented the mortality in my practice
3 and I wanted it to be kept under review and if possible
4 reduced. I think I was saying I was not happy
5 necessarily with the mortality as it stood, we possibly
6 could do better.
7 Q. You are saying "here is something where we could do
8 better, we need to do better and we need to take some
9 steps to deal with it", and you are suggesting the audit
10 review?
11 A. Yes.
12 Q. Indeed you go on to say:
13 "For both paediatric and adult work we must have
14 mandatory convenient morbidity and mortality meetings"
15 and you look forward to the speedy production of those
16 meetings.
17 Go back to the page before, the foot of the page:
18 "Peri-operative mortality in this group is higher
19 than the adults but this is to be expected. My clinical
20 priority in this area is to improve the peri-operative
21 management of children and I feel I should pay more
22 attention to details of heat losses in theatre, acidosis
23 and inotrope requirement in small children to improve my
24 clinical service."
25 What you were saying by way of contrast with the
0082
1 adult position is: "the paediatric mortality is high but
2 that is only to be expected". In other words you were
3 not saying so far as paediatrics were concerned that
4 there was an issue there that needed to be addressed?
5 A. Not at this point, no.
6 Q. This document -- let us put a date on it shall we --
7 61/10, 18th September 1989, "Copy of the First Annual
8 Review".
9 We may take it, may we, that by September 1989 you
10 felt the department needed to address the adult
11 position, but that the paediatric position nothing
12 needed to be addressed as such; that was not your
13 feeling at the time? You decide what you now know, but
14 that was not your feeling at the time, that is what I am
15 asking you.
16 A. I think at the time of producing the report there are
17 some things that I have identified that we could use to
18 improve the service. So there was the question of
19 continuous improvement of the paediatric services, the
20 one you are asking me about. Yes, I felt we could
21 improve and that we needed to be able to do that or to
22 have a mechanism for doing that.
23 Q. Was there ever any conscientious doctor who did not wish
24 to improve his service to his patients?
25 A. Is that a rhetorical question?
0083
1 Q. It is a question.
2 A. No, I think most doctors would want to improve the
3 service to their patients.
4 Q. If one went to the best unit in the country for
5 a particular operation or a particular service, one
6 would expect to find them trying to improve it, would
7 one?
8 A. Absolutely.
9 Q. There is a difference, nonetheless, is what I am
10 suggesting to you between needing to address something
11 which suggests the standards have slipped below what may
12 be acceptable, or are going that way and: "these are the
13 results only to be expected but nonetheless there are
14 improvements we can make"; do you follow the
15 distinction?
16 A. Yes, I do. I think the vehicle that was being suggested
17 again within a year was that we should be reviewing
18 mortality and morbidity and that this would identify any
19 problems if they existed and we would then be able to
20 deal with them.
21 Q. Let me put this question a different way: did you get
22 any hostile feedback from Mr Wisheart in response to
23 that report?
24 A. No.
25 Q. Even though it might be read as saying: "we are really
0084
1 doing worse than we ought to be doing in adult surgery,
2 we have a problem we need to address"?
3 A. I did not get any hostile feedback even though it may be
4 interpreted to be suggesting that there was a problem
5 with adult cardiac surgery.
6 Q. 61/107, 18th December 1989, so it is a matter of three
7 months since your report. We see who the letter is
8 from, from Dr Martin. You will see the addressees, it
9 includes yourself, other anaesthetists, cardiologists
10 and the surgeons. If we go back to the top:
11 "At a recent meeting it was suggested we ought to
12 hold regular clinical audit meetings ..."
13 You had made the suggestion in your report, was it
14 you who made the suggestion at the meeting or somebody
15 else thinking the same way?
16 A. I cannot remember the meeting so I would not be able to
17 comment.
18 Q. What this might suggest, there was a groundswell along
19 the lines you were suggesting, that this is what ought
20 to happen?
21 A. (Witness nodding). It could be I showed leadership.
22 Q. It may well be a response to the suggestion you had
23 made, but one way or the other it appears to be
24 formalised?
25 A. Yes.
0085
1 Q. There was Dr Martin who was suggesting that the purpose
2 of the clinical audit meetings was to, and he sets it
3 out:
4 "Discuss clinical cases, complications,
5 post-operative management, other relevant problems in
6 the unit."
7 He is suggesting a Monday morning meeting, monthly
8 basis. Let us have a look at the middle of the second
9 paragraph:
10 "The kind of problems I think it would be helpful
11 to discuss would be where there has been a difference
12 between investigation and operative findings or cases
13 that have posed particular problems in their
14 post-operative management and a venue to discuss
15 complications. Every three months we would try to
16 present figures detailing the workload at the unit for
17 the preceding period."
18 Did you respond to this letter?
19 A. No, I do not think so.
20 Q. You got it, I take, it as one of the addressees?
21 A. Yes, and in fact I think I did attend a Monday morning
22 meeting. The problem with the timing of this meeting
23 between 8.00 and 9.00 is that on most Mondays I had
24 a cardiac surgery list starting at 8.00. That was at
25 the Bristol Royal Infirmary, not at the Children's
0086
1 Hospital which is where I think these meetings were
2 held.
3 Q. Can we have a look at the addressees? That would have
4 been a problem for others on that list as well, would it
5 not?
6 A. Some others, yes. It seems from the letter that some of
7 them were already holding normal clinical meetings at
8 that time anyway.
9 Q. It would appear there were in addition
10 clinicopathological conferences, but this was not
11 intended in any way to detract from those?
12 A. Yes.
13 Q. At about this time do you remember an article being
14 published by Professor Berry, just focusing on that last
15 paragraph?
16 A. No.
17 Q. Was it discussed at all that he had, together with
18 Dr Russell, published a paper talking about pathology in
19 paediatric cardiac cases, the lessons that might be
20 learnt from the dissection and examination of hearts,
21 amongst them surgical failures?
22 A. No, the first time I saw I think the article you are
23 talking about, which is Professor Berry's article was
24 probably a year or so ago.
25 Q. In any event that is December 1989. March 1990, can we
0087
1 go to UBHT 133/73. Can we scroll down. "The annual
2 report for 1989 to 1990".
3 UBHT 133/85. There is a summary given there of
4 the results for the under 1 year of age open and
5 closed. The figures are plain as matters of
6 percentages, are they not, to read?
7 A. Yes.
8 Q. Did you get this report?
9 A. I am not sure to be quite honest with you, I would have
10 to look at the back page I think if there are more
11 tables. I think I got the subsequent one but I am not
12 sure I necessarily received this one.
13 Q. Let me find that for you then. I think we need to go to
14 further tables if we go overleaf. Table 6, does that
15 ring a bell?
16 A. Yes, it is a classification that I have certainly seen
17 before.
18 Q. That is the last page we have for the document itself.
19 So you remember seeing that at some stage?
20 A. Yes, yes, I think so.
21 Q. There is a comparison made here between open heart
22 surgery over 1 year and under 1 year and the performance
23 in the United Kingdom taking the year 1988 which,
24 presumably, would be the last year for which
25 the cardiothoracic surgical register had results
0088
1 available in 1988?
2 A. Yes.
3 Q. On the face of it, if one looks at the total for under
4 1 year open operations, the percentage of deaths under 1
5 year in Bristol is 32.2 per cent over a five-year period
6 compared to the UK average of 18.8 per cent?
7 A. Yes.
8 Q. Broadly speaking between 1.5 and twice as many
9 fatalities in Bristol fatal outcomes as in the UK
10 average?
11 A. Yes.
12 Q. The UK average of course would include the Bristol
13 figures?
14 A. Yes.
15 Q. So if one were taking or inferring a comparison between
16 the performance of Bristol and the performance of the
17 rest of the United Kingdom, you would (on the basis of
18 those figures) say:
19 "Broadly speaking Bristol's results are over this
20 five-year period half as good or twice as bad --
21 whichever way you wanted to put it -- as the average of
22 the UK"?
23 A. I think it is actually slightly worse than that is it
24 not because for the most recent year, in 1989 when you
25 would have expected them to have been better than the UK
0089
1 average for 1988, they are actually getting worse, they
2 are 37.5 per cent, but I agree with you that is about
3 twice as bad.
4 Q. One can see, if one goes back to table 5, that is
5 37.5 per cent?
6 A. Yes.
7 Q. Back to table 6 again, the 84 to 88 average is 30.1. So
8 the situation appears on the face of statistics, bearing
9 in mind as one would that they are crude statistics, it
10 looks as though it is not getting any better, it is
11 getting worse?
12 A. Yes, I agree with you.
13 Q. Do you think you had these figures in 1990 or not?
14 A. I think I may have done, yes.
15 Q. You wrote a letter to Dr Roylance. Let us have a look
16 at that letter, it is UBHT 61/19. 25th July, that is
17 the first date we have?
18 A. Yes.
19 Q. You will be aware I think that there is a second letter
20 in identical form which is dated 7th August 1990 which
21 we have at UBHT 118/8. The difference I think you will
22 find if we go down to the bottom is in those to whom the
23 letter is copied?
24 A. Yes.
25 Q. Can you help me as to why we should have two copies of
0090
1 the same letter with different dates?
2 A. I think it was the nature of the secretarial assistants
3 at that time that we would get letters produced, we did
4 not get them done on a computer and then just printed up
5 at the last minute. We actually got letters produced
6 and then reviewed them and if necessary altered them and
7 then sent them afterwards.
8 Q. I think if we actually look at the text -- it is
9 unnecessary to have a detailed comparison here in
10 evidence -- but you would accept from me -- please come
11 back to me if you think it is wrong -- that there are
12 some drafting changes and grammatical improvements in
13 the second version we are looking at now compared to the
14 first?
15 A. Yes.
16 Q. Between 25th July and 7th August the letter has been
17 tidied up a bit; is that what happened?
18 A. I think that is probably what happened, yes, yes.
19 Q. What you were responding to here, can we have a look at
20 where the letter starts? You were writing to
21 Dr Roylance saying you had "read with particular
22 interest the appendix to the application for Trust
23 status".
24 A. No, "application for Trust status on cardiac surgery",
25 it is a very specific statement.
0091
1 Q. The application for Trust status had an appendix on
2 cardiac surgery?
3 A. Yes.
4 Q. And it was that appendix that you are looking at?
5 A. Yes.
6 Q. You were picking out, were you, in the first paragraph,
7 the second paragraph, two areas where you felt the
8 application for Trust status might be misleading?
9 A. Yes, I was.
10 Q. Were you personally in favour or hostile to the creation
11 of Trusts?
12 A. I think my attitude was that I was not necessarily sure
13 that they were going to improve patient care and under
14 those circumstances a change would not necessarily be
15 for the better. I think I was reasonably ambivalent to
16 Trust status for the hospital.
17 Q. The points you have made are verging on the negative
18 side or leaning towards the negative; is that the way
19 you were leaning or not?
20 A. Yes, I think I had not been persuaded by any of the
21 meetings that we had had as anaesthetists or doctors
22 that Trust status had advantages for us as clinicians
23 involved in the delivery of patient care.
24 Q. So you thought it was an unnecessary irrelevance?
25 A. Probably, yes, I think that is a reasonable summary.
0092
1 Q. What you are doing here is responding to Dr Roylance, as
2 the Chief Executive, putting forward the application for
3 Trust status, saying: "Look, is this actually right?",
4 querying part of the application made to get the UBHT,
5 as it was going to be, Trust status?
6 A. I think it is more specific than that. What I am
7 actually doing is saying: "You have made some statements
8 in a document which is an appendix to an application for
9 Trust status and deals specifically with cardiac
10 surgery. I am an anaesthetist who has a particular
11 interest in cardiac surgery. I think there are two
12 wrong statements in the appendix and I also want you to
13 know about another problem".
14 Q. Dealing with the first two problems: before you drew to
15 Dr Roylance's attention those two false statements, had
16 you, as an anaesthetist, discussed them with any other
17 anaesthetist?
18 A. Yes, I had discussed them with Dr Thomas.
19 Q. With anyone else with whom you worked regularly?
20 A. It is difficult for me to recall. I mean I would have
21 been looking at the document in the common room with
22 other anaesthetists. I might have said "Gosh, this is
23 terrible, I feel quite strongly, they have never
24 actually done this and I have never had any money for
25 that. This is wrong... What should I do about it?"
0093
1 They would have been just conversations over coffee or
2 sitting in the common room or something like that.
3 I cannot say I did not; I cannot say I have evidence
4 that I did, but I might well have done.
5 Q. You might have done?
6 A. Yes.
7 Q. Did any of them know you were actually going to write,
8 apart from Dr Thomas?
9 A. I do not know. I might have shown the letters. The
10 fact that there were several letters, I would have been
11 drafting letters, possibly drafting them in theatres,
12 correcting them, sending them back to the secretary,
13 they may have been lying around. I cannot say that
14 people did not know, I cannot say that I stuck them in
15 the front of people's noses and said, "What do you think
16 of this?"
17 Q. The last paragraph:
18 "You would have thought that a management director
19 should have attempted to address the unfortunate
20 position of the South West Regional cardiac centres
21 mortality for open heart surgery on patients under
22 1 year of age. This, as you may or may not know, is one
23 of the highest in the country and the problem should be
24 addressed."
25 The same wording there, "the problem should be
0094
1 addressed", as you had used in your first report in
2 respect of the adult work?
3 A. Yes.
4 Q. Here you are using it for paediatric work?
5 A. Yes.
6 Q. Is this the first written expression of concern that you
7 made in respect of the paediatric cardiac surgery
8 outcomes?
9 A. Possibly, I am not sure when the minutes of the meeting
10 dealing with the tetralogy of Fallot results were
11 produced.
12 Q. I think you will find that is 1991.
13 A. In that case this could well have been the first written
14 expression of concerns about paediatric cardiac surgery,
15 yes.
16 Q. At this stage you had not collected any data of your
17 own?
18 A. I was continuously collecting data in my logbooks about
19 the operations that I was undertaking.
20 Q. I am sorry, it was my question; I did not mean to imply
21 anything different. You had not coordinated with
22 Dr Black to collect data across the whole service?
23 A. No.
24 Q. What data did you actually have in your possession
25 before you wrote this?
0095
1 A. The data would have been the logbook data which would
2 have --
3 Q. Your logbook?
4 A. Yes, my logbook data -- which would have included some
5 mortality data and I suspect probably the report for
6 1989/90 which you have just shown us, which would have,
7 I think, probably confirmed the concerns that I had.
8 I think what developed in Bristol, in my mind, was
9 the perception of a service that was under achieving in
10 terms of the outcomes that it should have expected for
11 its paediatric cardiac surgical operations, particularly
12 in the under 1 age group. That was not something that
13 came as a flash of light, it was not a sudden
14 examination of a statistical table, it was not suddenly
15 looking at confidence limits not overlapping; it was
16 a gradual growing awareness of a potential or real
17 problem. My difficulty was getting people to deal with
18 the possibility that this was a real problem.
19 MR LANGSTAFF: What we will do, if you do not mind,
20 Dr Bolsin. We are in the middle of the questions I want
21 to ask you about this but we have come to a stage when
22 we should take a break for lunch. Sir, until 2.15?
23 THE CHAIRMAN: Shall we say until 2.15, please?
24 (1.30 pm)
25 (Adjourned until 2.15 pm)
0096
1 (2.15 pm)
2 THE CHAIRMAN: Mr Langstaff?
3 MR LANGSTAFF: We were talking about the letter which you
4 sent to Dr Roylance and about the basis that you had for
5 making the claim that you did at the bottom, talking
6 about the mortality for open-heart surgery on patients
7 under 1 year of age.
8 You told us, I think, that you had a feeling from
9 your work as an anaesthetist that grew and developed as
10 you were working. What did you base any feeling on?
11 A. I think the first and most striking thing about moving
12 from the Brompton Hospital to the Bristol Royal
13 Infirmary was the length of time the operations took,
14 and I think that was by far and away the most striking
15 component of the change between the Brompton and the
16 Bristol Royal Infirmary.
17 Q. You noticed that in your first year?
18 A. I noticed that on my first day.
19 Q. And yet you made no adverse comment on it in your first
20 annual report?
21 A. No, I think that what I was interested in, in the annual
22 report, was producing a mechanism whereby we could all
23 constructively review results as they were presented on,
24 let us say, an annual basis, and I think that one of the
25 things that I would have expected, the kinds of meetings
0097
1 that I had outlined as being required in that first
2 annual report would have been, "Let us look at bypass
3 times and cross-clamp times and see how they compare
4 with neighbouring centres or centres somewhere else".
5 So I was looking for a framework of acceptability,
6 I was not looking at a hostile document that was going
7 to point up all the serious shortfalls in the unit as
8 I saw it, because I did not see that as being
9 necessarily a constructive stage at the end of the first
10 year of my contract.
11 Q. Indeed, one might say that your letter to Dr Roylance
12 ended on what one might call an optimistic note; you
13 were looking to improve the service, I take it?
14 A. Yes.
15 Q. Not being critical but essentially looking forward.
16 The letter that you sent Dr Roylance did not ask
17 him to do anything, did it?
18 A. I cannot remember. I think it asked him to address the
19 problem. I do not know whether that is an action.
20 Q. I am sorry, it should be on the screen. It is on mine
21 but not yours, I am very sorry.
22 A. Yes, "to address the unfortunate position", the problem
23 should be addressed.
24 Q. If we go down, to see the whole letter:
25 "I look forward to your reply, which I hope will
0098
1 help to persuade me of the benefits of Trust status for
2 the Cardiac Unit".
3 So this is all in the context of responding to the
4 application for Trust status?
5 A. I beg to differ and say it is all in the context of the
6 application for Trust status with specific respect to
7 the Cardiac Unit.
8 Q. Which is the only perspective you could have on it?
9 A. It is the perspective I was most interested in, yes.
10 Q. At the time you wrote this, you were not asking for
11 anything except that the problem should be addressed,
12 which is asking nothing specific, is it?
13 A. Well, it is asking for something very specific, while at
14 the same time asking for something not very specific.
15 Q. Where is the specific request?
16 A. The specific request is that the problem should be
17 addressed.
18 Q. And if one were to say, "Do you suggest how?", the
19 answer is ...
20 A. I would have suggested that he would then confirm that
21 my suspicion or allegation was true and then deal with
22 any specific ways in which it could be improved.
23 Q. Would it be fair to say that your letter simply raises
24 a concern and no more than that?
25 A. I think it actually asks for a solution to a raised
0099
1 concern. Yes, there is a problem, or there is
2 a perceived problem of a mortality rate in paediatric
3 cardiac surgery in the South West Regional Cardiac
4 Centre, and I think it should be addressed. So it is
5 more than raising a concern, it is actually saying,
6 "I think you should do something about this, please".
7 Q. You do not, in the letter, make any complaint about not
8 getting access to data to which you wish to have access?
9 A. No.
10 Q. Can I take you to your answers when asked about this
11 letter at the GMC, GMC transcript Day 7, page 76, page 77.
12 If we go down to the bottom of the page, this is
13 Mr Henderson asking you questions:
14 "Question: Bristol Royal Infirmary and all its
15 departments, let alone cardiac surgery, would aspire to
16 be top of the tree?
17 Answer: Absolutely. That was my aspiration ...
18 Question: It is right, is it not, that your
19 letter could well convey a message of just that, an
20 aspiration that the hospital be put nearer the top of
21 the tree in this respect rather than where it was?
22 Answer: Yes, I think it ends on a reasonably
23 optimistic note.
24 Question: You do not in that letter ask
25 specifically for the Chief Executive to do anything, do
0100
1 you?
2 Answer: No, I am raising a concern."
3 So the words which I was putting to you were your
4 own words, in fact, and you say it goes beyond that now?
5 A. This is a couple of years ago and my reading of the
6 letter now would pick out the fact that I was asking for
7 something to be addressed, not once but actually twice
8 in that last paragraph. I think that a repeated request
9 for something to be addressed is probably more than just
10 raising a concern.
11 Q. Let us go back to the letter, [UBHT 118/8]. Where is
12 the second addressing?
13 A. The first is in line 3, word 3 "should have attempted to
14 address --
15 Q. I see; you are just repeating the word "address" so you
16 say this is two requests, or it is an emphasised
17 request?
18 A. It occurs in two different sentences.
19 Q. So what did you expect the response to be from
20 Dr Roylance?
21 A. I think my expectation at that time was that this
22 concern which is being raised -- which is about
23 a serious problem; it is not the length of a scar or the
24 duration of a hospital stay, this is about the most
25 serious outcome for a medical intervention -- should
0101
1 have been taken up by somebody at the Executive level
2 and they should have put it out on the table and said,
3 "Okay what is the reality behind this concern?"
4 Q. So what you would be looking for, what you would be
5 seeking, would be what, an investigation to see how the
6 figures stacked up, or what?
7 A. Yes, I think I would have expected possibly the
8 cardiologist, probably the surgeons, possibly the
9 anaesthetists, with the General Manager as he was then,
10 or another independent person, to have said, "This is
11 a very serious allegation, let us have a look at the
12 results and see if there is any justification in the
13 comment that is made".
14 Q. Can I go back to the basis for your making the
15 suggestion which you make there? You had your logs,
16 your own personal logs. Had you kept those from the
17 beginning?
18 A. Yes.
19 Q. You had your impressions that the surgery was taking
20 longer than it had done at the Brompton?
21 A. Yes, and with higher morbidity rates, I think, as well,
22 longer stays on intensive care, more respiratory
23 failure, more cardiac failure, that kind of thing.
24 Q. Had you any other information that you now recollect,
25 apart from the statistics that we have just had a look
0102
1 at?
2 A. I think that was probably most of it. I think the other
3 information that would have been available that
4 obviously is not available to the Inquiry was
5 conversations I had with my colleagues and other people
6 saying, "I am really concerned, it takes them 8 hours to
7 do this operation; Chris Lincoln used to do three of
8 these in a day. What do we need to do? How can we
9 improve this? How can we get the guys to do this
10 better? Is this what is leading to a high mortality or
11 complication rate?"
12 So I was not hearing from my colleagues, "There is
13 not a problem, don't worry about it", it was "Yes, we
14 ought to be thinking about this." The question was how
15 quickly should we deal with the problem?
16 Q. Did you speak to anyone outside the unit?
17 A. I think probably my first year I might well have spoken
18 to Charles Gilby at the Brompton Hospital, and discussed
19 the problem with him, because for me, it was a problem
20 I just wanted to be sure in my own mind that I was not
21 being unreasonable in my expectations of my surgical
22 colleagues.
23 Q. Did you speak to Mr Wisheart about it?
24 A. I think I would have raised the duration of operations:
25 "These are taking a long time; Chris Lincoln used to do
0103
1 three of these in a day", that kind of thing, perhaps
2 casually.
3 Q. The way you put that, you "think" you "would have" done:
4 did you?
5 A. I cannot say that I definitely did, but I cannot believe
6 I would not have made those kinds of comments to find
7 out from Mr Wisheart what he was thinking about the
8 processes that were going on.
9 Q. What about Mr Dhasmana?
10 A. I did not work so much with Mr Dhasmana in paediatric
11 cardiac surgery, and the reason for that was that he
12 used to operate on a Tuesday; he did most of his
13 paediatric cases on a Tuesday, and James did most of his
14 paediatric cases on a Monday.
15 Q. But you did operate with him, did you?
16 A. Less frequently than James, yes.
17 Q. Was he also someone that took time in the way Mr Lincoln
18 did not?
19 A. Yes, I think that is true. I do not think he was as
20 slow as James, but he was certainly slower than Chris
21 Lincoln.
22 Q. Might that have been, perhaps, because Mr Lincoln was
23 unusually fast?
24 A. I do not think so, no.
25 Q. Why did you not think so?
0104
1 A. Because of my experience of other consultant surgeons.
2 For example, Ravi Pillai who worked in Oxford -- he
3 worked as a Senior Registrar at the Brompton and he was
4 now a consultant at Oxford -- I knew he was of a similar
5 alacrity to Chris Lincoln.
6 Q. But you had not seen him do any of the complex
7 operations Mr Lincoln had, not as a Senior Registrar?
8 A. I think as a Senior Registrar he would have done VSDs
9 and possibly AV canals at the Brompton.
10 Q. So did you know quite how the case mix compared at
11 Bristol with that which you have seen at the Brompton?
12 A. In detail, no.
13 Q. So there may very well have been reasons, no doubt it
14 suggested itself to you, why children seemed to take
15 longer at Bristol than they have done elsewhere?
16 A. There were no obvious reasons: if that was the case,
17 then no obvious reasons that I can think of. The
18 Brompton was an international referral centre, a centre
19 of excellence that received children from all over the
20 country rather than just the regional centre that
21 Bristol was, so there was no reason to believe there was
22 a case mix component to the outcome discrepancy.
23 Q. I wonder if you can help me with this: at the time that
24 you wrote this letter seeking for the problem to be
25 addressed, we have seen already that there were
0105
1 statistics which compared the performance of Bristol on
2 the face of it with the United Kingdom and compared it
3 over a period of time.
4 They would be, would they, probably the best
5 available figures at the time?
6 A. I would have thought so, yes.
7 Q. What more did you want?
8 A. I think I wanted to find out what the cause for the
9 higher mortality in Bristol was, and then I wanted it
10 dealt with.
11 Q. So it was a question of having someone say, "We have
12 high mortality here compared to the UK. What is the
13 reason for it? Now let us do something about that
14 reason".
15 A. Yes.
16 Q. That is the process?
17 A. Yes.
18 Q. So what you were not saying -- let me get this clear --
19 is that this was a situation in which Bristol ought not
20 to be doing paediatric cardiac surgery; it was a crude
21 response like that, it was a question of "These results
22 appear to be worse, let us see if we can improve them"?
23 A. Yes. I think that the question of addressing the
24 problem was to identify if there was anything that we
25 should not have been doing. At that stage, I did not
0106
1 have the information to suggest there was not something
2 we should be doing or that there was a problem across
3 the board, but I felt that in addressing the problem,
4 information would flow from that process.
5 Q. Were there any particular operations that concerned you?
6 A. At that stage, it would be difficult for me to say
7 "Yes". The answer is, I am not sure.
8 Q. Can you think again about that? The reason I ask you is
9 that in the letter you talk generally about open-heart
10 surgery on patients under 1 year of age, so it is all
11 operations in that age group. That is what you are
12 referring to?
13 A. Yes.
14 Q. Is that what you had in mind, simply the general
15 position in so far as mortality was concerned?
16 A. I think so, yes.
17 Q. At the GMC, you were asked quite a lot about this
18 particular letter, were you not?
19 A. Yes.
20 Q. Do you recall saying that you had in mind two
21 operations, the VSD and the tetralogy of Fallot, as
22 being particular problems in your mind?
23 A. I do not actually recall saying that.
24 Q. Do you recall saying that the evidence that you had was
25 evidence solely from your own logbooks and your
0107
1 conversations with others, the people at the Brompton,
2 and conversations with colleagues, and you suggested, at
3 any rate, that you had had no such data, as I have shown
4 you, in respect of the years up to 1989?
5 A. I do remember saying that at the GMC. I think that
6 having gone back to this and gone over it in my mind,
7 and also the other thing that I did not have at the time
8 was the 1989/90 results, or the results that you have
9 just shown me. I only had the 1990 to 1991 annual
10 report, and I did not know that the 1989/90 annual
11 report existed.
12 It was not until it was shown to me by the Inquiry
13 Secretariat that I realised that a report of that nature
14 existed, and my conclusion -- it is certainly a post hoc
15 analysis -- is that my very specific reference there to
16 children under 1 year of age would have been in relation
17 to the 1989/90 annual report results and would have been
18 related to data that I had then but I had then lost and
19 then saw again in the last year.
20 Q. It went further, did it not, because in the GMC -- can
21 we look, please, at the transcript for Day 6, page 21,
22 down the bottom of the page, please. What you said
23 there was:
24 "Question: Why did you think it necessary or
25 appropriate to write a letter in those terms?
0108
1 Answer: I think there was a problem with children
2 dying unnecessarily in the cardiac surgery unit in the
3 United Kingdom. I had tried to get some idea of what
4 the figures were from that unit and it was very
5 difficult to find out exactly what was going on. I was
6 concerned for the safety of children that were dying
7 unnecessarily and I needed to know what the exact data
8 was. That data was not coming out of the unit. I was
9 a member of the unit and it was not being given or
10 shared with me. That was the reason for bringing the
11 Chief Executive in. I believe there was a problem.
12 I believe the children were dying unnecessarily and
13 I wanted to find out if my suspicions were correct."
14 That is what you said to the GMC without having
15 the advantage of having seen the document which you have
16 seen since, the 1989 results?
17 A. Yes.
18 Q. Looking back, thinking again about it, might that be
19 wrong and misplaced in respect of the 1990 letter,
20 however true it may have been later on in the story that
21 we will come to?
22 A. I am sorry, how might which be wrong?
23 Q. What you appear to be saying here is "I wrote the letter
24 because ... I was trying to get the Chief Executive
25 involved because ... there were no figures being shown
0109
1 to me by the unit, and I needed to know what the exact
2 data was because I thought children were dying
3 unnecessarily."
4 A. Yes. What you are saying is coming from the GMC
5 transcript?
6 Q. Yes, in respect of this letter to Dr Roylance.
7 A. Yes.
8 Q. And the question that arises is this: you now think,
9 because you have been shown the document, that you
10 probably actually had the data up to 1989?
11 A. Yes.
12 Q. You have accepted in the course of the questions
13 I have been asking you, that was the best data available
14 at the time?
15 A. Yes.
16 Q. And it would follow that if you had had that in March
17 1990, it is difficult to see what you were complaining
18 about to the GMC?
19 A. I think I can help to clarify this, because there is
20 obviously a potential for confusion. What the letter to
21 the Chief Executive says is "We have a problem, or we
22 may have a problem that needs to be addressed, and it is
23 in the under 1 year age group", a very specific category
24 of patients. My logbook data would not have allowed me
25 to make that very specific category of patients
0110
1 a problem area.
2 Therefore, having seen the 1989/90 report with its
3 excess mortality in the under 1 year age group,
4 I believe, now, and I had not seen that report when
5 I was interrogated or cross-examined at the GMC,
6 I believe that what I am saying to the Chief Executive
7 is not, "I cannot get any information", because that
8 request is not made in the last paragraph; what I am
9 saying to him is, "There is a problem and I have seen
10 evidence of a problem, and I have seen evidence of
11 a problem in the under 1 age group", and I am also
12 saying, "You must address this problem".
13 I think that was because yes, the data was
14 available, the data was available in the table at the
15 end of the 1989/90 report. It was very specific data in
16 the under 1 years, and I am not saying I cannot get any
17 information, I am saying "There is a problem and you
18 need to address it".
19 Q. I am glad that you clarified that, but the point is
20 a slightly more complex one. It arises in this way: you
21 will appreciate, because you have seen the rebuttal
22 statements which others have produced, as you would have
23 expected, that there are a number of people interested
24 in the proceedings of this Inquiry who do not accept
25 some of the meetings or conversations to which you
0111
1 depose.
2 A. Yes.
3 Q. It is a matter for the Panel to make of that what they
4 will. One of the matters which may be important is how
5 accurate your recollection is of the motive that you had
6 for doing X or Y or whatever it may be.
7 When we come to the question of the motive for
8 writing this particular letter, the one thing you have
9 remained entirely consistent on is that your interests
10 were the best interests of the child, the patients, and
11 you wanted that investigated and looked at: no problem.
12 But the secondary motive, if I can call it that,
13 for your writing this letter to the Chief Executive at
14 the time -- because that is one of the questions, why
15 should you write it to him rather than do something
16 else -- arises in the way: you appear to have told the
17 GMC you did it because you could not get the data from
18 the unit. What you are saying on reflection to us is,
19 "That is not right; I was saying I was doing it because
20 there was a problem which needed to be sorted. Having
21 seen the data, I knew there was a problem".
22 So there are two different secondary motives; do
23 you follow me?
24 A. Yes.
25 Q. The Panel may be interested to know why it should be
0112
1 that really you should get it so badly wrong as to the
2 secondary motive in talking about this letter to the
3 GMC, when the truth is that you, still having the motive
4 of the interests of the patient, had a different
5 underlying reason for writing to the Chief Executive
6 rather than taking up your concerns in some other way.
7 That is the point.
8 A. I think again I would explain that by saying that the
9 process of the GMC was very much one of relying on
10 memory, and being confronted occasionally with
11 documents, but essentially, this was a memory exercise
12 at cross-examination and I had not seen and did not
13 remember the existence of the 1989/90 report.
14 Having seen the 1989/90 report recently, when
15 through a very different process of gathering evidence,
16 this Inquiry has made these documents available and
17 certainly made them available to me, I was then able to,
18 I think, probably remind myself that, yes, the data did
19 exist. That is why I was not saying in the letter to
20 John Roylance, "I have a problem with getting data";
21 what I was saying was, "We have a problem and we need to
22 address it".
23 The existence of the problem is very clear in the
24 last paragraph of that letter; it is not, "We need some
25 more information to find out if there is a problem". It
0113
1 was "There is a problem and we need to address it."
2 Q. The second aspect I had asked you about was whether
3 particular operations were in your mind at the time you
4 wrote the letter.
5 A. Yes.
6 Q. And again, if we have a look at what you said to the
7 GMC, page 19 of the transcript, down at the bottom of
8 the page this is summarising evidence which you have
9 been giving:
10 "Question: You have mentioned VSD, you have
11 mentioned switch. Were any other operations a matter of
12 concern to you as to their mortality at that time?
13 Answer: Not specifically, no."
14 A. Can I just ask, "at that time" --
15 Q. The time you wrote the letter to Dr Roylance. I can
16 tell you -- by all means, if you want to get the
17 reference it can be found, but later on this was picked
18 up by those who cross-examined you, and you were asked,
19 well, why is it, if you actually were concerned about
20 VSD and switch, why is it that in your letter you talk
21 about open-heart surgery generally in the under 1 age
22 group? That point is then pursued with you by one of
23 the representatives for the doctors.
24 A. Yes.
25 Q. You may remember that, perhaps. Again, it may be
0114
1 a question of having your recollection prompted by
2 seeing what you have seen. Do you think that is
3 accurate, that it was just VSD and switch that was in
4 your mind, or not?
5 A. I think VSD is certainly one that would have been in
6 my mind, because I think by this time we would have had
7 a meeting about VSDs, an informal evening meeting, at
8 which we looked at the results of VSD, and we looked
9 specifically at the results of VSD in the under 1 age
10 group. I am not sure that figures were brought to that
11 meeting, but we did look at VSDs and we did look at the
12 time of operation vis-a-vis the age of 1 year.
13 Q. But so far as what was in your mind when you wrote the
14 letter to Dr Roylance, was it VSD and switch or was it
15 general? Or do you not remember?
16 A. Does it have to be one or the other?
17 Q. No, not at all.
18 A. There was a general concern, but VSDs was one we
19 highlighted because we had had a meeting at that stage
20 about the VSD operation, and it was an evening meeting
21 at which we discussed it, so it may have been general
22 plus VSD. I am not sure if the switch was an operation
23 that I was particularly concerned about by then, but if
24 I was not, I would have been relatively shortly after
25 that, I think.
0115
1 Q. Before I leave the letter itself and come to the
2 consequences of it, you have described in your statement
3 how you were assisted in deciding to formulate the
4 letter by Dr Thomas?
5 A. Yes.
6 Q. Did you suggest to him that you should write the
7 letter?
8 A. Yes.
9 Q. Did he give you advice?
10 A. Yes. I think he advised who I should address it to.
11 I am not sure if my initial suggestion -- I think
12 I probably suggested it should go to John Roylance.
13 Q. He recollects that you had in mind the Chairman.
14 A. Okay, well, possibly, yes. He may then have said John
15 Roylance and he would have said who to cc it to.
16 Q. That is exactly what he says. So thus far, entirely in
17 line with his recollection. He recollected when he gave
18 evidence to us that he also advised you that you should
19 discuss that particular point, the last point in the
20 letter, with colleagues within the unit. His
21 recollection was that you said you had done.
22 Is he right about that, that that is what you
23 said, at any rate?
24 A. I cannot remember whether I would have said that.
25 I think the concerns of the anaesthetists at that time
0116
1 were that there was a problem with length of operations;
2 there was a problem with outcomes, and there was
3 probably very much a problem with outcomes in the
4 under 1s. Certainly, the data that was around, whether
5 I was exposed to it or not, was that there was a problem
6 in the under 1s in the 1989/90 report. I think that
7 anaesthetists working in the unit would have been
8 talking about that data and we would have discussed it,
9 so I think if I had said to Dr Thomas that I had
10 discussed it, then I think that would have been a point
11 of fact.
12 Q. He says he went on, when you told him that that was the
13 case, that you should then copy the letter to them too?
14 A. Yes. I may have thought that was unnecessary and I may
15 very well have already raised it with them, or I may
16 have said I will put a copy on their desks, or something
17 like that.
18 Q. Again, just so there is no lack of clarity about this,
19 what Dr Thomas was responding to was a draft which you
20 prepared, and he commented on it and suggested one or
21 two changes in the English, I think?
22 A. Yes.
23 Q. Which is why we have the two different versions, is it?
24 A. Yes, I think that is right.
25 Q. So the version of 25th July is pre discussion with
0117
1 Thomas, and then the August letter is post-discussion
2 with Thomas, with the additional ccs at the bottom as he
3 has suggested?
4 A. Yes, I think so.
5 Q. So it was your draft, not a co-draft?
6 A. I think that is true, yes.
7 Q. Can we move, then, from the actual letter itself to what
8 happened afterwards? You spoke up, I think, did you, to
9 Mr Dean Hart?
10 A. Yes.
11 Q. We have what he has to say at WIT 80/98 and it is
12 page 99 that I want to take you to. Can we scroll down,
13 please. What he is suggesting there is that if you had
14 been very concerned, that he [Mr Dean Hart] should be
15 properly briefed about your concerns on paediatric
16 cardiac surgery, then you might well have considered
17 using a stronger line of approach.
18 "A copy letter to two other colleagues where the
19 matters raised were in the last paragraph of
20 a three-paragraph letter mainly about his opposition to
21 Trust status did not suggest that the matter was the
22 prime issue of his letter but rather that it provided
23 additional support on his views on Trust status."
24 Is that a fair point?
25 A. No, I do not think he has interpreted it correctly,
0118
1 because the letter was not opposition to Trust status,
2 it was dealing specifically with the appendix to the
3 application for Trust status vis-a-vis cardiac surgery,
4 so it was not in general opposition to Trust status,
5 which is unfortunately it seems the sort of "dustbin" it
6 has been put into, that this was a letter opposing Trust
7 status. It was a very specific letter dealing with the
8 appendix to an application for Trust status with respect
9 to cardiac surgery. I would have said that putting
10 those three paragraphs into a letter, sending it to the
11 District General Manager, to the Chairman of the
12 Hospital Medical Committee and to the Chairman of the
13 Health Authority was a reasonably strong expression of
14 a problem which needed to be addressed.
15 Q. So did you ever get any response to that letter from
16 Dr Roylance, to whom it was addressed?
17 A. I think he phoned me up, and took possibly a similar
18 line to Dr Dean Hart that Trust status was going to be
19 good for the unit or whatever, but did not really deal
20 with my perception of the problems, which was that there
21 was a higher mortality rate in the under 1 year old
22 children in Bristol compared to the rest of the country.
23 Q. So he seemed to be reading it in the same way, this was
24 to do with the application for Trust status rather than
25 a separate concern?
0119
1 A. Yes, that is how he wanted to deal with it, yes.
2 Q. That is how he dealt with it. Do you know what his
3 intention was?
4 A. I do not know what his intention was, no.
5 Q. When he spoke to you about it, did you say to him,
6 "Well, John", or "Dr Roylance", or whatever it was you
7 called him, "actually the third point there I raised is
8 something which requires further action and we need to
9 do something about it"? Did you emphasise that at all?
10 A. No. I just got a relatively dismissive phone call, as
11 I remember, and I was not really in a position to be
12 able to say "Hang on a sec', I really think you should
13 call a meeting of everybody involved and we really have
14 to go through these results". It was not that type of
15 conversation. It was a very one-sided conversation to
16 me in a cardiac theatre at the time and I did not have
17 a lot of input into that conversation.
18 Q. So the upshot is that for the reasons you have given,
19 you never actually pressed the concern upon him at that
20 stage?
21 A. No.
22 Q. You heard no more from Dr Roylance about this until, you
23 have told us, some time in 1994 was the next time you
24 had any contact with him?
25 A. Yes, whenever the next contact was.
0120
1 Q. So when we look at your statement to the Inquiry,
2 WIT 80/109, line 8, you begin there to say that the
3 response was actually the telephone call from Mr Dean
4 Hart; but there was also the telephone call from
5 Dr Roylance?
6 A. Yes. I believe there was a telephone call from
7 Dr Roylance as well, yes.
8 Q. Mr Dean Hart: what was the nature of that conversation,
9 as you recall it?
10 A. Mr Dean Hart wanted to get to the bottom of why I had
11 written the letter to the District General Manager, and
12 when I explained to him that I had taken advice from
13 Dr Thomas and that he had advised that this was the
14 route to take and that he had reviewed the letter before
15 it was sent, he then perceived that I may have been
16 being involved in a game of medical politics, which
17 certainly I was not aware of, and he suggested that he
18 had been in a similar situation when he had been a young
19 consultant at some point, and that I should -- I am not
20 sure he necessarily gave me any advice, but perhaps be
21 a bit more circumspect in sending these kind of letters
22 off.
23 Q. Was it a bit avuncular, as you describe it, or not?
24 A. Certainly not from my point of view. I was called by
25 the Chairman of the Hospital Medical Committee -- I had
0121
1 never met him before but he was obviously one of the
2 influential consultants in the hospital -- to come out
3 of a cardiac theatre list. I had to get changed and
4 meet him in the Post-graduate Medical Centre. It was
5 all, "This is what you are going to have to do, you are
6 going to have to come out and meet me". I said "I am in
7 a cardiac surgery list", he said "Do not worry, you have
8 to come and see me", so I was very much under pressure
9 of being ordered and I was in some dread of what might
10 be said to me at this meeting.
11 Q. As it happened, the meeting was in the common room, was
12 it?
13 A. Yes.
14 Q. So there may well have been other people around?
15 A. There weren't, but there may well have been, yes.
16 Q. That is the point made by Mr Dean Hart, that that is not
17 the sort of forum where you would expect to go if it was
18 a dressing-down, you would expect to go to his office,
19 which may be a fair point, may it?
20 A. I am not sure. I was not sure what to expect from that
21 meeting.
22 Q. As you described it, the conversation appears to have
23 been relatively amicable?
24 A. Yes.
25 Q. Is that right?
0122
1 A. I think it was a senior colleague saying, you know,
2 "Do not get involved in this sort of thing". My
3 disappointment was that he did not really take the
4 concerns expressed in the letter seriously, and I think
5 that that was again possibly a failing of mine in not
6 saying to him, "Well, actually, Mr Dean Hart, you have
7 completely misread the letter and I have serious
8 concerns". But I was not senior enough or confident
9 enough to be able to take that role in that
10 conversation.
11 Q. Was there any further "fall-out", so to speak, from that
12 particular letter?
13 A. Yes. Some time later, Mr Wisheart asked to see me in
14 his office as well.
15 Q. How long later?
16 A. To be quite honest with you, I am not sure but it
17 would certainly have been after the Dean Hart
18 conversation which was after the Roylance conversation
19 which was after the letter. So there would have been
20 a gap in the time. I cannot tell you exactly how long
21 it would have been.
22 Q. Can we go back to the letter itself? Scroll down to the
23 bottom. "Mortimer, Dean Hart, Williams". Mortimer, the
24 Chairman, and Dean Hart, the Chairman of the HMC, got
25 a copy of the letter and spoke to you about it?
0123
1 A. Yes.
2 Q. In a sense, that is what you would expect, is it not: if
3 the letter was a serious letter requiring respect, the
4 persons to whom it was copied would probably talk to you
5 about it?
6 A. Yes.
7 Q. Did Mr Mortimer ever say anything to you?
8 A. No.
9 Q. Did Mr Williams ever speak to you about the letter?
10 A. Yes, Brian Williams did.
11 Q. What was said by him to you, and when?
12 A. He was pretty horrified by the letter and wanted to know
13 why on earth I had done it. He did not understand that
14 I had spoken to Trevor Thomas about the letter before
15 I had even sent it, and when I explained that, he still
16 I think could not quite understand what I was doing
17 sending off this letter. But I explained what was in
18 the letter and he seemed more -- I would not say
19 contented, but he seemed to accept what I said.
20 Q. He was your immediate Chairman in your division?
21 A. Yes, he was the Director of Anaesthesia.
22 Q. So he was the person who might have expected, I suppose,
23 to have been told beforehand that you were thinking of
24 writing the letter?
25 A. Yes.
0124
1 Q. But you had not obviously spoken to him?
2 A. I had not spoken to him. He was a very good friend of
3 Trevor Thomas's, and it would not have surprised me if
4 Trevor Thomas had spoken to him about the letter.
5 Q. There may be an easy explanation, but why is it that you
6 did not have a word with your Director before you sent
7 the letter?
8 A. I am not sure that there is an explanation; it may have
9 been that I just did not think it was important enough
10 to bother him with, or that he just needed to know I had
11 sent this letter and would find out about it. I am not
12 sure. I mean, he may have been on holiday. It was
13 August, was it not?
14 Q. Yes, it was. If you are going to do this tomorrow, as
15 it were, you would follow the advice I expect along the
16 lines of the advice that you gave to Melbourne, the
17 blueprint, and raise it within the division first,
18 presumably?
19 A. Well, I had done that.
20 Q. And then get the division to agree, go to your
21 Director?
22 A. Yes, if he was there, yes.
23 Q. In any event, you copied the letter to him, so he knows
24 you have done it?
25 A. Yes, can I just say, the blueprint is produced, I think,
0125
1 probably in 1999. I am not sure of the date of the
2 transcript we have.
3 Q. It is March 1999?
4 A. Since then I have under taken a Master's in health care
5 management and I think I am much more familiar with and
6 have developed my own ideas about how to address this
7 type of issue in the future. We are talking here about
8 a letter in 1990, almost ten years ago, in which I was
9 in my first 10 months of a career as a consultant
10 anaesthetist. I can certainly say I did what I thought
11 was the best thing at the time and took what I thought
12 was the best advice at the time. It may not conform to
13 a blueprint ten years later, but I was doing what
14 I thought was the best at the time.
15 Q. Do not misunderstand the questions, they are designed,
16 so far as they can, to probe what you thought and also
17 to help with an evaluation of the problems that it may
18 have given others, if it did.
19 A. Yes, I understand that.
20 Q. I think what you are saying is that if you had known
21 then what you know now, you might not have done it this
22 way?
23 A. I might have done in it a different way, yes.
24 Q. The reaction of Mr Williams was to that effect: if you
25 wanted to do this, you ought not to have done it this
0126
1 way?
2 A. Yes, I think that is a fair summary.
3 Q. What about Mr Wisheart?
4 A. He spoke to me -- again, it is a variable time later --
5 and asked me to see me in his office. He shared an
6 office at that time with Mr Dhasmana. I went up to see
7 him. Again, to the best of my recollection, he had the
8 letter on the desk in front of him. It is an unusual
9 letter because it is long and there is not much space
10 for the signature underneath. We deliberately did it
11 that way because otherwise you would just leave off the
12 last few lines.
13 He made it quite clear to me this was not the way
14 I should carry on, that I should have taken the results
15 outside the unit, and this was not the way to progress
16 my career in Bristol. That was a very salutary
17 conversation.
18 Q. Do you recollect the exact words that were used by him?
19 A. The exact words? No.
20 Q. How long roughly did the conversation take?
21 A. I think it probably took about 10 minutes or so.
22 Q. What was the tone of the meeting?
23 A. The tone of the meeting was that Mr Wisheart was very angry
24 that a young consultant had taken results of the unit
25 outside of the unit and expressed them to non-cardiac
0127
1 colleagues, as it were.
2 Q. In terms of the audit cycle, as suggested by the Royal
3 College of Surgeons' guidance at the time, discussions
4 about results and audit ought, in the first place at any
5 rate, to have been within the unit, ought they not?
6 A. Within colleagues, yes, within the unit.
7 Q. At the time you sent the letter to Dr Roylance, there
8 had not been any such discussion of these particular
9 results, or had there?
10 A. We had had the discussion of the VSDs where we looked at
11 mortality rates above and below 1 year of age, and come
12 to a relatively -- I am trying to think of the best
13 words to use. We had come to a conclusion that we
14 should try and operate on children at 11 and a half
15 months rather than 13 months or over a year, in order to
16 perhaps try and improve the figures. To me, that was
17 not actually addressing the problem, which was could we
18 or could we not operate on tiny children?
19 I think that the impression that again I had, but
20 I think probably the paediatric cardiac anaesthetists
21 had, was that for the bigger children the operating was
22 okay, the technical skills were adequate, but for the
23 smaller children, the technical skills just were not
24 really up to the job of operating on these tiny
25 children.
0128
1 Q. Was there any other discussion that you recall having
2 had about the results which we have seen from 1989?
3 A. No, I cannot remember -- I mean, as cardiac
4 anaesthetists we would discuss in the department the
5 results and we would talk about perceived problems or
6 perceived good outcomes, perceived good drugs, perceived
7 good treatments, that we might be using. I think one of
8 the concerns I was expressing here was that I -- and
9 I was not alone, I did not think, when I wrote the
10 letter, although I was the sole signatory -- had
11 concerns in the under 1 age group.
12 Q. The conversation must have taken place after August
13 1990. Before when, roughly, so we can get a handle on
14 the date? Was it before Christmas, do you think?
15 A. Yes, I am sure it was before Christmas.
16 Q. So how quickly, roughly, after sending the letter did
17 this meeting with Mr Wisheart take place?
18 A. I think there were, as I say, several meetings, so there
19 was a sort of passage of time; there was a phone call
20 from Dr Roylance, then there was Mr Dean Hart on the
21 phone and a meeting with him, then Brian Williams
22 picking it up and realising I had taken advice, then
23 there was him saying, "Okay, I will speak to Mr Wisheart
24 about this and see if we can sort it out, smooth it over
25 or do something". So I suspect that Brian may well have
0129
1 spoken to James by the time I spoke to him, or James may
2 have spoken to me before Brian had a chance to speak to
3 him.
4 Q. Throughout this time you were operating in lists with
5 Mr Wisheart, were you?
6 A. Yes.
7 Q. Both before and after the conversation in his office?
8 A. Yes.
9 Q. So far as you can tell, did it make any difference to
10 your relationship as you operated?
11 A. I think professionally it did not alter the level of
12 service that I was offering. I may have spoken less
13 about rugby and cricket and possibly been more focused
14 on the children and less friendly towards him, which is,
15 I think, a change that Kay Armstrong says she noticed at
16 the time.
17 Q. You prepared, after the Loveday operation and around the
18 time of the operation, what we see at UBHT 61/49. This
19 "Calendar of Events" is yours, is it?
20 A. Yes.
21 Q. When roughly did you prepare it?
22 A. I think it would have been prepared -- again, it may
23 have been one of these things you put on a computer and
24 then you add to it as events go by, but it would have
25 been prepared by the time of whatever the last date on
0130
1 the calendar is.
2 Q. Let us see what the last date is. Page 51: does that
3 help?
4 A. Yes. It looks as if it was prepared in the second half
5 of 1994.
6 Q. This, we know, was given to Messrs Hunter and de Leval
7 in the process of the preparation of their report?
8 A. Yes.
9 Q. Did you give it to them for that purpose, in part?
10 A. Stuart Hunter and Marc de Leval came down to undertake
11 an inquiry into the service --
12 Q. Can I just stop you and ask you to concentrate on the
13 question? Did you give it to Messrs Hunter and
14 de Leval?
15 A. Yes.
16 Q. And did you give it to them for the purpose of telling
17 them what had happened, as you saw it?
18 A. Yes.
19 Q. The significant events from your perspective?
20 A. It was an aide-memoire that I had prepared for myself,
21 yes.
22 Q. In preparing that aide-memoire, did you try and put down
23 in it those events which you thought were of particular
24 significance?
25 A. Yes. I think probably concentrating more on clinical
0131
1 significance.
2 Q. If you look at the start, 1989, going back to UBHT
3 61/49, you pick up there what you recollect now having
4 seen the document?
5 A. Yes.
6 Q. And the actual results showing twice, or thereabouts,
7 national average mortality?
8 A. Yes.
9 Q. 1990: a letter to the then District General Manager.
10 That is not a clinical event but it is recording your
11 expression of concerns?
12 A. Yes.
13 Q. The next event is 1991?
14 A. Yes.
15 Q. If we scroll down to get a flavour of the paper, you
16 deal with Kathy Orchard, applications for posts, and so
17 on?
18 A. Yes.
19 Q. Go back, please, to the top of the page. It is obvious
20 there is no mention of the meeting with Mr Wisheart.
21 A. Or Mr Dean Hart or Dr Williams, I agree.
22 Q. Tell me if this is right or wrong, because I do not want
23 what you say simply to be agreed to if it is not right;
24 I will put it in these terms: have you placed an
25 emphasis on what you have said before about the events
0132
1 in Bristol upon the meeting that you had with
2 Mr Wisheart as indicating to you that it was pointless
3 to raise concerns with Mr Wisheart because they would
4 get nowhere?
5 A. No, I do not think that is quite the right emphasis
6 I would put on it. The emphasis that I would put on it
7 is that the nature of the threat that was delivered at
8 that meeting was such that I did not want to go back
9 down that route to express concerns about the unit to
10 Mr Wisheart directly again. That is why, if you look,
11 "In 1991, I remember that Dr Bolsin was not to be the
12 vehicle for criticism of the paediatric cardiac surgery
13 unit."
14 Q. We will come to that. So what did you think Mr Wisheart
15 was warning you off?
16 A. He was saying that if I valued my career in Bristol,
17 then I would not undertake this type of action again.
18 Q. What specifically about the action?
19 A. I think it was dealing with results, raising concerns
20 about results, and outside the unit. I think it was
21 those two specific things that concerned him.
22 Q. As separate matters, or together? Let me explain the
23 difference. It may be said that the complaint or
24 concern might be with raising matters outside the unit;
25 it might be said that it was raising matters at all,
0133
1 within or outside the unit. What was the flavour?
2 A. I think that it was raising concerns specifically and
3 outside the unit that was the problem.
4 Q. So it was both?
5 A. It was a sensitivity to criticising bad results, and it
6 was a distinct dislike of those bad results being taken
7 outside of paediatric cardiac surgery.
8 Q. Because what Dr Williams had been saying to you,
9 effectively, was the second of those two: it is all
10 right to discuss the results, but do not do it outside
11 the unit. That was, as I have understood what you said,
12 his line, was it?
13 A. Yes. I think Brian is somebody who does not like people
14 to rock boats. He wants things to just smoothly go on,
15 and I think he saw this very much as a boat-rocking
16 exercise and wanted to try and calm things down a bit.
17 He did not have any expertise in judging whether there
18 was a problem in paediatric cardiac surgery and he did
19 not particularly want to get involved in dealing it if
20 there was a problem in paediatric cardiac surgery.
21 I think he did not like the idea that anybody in his
22 directorate or in his Department of Anaesthesia was
23 writing to the District General Manager, who was going
24 to be the CEO.
25 Q. So come back to my question again: was he concerned more
0134
1 with the fact that matters had gone outside the unit
2 than with the nature of the matters, or was he concerned
3 with both?
4 A. I think he was concerned with both. He was concerned
5 that an anaesthetist was actually taking an action of
6 going outside the Department of Anaesthesia and raising
7 concerns with the District General Manager.
8 Q. I understand that. Was Dr Williams also upset that you
9 were raising concerns at all?
10 A. Was he concerned?
11 Q. The flavour you have given thus far was that you
12 understood why that should be, because you explained you
13 had concerns and had spoken to Dr Thomas. The flavour
14 of what you have explained thus far is that he was
15 telling you off in the end (my words) for going about it
16 the way you did --
17 A. Yes.
18 Q. -- as opposed to telling you off for having the
19 concerns. Do you follow?
20 A. Yes.
21 Q. If that is right, then what he was focusing on was the
22 externalising of the concerns rather than the concerns
23 themselves?
24 A. Yes.
25 Q. Is it right?
0135
1 A. I think he was concerned about both issues. I think he
2 did not necessarily feel he, as the Director of
3 Anaesthesia, had the skills to deal with the concerns
4 I was raising, but he was also worried about the fact
5 that an anaesthetist had taken this outside the
6 Department of Anaesthesia. So I think he had two
7 different sets of concerns. I do not think I could
8 categorise them into one or the other.
9 Q. And Mr Wisheart had both sets of concerns himself?
10 A. Yes.
11 Q. Can you explain why it is that a meeting such as this is
12 not in your calendar of events?
13 A. As I have said, there are three meetings that are not in
14 the calendar of events: the meeting with Mr Dean Hart is
15 not in there; the meeting with Brian Williams is not in
16 there; and the meeting with James is not in there.
17 I think I was producing almost one-liners to help me
18 remember the sequence of events.
19 Q. You will appreciate that, as far as Mr Wisheart is
20 concerned, this meeting did not take place.
21 A. Yes, I do.
22 Q. He recollects being angry with you on one occasion only,
23 which was an occasion when you were not in the operating
24 theatre when he thought you should have been.
25 A. Yes.
0136
1 Q. And we will probably come to it, but so far as that
2 occasion is concerned, is that something which happened
3 in respect of which he did express anger to you, that
4 particular incident, do you recall, or not?
5 A. Yes, I think I probably do recall that.
6 Q. Is it also right that, as far as you are concerned,
7 there was no other incident in which he expressed any
8 anger towards you?
9 A. Apart from this meeting?
10 Q. Apart from this meeting?
11 A. I would have thought so.
12 Q. If you recall, let us know.
13 A. Yes, okay.
14 Q. But he is, therefore, saying that this meeting did not
15 happen. He points to your calendar of events, saying
16 that you would have mentioned it in the calendar of
17 events if it had happened, if it was so significant.
18 A. Yes.
19 Q. And that if it had happened that Mr Wisheart had said to
20 you that you had better watch your career, or it was not
21 good for your career to do things like this, that
22 inevitably things would not have proceeded as they did,
23 with you appearing to operate with him quite happily
24 thereafter. That is what he is saying. Would you like
25 to comment on that?
0137
1 A. I think there are several comments that need to be made
2 there. Firstly, Mr Dean Hart does not remember the
3 meeting that we had, although he accepts that it
4 probably took place on the basis of the information that
5 was provided in the statement, so there is a sort of
6 corporate amnesia beginning to develop about possibly
7 some of these events in the late 1980s/early 1990s.
8 I think that Sister Armstrong, in her evidence to
9 the Inquiry, gives contemporaneous confirmation of
10 a meeting between me and Mr Wisheart which changed the
11 relationship in theatres, and which was related to
12 a letter I sent, and that could well be this meeting.
13 I think Alan Bryan did the same.
14 Q. Let me just see if I can take a contextual view of this
15 and ask you a couple more questions before we have
16 a break.
17 Looking ahead, we are going to hear about concerns
18 that you had about data which you collected and
19 analysed, and about material which you showed to others
20 around the department, if not within it, but you have
21 already accepted in some of the opening questions that
22 I asked you that you never showed, yourself, that
23 material to Mr Wisheart, nor did you confront him with
24 your concerns expressly at any stage, I think, until
25 after the Loveday meeting, or at the Loveday meting.
0138
1 Why did you not do so?
2 A. I think part of the answer is on the screen in front of
3 us, which is that in 1991, a meeting of cardiac
4 anaesthetists with the Director of Anaesthesia and the
5 President of the Association of Anaesthetists, who was
6 Dr Baskett, a cardiac anaesthetist, said "Steve Bolsin
7 should not be the vehicle for criticism of the
8 paediatric cardiac surgery service". Peter Baskett, who
9 is a territorial army officer, actually said "Steve has
10 to keep his head down. He has had enough flack from
11 this letter", and Brian Williams and Chris Monk have to
12 take this on. Chris Monk was the cardiac liaison
13 anaesthetist.
14 Q. So you are saying that the reason you did not do so was
15 because of the flack from this letter?
16 A. It was because of the flack from the letter that I was
17 advised to keep my head down and that it was the
18 Director of Anaesthesia was advised by the cardiac
19 anaesthetists that he and the cardiac liaison
20 anaesthetist, Dr Monk, should take up the issue with the
21 paediatric cardiac surgeons.
22 Q. Again, so I understand, are you saying that the reason
23 you never thereafter raised the matter directly, or
24 handed the material directly to Mr Wisheart, was that
25 you had been advised to keep your head down at the
0139
1 meeting of anaesthetists?
2 A. And that fitted in very much with my experience at the
3 time of being threatened in terms of my career in
4 Bristol.
5 MR LANGSTAFF: Sir, I look at the time. Is that perhaps the
6 time for our short afternoon break?
7 THE CHAIRMAN: Yes. Shall we say 15 minutes, until
8 a quarter to four?
9 (3.25 pm)
10 (A short break)
11 (3.50 pm)
12 MR LANGSTAFF: Dr Bolsin, I told you in advance that we
13 would stop today round about 4.15. If it is all right
14 with you, with the stenographers and with the Chairman,
15 may we go on until about 4.30 unless between 4.15 and
16 4.30 you feel tired and want a break? If so, please say
17 so.
18 A. I am very happy to go on, yes.
19 THE CHAIRMAN: You must feel free to say if you feel
20 otherwise because you have recently been on a long trip.
21 A. Yes.
22 MR LANGSTAFF: Can we look at your statement at WIT 80/109,
23 the foot of the page.
24 You begin there to describe, under the heading
25 "Arterial switch programme" -- straight after you had
0140
1 dealt with the letter we have just been looking at --
2 a meeting of the anaesthetists chaired by Dr Williams?
3 A. Yes.
4 Q. If you go over to 110, we see there what you say about
5 the content of that meeting.
6 There was a meeting of the anaesthetists at some
7 stage. The description that you give there of what
8 Dr Peter Baskett said, that "Steve should keep his head
9 down after the letter he wrote to John Roylance". First
10 of all, you put that in quotes, is that actually what he
11 said or just a reflection of what he said?
12 A. No, it is a reflection of what he said. It was the kind
13 of language that he used.
14 Q. Secondly, was this a meeting which followed on from the
15 three discussions which you recall having taken place
16 after the Roylance letter?
17 A. It certainly followed the discussions, whether it
18 followed on from them or not I am not sure but it
19 occurred in time after the letter.
20 Q. It would obviously have to be after the letter for the
21 reference to be made?
22 A. Sorry, yes.
23 Q. You have given a number of different dates at different
24 times for this particular meeting. You say, page 109,
25 in 1990 you were instrumental in arranging a meeting of
0141
1 the cardiac anaesthetists. I can tell you that at the
2 GMC you said two things, in your statement I think it
3 was, you said "in early 1991", in evidence "in 1991 or
4 1992".
5 Do you have any better way of helping us to place
6 this meeting in time?
7 A. Not really, no. I know Brian Williams was the Director
8 of Anaesthesia which would have been therefore before
9 Chris Monk took over as Director of Anaesthesia.
10 Q. It would have to be 1990, 1991 or 1992?
11 A. Yes, and I know that Peter mentioned the letter or the
12 flack that was flying around.
13 Q. That must have been current?
14 A. Relatively, yes, but exactly when it occurred. I think
15 it was winter, I think it was dark outside, or an early
16 evening meeting.
17 Q. By "winter" you are thinking in English terms?
18 A. Yes, English winter, yes.
19 Q. Some time between, what, September/October of one year
20 and January, February, March the next?
21 A. Yes.
22 Q. We can place this either at the end of 1990 or the very
23 beginning of 1991?
24 A. Yes.
25 Q. But probably before March?
0142
1 A. Possibly, yes, I would have thought so. I cannot really
2 help you to pin it down I am afraid.
3 Q. The conclusion that the meeting reached was that
4 Dr Williams and Dr Monk would convey the concerns to the
5 surgeons about the switch operation. We have known from
6 what Dr Monk has told us that in fact he and Dr Williams
7 spoke to one another and it was agreed between them that
8 Dr Williams would be the messenger rather than the two
9 of them. That may not have been something you knew
10 about?
11 A. No, I did not.
12 Q. What was said to you apart from the comment by Dr Basket
13 about keeping your head down, keeping a low profile,
14 words to that effect; anything else?
15 A. No, I think the meeting had genuine concerns about the
16 progress of the arterial switch programme and wanted to
17 review results or wanted to be shown some results to see
18 how outcomes could be improved.
19 Q. What was the object: to review the programme and to see
20 whether it should continue at all or to review it to see
21 whether it could improve, whether something was going
22 wrong, or what?
23 A. I think it was to review the programme. The outcome of
24 the review could either have been to curtail the
25 programme or to have identified points at which it could
0143
1 be improved. So it could have been either of the two
2 outcomes that you suggest for the review.
3 Q. It must have been known then that on this particular
4 operation there was a high death rate. That must have
5 been something which was impinging on the thoughts of
6 the anaesthetists at this stage; am I right?
7 A. Yes, I think so. I think "comparatively" high mortality
8 rate would be my interpretation because I remember at
9 the Brompton that the goal we were working to in our
10 arterial switch programme was a 5 per cent mortality.
11 That was just a ball-park figure that people talked
12 about.
13 Q. But you do not now recollect what the figures were that
14 would have been discussed at this meeting, or do you?
15 A. I do not think we actually had figures. I think we just
16 knew of deaths that had occurred and we wanted to find
17 out in what context those deaths were occurring, whether
18 they were in the context of a 5 per cent mortality rate
19 or something very different.
20 Q. Which of you attending the meeting were actually doing
21 the paediatric anaesthesia for this sort of operation?
22 Dr Williams was not; Dr Burton was not, was he?
23 A. No, Dr Burton was a paediatric --
24 Q. Was he actually anaesthetising for these operations?
25 A. I do not know whether he did switches or not.
0144
1 Q. Dr Masey did, I think?
2 A. Yes.
3 Q. Dr Monk?
4 A. Yes.
5 Q. And if we go over, Dr Baskett?
6 A. No, adults only.
7 Q. Dr Short?
8 A. Adults only.
9 Q. And obviously yourself?
10 A. Yes, paediatric/adult.
11 Q. In a sense there was obviously a reason for your needing
12 to keep your head down because you were one of those
13 involved in the actual programme?
14 A. Yes, I think the impression I got from Peter who had
15 also trained in Belfast where James trained and they
16 were reasonably close friends, was that Peter had heard
17 from James that he was not happy with what had gone
18 before.
19 Q. The way of dealing with the concerns here was to take
20 it through the department and get the head of the
21 department, the directorate, to raise those issues of
22 concern with the surgeons involved and, I do not know,
23 perhaps the cardiologists. That was the proper way of
24 handling a concern such as this, was it, do you think?
25 A. I think it was appropriate that we all discussed the
0145
1 concerns and that they were taken as a specialist group
2 to the surgeons rather than individuals being possibly
3 picked off in expressions of concern.
4 Q. Would it be the case that concerns such as this are
5 likely to be seen to have a greater impact and force if
6 they are indeed the concerns of a group putting it
7 forward as such?
8 A. Yes, I think they would carry more weight if the
9 director was conveying those concerns, yes.
10 Q. Can I take you back to a meeting in 1990 and then
11 forward to one in 1991 because they straddle both sides
12 of the meetings and the events we have been talking
13 about in relation to the letter which you wrote to
14 Dr Roylance in August 1990.
15 A. Yes.
16 Q. The first is UBHT 61/126. This is described as an audit
17 meeting. It is the first I think that we can find of
18 its type after the letter in 1989, do you remember
19 I showed you that earlier from Dr Martin saying "here
20 I am co-ordinating these meetings"?
21 A. Yes.
22 Q. They were going to be, if you remember, quarterly
23 meetings at which the workload of the unit was going to
24 be discussed?
25 A. Yes.
0146
1 Q. Present we can see the surgeons, cardiologists and at
2 least two anaesthetists, yourself and Dr Monk?
3 A. Yes.
4 Q. "Open heart surgery under 1 year. Clinical details and
5 outcome, patients that underwent heart surgery for 1989
6 were reviewed. Overall 39 patients were treated with 14
7 deaths giving an overall mortality of 35 per cent."
8 Then if we just scroll down, VSD, Senning, TAPVD,
9 go overleaf, AVSD, other operations and "Future
10 direction".
11 Can we go back to the first page? This meeting
12 appears to be reviewing the figures we have seen for
13 1989 and the comparative figures comparing Bristol with
14 the rest of the UK.
15 A. Yes.
16 Q. Do you recall the discussion at this meeting?
17 A. I recall being present at the meeting and I can recall
18 the data being put up. Again it is a Monday morning and
19 I would have had a cardiac surgical commitment in the
20 BRI following the meeting, so I can also remember that
21 I left the meeting before the end or as soon as the sort
22 of last agenda item was put up. Then I would have gone
23 down the road and started my cardiac list.
24 Q. You would have got the minutes?
25 A. I am not sure whether the minutes were only produced at
0147
1 the next of these meetings which I may not have attended
2 so I may not have seen these minutes, I do not recognise
3 having seen them before.
4 Q. Let us look at what it says. You were saying earlier
5 that when you had an audit meeting obviously what is
6 important is the discussion but also the recording of
7 the discussion, and here it appears there is
8 considerable recording of discussion that took place at
9 this meeting. You say in what you had told me about the
10 background to the letter of 1990 that there had been
11 a discussion about VSDs beforehand?
12 A. Yes.
13 Q. Do you think it was this meeting at which the VSD
14 results were discussed?
15 A. No, no, there was a VSD meeting at the BRI. It was in
16 the common room of the anaesthetic department, again it
17 was an evening meeting.
18 Q. It would follow that the VSD results had been discussed
19 more than once before you wrote your letter to
20 Dr Roylance?
21 A. Yes.
22 Q. Here, nine patients, two deaths, and it deals with the
23 cause or supposed cause of the deaths. "Post-operative
24 pulmonary hypertensive difficulties"; that is
25 a recognised problem for congenital heart conditions in
0148
1 this age group, is it not?
2 A. Yes.
3 Q. There is a discussion about phenoxybenzamine?
4 A. Yes.
5 Q. Which would interest you because that is a drug which
6 would fall particularly within your speciality?
7 A. Yes.
8 Q. There were pros and there were cons to it but in
9 general, at this stage anyway, the pros were thought to
10 outweigh the cons?
11 A. Yes. Can I say that the new regime of phenoxybenzamine
12 was the regime that had been raised at the earlier VSD
13 meeting at the Bristol Royal Infirmary by Kevin Waterson
14 who was an Australian cardiac surgeon who is now in
15 Leeds who had been to Melbourne where they used
16 phenoxybenzamine as a routine and we were adopting this
17 routine on his recommendation. So this meeting
18 postdates the earlier meeting on VSDs.
19 Q. So it describes and talks about the causes of the
20 deaths, one would suppose, with a view to preventing any
21 such death happening again?
22 A. Yes.
23 Q. It deals with the Sennings repairs and the results and
24 possible explanations for the particular results. The
25 last two sentences:
0149
1 "The merits of changing neck lines and use of
2 Doppler ultrasound... No definite policy changes were
3 recommended at this stage."
4 One has the flavour, does one, of trying to
5 understand why particular deaths occurred, reviewing
6 procedure in the light of the results with a view to
7 seeing whether any change was needed and no doubt if so,
8 monitoring the change would be what one would expect?
9 A. Yes.
10 Q. The same for "TAPVD". It looks there as though the
11 discussion is aimed more at the cardiologists than the
12 anaesthetists or the surgeons, if one looks at the very
13 last paragraph on the page?
14 A. Yes.
15 Q. That was, was it, from time to time when you had such
16 discussions said to be a problem; sometimes the surgeons
17 felt they did not have the anatomy sufficiently clearly
18 defined when they came to operate?
19 A. I think it was an occasional complaint of the surgeons,
20 yes.
21 Q. The next page, "AVSD". Again, there is going to be
22 a review of that. "Other Operations", "Further
23 Direction". Can we go down. Looking at VSDs with
24 a view to trying to get it right, a reflection so far as
25 Sennings is concerned as to the age of operation and
0150
1 then a comment on the tetralogy of Fallot.
2 This meeting appears to look at most of the
3 complex operations performed by the unit in March 1990,
4 does it not?
5 A. Yes.
6 Q. The exception is the switch but at that stage the switch
7 was being done largely on older children, was it not,
8 the children tended to be over 1 year of age because, as
9 we understand it, it was the arterial switch where one
10 found a transposition of the great arteries in the
11 presence of a VSD?
12 A. Yes.
13 Q. So it was amenable to later, albeit more complex,
14 repair?
15 A. (Witness nodding).
16 Q. Have I got it right?
17 A. I think that is right. Without looking at the series in
18 detail, I think you are probably correct.
19 Q. In some respects a different operation from the neonatal
20 switch which would be, what one might describe, as
21 a simple transposition anatomically?
22 A. Yes.
23 Q. This, on the face of it, records an analysis of
24 statistics, a discussion as to how to improve figures
25 which are thrown up, certainly not an acceptance of
0151
1 those figures as being good enough and pointing the way
2 forward in various respects which could be monitored
3 thereafter; is that do you think a fair reflection of
4 what the minutes suggest?
5 A. Yes, I think that is a reasonable summary.
6 Q. Do you accept that those minutes are probably
7 a reasonably fair summary of the meeting that in fact
8 took place?
9 A. Yes. As I say, I have not seen these minutes before,
10 I do not think, because they would probably have been
11 produced at the next of the Monday morning meetings and
12 I did not attend the Monday morning meetings on
13 a regular basis. This was an unusual arrangement where
14 I think Chris Monk and I have been asked to the meeting
15 because -- and the theatre start was delayed because of
16 that.
17 Q. This was the unit in March 1990 coming to grips with the
18 poor results, or trying to?
19 A. I am not sure it necessarily accepted that these were
20 poor results, I think that was my problem. The
21 impression I was getting from the unit was that we
22 should carry on with what we were doing because it
23 seemed to be perfectly adequate and my problem was that
24 I did not think this was adequate.
25 Q. That is a problem, is it not, of interpretation of the
0152
1 data? One begins, does one not, with the crude
2 difference?
3 A. (Witness nodding).
4 Q. In the statistics to which I have drawn your attention
5 to the difference between 37.5 per cent on the one hand
6 as against 18.8 for the UK as a whole including Bristol
7 on the other?
8 A. Yes.
9 Q. So on the face of it there is a difference which has to
10 be explained in some way. One does not know because of
11 the size of the figures how much may be due to chance,
12 that is inevitably the first point?
13 A. Yes.
14 Q. One does not know whether there are particular factors
15 relating to particular cases on the face of the figures,
16 does one?
17 A. No.
18 Q. Again, if one looks here at 19th March 1990 meeting,
19 there appears to be an attempt to grapple with whether
20 there may be particular factors in particular cases to
21 explain at least some of the cases?
22 A. Yes.
23 Q. Whether such explanations might have applied elsewhere
24 is for elsewhere to say; that is effectively the flavour
25 of it?
0153
1 A. Yes.
2 Q. One does not, you are quite right, get an impression
3 from this document that there is a crisis because
4 Bristol is so far out of step with elsewhere, one gets
5 rather a sense that there are explanations for figures,
6 the figures are taken into account and a way forward is
7 looked for?
8 A. (Witness nodding).
9 Q. Have I interpreted the resonance of the document
10 correctly or not?
11 A. I think that is probably right. It was the type of
12 analysis that Alan Bryan in his evidence suggested was
13 one of the problems with lack of improvement in Bristol
14 and that there was always a desire to identify the
15 problems and then explain them away on that basis. You
16 have to remember that this is the second year and if we
17 look at the 1990 to 1991 statistics it will be confirmed
18 that this is the second year where our mortality rate is
19 twice the national average.
20 What I am saying is "This is an immediate problem,
21 we have to do something about this", that is why I wrote
22 to the District General Manager because this meeting is
23 saying "There is not a problem, we will carry on and
24 explain away our results on the basis of unusual anatomy
25 or, whatever".
0154
1 Q. Why did you not then say at this meeting in March 1990
2 to the assembled company "Look, have we not missed
3 something here? These results are really so bad that we
4 ought to investigate in greater detail"?
5 A. I think the data that was presented at the beginning --
6 it is on the preceding page -- was just the crude
7 35 per cent mortality rate. Exactly how that compared
8 to national average may not have been immediately
9 apparent or may not have been readily available.
10 I am not sure any tables were produced with the
11 data presented at this meeting. If tables had been
12 produced or produced subsequently then it may have been
13 we would have said "This really is not very good at all,
14 we really do need to do something about this" and
15 I think under those circumstances you have a different
16 interpretation of what I thought was data that needed
17 something urgent to be done about it.
18 Because you have to remember, if these children
19 had been sent to any other hospital with the national
20 average performance or better they would have survived.
21 That to me was the constant comparison: would this child
22 have survived in another hospital? If the answer to
23 that was "yes" it was very urgent that we did not expose
24 that child to any further risk.
25 Q. Can I have a look at UBHT 61/128. This I understand,
0155
1 can we scroll down, appears to be the figures, albeit at
2 this stage handwritten, which were displayed at this
3 meeting. We can go over to 61/130 where we have them
4 written up. Can we scroll down. You see the note that
5 someone has made at the bottom there, UBHT 61/133,
6 corrects, if you see the top line, the VSD figure. So
7 if we go down to the bottom -- it is not very easy to
8 read -- you will see there the figures have been
9 adjusted to 39 and 14, 39 operations, 14 deaths, which
10 is exactly the figures we have in the first line of the
11 meeting. That is why we understand these are the
12 figures that were presented to the meeting at the time.
13 Indeed, you will see, albeit this is a poor copy
14 -- perhaps you had better go back to the one before
15 because it is clearer and easier to read -- this shows
16 the differentiation between the various series of
17 operations. It also, as it happens, shows the different
18 performance of the two surgeons, it breaks it down by
19 surgeon as well as by unit.
20 A. Yes.
21 Q. When the figures were produced comparing these results
22 with the national results which came, as you have
23 agreed, shortly thereafter --
24 A. Yes.
25 Q. -- and it was apparent that these results were on the
0156
1 face of it showing a discrepancy from the UK average,
2 what degree of alarm if any do you recall there being
3 within the unit?
4 A. I cannot really remember any alarm I do not think about
5 the nature of the results.
6 Q. Was there any alarm so far as you were concerned?
7 A. I think, yes, because I wrote to the District General
8 Manager.
9 Q. I think you are describing there that because you took
10 a certain act you had a particular feeling, where
11 I think the actual description you have given us is you
12 had the feeling of alarm or concern, hence you wrote.
13 Leave that aside.
14 What we have are these figures analysed at the
15 audit meeting. Given the best figures --
16 A. Can I say that before we had these figures we would have
17 had 15 months or even 18 months of rising concerns about
18 the length of bypass times, watching the operative
19 techniques of the surgeons, we would have had not just
20 this first set of figures, but we had talks amongst
21 cardiac anaesthetists saying "It does take a long time,
22 I am not sure this is right". It was not just one set
23 of figures that triggered something, it was the
24 culmination, it was the gradual rising tide of concern
25 certainly on my part and I felt some of those concerns
0157
1 were shared by my colleagues.
2 Q. Looking at the notes, going back to 61/126, it does not
3 appear at this meeting that anyone raises any query over
4 cross-clamp times or the length of operations?
5 A. There are no cross-clamp times documented or operation
6 lengths documented and there is no comparative data
7 provided in this minute.
8 Q. No-one says "Can we have a comparative analysis of such
9 data?"
10 A. No, that is true.
11 Q. May I take it that neither you nor Dr Monk asked for
12 such data at this stage?
13 A. No, I think we probably expected to see it at some
14 stage, but we certainly did not ask for it at that
15 meeting.
16 Q. This was at a stage before you had the meeting with
17 Mr Wisheart and there was no reluctance on your part to
18 put your head above the parapet if need be?
19 A. No, no.
20 Q. Can we look, please, at the meeting which takes place
21 after --
22 A. Can I add to that "no": there was always a sensitivity
23 in the unit on the part of the surgeons as to their
24 results and I think that became increasingly apparent as
25 time went on and it was a very intangible thing, very
0158
1 difficult to actually document, but there was an
2 enormous sensitivity about poor results in paediatric
3 cardiac surgery.
4 Q. Can I ask you to move on to 61/145. Your memo of the
5 17th September 1991 enclosing minutes of a meeting of
6 28th July 1991?
7 A. Yes.
8 Q. We have seen what was happening in March 1990, looking
9 at the various operations and the way it was there
10 done. We have gone forward now 15 months and in the
11 middle was your letter to Dr Roylance and the meetings
12 you have told us about?
13 A. Yes.
14 Q. I have the chronology right, have I, that is the way it
15 went?
16 A. I cannot tell you exactly when, I do not think we have
17 decided on a time for the meeting at which Peter Baskett
18 said "keep your head down" but if it was the winter of
19 1991 then it would have antedated this meeting, yes.
20 Q. The winter 1990 you mean?
21 A. 1990 to 1991.
22 Q. Let us have a look at that meeting, 61/146: at
23 Mr Wisheart's house and the purpose is to review the
24 progress and management of pulmonary hypertension. That
25 picks up the theme raised the previous March, does it
0159
1 not?
2 A. Yes.
3 Q. Review of difficult operations e.g. Fallots, AVSD
4 et cetera?
5 A. Yes.
6 Q. There was a recognition in the unit they were difficult
7 operations?
8 A. There was a recognition by me because I produced these
9 minutes. I thought I was reflecting what the unit told
10 me, but I was subsequently told after producing these
11 minutes that they were not representative and I was not
12 to produce them ever again.
13 Q. So far as you were concerned was that on the agenda?
14 A. Was what on the agenda?
15 Q. The review of difficult operations, e.g. Fallots, AVSD
16 and so on?
17 A. The meetings in people's houses did not have agendas and
18 I was trying to formalise this type of discussion
19 because I felt this was a point at which we could
20 actually begin to constructively decide what we were
21 doing well and what we were doing badly and if we were
22 doing something badly then to make sure we did not keep
23 on doing it badly.
24 Q. Let me concentrate on what happened. Your description:
25 "By way of introduction to the meeting,
0160
1 Mr Wisheart provided tables of open and closed cardiac
2 surgery results for the Bristol paediatric unit."
3 That is what you say, so presumably that happened?
4 A. Yes.
5 Q. "Comparison was made for mortality in the Bristol
6 Cardiac Unit in 1990 and the UK national average in
7 1988"?
8 A. Yes.
9 Q. That presumably is what happened?
10 A. (Witness nodding).
11 Q. Figures were being made available at this stage to
12 everyone in the unit including yourself?
13 A. Yes.
14 Q. May I take it there was no difficulty at this stage in
15 obtaining such figures?
16 A. I think they were presented at these meetings but I do
17 not think I necessarily saw the data being circulated
18 afterwards. I mean I certainly do not have copies of
19 the data from that March 1990 meeting and I do not
20 remember having copies of this data, although it did
21 appear in the annual report for 1990/1991. So data was
22 produced at meetings but it was not necessarily readily
23 available within the unit.
24 Q. Let us have a look at the data. 55/82. This was the
25 summary data, was it?
0161
1 A. I am not sure. This to me looks like the data that was
2 produced at the end of the 1990 annual report. Whether
3 it was the data that was shown at the meeting or not
4 I cannot tell you.
5 Q. Shall we turn over the page to 55/83.
6 Simple/moderate/complex operations there set out. 84 to
7 89 and 90 are the total operations and the percentage of
8 those operations. Then we go to the next page, "30-day
9 mortality by complexity", there is a picture painted
10 there analysing into "simple", "moderate" and "complex",
11 which would appear to suggest that Bristol from 84 to 89
12 had a mortality rate in complex operations on the over
13 ones of 26 per cent. In 1990 45.5 per cent compared to
14 the UK 1998 figures of 18.2 per cent.
15 So in complex operations in the over ones the
16 information available to Bristol, to the unit, was
17 suggesting a mortality taken across the years 84 to 90 a
18 six-year period which statistically would be giving you
19 figures getting on for robust?
20 A. Yes, yes.
21 Q. Of more than twice the UK?
22 A. (Witness nodding). Can I ask where this data came from,
23 was it the back of the 1990 annual report or is this
24 from another source?
25 Q. This we understand to have been the data available at
0162
1 and for the meeting. This is why I am asking you about
2 it. Indeed it comes from the 1990 report as well.
3 A. I think if this had been presented at the meeting
4 I would have wanted to express serious concerns about
5 what was happening in these complex and moderately
6 complex operations. I would have been suggesting that
7 we needed to find out where the mortality rate was in
8 these procedures and that we should actually be looking
9 at not doing it or we should be improving our practice.
10 Q. If you have a look at table 7 which is page 88, looking
11 at the under 1s here where you may remember that 1984 to
12 1989 had shown a bad, in terms of high, figure earlier,
13 and the 1990 figure is considerably lower. So it is
14 32.2; 1990 12.8 compared to the UK 1984 to 1988 figure,
15 21.2; that is the comparison which is made there.
16 A. Yes.
17 Q. If we go overleaf, page 89, there is a breakdown of
18 those figures that you may want to take a moment to look
19 at.
20 A. Yes.
21 Q. Which would appear to suggest that the complete AVSD was
22 a problem operation, that there was (as you had thought)
23 an appearance that the VSD mortality was high and TGA,
24 that is transposition of the great arteries I think plus
25 VSD, again getting on for double the UK 1988 mortality.
0163
1 So those are the figures that are presented?
2 A. Yes.
3 Q. Can we go back to page 146, 61/146. Scroll down,
4 please:
5 "By way of introduction" I would ask you to focus
6 on those words "Mr Wisheart provided tables of open and
7 closed cardiac surgery results for the Bristol
8 paediatric unit."
9 Those are your words. That would suggest you did
10 not simply put it up on a blackboard or a whiteboard.
11 If you look at the paragraph which follows:
12 "Dr Bolsin said that he thought that the data in
13 the tables in which the Bristol mortality was higher
14 than the UK average for 2 years prior", the description
15 table fits with what we have just seen, does it not?
16 A. Yes.
17 Q. Do you think, looking at that, that the tables I have
18 shown you must have been the tables viewed at the
19 meeting?
20 A. Yes, I think they could well have been.
21 Q. There appears, does there, to have been discussion about
22 what those tables showed and how serious a picture they
23 painted?
24 A. Yes.
25 Q. The third paragraph: "Mr Dhasmana and Mr Wisheart both
0164
1 made the point that there had been recent improvements
2 in operative and post-operative management on the BRI
3 site in the last year which had made meetings like this
4 extremely valuable." Then it says how successful they
5 had been in dealing with pulmonary hypertension at the
6 previous meeting, which I think is a reflection back to
7 the previous March?
8 A. Yes.
9 Q. These are your minutes. That presumably was said, was
10 it, as you recollect it?
11 A. I think, yes, all of those comments were made during
12 that meeting.
13 Q. Did you, as the second paragraph might lead us to
14 believe, put your pennyworth in, commenting upon the
15 data and commenting upon the difference between Bristol
16 which had a higher mortality and the UK which had
17 a lower mortality?
18 A. Yes, I would have to look at the figures again. I am
19 slightly confused by the table we had up immediately
20 prior to this because it compares the 1984 to 1990 data
21 all together and I wanted to look at the reason why
22 there was a 12.8 per cent overall mortality in the 1990
23 data. I think it was because there was an increase in
24 survival in the VSDs, but I am not sure that there was
25 any change in the survival of some of the other complex
0165
1 operations.
2 Q. What I propose is that you will have a chance to look at
3 that overnight. We are coming to the time I promised
4 you we would finish.
5 The question which arises out of this is that it
6 would appear from your own record that you are taking as
7 it were the lead in saying "Look, the fact that the
8 mortality was higher than the UK for two years
9 previously vindicates the vigilance of the anaesthetic
10 staff in recording their mortality data and vigorously
11 pursuing requests for a combined meeting".
12 You are emphasising your role in bringing this
13 sort of review about, are you not?
14 A. I thought that minute correctly did that, but the
15 minutes were never accepted by the group.
16 Q. Your recollection of the meeting, is that what you did?
17 A. I think I said that I was pleased that as anaesthetists
18 we had been able to bring about this combined meeting
19 where we had been able to share figures.
20 Q. Did you use words such as are recorded there,
21 "vindicated the vigilance of the anaesthetic staff"?
22 A. I think I am summarising certainly the feeling of
23 Dr Burton, Dr Masey, Dr Monk and myself that the
24 anaesthetists had now managed to get hold of some data
25 which indicated we were probably improving some of our
0166
1 operative records but it may be some of the others were
2 staying the same.
3 Q. The point for you to comment on is this: you are
4 recording yourself here as being the front-runner on
5 this particular point?
6 A. I am recording paediatric cardiac anaesthetists.
7 Q. Have a look at what is said: "Dr Bolsin said ... This
8 was supported by"?
9 A. But what Dr Bolsin said, with all due respect, was that
10 this "vindicated the vigilance of the anaesthetic
11 staff". Dr Bolsin was not going to put his head above
12 the parapet again. He was going to say: "As a group we
13 have got together and we have done it together. No one
14 person here has said anything particularly out of the
15 ordinary. This has been a group effort of the cardiac
16 anaesthetists" and I wanted that recognised.
17 Q. So do we have this position at that stage: you would not
18 on your own want to put forward data, make a complaint
19 or make a criticism because you had been advised that
20 was not the way to go about it and you had to keep your
21 head down, but you were happy to take the lead in
22 representing a common point of view with the other
23 anaesthetists; is that the position we are at?
24 A. That is the position I took at this meeting, yes.
25 Q. You were happy to do that despite what had been said to
0167
1 you by Mr Wisheart a few months earlier?
2 A. I was happy to document that my view was supported by
3 other paediatric cardiac anaesthetists.
4 Q. That is not the question. You were happy, were you, to
5 take the lead in saying, knowing no doubt you would be
6 supported by others at a meeting such as this despite
7 what had been said to you by Mr Wisheart at a meeting
8 the previous autumn or earlier that spring?
9 A. You will have to repeat the question, I am sorry.
10 Q. I will break it down: you were happy to say what you
11 did?
12 A. Yes.
13 Q. What you said is reflected by that paragraph, is it?
14 A. Yes.
15 Q. You were happy to say that despite the warning-off which
16 Mr Wisheart, as you recall it, had given you the
17 previous autumn or earlier that spring?
18 A. I was happy to say it knowing that I was supported by
19 the cardiac anaesthetists.
20 Q. And it was the support of the cardiac anaesthetists that
21 made the difference because you were not doing it on
22 your own; is that the point?
23 A. It was important that we all said the same thing because
24 if they had not been prepared to support me I would not
25 have been able to say "This is ... ", I would not have
0168
1 been able to say the first sentence. I was not prepared
2 to say it on my own, I was only prepared to document it
3 with the support of the others.
4 MR LANGSTAFF: I am not sure, Dr Bolsin, that there is
5 anything between what I am putting to you and what you
6 are saying to me, but if there is, you might like to
7 reflect on it overnight and we will come back to it in
8 the morning.
9 THE CHAIRMAN: Dr Bolsin, thank you.
10 Mr Langstaff, thank you also. We now adjourn
11 until 9.30 tomorrow morning. You reminded us I think
12 last Thursday that it is a day which will end, correct
13 me if I am wrong at around --
14 MR LANGSTAFF: Around 1.00, at a convenient moment around
15 1.00. What is anticipated, subject to yourself,
16 Chairman, is that we will have one morning break of
17 about a quarter of an hour in the middle of the morning
18 session.
19 THE CHAIRMAN: That is helpful. Shall we adjourn until
20 tomorrow morning at 9.30. Good afternoon to everyone.
21 (4.35 pm)
22 (Adjourned until 9.30 am on Tuesday, 23rd November 1999)
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5 Examined by MR LANGSTAFF ................... 1
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001