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Daily transcripts
Hearing summary
24th 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 continued his evidence today by discussing the
management of the cardiac intensive care unit focussing on its mixed use for both adult
and paediatric patients. He then returned to his discussions regarding his concerns about
the paediatric cardiac service in 1992 with Dr Phil Hammond, GP trainee, one half of the
satirical double act "Struck Off and Die" and columnist with Private Eye
Magazine. He commented on the collection of outcome data he undertook with Dr Andy Black
of Bristol University, identifying sources of figures and who had recorded them. He talked
about when, where and with whom he shared his concerns and mortality data both within and
outside the Trust. He then spoke about the role of the Director of Anaesthesia and other
consultants in bringing the concerns of the anaesthetists to the cardiac surgeons and the
hospital management. He concluded today’s evidence by discussing an evening meeting
he had with Dr Chris Monk, Director of Anaesthesia, Professor Gianni Angellini, Professor
of Cardiac Surgery and Mr James Wisheart, Medical Director and Cardiothoracic Surgeon.
Dr Bolsin’s evidence continues tomorrow morning after the evidence
of Diana Hill, a parent from Bristol who will commence the oral hearings at 9.30 a.m.
|
FULL TRANSCRIPT
1 Day 82, Wednesday, 24th November 1999
2 (9.45 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Mr Langstaff.
5 MR LANGSTAFF: CLARIFICATION OF SCOPE OF THE
6 INQUIRY IN THE LIGHT OF RECENT MEDIA REPORTING:
7 MR LANGSTAFF: Good morning, sir. Sir, it is regrettable
8 that we should be starting late this morning. As ever,
9 and at the risk of giving the same old excuse again,
10 what has happened is that we have had an amount of
11 documentary material and information which has come to
12 us really very late in the day which it will be
13 necessary to ask Dr Bolsin about at an early stage. Can
14 I identify what they are, but first of all say that the
15 latest piece of information which has come to me which
16 we have not yet been in a position to check
17 authoritatively, but nonetheless which requires
18 a comment is this: apparently BBC Radio 4 yesterday
19 mentioned, it is reported to us, that this Inquiry was
20 investigating the deaths of 29 babies and the cases of
21 4 children who had been brain damaged.
22 That plainly is a misconception or a misreporting
23 and whether it was misheard by the person listening to
24 BBC Radio 4, whether it was an error in that programme,
25 it does need to be said that of course this Inquiry has
0001
1 a much wider perspective than the deaths of 29 babies
2 and the cases of 4 who have been brain damaged.
3 I have said repeatedly, but it probably bears
4 repetition now, particularly given some of the evidence
5 we heard yesterday, that the scope of this Inquiry is to
6 look at all complex paediatric surgical services from
7 1984 until 1995. What that means is that we have
8 already carefully analysed and examined the records in
9 detail of very nearly 1,900 children who underwent
10 paediatric cardiac surgery between those years. We have
11 had information from a considerable number of others who
12 have had follow-up from earlier operations within those
13 years; we have examined moreover of those cases 80 as
14 a sample in order to draw representative lessons.
15 The focus, it needs to be said, is upon the whole
16 of paediatric cardiac surgical services. As Dr Bolsin
17 himself said yesterday, cardiac surgery is a team effort
18 and looking at the outcomes of a unit mean that
19 inevitably you as a panel have to be prepared to focus
20 upon any part and the whole of the unit, not simply upon
21 two or three surgeons or doctors who were subject to
22 disciplinary proceedings at the GMC. They come into it
23 but they are not necessarily the whole picture. It is
24 the whole picture which this Inquiry is required to look
25 at, consider and evaluate.
0002
1 I am sorry for repeating what you the Panel will
2 know. The reason I am doing it is because of the report
3 which of course is disturbing, particularly at this
4 stage in our proceedings. It has to be said, since the
5 comment which has been handed to me relates to the BBC,
6 albeit Radio 4, that the commentator has expressly
7 complimented the BBC's TV journalist Fergus Walsh for
8 the accuracy of his reporting.
9 THE CHAIRMAN: Mr Langstaff, thank you for that.
10 We have been here since March and I thought we had
11 made it clear from the outset what our intention was,
12 indeed what our terms of reference required of us. You
13 have set them out again this morning very clearly. One
14 would hope that that would be heard by all and proper
15 account be taken of it.
16 MR LANGSTAFF: Thank you. I am told by Miss Grey that what
17 I said may have sounded like a criticism of Mr Fergus
18 Walsh; it was quite the opposite. Again that needs to
19 be made clear; he has been complimented upon the
20 accuracy of his reporting. The reason I mentioned him
21 is that he is of course a correspondent for the BBC and
22 the commentator who passed the information to us, which
23 as I say we have yet to authenticate but it seemed to
24 justify a commentary at the start of today relating to
25 the radio programme with which, as far as I know, he may
0003
1 not have been involved.
2 THE CHAIRMAN: For obvious reasons we express no view on any
3 commentator save to remind all of what you said at the
4 outset.
5 MR LANGSTAFF: The second reason is that we have had
6 documentary material which has been handed to us by
7 Dr Bolsin which consists of the originals of the
8 material which I understand he will say he obtained from
9 the perfusionist. Let me just verify that.
10 DR BOLSIN: Yes, that is right.
11 MR LANGSTAFF: We are having that scanned in. It has to be
12 redacted in order to ensure patient confidentiality and
13 once we have done that there will be some tidying-up
14 questions which will arise from that.
15 There are also some other tidying-up matters, but
16 the third thing which again is one of the matters I will
17 come to very early on today is a document which has come
18 into our possession which is dated 19th April 1995 and
19 touches upon the issues we were dealing with yesterday,
20 which was amongst other things, the management and
21 organisation of the Intensive Care Unit for
22 post-operative care.
23 DR STEPHEN BOLSIN (RECALLED):
24 Examined by MR LANGSTAFF:
25 Q. First, Dr Bolsin, before I come to that letter which
0004
1 I will in a moment or two, can I tidy up some of the
2 aspects we were looking at yesterday?
3 A. Yes.
4 Q. First of all I think just so there is no
5 misunderstanding, when Dr Hammond gave evidence to us,
6 you may know because you have I think followed some of
7 the transcripts --
8 A. Yes.
9 Q. -- that he felt unable to say that he had identified
10 himself as "MD", the correspondent for Private Eye?
11 A. Yes, that is right.
12 Q. Nothing that I said yesterday of course suggested that
13 he did.
14 A. Thank you.
15 Q. For those who are listening, that perhaps needs to be
16 made clear, and I make it clear.
17 A. Thank you.
18 Q. The second matter is: you told us yesterday that you
19 had not ever claimed that you had passed your data or
20 information to the Royal College of Surgeons?
21 A. Yes, that is true.
22 Q. Would you please have on the screen WIT 80/102, it comes
23 off the internet and it is a copy of "Blowing the
24 Ethical Whistle" written by Amanda Tattam, an Australian
25 doctor, of 31st July 1998. Have you ever met
0005
1 Amanda Tattam?
2 A. No, I do not think I have actually. This was an
3 interview that was conducted, I think probably with
4 telephone calls and possibly the odd e-mail.
5 Q. The material for her article about "Blowing the Ethical
6 Whistle" probably came from her information about you
7 and things which you may have said over the telephone?
8 A. Yes, I think that is probably true. She may have
9 attended one or two of the lectures that I had provided
10 as well.
11 Q. Can we go to WIT 80/103. "How it Started", bottom of
12 the page. It sets out there an account of how it began
13 and quotes you as saying:
14 "'Control was held by one person and no-one felt
15 able to challenge him because of the system of
16 patronage', Dr Bolsin says".
17 Do you think you probably said that?
18 A. Sorry?
19 Q. It is beside the mark at the top left-hand side.
20 A. Yes.
21 Q. Do you think you probably said that?
22 A. I think what she is actually quoting is the general gist
23 of what I was saying. I could not comment seriously on
24 whether I had actually said that or not. I may well
25 have used those phrases, whether I used them in that
0006
1 exact sentence I would not be able to say.
2 Q. "Then the subtle warnings came over to threats", the
3 next quote attributed to you: "I went through an
4 appalling five years at Bristol but I tried to work
5 within the system to achieve change, that is why I do
6 not think I am a whistleblower. I went to the Royal
7 College of Surgeons and the Royal College of
8 Anaesthetists, the Trust, and the Professor of Cardiac
9 Surgery" and the quote ends and it goes into reported
10 speech.
11 Did you, do you think, say that?
12 A. I think she may have misinterpreted. I would have said
13 I alerted the Royal College of Surgeons and the Royal
14 College of Anaesthetists. I never actually went to the
15 Royal College of Anaesthetists, I spoke to the President
16 Elect of the Royal College of Anaesthetists who was
17 Cedric Prys-Roberts, but there was no question of going
18 to the Royal College of Anaesthetists and I did alert,
19 I thought, the Royal College of Anaesthetists. I also
20 thought that I alerted through John Zorab the Royal
21 College of Surgeons.
22 Q. Because it would be wrong, I take it, to say (if it were
23 accurate) that you went to the Royal College of Surgeons
24 because you did not, you spoke to John Zorab and you
25 later understood he had spoken to Sir Terence English?
0007
1 A. Absolutely right.
2 Q. That is the route, you never spoke to Sir Terence
3 yourself?
4 A. No.
5 Q. The Royal College of Anaesthetists, that is similar in
6 the sense that Dr Cedric Prys-Roberts became the
7 President of the Royal College of Anaesthetists and you
8 had spoken to him beforehand, as we will talk about this
9 morning.
10 A. Yes, I think that Sheila Willatts who was also the
11 Director of Intensive Care in Bristol was on the Council
12 of the College of the Royal College of Anaesthetists, so
13 by sharing concerns with her I felt that I was alerting
14 the Royal College of Anaesthetists, but I had not gone
15 formally to the Royal College of Anaesthetists.
16 Q. This is a misquotation even though it is in quotes, is
17 it?
18 A. I would have said so, yes.
19 Q. Could we have a look at WIT 80/79. Again to put this
20 in context before I go to page 79, can we go to
21 WIT 80/75, please?
22 ABC Radio National, it is a health report
23 transcript for 12th May 1997. It is the health report,
24 a severe case of surgical misconduct, and Norman Swan
25 presents the programme.
0008
1 Do you recollect taking part in this programme?
2 A. Yes, I do.
3 Q. We see a transcript beginning there. Can I take you to
4 WIT 80/79. The top of the page:
5 "Norman Swan: Now you have said you complained
6 to the hospital authorities. What sort of response did
7 you get?"
8 Your answer: "The response that I got was a very
9 unofficial one. I certainly got no written response
10 from the hospital, but I was hauled up in front of the
11 Chairman of the Hospital Medical Committee and also the
12 Chief of Cardiac Surgery, who was Mr James Wisheart, and
13 told this was not really the way to behave and if
14 I valued my position in Bristol then I would not be
15 doing this kind of thing again."
16 That is exactly what you told us yesterday?
17 A. Yes.
18 Q. " -- which essentially, as a young consultant I had been
19 in the post probably less than two years, this was
20 a very serious threat to my livelihood and I think as a
21 result of that I took stock and I then decided on other
22 avenues, which were..." and you then are reported to
23 have said this: "...the President of the Royal College
24 of Surgeons, who is Sir Terence English, and I contacted
25 him and provided him with my own figures and I know that
0009
1 he subsequently told the Department of Health that
2 Bristol should be dedesignated as a supra-regional
3 centre."
4 A. Yes.
5 Q. Did you say that?
6 A. If that is what the transcript says then I would have
7 done. I think what I meant was I contacted him
8 indirectly because, as we have established, I did not
9 actually speak to Sir Terence English.
10 Q. That is what you told me a moment ago.
11 A. That is true.
12 Q. "And provided him with my own figures"?
13 A. The figures would have been the figures that were
14 concerning me and they would have been through
15 John Zorab.
16 Q. Because you did not give figures to John Zorab, did you?
17 A. I would have discussed possibly twice the national
18 average mortality rate, but I would not have given him
19 detailed figures, no.
20 Q. So the only figures he could have passed on to
21 Sir Terence was a broad twice the average national
22 mortality rate?
23 A. That sort of figure, yes.
24 Q. That you felt able to describe as plainly, if this is
25 accurate, providing Sir Terence with your own figures?
0010
1 A. Yes, I think if you say that I contacted Sir Terence
2 indirectly then I provided someone with my own figures
3 and the figures that were giving me cause for concern at
4 that time would have been twice the national average
5 mortality rate.
6 Q. Might it have been, do you think, misleading to the
7 listener or the reader potentially who might conclude
8 from what you had said there that you had actually
9 spoken or written to Sir Terence English and given him
10 detailed a tabulation of figures, whereas the reality is
11 that any contact was indirect through a third party to
12 whom you had actually given no tables, no data but you
13 had given a summary overview of what you thought?
14 A. Yes, I think that is right. I am sorry that that
15 impression has been created and I would retract it
16 formally and publicly now. I am sorry about that.
17 Q. The next matter, which again I need to pick up and ask
18 you about is: yesterday you told us that the reason for
19 wanting to discuss concerns about the result within the
20 unit outside the unit involved a paediatrician from
21 Plymouth. If I can quote what we have on the transcript
22 as your answer, you say:
23 "I think the reason was I was concerned about the
24 mortality rate for paediatric cardiac surgery in
25 Bristol. I had been introduced at an anaesthetic
0011
1 meeting that winter to a paediatrician from Plymouth who
2 had actually been involved in (peripherally, not
3 centrally) the change of referral patterns of paediatric
4 cardiac service cases from Plymouth to Bristol to
5 Plymouth to Southampton and I was aware that if there
6 was a perceived problem with the provision of a regional
7 or supra-regional service, the referral pattern was one
8 of the key components to maintaining that service.
9 I think it was important that the region was aware of
10 potential concerns about this unit ..." and you then
11 went on?
12 A. Can I say it was an anaesthetic dinner, it was the South
13 West Region Association of Anaesthetists and it would
14 have been a paediatric anaesthetist not a paediatrician
15 so if I said "paediatrician" I am sorry, I meant
16 paediatric anaesthetist.
17 Q. What part would a paediatric anaesthetist have to play
18 in referral patterns?
19 A. He may well have been an observer, he may well have
20 discussed the conditions, but essentially the
21 conversation we had which had to be an informal one, it
22 was pre-dinner drinks I think, was that he was aware of
23 the problems in Bristol and one of the ways Plymouth had
24 dealt with the problem was to refer patients to another
25 centre.
0012
1 Q. Does he have a name?
2 A. I cannot remember his name. I can tell you who
3 introduced me to him, it was Les Schutt who was one of
4 the consultants in the Bristol Royal Infirmary
5 Department.
6 Q. He was a neurologist, was he not?
7 A. No, Les Schutt was an anaesthetist. There was another
8 Schutt who was a neurologist and we saw some of his
9 notes in the data yesterday.
10 Q. Les Schutt introduced you and the anaesthetist from
11 Plymouth?
12 A. Yes.
13 Q. You cannot remember the name?
14 A. I cannot I am afraid.
15 Q. I do not criticise you for that, it is a long time ago
16 and it is a dinner.
17 A. The reason for being introduced to the chap from
18 Plymouth was because Les said "I know you have concerns
19 about paediatric cardiac surgery in Bristol. Why do you
20 not come and talk to this chap? They have had an
21 experience in Plymouth which may be helpful to you."
22 Instead of talking about the weather or what had
23 been happening at the meeting before or other things, we
24 immediately got into a discussion of referral patterns
25 for paediatric cardiac surgery within the region and how
0013
1 Plymouth had been aware of the problems that Les knew
2 I was aware of and had obviously told this chap and that
3 they had changed their referral patterns as a result.
4 So that was the background to that meeting.
5 Q. The understanding that you had -- I appreciate it is
6 a long time ago and I am asking you to rack your memory
7 for it -- was that the anaesthetist was saying that
8 pediatricians who would refer to one centre or another
9 from the Plymouth area had had concerns about the
10 service of Bristol such that they were transferring
11 elsewhere?
12 A. Yes, that was the gist of what I understood.
13 Q. It would follow that there had been, in his eyes,
14 reported to you, a change of practice as to referral?
15 A. Yes.
16 Q. Did you have any view as to how recent that change of
17 practice was?
18 A. No, we did not talk about the dates of it, we just
19 talked about it as being an existing reality in Plymouth
20 that they did not now refer to Bristol, and the reason
21 was because of the perceived problem and it had led to
22 a change in practice.
23 Q. The dinner was when, 1991, 1990, 1992?
24 A. Yes, they used to have autumn and spring meetings, the
25 South West Region, and this one was at an hotel out by
0014
1 the M32 near the new University out there.
2 Q. Let me tell you why I am asking these questions: the
3 Inquiry is obviously keen to pursue every avenue which
4 may help with information. One of the avenues we have
5 pursued is to go to all the pediatricians that we can
6 identify, we think we have most of them, but we may not
7 have got all of them in the area and amongst those we
8 have had quite a considerable number from Plymouth and
9 anyone who wants to have a look at what they say will
10 find them under the reference as REF 1, and there are
11 various numbers.
12 Thus far all the paediatricians from Plymouth have
13 told us they had no particular problem with Bristol
14 because there was a long-standing practice of referring
15 which goes back to before 1982 from Plymouth to
16 Southampton. What you are saying is of particular
17 interest. If you can help us to identify the individual
18 then we may find out something we did not already know?
19 A. Yes. Les Schutt would be the contact and whether he
20 could remember the name of the doctor involved, I am not
21 sure.
22 Q. The references I quoted are published, may I say -- this
23 is for the wider audience -- on the web site. On the
24 face of it there is something odd between why it is that
25 a paediatric anaesthetist should say that to you in
0015
1 Plymouth when it appears there were established patterns
2 amongst his paediatric colleagues, that is the matter we
3 want to investigate?
4 A. On that same line, was there not a professor of
5 paediatric cardiology in Southampton who said in one of
6 the television broadcasts, possibly the Panorama
7 programme, that the Plymouth cardiologists had asked if
8 they could refer out of region to Southampton at some
9 stage in the early 1980s.
10 Q. Do you have a name for him?
11 A. No, but he is a Scotsman and I just remember seeing it
12 in one of the television programmes and thinking "that
13 fits in with my experience of this conversation in
14 Bristol".
15 Q. Let me give you an example again to show the point,
16 partly for the benefit of the wider audience but to show
17 what I am asking about. Can I have a look at REF 1/76.
18 This is from Harry Baumer, consultant paediatrician.
19 What he records, it is the second paragraph:
20 "I was appointed in Plymouth as consultant
21 paediatrician in August 1982 having previously been
22 a lecturer in child health at Bristol ..."
23 The next paragraph: "My recollection is that when
24 I arrived in Plymouth children's cardiological problems
25 were routinely referred to the Brompton with a primarily
0016
1 adult cardiologist seeing them at a regular clinic held
2 at Plymouth. When he retired the paediatricians in
3 Plymouth had an opportunity to review the referral
4 pattern in 1983 [he identifies the paediatricians]. The
5 options were to continue sending children to Brompton,
6 to initiate referrals to Bristol or develop a link with
7 Southampton. The decision we made at that time, prior
8 to 1984, was to develop the link with Southampton. Thus
9 by the beginning of 1984 this was our local practice."
10 He reports that "between 1984 and 1985 they
11 referred babies and children with non-cardiac surgical
12 problems to Bristol."
13 The other letters are to similar effect. That was
14 the point there.
15 Can I then pick up with you the particular
16 letter. Again this is by way of tidying up some of the
17 points we dealt with yesterday. Can we have on the
18 screen UBHT 332/8. 19th April. It is from a firm of
19 solicitors addressed to Dr Roylance:
20 "Dear John, this letter is intended for the
21 Chairman of the Trust and yourself only."
22 A. Can I ask who the Chairman was at that time?
23 Q. Yes, Mr McKinlay.
24 "The letter follows an indication from you
25 earlier this week that Robert France and I privately in
0017
1 three or four cases had become concerned about areas of
2 medical management in three or four cases. Our views
3 arose in the normal course of investigations into
4 particular claims against the Trust. No cause at the
5 time to relate one to the other. Any observation should
6 be dealt with objectively within the management of each
7 individual case."
8 This letter mentions two of the cases. When we
9 come to look at the letter those are blanked out.
10 If we can go overleaf, UBHT 332/9, bottom of the
11 page. This letter appears to be a letter written by
12 solicitors to the Trust drawing the Trust's attention to
13 particular problems which they thought they had
14 identified in consequence of handling medical negligence
15 claims against the Trust. The problems to which they
16 refer are not, as I understand the letter, specific to
17 those cases, they are systemic in nature which is where
18 we pick up on the discussion we were having yesterday
19 about Melissa Clarke's case. Bottom of the page:
20 "We found it difficult to form a clear and
21 detailed picture of events and sensed an air of dissent
22 between Mr Wisheart and Dr Bolsin although no explicit
23 criticism was voiced by either of the other. On
24 Mr Bolsin's part however there seemed to be disquiet
25 over the management of cases in the Intensive Care
0018
1 Unit. Our inquiries of Mr Wisheart and Dr Bolsin into
2 the overall responsibility and the division of
3 responsibilities of patients in the Intensive Care Unit
4 met with somewhat vague replies. It seemed that broadly
5 speaking the consultant surgeon and his junior staff
6 (Senior Registrar, Registrar and SHO) took
7 responsibility for any surgical complications and the
8 consultant anaesthetist and his junior anaesthetic
9 colleagues took responsibility for ventilation and
10 perhaps pain control."
11 Is that, do you think, broadly accurate?
12 A. Yes, I think broadly, yes.
13 Q. Top of the next page, UBHT 332/10:
14 "Cardiac function was in the province of the
15 surgical team and respiratory function in that of the
16 anaesthetic team."
17 Again, is that broadly accurate?
18 A. Yes, I think it probably did change from time to time.
19 At the time of the case they are discussing there were
20 very few inotropes and the surgeons would have been
21 familiar with many of them. A new group of inotropes,
22 drugs to support the heart, came out after this case and
23 we became a centre of expertise in dealing with it and
24 the anaesthetists were the people doing research into
25 these drugs so we would then advise and participate more
0019
1 in the drugs supporting the heart with the surgeons.
2 Q. So cardiac function was, as it were, a mixed
3 responsibility?
4 A. At this time it was the surgical responsibility exactly
5 as the letter says, but it may have changed in time.
6 Q. The person who would know about the inotropic drugs and
7 their effects, the expert would be the anaesthetist,
8 would he?
9 A. Later, at a later stage, yes.
10 Q. As between surgeon and anaesthetist in 1995, which was
11 the more expert in inotropic drugs and their effects?
12 A. I think probably the anaesthetist, but they would
13 discuss any changes with the surgeon before they were
14 implemented.
15 Q. The next sentence: "The members of one team seemed
16 largely to act independently of those of the other
17 team ..."
18 Pausing there, is that a fair reflection of how
19 things were in the Intensive Care Unit at this time?
20 A. When you say "at this time" are we referring to --
21 Q. It is difficult to know because it is commenting on
22 cases which have come into their hands and so the cases
23 will, I would have thought, have arisen in the three
24 years prior to this report. That may be wrong and we do
25 not have a date.
0020
1 A. Yes. I think they are summing-up the position in the
2 Intensive Care Unit in the late 1980s and early 1990s
3 and I think that evolved and may not be quite as they
4 describe it, but they are describing it from their
5 review of cases that have been referred to them from
6 earlier --
7 Q. And their conversations with you and with Mr Wisheart?
8 A. But those conversations were in 1990 or 1992.
9 Q. 1995. This is a letter written in 1995 and they are
10 saying they made inquiries of you and Mr Wisheart into
11 "the overall responsibility and division of
12 responsibilities in the Intensive Care Unit" hence this
13 letter, hence their concern; that is the previous page?
14 A. Yes. I certainly do not remember having detailed
15 discussions with Robert Johnson.
16 Q. Do you remember talking either to Robert France or to
17 Robert Johnson?
18 A. Yes, I spoke to Robert France in 1990 about one of the
19 cases that I think is probably blacked out, and I would
20 have spoken to Robert Johnson in some detail concerning
21 the case that I was involved which he details in the
22 letter.
23 Q. Do you remember at some stage -- I do not know whether
24 this happened or not, please just give me a yes or no
25 for various legal reasons on this -- making a witness
0021
1 statement or a proof of evidence with him at some stage
2 about one or other or both of those cases?
3 A. Yes.
4 Q. The process of producing such a witness statement would
5 necessarily involve discussions between you and him?
6 A. Yes. Can I say that the case I was involved in with
7 Robert Johnson in 1995 or 1994 and 1995 was an adult
8 case, and we have specific mention of paediatric
9 cardiologists and paediatricians here, indicating they
10 may have been referring to the earlier cases which are
11 the names blacked out in the sort of 1990/1992
12 discussions. I do not know whether that helps or not
13 but...
14 Q. I think it does even if it adds to the vagueness of the
15 time period that this relates to. It is plainly within
16 the Inquiry's terms of reference.
17 A. Certainly.
18 Q. You can help us with the development of events in the
19 Intensive Care Unit over that period of time?
20 A. Yes.
21 Q. Where it says: "The members of one team seemed largely
22 to act independently of those of the other team", are
23 you then saying this was true once but it was developing
24 and improving or what?
25 A. Yes, I think it probably was true in the early time but
0022
1 not latterly.
2 Q. He goes on: "and it appeared there was no formal
3 co-ordination, rounds of the Intensive Care Unit being
4 carried out separately rather than jointly."
5 Two points there, can I deal with the second
6 first: "rounds of the Intensive Care Unit" were through
7 much of the period we are concerned with carried out
8 independently, were they not, I think you said as much
9 yesterday?
10 A. Yes.
11 Q. Did that ever stop whilst you were concerned with the
12 management of the ICU?
13 A. When the intensivists arrived then they tried to form a
14 unified ward round, but there were still ward rounds
15 occurring at several times during the day.
16 Q. That I think is given as an example of the lack of
17 formal co-ordination. Was there in fact a lack of
18 formal co-ordination?
19 A. Yes, certainly.
20 Q. The letter goes on:
21 "Moreover there was no indication of any routine
22 and regular involvement of a paediatrician, a paediatric
23 cardiologist or an intensive care specialist"; we know
24 that was rectified late on?
25 A. Yes.
0023
1 Q. I think in 1995?
2 A. Yes.
3 Q. "And thus nobody to watch over the general wellbeing of
4 a patient."
5 How far is that comment by the solicitors
6 justified?
7 A. I think just to correct you, and I do not often do this,
8 but the intensive care specialists arrived in 1993 not
9 1995 and their sessions were allocated.
10 Q. Yes, at that stage three sessions a week I think?
11 A. Yes, so it indicates that it is talking about the time
12 before 1993.
13 Q. It may be talking about there being, as it were,
14 sufficient sessions to have a controlling eye?
15 A. Yes, okay.
16 Q. Again it is blurred but I accept your correction.
17 What do you say then about this sentence?
18 A. I think it is largely true for a considerable part of
19 the time I was working on the Intensive Care Unit.
20 Q. Was there a time that it ceased to be true, that matters
21 improved or not?
22 A. I think with the first allocation of intensive care
23 sessions and the increasing allocation of intensive care
24 sessions the situation did change and it did improve.
25 Q. Nobody to watch over the general wellbeing of a patient
0024
1 was something which may have been a lesson to be drawn
2 from the Case Note Review, as Dr Sumner was telling us
3 yesterday and with particular reference in yesterday's
4 evidence to Melissa Clarke.
5 That I think is picked up in the next paragraph,
6 is it:
7 "Whilst Mr Wisheart would accept overall
8 responsibility for the care of patients on whom he had
9 operated, we formed the impression that the division of
10 responsibilities minute by minute hour by hour and day
11 by day was not at all clearly defined."
12 Again, is that a fair comment?
13 A. Yes, I think that is fair.
14 Q. "And it was left to the duty SHO in cardiac surgery to
15 assess the patient's condition and relatively
16 inexperienced as he was, to decide whether more
17 experienced medical staff should be summoned."
18 Fair?
19 A. Yes.
20 Q. "And if so whether he should approach the anaesthetic
21 Registrar on call or the Cardiac Surgical Registrar on
22 call."
23 A. Yes, fair.
24 Q. "Our feeling was that this was an unsatisfactory and
25 unsafe system."
0025
1 A. I think that is their opinion. I think it was the best
2 we could provide and in their opinion it was
3 unsatisfactory and unsafe, but that seems to be a fair
4 comment following on from what they are saying.
5 Q. Can I unpick because it is a matter of importance to
6 have your recollection of events on the ICU obviously.
7 You are accepting as a proper conclusion, a matter
8 of logic from the solicitor's letter that that is
9 a proper conclusion from what they have said before.
10 You have largely accepted the points they have made
11 before. Do you then accept, looking back on it, that
12 there was an unsatisfactory and unsafe system for much
13 of the time during the 1990s of management of the ICU or
14 not?
15 A. I think that it is a very bold conclusion to be drawing
16 in April 1995. I think it is slightly flawed in that it
17 served a lot of patients well in that a lot of patients
18 went through the Intensive Care Unit with good outcomes,
19 and I do not think we must forget that while we are
20 concentrating on the parents who had the bad outcomes.
21 I think it is possible, given that the legal
22 involvement in patients going through the Intensive Care
23 Unit would almost entirely be with the patients who had
24 bad outcomes, it may be there were times when this
25 system was unsatisfactory and unsafe for some of the
0026
1 patients who subsequently suffered bad outcomes.
2 I think to generalise that it was unsafe and
3 unsatisfactory from their experience, which is of the
4 bad cases, may not be entirely justified. I mean the
5 only other point I would make is, if they felt that in
6 1995, why did not they say it in 1992.
7 Q. The point they make at the beginning of the letter in
8 respect of that is that they were left with a feeling of
9 unease and concern because of similar factors in what
10 had appeared to be unrelated cases. So they are drawing
11 to attention to what they see as a systemic failure.
12 I am interested in the comment you made two or
13 three answers ago, that "it was the best we could do".
14 Why was this system the best that could be done at the
15 time, with all its deficiencies which you accept in part
16 and may have been deficient for some patients?
17 A. I think the problem was the level of seniority of the
18 people who were involved in the immediate day-to-day
19 care of the patients. I think if I make the comparison,
20 that in 1986 in an Intensive Care Unit in Australia we
21 would have had two senior house officers who were
22 intensive care in their intensive care training, not in
23 surgical training, not in medical training but in
24 intensive care training. We would have had an intensive
25 care registrar and an intensive care senior registrar
0027
1 all resident on site 24 hours a day for looking after
2 patients after cardiac surgery, and that included
3 a small amount of paediatric cardiac surgery. That was
4 possibly a measure of the commitment of that speciality
5 in that country to the care of patients, so that you
6 were not more than two minutes away from a subconsultant
7 grade opinion.
8 I think the unsatisfactory and unsafe comments
9 there relate to the fact that junior surgical staff who
10 had no intention of pursuing a career in intensive care
11 were being asked to make decisions and pick up early
12 warning signs about deteriorating conditions of children
13 after cardiac surgery and were from time to time to
14 getting it wrong, not through any fault of their own but
15 because they should not have been the people who were in
16 the position to make that decision.
17 Q. I do not think it seems to address the fault of any
18 individual. I think it goes further than what you have
19 said because it is suggesting, is it not, that not only
20 is there too junior member of staff with any control,
21 secondly he has a particular perspective which is
22 surgical and there is a very difficult division of
23 responsibility, very unclear division of responsibility
24 between the surgeons on the one hand and the
25 anaesthetists on the other?
0028
1 A. Yes.
2 Q. And no co-ordination between the two is what it appears
3 to be saying; those are the principal faults, are they
4 not?
5 A. Yes, we tried to address that. When I did a ward round
6 at 10.00 at night, we would go round the critically ill
7 patients and say "if the blood pressure falls below this
8 figure what will you do" and we would then discuss with
9 the surgical SHO who would be on call at night: "What
10 will you be thinking about, what will you be doing. If
11 the pulse rate goes above this what will you be thinking
12 about, what will you be doing if it goes down...", and
13 we would have a series of parameters laid out, so that
14 we would be trying to put their clinical management into
15 a straightjacket which would mean they would be best
16 serving the patients, and of course we would always say
17 "if you have a problem then just give us a ring at
18 home".
19 Q. That is what you are referring to as "the best we could
20 do", is it, or as part of "the best we could do"?
21 A. Yes, yes.
22 Q. What prevented the unit as a whole do you think doing
23 better?
24 A. I think they needed to have more senior staff and more
25 senior staff require funding and I suspect that there
0029
1 was not the ability to put the funding into the
2 paediatric cardiac surgical component.
3 The problem reemerged interestingly enough when
4 Andy Wolf and Ash Pawade took over, when the service
5 moved to the Children's Hospital it moved up a couple of
6 gears and it started to have children on left
7 ventricular assist devices on the Intensive Care Unit
8 and the anaesthetists stayed in and slept at night.
9 They then said "actually we cannot sleep in at
10 night looking after these critically ill patients, we
11 are consultant anaethetists sleeping in at night, we
12 cannot then go and do an ENT list which is part of our
13 job and we think you have to take over those ENT lists
14 for us by providing more consultant anaesthetic
15 sessions" and there was a very big debate.
16 In fact, I was asked to draft a letter to
17 Chris Monk to say that this had to be funded because
18 Chris Monk had said to the paediatric anaesthetists
19 "accept a higher mortality rate, go home to bed and
20 come in and do your sessions in the morning because we
21 do not have the money for these sessions." This was in
22 1996, I thought "this hospital has clearly not learnt
23 its lesson".
24 Q. So one thing about it being done was staffing and
25 resources. What about the lack of co-ordination, could
0030
1 that have been addressed better do you think?
2 A. Yes, I think we all had to coordinate through the person
3 who was there on site and that was the senior house
4 officer and we did take out time to communicate with
5 them, they were always there and we would make sure they
6 understood what we wanted for the patients.
7 Q. The ward rounds, what steps were taken to address the
8 obvious difficulty of there being blurred
9 responsibilities between anaesthetists on the one hand,
10 surgeons on the other and the difficulty of the one
11 group, because of timing, talking to the other?
12 A. One of the big advances was bringing in an anaesthetic
13 registrar into the Intensive Care Unit who became the
14 communication point for the consultant anaesthetists
15 with the surgical side. So that whenever the surgeons
16 did a ward round there was always an anaesthetic
17 presence. If we as anaesthetists had done our ward
18 round earlier he would be able to pass on our view of
19 what was happening to the patient.
20 Q. Were the -- if I call them "problems" that may be a fair
21 word, I do not know -- were the problems of the
22 Intensive Care Unit a matter of regular discussion
23 amongst the anaesthetists and others?
24 A. I think the fact that things improved over time indicate
25 that people were aware of the problems and were trying
0031
1 to address them as best they could.
2 Q. Did the situation ever in your view become so critical
3 that you for your part said: "Look, I will not
4 anaethetise any more patients because if I do they are
5 going to end up in this Intensive Care Unit and really
6 the system is a mess, we do not have the right staff, we
7 do not have the right resources so I am exposing
8 a patient to an unsafe and unsatisfactory system."
9 A. I do not think that specific decision was ever made by
10 me, but I think a parallel decision was sometimes made
11 by the surgeons where they would cancel a paediatric
12 case in order to do an adult case because there were
13 already critically ill children on the Intensive Care
14 Unit. Whether that was because there were not enough
15 paediatric nursing staff to go round, or whether it was
16 because they were worried about the human resources and
17 medical resources available, I am not sure.
18 Q. Decisions were taken, as you best recollect, in the
19 interest of patients' safety to avoid the worst aspects
20 of the system, but taken by the surgeon on their own?
21 A. Yes, they would change their operating lists.
22 Q. Do you remember talking to a surgeon about it and
23 saying: "Look, I do not think we ought to do little
24 Johnny or whoever because we actually have a serious
25 problem on the Intensive Care Unit at the moment and it
0032
1 would really be safer to wait"?
2 A. I think they are the sort of discussions we might have
3 been involved in, or conversely we would endorse the
4 surgeon's decision not to take on a paediatric case, "we
5 think you have made a wise decision there. A routine
6 coronary artery graft will mean there will be less
7 pressure on the staff on the unit".
8 Q. When you say "we might have been involved in those
9 discussions", were you as you recollect it?
10 A. Yes, I think occasionally we would have those
11 discussions early in the morning before the operating
12 started and we would be planning the workload for a busy
13 unit.
14 Q. Can I leave this now. The other matter which I want to
15 tidy up on with you, these are the sheets you gave us
16 this morning. You remember yesterday I asked you four
17 or five times about whether you collected data?
18 A. Yes.
19 Q. Before April 1992 when you spoke to Dr Hammond?
20 A. Yes.
21 Q. We now have the perfusion sheets. Can we have a look,
22 please at WIT 80/423. Let me just check before it goes
23 public. Can we scroll down to the bottom please and
24 back up to the top. The reason for checking is again to
25 make sure there is maintenance of confidentiality. That
0033
1 is why the day of the operation and the name of the
2 patient have been blacked out. If it becomes important
3 to identify the date or the name then we will have to
4 think about it.
5 A. Okay.
6 Q. These are computer printout sheets, are they?
7 A. Yes.
8 Q. Can we scroll right down to the bottom of this page and
9 go over to WIT 80/424. Scroll down to the bottom of
10 that page. That takes us through to the beginning of --
11 we better check this page first. I wonder, before this
12 page goes out, can we make the block from 82 to 85
13 wider? Can we do the same with 91 and 95?
14 That takes us through to January 1992. Can we go
15 overleaf? That takes us down to February 1992. That is
16 okay that document.
17 THE CHAIRMAN: Should we scroll to the bottom just in case
18 there is anything else?
19 MR LANGSTAFF: Yes, we should, but there is not anything.
20 What we see on the screen are three pages, are
21 they, of computer printout material?
22 A. Yes.
23 Q. On whose computer were they printed out?
24 A. That came from the perfusionist's own computer system in
25 the Perfusion Department.
0034
1 Q. The way that the document was produced was: you went to
2 the perfusionist and said to him words to the effect of
3 "can you let me know the results of paediatric cardiac
4 operations", something along those lines?
5 A. Yes. Sorry, it would not have been "results", it would
6 have been the operations done rather than results.
7 Q. I beg your pardon. You were then given this printout.
8 Was it a matter of them pushing a button or them having
9 to analyse the data and extract this for you or what?
10 A. I think there would have been some extraction because it
11 was not possible just to get the data straightaway.
12 I think they had to extract the adult cases which would
13 have been embedded in this database.
14 Q. All the cases on the original of these three sheets
15 which you kindly supplied are dated in sequence, are
16 they not?
17 A. Yes.
18 Q. So that although we have it blanked out, in fact we
19 begin on the first page -- can we go back to WIT 80/423
20 -- we begin in October 1990?
21 A. Yes.
22 Q. And each of the cases is then chronologically later than
23 the other, than the one immediately before it, until we
24 get to February 1992?
25 A. Yes.
0035
1 Q. Shall we go back to WIT 80/425? Is the point that you
2 are, or would wish to make in respect of these three
3 pages, that this must have been data which you had
4 "collected" (the word that you used yesterday) some
5 time shortly after the beginning of February 1992?
6 A. Yes, I would have been starting a data collection at
7 that time.
8 Q. Presumably, unless it took a very great deal of time to
9 push the button on the computer and clear out the adult
10 cases, if there had been an operation after the
11 beginning of February 1992 we would have seen it as 17
12 or 18 or 19 or whatever on the sheet?
13 A. Yes.
14 Q. Is it then the best evidence we have from this sheet
15 that probably it was round about mid February 1992 or
16 thereabouts that you would have had this document?
17 A. Yes.
18 Q. Can we go down a bit? That notation, whose is it?
19 A. That is my writing.
20 Q. What does it show?
21 A. I think I have used this as a teaching aid to somebody
22 to explain about cumulative summation analysis.
23 Q. Did it relate to the data that we see above it?
24 A. I do not think so, no. No, because you see this goes on
25 to 100 patients and I am not sure there are necessarily
0036
1 100 patients there and I have also just drawn in
2 illustrative alert and alarm limits.
3 Q. The circle we have somewhere between 50 and 75 is where
4 the alarm limit is reached, is it?
5 A. Yes, yes.
6 Q. I suppose one of the reasons why that graph may not
7 connect with the data we have is there is no obvious
8 relationship of the pages above to deaths?
9 A. No.
10 Q. Can we scroll back on to the other pages?
11 THE CHAIRMAN: Mr Langstaff, there is a column on the far
12 right which it may be desirable to take out.
13 I apologise I did not pick that up straightaway.
14 MR LANGSTAFF: Can we go right back up to the very top?
15 THE CHAIRMAN: And on the previous page.
16 MR LANGSTAFF: The previous page, please. Can we take out
17 the dates?
18 THE CHAIRMAN: Just to explain to everyone: we are having
19 a slight technical problem, but it will come back.
20 MR LANGSTAFF: Can we keep the page as it is now. We will
21 not scroll down further because we will have to blank
22 out what follows. If we look across the notations at
23 the top of the page, can we show what it appears to
24 record? The number obviously is sequential; the date
25 speaks for itself, as does the name and the operation.
0037
1 Then the initials "JDW" would be Mr Wisheart,
2 would it?
3 A. Yes.
4 Q. It is "Con Surg Operator"; what is the difference
5 between "Con" and "Operator"?
6 A. If the operator was a Registrar, for example, then they
7 might be made. I think in fact in column 6 you can see
8 that somebody's initial, it looks like "AX" operates on
9 a JPD ASD.
10 Q. "Con" is for consultant, "operator" for the person who
11 actually does the operation. "Bypass time in minutes.
12 Cross-clamp time in minutes. Circulatory time in
13 minutes. Lowest body temperature. Perfusionists data."
14 Then do we have "DOT" death on table?
15 A. Yes.
16 Q. And "DIH" death in hospital, and that would be within 30
17 days?
18 A. I am not sure whether it would be the 30-day limit. It
19 would be data that the perfusionists would have
20 collected because they used to go and follow-up their
21 patients loosely on the Intensive Care Unit. So if they
22 saw that the patient had died on the Intensive Care Unit
23 then they would have documented that.
24 Q. There was data which at least came to the perfusionists;
25 how reliable it is we would have to ask the
0038
1 perfusionists about or get some idea of the system by
2 which it came to them?
3 A. Yes.
4 Q. Data which came to them from which they were able to
5 record on their computer system whether there had been
6 a death on the table or a death in hospital?
7 A. Yes.
8 Q. We have blanked out on the right-hand side the death in
9 hospital for obvious reasons of confidentiality.
10 A. Yes.
11 Q. What I shall do is come back to this, if I may, after
12 a break with any conclusions that may be drawn from the
13 numbers and you will of course, because it is your data,
14 have the original and can check the numbers during the
15 break to see whether those figures may tell us anything
16 of use.
17 A. Yes.
18 Q. Sir, that is by way of indicating it might now be
19 appropriate to have a short break?
20 THE CHAIRMAN: Yes, Mr Langstaff. Can we just for the sake
21 of all of us make sure that we go through the data and
22 redact everything that could be identified, not only
23 "DIH" but "DOT" just in case. I will leave that to you
24 if I may. Let us break now for 15 minutes until 11.05.
25 (10.50 am)
0039
1 (A short break)
2 (11.10 am)
3 MR LANGSTAFF: Dr Bolsin, when you first had concerns, did
4 they, as you recollect it, centre upon any particular
5 operations?
6 A. No, I think the initial concerns were more generic about
7 the length of time taken and the duration of the
8 operations and the bypass time.
9 Q. Just pausing there, that was data you could get from the
10 perfusionists, and as we can see in respect of these
11 particular operations, the data is there set out.
12 A. Yes. It was also data that, from Day 1, having worked
13 at the Brompton where you would do five or six cases in
14 a couple of theatres a day, to go to Bristol where we
15 were doing just one case in a day.
16 Q. The time that the operation took?
17 A. Yes, exactly.
18 Q. So those were the essential concerns, rather than the
19 particular operations?
20 A. Yes. Then there was the 1989 data, which indicated that
21 we had twice the national average mortality, and it
22 became apparent that there was a possible link between
23 what I had observed as a distinct comparison between the
24 Brompton and Bristol performance and a mortality rate
25 and we then needed to start to look at what were the
0040
1 operations in this mortality rate in which we were
2 achieving a higher mortality rate.
3 Q. Those you identified?
4 A. Well, I think that was partly through the audit meetings
5 and partly -- possibly through this type of activity,
6 but this type of activity comes much later on. The
7 initial concerns were a sort of professional intuition;
8 "There is something wrong here". Then the figures come
9 and confirm that the professional intuition is right,
10 there is a high mortality rate, then there is a "Now we
11 must examine this high mortality rate and find out what
12 it is. We think in VSD we have lowered the mortality
13 rate. We think for some of the other operations we may
14 also have lowered the mortality rate".
15 Q. This data obviously you had collected, as we went
16 through this morning, some time February-ish 1992.
17 Apart from your own log, did you have any further data
18 before the time that you spoke on 29th April to Dr Phil
19 Hammond?
20 A. I am not sure that I would have. I cannot be certain
21 that I did not have, but I am not sure that I did have.
22 Q. I will tell you why I ask in a moment, but may I just
23 interpose to say that you have very kindly given us the
24 logs which you kept, with the exception of the log which
25 goes from 1990 to March 1992.
0041
1 A. Yes.
2 Q. Can you help us as to why that log is missing?
3 A. I am afraid I have lost it. Since I left Bristol I have
4 had about three house moves, and it is around somewhere
5 and as soon as I find it, I will make it available to
6 the Inquiry, but at the moment, and up until now, I have
7 been completely unable, my secretary at work and at
8 home, we have been completely unable to find it. It
9 somehow got separated from all of the others which were
10 in a folder, and I do not know where it is. I am sure
11 it has not been irretrievably lost, and I will search
12 and have a look for it.
13 Q. What Phil Hammond has told us, as I think you have seen
14 overnight, was that he did not get the figures from you,
15 then he put figures to you which he had from another
16 source, the source he has not identified, in order to
17 confirm the accuracy.
18 Can we look at SLD 2/3? Again, it is the bottom
19 of the left-hand paragraph, the top of the central
20 paragraph:
21 "Recently the unit ..."
22 The top of the middle paragraph:
23 "Although Liverpool surgeons have successfully
24 operated on 160 babies with Fallots, the Bristol
25 mortality rate is between 20 and 30 per cent, hardly the
0042
1 stuff of commendations."
2 If he had run that figure past you on the basis of
3 the information you had at the time -- which your best
4 recollection is the perfusionist's data you have shown
5 us and your own log -- it would not have justified 20 to
6 30 per cent because the perfusionist shows I think one
7 or two deaths -- two deaths out of 13?
8 A. Yes.
9 Q. Which is a bit less, certainly not within the range of
10 20 to 30 per cent?
11 A. Absolutely, no.
12 Q. So if he had put that figure to you, you would have
13 said, "Well, that does not correspond with my figures",
14 presumably?
15 A. I would have thought so, yes.
16 Q. Unless you had other information?
17 A. Yes. I mean, the one missing link is the logs and as
18 I say, I will do my best to locate them for you. I do
19 not remember so much of the 'him putting the position to
20 me' side of the conversation that I had with Dr Hammond.
21 Q. Again, doing your best, because I know it is some time
22 ago, you obviously would have wanted to check and verify
23 the data that you had?
24 A. Yes.
25 Q. How did you go about checking mortality?
0043
1 A. Mortality rates were in some cases relatively easy to
2 find, because, for example, if the patient died in
3 theatre, then we would have that as the DOT. If they
4 died in hospital, we would be able to check that, but
5 one of the things that I would have to do is go down to
6 the medical records department with the patient's name
7 and the case note number and then check whether the
8 patient was still alive.
9 Q. So the process is this, if we go back to the
10 perfusionist's log: that using the name which is blanked
11 out and is the date of operation, you were able to
12 identify records?
13 A. Yes.
14 Q. And draw a conclusion as to whether the child was or was
15 not dead or alive?
16 A. Yes.
17 Q. Might you, do you think, have done that before
18 Dr Hammond spoke to you in April 1992, or not?
19 A. No, I think it is very unlikely. I do not remember
20 doing that until after the data collection with Andy
21 Black and myself, and I then started to do it for two
22 specific series of operations I was concerned about, the
23 AV canal which had been raised as a problem operation in
24 the Bolsin/Black data collection, and then also with the
25 arterial switch operation which we knew was an operation
0044
1 which we were not doing particularly well, but it was
2 not possible to make a comparison with the Cardiac
3 Surgical Register.
4 Q. At the GMC, what you told them was that the three
5 operations that you had in mind, you were looking at,
6 were tetralogy of Fallot, VSD and AV canal, as well as
7 the switch. The switch was something you added later,
8 I think, to analyse later?
9 A. Yes. I am sorry, what time period is this referring
10 to?
11 Q. Let me deal with it in this way -- I will come back to
12 it and come back to that question; you may have given an
13 answer by that stage.
14 I am going the leave Private Eye and move on.
15 Plainly at this stage -- April 1992 -- you had been
16 collecting data?
17 A. Yes, I had started to collect data, yes.
18 Q. You were discussing that data, or preliminary
19 conclusions or concerns outside the unit?
20 A. Yes.
21 Q. Had you, apart from your letter to Dr Roylance, at the
22 stage you were discussing your concerns outside the
23 unit, made any attempt other than getting the
24 perfusionist's log, to verify the data?
25 A. The data that I had at that time, which was the logbook
0045
1 data, would have been as firm as I could obtain it. The
2 other data came from a series of meetings which we
3 discussed probably on Monday, I think it was, which
4 included concerns about the VSD operation, the
5 management of pulmonary hypertension in the
6 post-operative period and the time of operation, and
7 also some concerns about overall mortality for the unit,
8 for the year 1989.
9 Again, that was data that was coming from the
10 surgeons rather than coming from me, so I did not think
11 I needed to verify all of the data, because it was
12 coming from the surgical source.
13 My problem was that I was confirming high
14 mortality rates, having had a professional intuition
15 that there was a problem, and I was then being told this
16 was not the way to go about it. That was my problem,
17 that going up through the unit was not getting me any
18 results; it was not getting me any changes and at that
19 point, I was looking for ways to go round the unit to
20 try and find if we could influence them to improve the
21 practice and perhaps not do the dangerous operations.
22 Q. Can I remind you of the blueprint which we find at
23 WIT 80/382, the bottom of the page.
24 The first point: "You should confirm the data is
25 correct". At the stage of April 1992, when you were
0046
1 speaking to others outside the unit, you had not done
2 that, had you?
3 A. Some of the data was coming from the surgeons, and
4 I assumed that it was correct, so I think that there was
5 external verification of some of this data, yes.
6 Q. So some of the data was correct, but not the rest of
7 it?
8 A. The rest of it was the best that we could do.
9 Q. Next, "You should then discuss it with the colleagues in
10 your specialty area."
11 A. Yes.
12 Q. Were you discussing the data, the figures that you were
13 collecting and the mortality figures that were produced
14 with the other anaesthetists?
15 A. Yes.
16 Q. "I think you should then take it to the Director of your
17 department."
18 Did you, in April 1992, take your data, your
19 concerns and the data to support it, to the Director of
20 Anaesthesia?
21 A. We had already done that in 1990, if you remember. We
22 had had a meeting in the later part of 1990 at which
23 Peter Baskett had said, "Steve should keep his head
24 down", and that the conduit for criticisms of the
25 paediatric cardiac service should be Bryan Williams, who
0047
1 was the Director of Anaesthesia, and Chris Monk, the
2 Cardiac Liaison Anaesthetist. So, as far as I can see,
3 we had earlier on followed this process. I was
4 continuing to liaise with Chris. He was a close
5 colleague of mine in the paediatric cardiac service, and
6 he knew that I had concerns.
7 Q. "I think you should then take it across with their
8 backing to the second professional group."
9 That is something which you say you left
10 Dr Williams and Dr Monk to do?
11 A. Yes. I had been warned off doing that.
12 Q. At the stage that Dr Williams and Dr Monk were involved,
13 you had concerns, but no particular data.
14 A. We had --
15 Q. It follows, I think, from our conversation yesterday,
16 does it not?
17 A. In 1990?
18 Q. In 1990 concerns with no particular data other than that
19 produced for the surgical meeting?
20 A. But we would have had the 1989 report with twice the
21 national mortality and we had a letter from me to the
22 Chief Executive, copied to the Director of Anaesthesia,
23 saying, "I think this should be addressed".
24 I mean, we were not operating in a vacuum. I was
25 an extremely concerned clinician who was seeing children
0048
1 being exposed to dangerous operations unnecessarily, and
2 I was prepared to do anything I could to stop that.
3 We have now moved on two years and nothing appears
4 to have changed.
5 Q. That is what I was going to ask you. The matter as you
6 understood had been handled by agreement amongst the
7 anaesthetists, the concerns were to be explored by
8 Dr Williams and possibly Dr Monk.
9 Did you ask them, at any stage, what result they
10 had had?
11 A. I can remember talking to Dr Monk about the issue
12 generally. In terms of a specific response, I am not
13 sure. I am not sure that we did get a specific
14 response. That was one of my concerns, that there was
15 no specific response.
16 Q. So do I take it you went to speak to Dr Williams and to
17 Dr Monk, and said, "Look, have you had any feedback
18 because I am still concerned and we need to resolve
19 these concerns; we need to take it forward again"?
20 A. I am not sure I actually said those words to Dr Williams
21 or to Dr Monk, but the fact that a lot of my colleagues
22 in the Department of Anaesthesia were aware of my
23 concerns would lead me to believe that Dr Williams and
24 Dr Monk should have been aware of my persisting concerns
25 and they should have been able to feed back to me what
0049
1 the results of their meetings were.
2 Q. I am not sure that I have put the question in the way
3 that you are addressing. Let me put it differently. If
4 there had been agreement, you, amongst those agreeing,
5 Dr Williams and Dr Monk should handle the matter arising
6 from that meeting --
7 A. Yes.
8 Q. -- and if you had thought that was an appropriate way of
9 dealing with it, so far as you were concerned, the
10 matter was being dealt with?
11 A. Yes.
12 Q. So the only reason for taking further action would be
13 some indication to you from them that they had got
14 nowhere with their expression of concerns?
15 A. There might be another reason for me to take action.
16 Q. Which is what?
17 A. That would be that there was no change in service and
18 the mortality rate remained at twice the national
19 average and we know that is what happened. That,
20 I think, is a perfectly reasonable reason for me to
21 continue to try and deal with the position in paediatric
22 cardiac surgery.
23 Q. Forgive me for asking, but if we go over to
24 page UBHT 61/49, and look at the third item on that
25 page, the meeting of cardiac anaesthetists with the
0050
1 Director of Anaesthesia and President of the Association
2 of Anaesthetists, Dr Baskett, agrees:
3 "(i) results of arterial switch not acceptable.
4 "(ii) matter to be taken up by directorate;.
5 "(iii) Dr Bolsin not to be vehicle for criticism",
6 that is relating to the arterial switch and not to the
7 more general concerns you are now addressing, is it not?
8 A. I think we discussed both, but certainly the information
9 for both was available to us.
10 Q. So going back, please, to the blueprint at WIT 80/302,
11 you say you had, by 1992, discussed it with the
12 colleagues in your specialty area?
13 A. Yes.
14 Q. Taken it to the Director of your department?
15 A. Yes.
16 Q. And you were telling us yesterday, in response to the
17 minutes of the "paediatric cardiology", as it is
18 described, group, that their approach to looking at the
19 results and looking at the specific operations was
20 entirely appropriate and entirely what you would expect
21 would wish to be done?
22 A. Yes.
23 Q. So if that was happening and if it was, as you have told
24 us, an entirely appropriate response, what was the need
25 for you to mention to anyone outside the unit your
0051
1 concern about results inside the unit which were already
2 being addressed in what, if you had reflected upon it,
3 was a perfectly acceptable way?
4 A. I think you have to separate in time the events that you
5 have described. You are perhaps compressing them
6 slightly. If you remember, when we talked about the
7 meeting at which we identified the 12.8 mortality rate
8 for the under 1 years, the data was presented at least
9 halfway through the next year, and if you remember, we
10 also alluded to the fact that that year the mortality
11 rate then went back up to twice the national average.
12 So the concerns that were being allayed by the
13 fall in mortality from twice the national average in
14 1989 to 12.8 per cent in 1990, were now back up to twice
15 the national average and that led me to be continuously
16 concerned.
17 Q. I understand that. I do not seek to ask you about your
18 concern. Anyone seeing the rate described in March 1992
19 by the meeting we looked at yesterday as being twice the
20 national average would be bound to be concerned. The
21 question is directed towards why express that concern
22 outside the unit when it appears that it was being
23 addressed properly within the unit?
24 A. I think when you say "properly", it may have been
25 addressed by the Director going across and talking to
0052
1 somebody, but there was no apparent change in the unit,
2 so that the minutes did not say "The action is this ...
3 and we will stop this if this does not improve". It was
4 "We will carry on doing things and perhaps review
5 things in a year's time".
6 I needed action because the mortality rates were
7 exposing children to an unnecessary risk of death and
8 that was my major concern. I have to emphasise that to
9 you, Brian.
10 Q. Did you need action in the sense of wanting to stop
11 operating?
12 A. I wanted to stop the operations that had a higher than
13 national average mortality rate. If we had dangerous
14 operations, we should not be doing it. Would you get
15 into a dangerous car and drive it off?
16 Q. Whether a driver of a dangerous car, or passenger,
17 nobody would get into such a car, would they?
18 A. I think the car should not be available to get into and
19 drive.
20 Q. So if anyone invited you to be a front seat passenger in
21 a dangerous car, you would not get in?
22 A. Yes, that is true.
23 Q. Because it might not only kill yourself, but kill other
24 road users?
25 A. Yes.
0053
1 Q. You went on, did you not, providing anaesthetic for
2 a number of the operations about which you subsequently
3 complained?
4 A. Yes.
5 Q. Is that not the equivalent of sitting in the
6 passenger-seat of the car while the surgeon drives, if
7 you regard the car in fact as being a dangerous one?
8 A. I think that you have to remember that by May 1992,
9 which is the time that we were talking about, I had
10 already applied for a post in another unit. I was
11 expressing my concerns in that I did not want to
12 participate in the paediatric cardiac surgical programme
13 in the Bristol Royal Infirmary. I was trying my hardest
14 to avoid getting into that car.
15 Q. It is not the question. The question was: why did you
16 do it -- it is a question for the Panel to assess
17 motivation and so on here -- if you really thought the
18 operations were dangerous for children at this stage?
19 A. Yes.
20 Q. And therefore, should not be done, because that is what
21 you have been telling us, the operations about which you
22 had particular concern. Why did you go on
23 anaesthetising for them?
24 A. I think that there are several reasons to that answer.
25 One is, that was my contract; that was my contract with
0054
1 the Bristol Royal Infirmary. And I think to have gone
2 to the Director of Anaesthesia and said, "I am not going
3 to do paediatric cardiac anaesthesia" would have led to
4 the kind of results that I had been led to believe would
5 have happened when I went to Mr Wisheart in 1990, and
6 I did not want to activate that process.
7 What I wanted was a thorough and open review
8 within the unit, within the profession, of what we were
9 not doing well, and let us see how we can do it better,
10 or not do it at all.
11 Q. Do you think, perhaps, that continuing to provide
12 anaesthesia both for operations that might be dangerous
13 for the child, as you saw it, with an Intensive Care
14 Unit that was going to look after the child later on in
15 respect of which there was, as you agreed with me
16 earlier this morning, an unsafe and unsatisfactory
17 system operating, made you perhaps complicit in the
18 danger, the risk, to the child?
19 A. Yes, I think there is certainly that possibility.
20 Q. And are you saying, as part of the reason for that, that
21 you felt, at the time, that your contract as a doctor
22 nonetheless required that you do this?
23 A. I think what I am saying is that if the evidence had
24 been available to show that these operations were as
25 dangerous as we now know, I hope I would have had the
0055
1 moral courage to have withdrawn from those operations.
2 At the time, I was not certain. I had the sort of data
3 you have shown this morning, which is not conclusive;
4 I was not getting any firm data about specific
5 operations that were dangerous from the surgeons, and
6 I carried on.
7 Q. Which was it? Was it a conclusion that you had reached
8 in 1992 that the operations were actually dangerous as
9 a result of the annual mortality figures showing that
10 the blip downwards was a blip rather than the start of
11 a consistent trend, or was it that you simply did not
12 have any material to make a proper assessment at the
13 time?
14 A. We did not have the detailed data to demonstrate which
15 of the operations were the dangerous operations, and
16 I felt we should not be doing the dangerous operations.
17 Q. So you thought there were dangerous operations, but you
18 had no data to show it?
19 A. Yes.
20 Q. And you supposed that there would be data to show that
21 some operations were dangerous?
22 A. Yes.
23 Q. Which, if the data showed it, you would not then do?
24 A. Yes.
25 Q. And it would follow that nobody else in the unit had
0056
1 the data at that time to identify which were the
2 dangerous operations producing the difference between
3 Bristol and the rest of the UK?
4 A. No, I think you have made a jump there. I think that
5 that data did exist within the unit, but it just was not
6 being shared, particularly with people like me who was
7 seen as a troublemaker, who was seen as somebody who was
8 rocking the boat. That data probably would not have
9 been shared with me, and I wanted that data to be shared
10 openly with all of us.
11 Q. In 1992, you were conducting audits of the adult cardiac
12 surgical outcomes with Mr Wisheart's assistance, as we
13 have seen?
14 A. Yes.
15 Q. No problems there, in collecting the data you wanted,
16 the risk stratification, the analysis and so on?
17 A. It was an anaesthetic data collection.
18 Q. And it included outcomes?
19 A. Yes.
20 Q. Would there, do you think, have been any difficulty in
21 going to Mr Wisheart, Mr Dhasmana, and saying "I would
22 like to do a similar exercise in respect of paediatric"?
23 A. Yes, there would have been an enormous difficulty.
24 Q. What would that difficulty have been?
25 A. The difficulty would have been that in 1990, I was
0057
1 confronted by a senior paediatric cardiac surgeon,
2 red-faced, angry, intimidating, bullying, telling me if
3 I wanted to do this sort of thing in this unit, I did
4 have not a future in Bristol.
5 In 1991 I collect minutes; I put my data in the
6 minutes, or I put the discussions of the meeting in the
7 minutes: "That is not the way we do things here, you are
8 never to collect minutes again". The mortality rate
9 remains high.
10 It was a subject of enormous sensitivity in this
11 unit at this time, to talk about paediatric cardiac
12 surgical mortality. You have heard in evidence from
13 Professor Vann Jones that it was easier in the corridors
14 of the hospital to talk about paediatric cardiac
15 surgical mortality than it was to talk about anything
16 else, but you have also seen in evidence the surgeon
17 saying, "Nobody came and talked to us", and the reason
18 was, it was extremely difficult to talk to them about
19 that subject.
20 Mr Wisheart would become angry, he would become
21 red-faced, clipped language, angry. Mr Dhasmana would
22 become defensive and you could not talk about it and you
23 could not have a reasonable discussion about it.
24 I think that is what put me off; it put Dr Masey off, it
25 put Dr Underwood off, it put Dr Pryn off, it put
0058
1 Dr Davies off, it put Dr Monk off, it put Professor
2 Angelini off. Even Professor Farndon could not get to
3 a reasonable conclusion about paediatric cardiac
4 surgical mortality, and that was the problem.
5 Q. I am going to move on. I will come back to that
6 answer later.
7 A. Can I just also say that we remembered when we produced
8 the blueprint yesterday, the blueprint for action, that
9 this was 1999 and I had undertaken a health care
10 management course. We were applying it to events in
11 1991 and 1992 with the benefit of hindsight, and I would
12 just like to say that that may mitigate some of the
13 criticisms or implied criticisms of this document
14 relevant to my actions in 1990 and 1991, in fairness to
15 me.
16 Q. Dr Bolsin, I have no wish to be unfair to you. You will
17 appreciate that a number of the questions which I put
18 will inevitably be searching because your evidence is
19 out there on paper; you have given us the best of your
20 evidence there, and it has, of course, to be tested.
21 A. Yes.
22 Q. Inevitably, the testing may seem to be critical because
23 that is what testing involves.
24 A. I understand. We have a job to do and we must get this
25 information out.
0059
1 Q. I think you told me yesterday, or the day before
2 yesterday, that looking at the blueprint, if you had
3 known then what you know now, you would not have done
4 what you did. That is one possibility?
5 A. Yes.
6 Q. But that supposes you would actually have done things
7 differently and gone through the routes you set out
8 there.
9 What you appear to be telling me now in relation
10 to 1992 is that you in fact did go through these routes
11 and the two are inconsistent, so that is an
12 inconsistency I should come back to and invite you to
13 comment upon, unless you want to make any particular
14 comment about it now?
15 A. You will have to clarify the inconsistency again.
16 Q. Either you were doing things in the proper way,
17 beginning in 1992, or as you now look back on it with
18 hindsight, you were not, albeit that you had your
19 reasons at the time. Which was it?
20 A. I think that the only thing that I did not do properly
21 in 1992 was go back to the second professional group,
22 and I relied on my anaesthetic colleagues to do that and
23 I am not sure that they succeeded in doing that. That
24 was the only thing that I did not do properly, according
25 to the 1999 blueprint for action.
0060
1 Q. I will come back to that answer. Can I take this fairly
2 quickly. In the middle of 1992 you tell us you applied
3 for a post elsewhere, at Oxford. You tell us that the
4 reasons for wishing to go to Oxford were that you did
5 not wish to be associated with paediatric cardiac
6 surgery in Bristol any longer?
7 A. Yes.
8 Q. So, as it happens, if you had got the job in Oxford, you
9 would have left Bristol, gone to Oxford and done your
10 work there?
11 A. Yes.
12 Q. And said no more about Bristol?
13 A. I would probably have moved on to other things,
14 I think.
15 Q. So the answer is "Yes, said no more about Bristol"?
16 A. Yes, probably.
17 Q. Does it follow that at that stage you were prepared,
18 although you had concerns about the effect of surgery on
19 children, to do nothing more about it?
20 A. I think it is difficult to answer that, because it is
21 a hypothetical question. When I went for my interview
22 in Oxford, Steve Westerby, the senior surgeon, said to
23 me "Why do you want to leave Bristol?" and I said
24 "I will tell you now, I do not think their standard of
25 paediatric cardiac surgery is particularly good and I do
0061
1 not want to be associated with that level of practice",
2 and he said "Everybody knows about that. If you get the
3 job here, we will be pleased to have you here". It
4 might be he would have said "Steve, you raise concerns;
5 they conform to the opinions of cardiac surgeons, should
6 we do something about it?", in which case I may have
7 gone with Steve to Sir Terence or the Department of
8 Health and said "Look, we both have concerns from
9 different areas, should we be doing something about
10 Bristol?"
11 I cannot answer that question. It may have been
12 that in the next register, Bristol is not an outlier.
13 Q. At about the time you went off to Oxford, you had
14 a conversation with Professor Prys Roberts, did you?
15 A. Yes.
16 Q. Professor Prys Roberts was asking, was he, why it was
17 you were off?
18 A. Yes.
19 Q. You gave him an indication?
20 A. Yes.
21 Q. When you had explained you had concerns about
22 paediatric cardiac surgery, what do you recollect as
23 being his response?
24 A. His response was that he actually told me that this
25 had been grumbling on for a long time. He told me when
0062
1 he was first appointed to the Chair in Bristol, he had
2 had to adjudicate the decision as to whether the
3 cardiothoracic surgeons were allowed to do two
4 operations in a day. At that stage they were doing one
5 operation in a day and taking most of the day and they
6 wanted to do two because that was what most units were
7 doing at that time, and nobody could agree whether the
8 surgeons could do it. The anaesthetists said "If you do
9 that, we will not finish until 10 at night" and the
10 surgeons said "We have to do it because that is what
11 everybody else is doing".
12 He investigated and concluded the surgeons should
13 only do one operation a day, because it would take too
14 long to do two.
15 Q. What, if anything, was the outcome of the meeting with
16 Professor Prys Roberts, as you recollect it?
17 A. The outcome was that we made a deal, a gentleman's
18 agreement, firstly he said he would back me very
19 strongly in Oxford, he would back me in Oxford; if I did
20 not get the job, would I come back and collect the data
21 on paediatric cardiac surgery in Bristol?
22 Q. Is it the case that by the time you spoke to Dr Prys
23 Roberts, you had already spoken to Andrew Black?
24 A. I was working with Andy Black on the adult data
25 collection.
0063
1 Q. So there was data collection in process, albeit adult?
2 A. Yes.
3 Q. It was not Professor Prys Roberts's position, no doubt
4 as you understood it, to commission any data, survey or
5 anything of that sort?
6 A. No. It was a gentleman's agreement.
7 Q. Do I understand that the proposal to collect data, to
8 see what the figures showed, came from you rather than
9 from him?
10 A. No, the proposal came from him and he said, "On the
11 basis of that data, you must either shut up or put up",
12 and I remember that phrase indelibly.
13 Q. Was he, then, do you think, saying "If you have
14 concerns, you have to back them up with hard figures"?
15 A. Yes.
16 Q. And that was effectively, was it, what made you carry
17 your data collection further than it already had gone?
18 A. Yes, he also offered Andy Black as a resource to
19 undertake and complete that data collection.
20 Q. Because you had not got any hard figures at that stage?
21 A. No. There was the unit's data and there were my
22 suspicions and logbook data and those figures.
23 Q. What Professor Prys Roberts has told us -- let us look
24 at WIT 382/3, the top paragraph:
25 "On 22nd July 1992", so that gives us the date,
0064
1 you informally discussed the concerns about the
2 paediatric cardiac surgery with him and Dr Williams.
3 "By that time, Dr Black, senior lecturer, had agreed to
4 assist Dr Bolsin with the statistical assessment of his
5 data gathered between 1989 and 1992."
6 That would have been a reference to the
7 perfusionists' data we have just been looking at which
8 ended in 1992?
9 A. That was actually a reference to the adult data. There
10 was an ongoing adult data collection which started in
11 1989 with Rob Ray, the visitor from Australia, and we
12 continued it to 1992, so it is a reference to adult
13 data, not paediatric data.
14 Can I take you back to sentence 1 and just suggest
15 that here we have evidence in July 1992 that Dr Bolsin
16 is still going through the proposed blueprint for
17 action, and talking to his academic superiors and his
18 Director of Anaesthesia about concerns in paediatric
19 cardiac surgery?
20 Q. Perhaps we ought to go back to the page before; where
21 Dr Prys Roberts recollects that in early 1992 -- this is
22 at the stage you were talking to others outside the
23 unit:
24 "Dr Bolsin expressed to me his continuing concern
25 about the results. I told Dr Bolsin I would speak to
0065
1 Dr Roylance .... met with Dr Roylance on one occasion,
2 discussed paediatric cardiac surgery, I explained to
3 Dr Bolsin...", this is the passage:
4 "I explained that Dr Bolsin had been collecting
5 data and he was correct to express concern about the
6 results".
7 A. I think that would have been the logbook data.
8 Q. The data we looked at earlier?
9 A. I have not been able to find the 1992 logbooks, but
10 there was an ongoing logbook data collection, was there
11 not?
12 Q. Shall we go back to WIT 382/3? He goes on in the second
13 paragraph:
14 "... aware that Dr Black and Dr Bolsin were
15 analysing what data they had available. I did not
16 consider these activities in any way constituted an
17 official involvement of either the University Department
18 of Anaesthesia or the University of Bristol."
19 You do not suggest that there was any official
20 involvement?
21 A. No. It was not official. There was no contract drawn
22 up to undertake an audit; it was an agreement.
23 Q. Just in case there is a problem with the chronology,
24 which Professor Prys Roberts has, can we go back to the
25 page before? The top of the page, please, N3. Can
0066
1 I just sort this out with you?
2 He recollects October 1991, discussions where you
3 showed him some preliminary data you had gathered
4 between 1989 and 1991 and the data showed high
5 mortality: "cannot remember the precise details.
6 Suggested he should continue to keep accurate records
7 then we would be able to make comparisons", and he said
8 he did not sanction any such process in his official
9 capacity, because he had no authority to do so, which
10 I suspect you would agree he did not, in any official
11 capacity?
12 A. Yes.
13 Q. October 1991. The time that I understand from what you
14 have said your recollection from talking to Prys Roberts
15 is the time that you were actually on your way to
16 Oxford, or applying for Oxford and that was the reason
17 for the conversation?
18 A. Yes.
19 Q. That was the first conversation you had with him about
20 concerns?
21 A. As far as I can remember. I am not going to deny that
22 this conversation took place, but I cannot remember it.
23 I mean, it fits in with the events. I was collecting
24 data and showing it to just about everyone. I showed it
25 to Dr Clements and a lot of other people, and this is
0067
1 consistent with my actions at that time.
2 Q. Again, so that I put it fairly to you what Professor
3 Prys Roberts recollects, can we go back to the
4 page before, the top of WIT 382/1, the very bottom of
5 the page, please. He says that in 1989 he was
6 approached by you, then a newly appointed consultant who
7 had expressed concerns about problems in managing small
8 babies and was very concerned about mortality in this
9 group of patients, which was much higher than you had
10 been accustomed to as a Senior Registrar.
11 Let us go back to page 2:
12 "I advised him that, rather than create waves with
13 little credible evidence, he would be better advised to
14 collect prospective data on babies and children."
15 A. Yes.
16 Q. So the timing of that conversation, can you help with
17 it? The conversation where Professor Prys Roberts said
18 "rather than create waves with little credible evidence
19 you had better get some data", was that when you were on
20 your way to Oxford?
21 A. No, I think this would have been much earlier. Looking
22 at the date of it, I suspect it may have been possibly
23 the time of the annual report, or something like that.
24 Q. And that is a fair reflection of what he was saying, was
25 it: rather than create waves with little credible
0068
1 evidence, you had better get some?
2 A. Yes.
3 Q. That is the style of the later conversation too: when he
4 knows you are on your way out, it is because of concerns
5 with paediatric cardiac surgery, and he says, "If you do
6 come back, make sure you get some hard data to support
7 what you are saying"?
8 A. Yes. I think I have gone to him in 1989 and said I have
9 concerns. He suggests I went to him in 1991 with
10 concerns. By 1992 I have said "I am out of here, this
11 is too much, I cannot deal with it, I have all these
12 concerns and nobody is doing anything about it".
13 Q. He was anticipating, then, that you would collect,
14 analyse and so on, the data. You then set about doing
15 so, did you?
16 A. Yes.
17 Q. Can I check with you what particular documents you then
18 produced? Can we look, please, at UBHT 61/90? That is
19 the current sheet as we have it. Can we go over the
20 page to UBHT 61/91? Do you recognise that page?
21 A. Yes. I think it was a mini-tab programme that Dr Black
22 used to store and analyse the data that we collected.
23 Q. The data you collected was from the perfusionists, was
24 it?
25 A. No, this was a new data collection and it was undertaken
0069
1 by Andy's daughter in her summer holiday from
2 University. We identified the patients from several
3 sources. Andy did most of the data collection and
4 collation, and he would give you a better opinion of it,
5 but I can remember going to theatre logbooks to confirm
6 operations that he and his daughter were picking up, and
7 I think we may have got some data from the
8 perfusionists, but there was another source and I cannot
9 remember what it was at the moment.
10 Q. So theatre logbooks, perfusionists. What was Dr Black's
11 daughter doing? Was she looking at the records and
12 making notes, or what?
13 A. Yes, she would be extracting the data on length of time
14 on intensive care, length of time intubated, length of
15 time in hospital, duration of operation, length of time
16 on bypass, duration of cross-clamp time, those kinds of
17 detailed data.
18 Q. What was she studying?
19 A. She was studying at Reading University -- I cannot
20 remember, actually. Pass.
21 Q. Was she employed by the Trust to do this job?
22 A. I do not know. That was an arrangement between Andy and
23 her, I think.
24 Q. Because if it was an arrangement between Andy and her,
25 there would, on reflection, be a breach of patient
0070
1 confidentiality, would there not?
2 A. I am not sure if patient confidentiality was breached
3 by this data collection.
4 Q. If somebody who is not an employee of the Trust, not
5 authorised by the Trust to do so, is going through
6 individuals' medical records in order to extract details
7 like cross-clamp times, bypass times and so on, that
8 must be a breach of confidentiality, must it not?
9 A. I am not sure if she may not have been an employee of
10 the University department. I do not know whether that
11 has any bearing on what you have just said.
12 Q. Does it follow that you never made any enquiries as to
13 why a student could properly be involved in an analysis
14 of the sort you have described?
15 A. I certainly did not make any enquiries. I assumed that
16 the probity of an employee of the University department,
17 albeit a technician, in dealing with patient records,
18 was reasonably bona fide.
19 Q. So you assumed that she was an employee who had the
20 status to look at the records, without enquiring?
21 A. I certainly did not make any enquiries, no.
22 Q. What was the object of the exercise going to be? You
23 were going to collect data for what purpose?
24 A. I think the object of the exercise was to establish
25 whether there was or there was not a serious problem of
0071
1 excess mortality in Bristol.
2 The secondary object would have been to have
3 identified in what group of patients that was occurring,
4 and from that would have flown a solution as to how to
5 prevent it. That was the goal. That is what we were
6 aiming for. The reason we had to do it was because for
7 two, possibly three, years, I and others had been unable
8 to get that information from the paediatric cardiac
9 surgical unit, however you wish to constitute that.
10 Q. Forgive me. The figures which we have seen produced in
11 March 1992, the latest figures, comparative figures,
12 with the rest of the UK, showed, as you have told us
13 already, twice the mortality, or appeared to show twice
14 the mortality in Bristol compared to elsewhere. They
15 identified problem operations. So the first two matters
16 that you were trying to discover had already been
17 discovered, had they not? What additional information
18 was your enquiry designed to achieve?
19 A. Hang on, where you are talking about problem
20 operations, that is a specific minute that was not
21 accepted by --
22 Q. No, I am looking at the March 1992 figures.
23 A. Yes, in what document?
24 Q. Let us go back to it: 26th March 1992. Just give me
25 a moment and I shall find the reference to it.
0072
1 PROFESSOR JARMAN: UBHT 55/81?
2 MR LANGSTAFF: UBHT 61/161. I am sorry, Professor.
3 PROFESSOR JARMAN: It is equally there.
4 MR LANGSTAFF: If we scroll down, this is the minute that we
5 looked at yesterday of the audit meeting of March 1992?
6 A. Yes.
7 Q. Where the mortality was compared, good results for
8 certain operations, poor results for others, and
9 appropriate steps taken?
10 A. Yes.
11 Q. Those figures were available. They appear to indicate
12 problem operations, they appear to indicate good
13 operations. What more was your data going to provide?
14 A. I had not seen these minutes. Certainly in the middle
15 of 1992 I would not have seen those minutes.
16 Q. But if you were interested and concerned and having been
17 invited to meetings, as you told us you were --
18 A. Yes, but it was a Monday morning when I had
19 a clinical commitment.
20 Q. Wait for the question.
21 A. I am sorry.
22 Q. -- did you not know that these figures had actually been
23 produced at that meeting?
24 A. No.
25 Q. Did you not ask whether figures had been produced? You
0073
1 have seen the 1991 minutes, the minutes that were
2 queried; you knew that the 1990 figures were being
3 discussed, you knew the 1991 figures were coming out and
4 would be discussed?
5 A. Yes, but the 1991 figures did not come out until later
6 in 1992.
7 Q. So you knew that there would be such figures; you knew
8 what they would show; you knew they might identify
9 problem operations. What was your survey going to add?
10 A. I think that the open availability of information was
11 a problem within this unit. I was not able to get this
12 kind of information that you, as an Inquiry, quite
13 rightly have. It was not coming to me. I did not know
14 what the data was. Nobody came to me and said "Steve,
15 there is nothing to be worried about, there is no
16 problem in paediatric cardiac surgery; all the figures
17 are fine, I have shown them, here they are."
18 Q. Did you ever ask for the figures in respect of 1991?
19 A. Ask who?
20 Q. Let us scroll up to the top of this page. For a start,
21 any of those who are recorded as having been at that
22 particular meeting? They would have told you no doubt,
23 "These are the figures, that is what we have
24 discussed."
25 A. My concerns were such that people were aware that I was
0074
1 concerned. I would probably have asked my colleagues if
2 they were happy with the way the unit was going. The
3 evidence that I was getting, albeit hearsay, was, well,
4 there were still some concerns and we do have some
5 problem operations, they were still keeping logbooks,
6 I was still keeping logbooks. The data was not coming
7 through that we could be reassured that there was no
8 problem.
9 Because I was not reassured that there was no
10 problem, I set about collecting the data myself.
11 Q. The question was, did you ever ask any of those
12 individuals for the data?
13 A. Possibly not directly, no.
14 Q. So the answer is "No"?
15 A. Not directly, no.
16 Q. Indirectly? How?
17 A. Indirectly, through Dr Brian Williams as you have seen
18 and Professor Prys Roberts, expressing concerns, "Can
19 you reassure me?" If you remember, the blueprint for
20 action was to go to the Director of Anaesthesia and he
21 was to take it across to the other professional group.
22 I was trying to get information, but the information was
23 not coming back to me.
24 Q. Are we to read that an expression of concern, saying
25 "I am very concerned about results", is to be
0075
1 interpreted by the person to whom the concern is
2 addressed as a request that he or she should go to
3 somebody else and say, "Give me the data"?
4 A. You have to remember that expressions of concern at
5 a meeting in late 1990 --
6 Q. Let us do the remembering that I should do in a moment,
7 and give me an answer.
8 A. In the context of what was happening in Bristol, the
9 answer is "Yes".
10 Q. And you were going to tell me to remember something?
11 A. I was going to say that, in a similar meeting in 1990,
12 we had expressed concerns and we had said, "The conduit
13 for the expression of concerns is the Director of
14 Anaesthesia and the Cardiac Liaison Anaesthetist.
15 Will you go and find out the data and check that we do
16 not have to be worried?"
17 Q. So if, in the context of 1992, you expected Dr Williams
18 or Dr Monk to have requested data because that was
19 implicit in the expression of concerns, you no doubt
20 would ask them if they had got the data and what it was?
21 A. Yes, I would have asked them if there was data to
22 reassure me.
23 Q. And they said ...
24 A. No, there was no data.
25 Q. Going back to the document 61/91 --
0076
1 THE CHAIRMAN: Mr Langstaff, Professor Jarman wants to say
2 something.
3 PROFESSOR JARMAN: I am sorry to interrupt. Just to
4 clarify, the thing I brought up before, UBHT 55/81, if
5 we can have it on the screen, the fifth row down, it is
6 the 30-day mortality open-heart surgery. This is the
7 audit report of the paediatric cardiac surgery unit?
8 A. Yes. It is the annual report, I think.
9 Q. The annual report, yes. You have told us earlier on
10 that you had seen it, and Dr Jordan told us earlier that
11 they were fairly widely available. In fact the earlier
12 ones were even sent out to purchasers?
13 A. Yes.
14 Q. Can you remember clearly whether you had seen this?
15 A. I am pretty sure I saw this. This is 1989, and we then
16 had to wait quite some time for the 1990 one, I believe,
17 but there is another one very similar to this, almost
18 exactly the same format, again in which the mortality
19 rate is high.
20 Q. A couple of days ago you drew our attention to the fact
21 that in 1989, looking along that row, it was 37.5 in
22 BRI, and 18.8 in 1988, in the UK?
23 A. Yes.
24 Q. You said it might have been even lower had you taken the
25 1989 figures?
0077
1 A. Yes.
2 Q. So you did actually have hard data available to you --
3 A. Yes.
4 Q. -- at that time, which you could have used?
5 A. Yes. I may well have used that double figure of twice
6 the national average mortality in the conversations that
7 I had.
8 Q. So information was available from these annual reports?
9 A. Yes, the information I wanted was to be reassured that
10 we were not still at twice the national average
11 mortality. I am sorry, is that --
12 Q. I was trying to say, there are figures for earlier years
13 as well. You were aware that there was information from
14 these annual reports of a higher death rate?
15 A. Yes.
16 Q. That is what I wanted to be absolutely clear.
17 A. Yes. This is backed up by professional intuition that
18 we had a problem. When I saw this, it became clear that
19 the problem was a very real problem.
20 PROFESSOR JARMAN: I think that is probably clarified, thank
21 you.
22 MR LANGSTAFF: If I can go back to UBHT 61/91, can we have
23 a look at UBHT 61/92 now? This is a result, I think, of
24 the pooling of three particular operations. I do not
25 know if you can help us with that particular page. Was
0078
1 that part of the same dataset as the page we just looked
2 at a moment ago?
3 A. Yes.
4 Q. The next page, "Bristol 1990 to 1992, rest 1989, rest
5 1991". If we look down the left-hand column, various
6 different operations. Was this part of the original
7 dataset as well?
8 A. Yes, I think so.
9 Q. Turn over again. UBHT 61/94.
10 A. Yes.
11 Q. Part of the original dataset?
12 A. Yes, as far as I can remember, yes.
13 Q. If we go on to UBHT 61/87, the same question, the same
14 answer?
15 A. Yes. I think we have moved from the dataset now to an
16 analysis of some of the data, so Andy has taken some of
17 the subgroups and he is doing a sort of subcollection.
18 Q. So the process, just going back for a moment to 1993 and
19 scrolling down a bit to "AV canal", is to identify
20 AV canal, 31 per cent mortality on the crude figures
21 compared with the rest of the UK, 17 per cent it appears
22 in 1991.
23 That then leads you to an investigation, does it,
24 of that particular series which we then see at page 87?
25 A. No, it was slightly more intuitive than that.
0079
1 I believed from the evidence we had before, in 1989 and
2 1990, that there were a couple of problem operations,
3 possibly three: tetralogy of Fallot, the VSD and
4 AV canals. We therefore decided that we would look at
5 those groups if the numbers were big enough, and it
6 turned out that the numbers were possibly big enough, so
7 we looked at them.
8 We also did not want to be seen to be unfair to
9 Bristol, and consequently, we knew that Bristol actually
10 thought they did the Fontan procedure particularly well,
11 and we wanted to try and identify excellence in this
12 unit if we could, so we took the Fontan operation and we
13 said "We will look at that as well".
14 Q. What about the switch?
15 A. The problem with the switch is that there are two
16 possible operations for the anatomical abnormality for
17 transposition of the great arteries, and you can either
18 do a Sennings operation or a switch operation. In the
19 Cardiac Surgical Register, which was going to be our
20 comparator, you cannot tell which operation is being
21 done, so it is impossible to use the Cardiac Surgical
22 Register as a comparison for the switch operation, so
23 that had to be analysed separately.
24 Q. Let me be clear about this. You are saying that the
25 reason why you did not analyse the switch as a problem
0080
1 operation was because you could not get any comparative
2 data from the UK Surgical Register?
3 A. Yes.
4 Q. No other reason?
5 A. No. That was the reason. You cannot get comparative
6 data and this was entirely about comparative data: where
7 does Bristol sit relative to the rest of the country?
8 It would have been unfair to have taken the switch from
9 this dataset.
10 Q. You appreciate that you have, on occasion, I think, said
11 that the reason you did not include the switch was
12 because you knew very well, as did the Bristol unit,
13 that the switch results were bad and you did not wish to
14 include them for that reason.
15 A. I may have said that. We did know that they were bad.
16 We did not want to harp on about the switch, but we also
17 did not have a national comparator for the switch.
18 Q. You appreciate then that you have on two separate
19 occasions given two separate reasons for not analysing
20 the switch in this original data source?
21 A. Yes.
22 Q. May I just clarify which reason is correct?
23 A. Can they both be correct?
24 Q. They can, if that is the case, absolutely.
25 A. Yes, I think there was more than one reason for not
0081
1 including the switch in this analysis, in that case.
2 Q. "In that case?"
3 A. I am sorry, there was more than one reason for not
4 including the switch in this analysis.
5 Q. So if one looks at the page that we have here, anyone
6 looking at these figures is going to see a range of
7 percentages, a range of percentages for the rest of the
8 United Kingdom, and the overall information is really
9 very much the same, is it not, in percentage terms as
10 the information you would get from any report of the
11 nature that Professor Jarman has just drawn your
12 attention to, because there cardiac surgical returns for
13 the unit are set out and analysed by operation and some
14 of the dataset by surgeon?
15 A. Yes.
16 Q. So your dataset thus far would add nothing to the
17 information you would expect to get from the unit if the
18 data were available?
19 A. It has added an awful lot, though, because it has bypass
20 times --
21 Q. I was going to ask you about that: thus far, no further
22 information?
23 A. If you are only concentrating on mortality and numbers
24 of operations, the answer is "Yes".
25 Q. The difference is, UBHT 61/94: you have bypass times,
0082
1 cross-clamp times, days of extubation, days in ITU, days
2 in hospital?
3 A. Yes.
4 Q. You would not have got this data because it was not
5 presented from the traditional surgical approach?
6 A. No, quite right.
7 Q. Did you think this data was important?
8 A. Yes.
9 Q. What did you think the data was likely to show?
10 A. I think we wanted to look for causation, if there was
11 a problem. If we were going to find a problem with our
12 data, we did not want to then be told, "Oh, the reason
13 is this", or "The reason is we had an outbreak of
14 superbug and all the children died"; we wanted to try
15 and find out if there were any generic systematic
16 associations that we could perhaps pull out.
17 One of the professional intuitive feelings by not
18 just me but by other paediatric cardiac anaesthetists
19 was that these operations were taking a long time and
20 this may contribute to a long ICU stay. So we collected
21 that data.
22 Q. You have told us that was your own intuition as an
23 anaesthetist?
24 A. Not just my intuition, but --
25 Q. And you discussed it around?
0083
1 A. Yes.
2 Q. Bypass time and cross-clamp time are both matters that
3 relate to the progress of surgery, are they not?
4 A. Yes.
5 Q. And they are matters, are they, which are essentially
6 under the surgeon's control?
7 A. Yes.
8 Q. If you were to draw any conclusion that statistically
9 bypass time and cross-clamp time appeared high, did you
10 have any view as to who that might appear to be directed
11 at?
12 A. It would be difficult at this stage to have considered
13 that we were able to make that comparison, because there
14 was no comparative data. We just thought that if we
15 collected this data and said, "Our average cross-clamp
16 time for this procedure is [this]", or "Our average
17 bypass time for this procedure is [this]", it might be
18 something that we could use in discussions with, let us
19 say, Bill Brawn in Birmingham or Francesco Musomecci in
20 Cardiff, or go down to Jim Munro in Southampton and say,
21 "What do you think, guys?" and see if there was
22 a difference, and whether that could possibly be the
23 cause. It was not intended to be critical; it was to
24 provide a constructive framework.
25 Q. So the intention was to collect material which might
0084
1 inform as to surgical progress and prowess, and then to
2 get the only comparative information one could by asking
3 outside the unit, because there was no central registry
4 of bypass times and so on?
5 A. Yes. It was not to deal with surgical prowess, it was
6 to deal with these as a possible cause. If they were
7 identified as a cause, we would then have to go on to
8 deal with that.
9 Q. And you thought they might be?
10 A. I suspected they might be, yes. As Dr Sumner said
11 yesterday, anaesthetists are in a very good position to
12 judge surgical technique.
13 Q. Was it the inclusion of this data in your analysis that
14 actually distinguished your data from any other data
15 that the unit had and might have been seen as, at least
16 potentially, or intentionally, critical of the
17 surgeons?
18 A. I do not believe so, because I do not think this data,
19 the detailed data, was ever circulated.
20 Q. Did you ever in fact have comparative data as opposed to
21 an expression of views when you asked around, any
22 comparative data as to bypass times, cross-clamp times,
23 and so on?
24 A. No. In fact, to be even more precise, we never
25 aggregated the bypass and cross-clamp times for the
0085
1 different procedures, so we never even got to the first
2 stage of discussing it.
3 Q. So you never analysed it?
4 A. No.
5 Q. Can I move on to page 97? Again, tell me: have there
6 been various different editions of the data, or not?
7 A. Yes.
8 Q. So far as this data is concerned, looking at AV canal,
9 we see that the data collection, you tell us in your
10 statement, finished in mid-1992?
11 A. Yes.
12 Q. So this relates to that period?
13 A. Yes.
14 Q. Who prepared the tables that we see -- let us take the
15 top one as an example: AV canal under 1 year?
16 A. This would have been Andy Black.
17 Q. If it was shown in that form to anyone who was not
18 himself a statistician, how meaningful do you think it
19 would be?
20 A. It does not help me much at all; it is not very
21 meaningful.
22 Q. Was the data as such properly characterised as crude
23 data?
24 A. Which data?
25 Q. The material which went into this calculation?
0086
1 A. Yes. I am not sure what you mean by "crude data", the
2 characterisation.
3 Q. There is no adjustment of the data?
4 A. Yes, it was crude outcome data if that is what you mean,
5 absolutely.
6 Q. So if one is looking at death, one is looking at a crude
7 mortality figure?
8 A. Yes.
9 Q. Unstratified?
10 A. Yes.
11 Q. Unadjusted?
12 A. Yes.
13 Q. Unverified data?
14 A. We had done our best to verify the data.
15 Q. That is not quite the same: unverified data?
16 A. Unverified by whom?
17 Q. So that it would carry statistical confidence if it were
18 published in a peer review journal, for instance?
19 A. The intention of this data collection was never --
20 Q. No, that is not the question. The question is: was the
21 data properly verified or not?
22 A. I think I verified it and Andy and Sue verified it.
23 I am not sure what level of verification you want, but
24 if you want me to say it was unverified, then I will say
25 it is unverified.
0087
1 Q. I do not want you to say anything in particular, I have
2 no case to put. I am enquiring: what was your view as
3 to the verity of the data?
4 A. As far as we knew, the patients had all died and we had
5 a paediatric cardiologist, Alison Hayes, to verify the
6 diagnostic categories of the patients who died, so the
7 data was as well verified as we could achieve, with
8 a consultant specialist in paediatric cardiology, and we
9 knew that all the patients that had died had actually
10 died.
11 Q. There was no cross-check between one data source and
12 another?
13 A. I do not know about that, I am afraid.
14 Q. It is not something you did, then?
15 A. I did not do it, no.
16 Q. So leave aside the word "verified"; not cross-checked at
17 any rate to ensure accuracy?
18 A. No.
19 Q. Would you expect your anaesthetic colleagues, if they
20 saw a document in this form, to understand it without
21 any detailed explanation and exposition?
22 A. No. I would not even understand this.
23 Q. Because this is Andy Black's work, is it?
24 A. Yes.
25 Q. That is despite your considerable involvement in the
0088
1 organisation of audit throughout the country?
2 A. Yes. I do not memorise chi-square tables, I am afraid.
3 Q. You are not a statistician, even though you had an
4 interest.
5 A. No.
6 Q. If we move on to UBHT 61/95, this is just to ask you
7 whether you can help with the writing. "FG": do you
8 recognise that at all? Can you help?
9 A. No. I do not know whose that writing is, I am sorry.
10 Q. If you cannot help, we will have to leave that one, but
11 at page 61/85, it is rather more helpfully presented?
12 A. Yes, I asked Chris Day -- he was doing an MD on the
13 adult data analysis with Andy Black and myself -- to
14 convert Andy's crude uninterpretable chi-squared tables
15 and put them into a much more interpretable form.
16 Q. So it is the same data, but presented differently?
17 A. Yes.
18 Q. When did you do that?
19 A. That would have been, I suspect, about the middle of
20 1993. I think that is when Chris was doing his MD and
21 he was doing statistics, a lot of detailed statistics,
22 and he was able to just formulate this, in the format.
23 Q. Although you are not a statistician yourself, you might
24 be able to confirm for me -- if you are not, please say
25 not -- that as statistical tables, there are, it
0089
1 appears, multiple comparisons and there does not seem to
2 have been any adjustment for multiple comparisons?
3 A. No.
4 Q. Equally, they are small datasets and it would appear
5 that Fisher's exact test has not been used, nor any
6 other form of collection for small dataset size?
7 A. Yes.
8 Q. And it appears plain that there is no confidence
9 interval expressed around the figures, and you would
10 need that to make a comparison?
11 A. I think this was used for guidance. The kind of things
12 you are talking about are what you would do if you were
13 going to present it for peer review. We have already
14 halfway gone down that cul-de-sac. This was never
15 intended for peer review.
16 Q. So this is a signpost rather than a destination?
17 A. Yes, absolutely.
18 Q. If one looks into the figures for VSD -- let us go to
19 page 84 -- we know now, and you accepted on Monday, that
20 the figure for deaths is out by 500 per cent?
21 A. Yes.
22 Q. In a series of 47 cases, that makes a very big
23 difference to the outcome. It says there that Bristol
24 is significantly worse than the rest of the UK on VSD;
25 that is the bold conclusion.
0090
1 A. Yes.
2 Q. Within the unit, there were, were there, in 1993, three
3 anaesthetists who were anaesthetising for paediatric
4 operations: Dr Masey, Dr Underwood and yourself?
5 A. And Dr Monk.
6 Q. Not so much, I think, as the other three. You can tell
7 me if that is right or wrong?
8 A. He may not have done quite so much, but he certainly was
9 providing paediatric cover and doing paediatric cases
10 during the day.
11 Q. So each you would have a view from their own dataset,
12 their own data sources, as to whether or not VSD deaths,
13 mortality, was of the order which this would indicate?
14 A. Yes.
15 Q. The intuitive reaction from knowledge of what was
16 happening in the unit would be that this was, on the
17 face of it, pretty way over the top?
18 A. My intuitive reaction was that this was plausible. We
19 needed a full and open review to refute or confirm it.
20 Q. I follow the scientific approach of being led by the
21 data and one has to draw one's conclusions from the data
22 rather than in advance of it, but so far as your
23 colleagues were concerned, would you expect, looking at
24 this before you ever showed it to anybody, that they
25 would look at the VSD figures and think, "Oh my
0091
1 goodness, this is very surprising"?
2 A. They might do. Knowing that we had had a problem with
3 the VSD operation which we had discussed in 1989, it
4 could be an indication that there were continuing
5 problems with this operation. So it was, as I say,
6 plausible and something that needed to be investigated.
7 Q. In fact, did you get the reaction from a number of your
8 colleagues that this was so surprising that it caused
9 them to worry about the data as a whole?
10 A. I do not remember getting that reaction, no.
11 Q. The reason I ask is that we have been told by a number
12 of witnesses, on paper and in evidence, that that was
13 their reaction to seeing the VSD figures.
14 A. Yes.
15 Q. Is it the case that you do not recall that it was their
16 reaction, or you would say it was not their reaction,
17 they must be mistaken, or what?
18 A. I do not remember anybody coming up to me and saying,
19 "This VSD data is obviously incorrect, Steve", you
20 know --
21 Q. The way they have put it -- because you have started off
22 saying "no-one came up to me and said ..." was that when
23 you showed them some figures, their eyes focused upon
24 the VSD and they thought, "This must be wrong", and said
25 as much. That is their recollection. It is not them
0092
1 coming up to you and saying, "Steve you have got the VSD
2 figures wrong", it is rather that when they are shown
3 papers for the first time with these sort of figures on,
4 they say to you, "Come on, this cannot be right", or
5 words to that effect.
6 A. I cannot remember them saying, "They cannot be right".
7 They may have been surprised. Certainly for me, the VSD
8 should be a much lower mortality than that, but as
9 I say, this was the best data we had. What we were
10 aiming for was a review of results if there were
11 potential problems in a unit with twice the national
12 average mortality.
13 Q. Neither the original nor the better presented form of
14 the data dealt with the switch operation. You say you
15 analysed that separately. May we have a look at
16 UBHT 61/46, a provisional report on switch operations at
17 the BRI, dated 13th July. Do you recognise this?
18 A. Yes, this is a document that I produced.
19 Q. The analysis there for simple death rates is described
20 as "provisional".
21 A. Yes.
22 Q. Attached to it was a page, was there? If we go overleaf
23 and show this on the Chairman's screen first, please,
24 UBHT 61/47, can we eliminate on the left-hand column
25 everything under the rubric "Operation Date" and just
0093
1 leave the heading? That may now be shown.
2 THE CHAIRMAN: Do you want to take out "Age at Operation",
3 Mr Langstaff?
4 MR LANGSTAFF: Since we have taken out the date, I think we
5 can safely put it on. If you prefer the age of
6 operation to come out, let us take it out.
7 THE CHAIRMAN: Thank you.
8 MR LANGSTAFF: That can now be shown. We know that in the
9 left-hand column there were the dates of the operations
10 and we know that the age was there in the original.
11 A. Yes.
12 Q. Was there a sheet like this attached to the provisional
13 report?
14 A. No. I do not think I attached this sheet to the
15 provisional report. This sheet was a purely working
16 document, and as you can see from the scribbles and
17 things, I do not think I would have left that out.
18 Q. So that was a document you had from which you prepared
19 your provisional report?
20 A. Yes.
21 Q. The provisional report then consisted of one page, did
22 it?
23 A. Yes.
24 Q. Can we look at UBHT 54/3? Sir, I think that is
25 sufficiently redacted, because issues may arise on the
0094
1 month and year of operation. May we have that on the
2 screen? Can we scroll down? "SB data from Dr Bolsin".
3 I do not know if you recognise that writing?
4 A. I think the "SB data" looks like my writing, but not the
5 "from Dr Bolsin".
6 Q. Can we look at the whole page? Is that a third piece of
7 data which you collected?
8 A. Yes. I mean, just to point out, we had moved on a year
9 now from the production of the early Black/Bolsin data
10 collection.
11 Q. I just wanted to make sure it was data that came from
12 you?
13 A. Yes.
14 Q. Can you tell me, and it will be the last matter I want
15 to deal with before we have a break for lunch: were
16 there any other analyses which you produced between the
17 period 1992 and the Loveday operation in January 1995?
18 A. I cannot think of any. I think that there was the
19 possibility of a sort of moving target in that, as
20 operations were continuing to be done, I might have been
21 adding to a database and producing changed total
22 numbers, but I think these are the two key documents
23 that I produced at that time.
24 Q. I think we have three or four. We have the original
25 draft; we have the better presented, one of the same; we
0095
1 have the switch, the summary provisional report of July
2 1994?
3 A. Yes.
4 Q. The AV canal data, summary information 31/10/94?
5 A. Yes.
6 Q. What I am asking is: was there anything else actually
7 produced by you?
8 A. I do not think so, no.
9 MR LANGSTAFF: Sir, may we then have a lunch break?
10 THE CHAIRMAN: Yes. Shall we say until just after a quarter
11 past 1 then?
12 (12.35 pm)
13 (Adjourned until 1.15 pm)
14 (1.20 pm)
15 MR LANGSTAFF: Dr Bolsin, later on from the period with
16 which we have been intimately concerned over the last
17 few questions and answers, you were part of a meeting
18 the night before the operation on Joshua Loveday?
19 A. Yes.
20 Q. At that meeting you are recorded as having talked about
21 there being an institutional problem at the Bristol
22 Royal Infirmary in respect of paediatric cardiac
23 surgery.
24 A. Just to correct you slightly, I said there was an
25 institutional problem with the switch operation at the
0096
1 Bristol Royal Infirmary.
2 Q. I stand corrected.
3 A. Thank you.
4 Q. By "institutional" what did you mean?
5 A. The term "institutional" was one that I had picked up
6 from a grant application I had read of Professor Marc
7 de Leval. He had produced, as you and the Inquiry
8 know --
9 Q. Can I again cut you short a little. You picked it up
10 from another?
11 A. Yes.
12 Q. What did it mean to you; what sense were you using it
13 in?
14 A. I was using it in the sense that I did not want to
15 apportion blame to any one group of professionals or
16 groups of professionals within the hospital but I felt
17 it was important that we as a hospital recognised we had
18 a problem with this operation and we had to examine
19 everybody's component contributions to the programme.
20 Q. In essence what you are describing, is it, is a product
21 of two factors: one is a recognition, as you have
22 already told us, that cardiac surgery is a team
23 activity, a team process?
24 A. Yes.
25 Q. Secondly, if one is a scientist and one approaches an
0097
1 issue in an attitude to prompt a scientific inquiry, you
2 have to be open to all factors that might influence
3 outcomes whatever they may be?
4 A. Yes.
5 Q. Whether alone or in combination with others?
6 A. Yes.
7 Q. Was that the sense of what you were trying to convey by
8 using the word "institutional" problem?
9 A. Yes, I think we had to examine all of the factors that
10 were brought to bear on adverse outcomes.
11 Q. Because simply looking at an adverse outcome would not
12 on its own tell you it was the referring physician or
13 the cardiologist or preoperative care or the
14 anaesthetist or the surgeon or the post-operative care,
15 whether it was the responsibility of the anaesthetist or
16 the surgeon or for that matter somebody else. The raw
17 data could not tell you that, it could only tell you
18 there was something that needed to be explored?
19 A. Yes.
20 Q. When you began in Bristol what you have said a number of
21 times is that you noticed that the cross-clamp times and
22 the time of operation was longer than you had been used
23 to as a Senior Registrar at the Brompton?
24 A. Yes.
25 Q. Now that you were a consultant anaesthetist, were you
0098
1 responsible at Bristol in a way you had not been
2 responsible for operations or serious operations at the
3 Brompton?
4 A. I am not quite sure in what way you mean "responsible".
5 Q. As a Senior Registrar in anaesthetics would you have had
6 the sole, may I say "control", I hope it is the right
7 word, of the anaesthetics during an operation of
8 paediatric cardiac surgery?
9 A. Yes, as a Senior Registrar certainly you would have been
10 left on your own to complete a list or to complete
11 cases.
12 Q. For even the most serious of cardiac conditions?
13 A. If it was a very seriously ill child or a very serious
14 operation, there would probably have been a consultant
15 there as well, yes.
16 Q. At Bristol you were in the consultant position?
17 A. Yes.
18 Q. So, if you like, the ultimate responsibility for the
19 anaesthetics would have been yours?
20 A. Yes.
21 Q. In a way that the ultimate responsibility had not
22 entirely been yours before?
23 A. Yes, I think that is probably true.
24 Q. Do I detect in the report the fact that you produced
25 a report on your operations during the first year, as
0099
1 a sign that you were gaining confidence which you would
2 need to have obviously as a consultant and being
3 prepared to be self-critical?
4 A. Yes.
5 Q. You would have looked at what was happening and said
6 "Am I doing the right thing? Am I exercising my
7 responsibility properly in the interests of the patient
8 and the patient's safety?"
9 A. Yes.
10 Q. One of the features that you would have noticed at
11 Bristol inevitably with operations of this sort would
12 have been the death of some children who were operated
13 on?
14 A. Yes.
15 Q. As I imagine is the case of any properly responsible
16 consultant engaged in operations on young children, if
17 they went wrong not in the sense of there being any
18 error but in the sense of there being an adverse
19 outcome?
20 A. Yes.
21 Q. You would want to analyse, go over in your own mind why
22 that happened?
23 A. Yes.
24 Q. Was that a process that you as a young consultant
25 went through in Bristol, particularly whenever there had
0100
1 been, as you discovered on the table or afterwards in
2 ICU, a death of which you were aware?
3 A. Yes, I think we would have discussed patients which we
4 had had problems with, whether they were adverse
5 outcomes in terms of death or just long ICU stays. We
6 would on the ward rounds or amongst ourselves have
7 discussed if there were any ways of doing things better.
8 Q. Did the thought go round in your mind, however
9 unjustified it may have been and I am making no
10 suggestion at all, may I make it absolutely plain:
11 "Is it my fault?"
12 A. Certainly, yes.
13 Q. So you were looking at the factors that may have given
14 rise to the death of a particular child?
15 A. Yes. Can I add to that that at the time of that
16 I examined with my colleagues the processes we were
17 using for paediatric cardiac anaesthesia and concluded
18 my techniques were exactly the same as theirs.
19 Q. This was part of the self critique really, you were
20 saying "Look, is there something I am doing?" because
21 obviously any death is discomfiting and a number of
22 deaths is very worrying, whatever the reasons may be,
23 however inevitable they may be?
24 A. Yes, in fact in my case it led me to introduce
25 techniques and technologies that we mentioned before
0101
1 that had not been used in the UK and we were the first
2 to try new inotropes and use them in children in doses
3 that had not been described before in order to try and
4 improve perioperative care from our anaesthetic
5 viewpoint.
6 Q. It follows, does it, you were looking, if you could find
7 it, for a reason why children were dying if you could
8 find one because if you can find the reason you can sort
9 out the problem?
10 A. Yes, and for ways of improving the service we were
11 providing.
12 Q. You could not find that in your own conduct?
13 A. I think my practice evolved in order to try and deal
14 with that so I was continuously improving, as new drugs
15 came out, we adopted them. I was never complacent
16 enough to say I could not do better.
17 Q. Although not complacent, you satisfied yourself it was
18 not anything you were doing?
19 A. Yes.
20 Q. Was there an occasion, an early occasion during an
21 operation, I think perhaps on a switch, it may have been
22 an AV canal, when Mr Wisheart and you had an argument
23 because you had been out of the theatre in an operation
24 where the child subsequently died? I am not suggesting
25 anything wrong in this, but was there an argument?
0102
1 A. I have heard reference to it but I cannot remember it,
2 but there may have been.
3 Q. There was a discussion of it in the GMC transcript. Do
4 you recollect it at all?
5 A. No. I mean I am not saying it did not happen, but
6 I could not do anything about dating it or anything.
7 Q. In any event -- this is how this line of questioning
8 ties up with the data which you were producing -- we
9 have seen from looking at the sheets how you were
10 looking to see if there were data available on
11 cross-clamp times and intubation times and length of
12 stay in the ITU.
13 A. Yes.
14 Q. You also analysed the data in respect of consultant 1
15 and consultant 2?
16 A. Yes.
17 Q. Without giving their names, I think, as just "1" and
18 "2", but you had in mind, did you, Mr Dhasmana and
19 Mr Wisheart?
20 A. Yes, it was an analysis that Andy Black undertook and
21 I think he held the codes to the numbers.
22 Q. Yes. In each of those cases there may have been
23 different cardiologists?
24 A. Possibly, yes.
25 Q. Did you ever do or attempt any analysis by
0103
1 cardiological consultant?
2 A. No, we had not collected the cardiological data in the
3 database. I do not think there was a column on any of
4 the data sets you showed earlier that said
5 "cardiologist".
6 Q. We saw on Monday the data which Dr Pryn later produced
7 to the pre-Loveday operation meeting.
8 A. Yes.
9 Q. Which did show the particular, if I call it
10 "performance", the crude statistics of the performance
11 of different anaesthetists?
12 A. Yes.
13 Q. When you collected your data, did you look at the
14 results and analyse it by anaesthetist at all?
15 A. No.
16 Q. Was there then a focus so far as consultants involved
17 with the case were concerned purely upon the surgeons?
18 A. In terms of the Bolsin/Black data?
19 Q. Yes.
20 A. Yes, that was the major clinician focus, yes.
21 Q. The focus upon particular factors that might, because
22 you did not know, have contributed to outcome was
23 essentially, was it, upon matters which related to the
24 surgical conduct of the operation? It is a question
25 which I asked you this morning and I think you agreed
0104
1 with it.
2 A. Yes, yes.
3 Q. If the surgery was a team, which might depend as we have
4 agreed upon the input of a number of different
5 individuals --
6 A. Yes.
7 Q. -- and different disciplines and different procedures,
8 why was it that there was a focus on the surgeons?
9 A. I think in that elegant preamble we started with my
10 complaints about the Joshua Loveday operation in 1995
11 and the institutional factors which had been raised in
12 a paper by Marc de Leval in the latter part of 1994.
13 The focus in 1992 in setting up a data collection
14 was that we were looking at the major factors in which
15 we had intuitively surmised that some of the surgical
16 factors may be important. So we had confined ourselves
17 to the surgeons as opposed to including cardiologists
18 and anaesthetists and other things, so the whole thing
19 had evolved over that period.
20 Q. Again going back to the process of question and answer
21 about being quite rightly self-critical and excluding
22 yourself as a cause of excess mortality because your
23 procedures were exactly the same as others --
24 A. Yes.
25 Q. -- the intuitive approach you have described arose, did
0105
1 it, out of essentially that process, your logbook, your
2 focus on your logbook, your focus upon your own
3 experience with children and in essence was it perhaps
4 a question "It is nothing I am doing, so it must be
5 something the surgeons are doing"? It is a very crude
6 way of putting it, but is that broadly how the intuition
7 arose, do you think?
8 A. Yes, I think what we were wondering was whether the
9 surgical techniques and the surgical management of the
10 cases was one of the major causes for serious morbidity
11 and mortality.
12 Q. I suppose one of the weaknesses ultimately of the data
13 when you did it, and again I do not wish to be
14 overcritical because no data source is necessarily
15 perfect, we know from our own Inquiry reports they are
16 not perfect. But there was no attempt in those data
17 tables you produced to exclude the influence there may
18 have been from the cardiologist or the time of referral
19 which may be down to the deferring paediatrician or
20 physician?
21 A. No, we did not collect that data.
22 Q. So suppose there had been, as our Clinical Case Note
23 Review has suggested might be the case, problems at the
24 preoperative stage in coming to a proper diagnosis and
25 mapping of the arteries and therefore a proper agreement
0106
1 as to surgical technique and approach to be adopted:
2 that is something which may very well have influenced
3 the outcome inevitably from your data given the way it
4 was produced?
5 A. No, you mentioned two features there, one was the
6 cardiological anatomy; we certainly did not take any
7 account of that. You also mentioned age at operation,
8 and I think that was one of the columns in the
9 Bolsin/Black data collection, because I can remember
10 some of the comparisons between the surgeons having age
11 at operation distinctions measured of them.
12 Q. The other feature which I mentioned was the question of
13 the surgical approach, the agreement on the surgical
14 approach and whether that was appropriate, which would
15 involve the cardiologist and the surgeon?
16 A. Yes.
17 Q. Again with the exception of length of stay on ITU, there
18 was not any attempt to adjust for what might have
19 happened on the ICU and suppose it is right what we were
20 discussing this morning, the inadequacies, the unsafety
21 of the ICU environment as it was --
22 A. Yes.
23 Q. -- despite the best efforts of those involved to improve
24 it: one could not adjust, could one, for that as
25 a factor?
0107
1 A. No, it would be very difficult to. People have tried to
2 do that but it is not easy. I mean Hannan and Kilburn
3 have done that sort of thing in New York State in terms
4 of adult cardiac surgery and identified centre as a risk
5 factor and they have also identified surgeon as a risk
6 factor and they have also, as I mentioned earlier,
7 identified a number of operations in the preceding
8 twelve months as a risk factor. So there are risk
9 factors but had we been able to bring in other features
10 we would probably have been leading the world.
11 Given this was not that standard of data
12 collection, this was, as you said I think very correctly
13 earlier on, a signpost rather than a destination.
14 Q. Given I suppose you sat and thought about it, and
15 plainly you did, you would have realised beforehand it
16 could ultimately be no more than a signpost, it would
17 have to lead on to something else?
18 A. Yes, it was intended that it would lead on to the
19 review, the full and open review was where we were
20 headed. What we wanted to say was "Is there a need for
21 one?" If we had provided data in the spring of 1993
22 which had showed there was no operation in which Bristol
23 was no worse than anywhere else in the country I would
24 have said to Cedric "You told me I had to shut up or put
25 up; I am now going to shut up and I am going to be very
0108
1 happy working in this unit".
2 Q. At one stage in the GMC in respect of 1993 when the data
3 was first shown to colleagues in the unit, you were
4 saying quite frankly "We did not know if there was
5 a problem" presumably, "until we had actually got the
6 data"?
7 A. Yes.
8 Q. So you were looking at the hypothesis that there might
9 be a problem, you did not know?
10 A. Yes, there were serious suspicions and concerns.
11 Q. There was enough to make you go on the exercise but you
12 did not know the answer?
13 A. No.
14 Q. Essential to being a signpost would be that those who
15 needed to read the signpost, those needed -- moving away
16 from the analogy -- to take the decisions to have the
17 review, the detailed review exercise would look at the
18 data you had and say "This is something which means we
19 must investigate further"?
20 A. Yes.
21 Q. That is what you were looking for. When you started the
22 whole exercise, obviously you hoped that review would
23 throw up problems you would rectify?
24 A. Yes.
25 Q. And rectify so Bristol would become a better centre and
0109
1 children would have the best possible outcome?
2 A. Yes.
3 Q. From the outset what was important about the data
4 collection exercise was that it would ultimately carry
5 people with it, sufficient to get an investigation?
6 A. Yes, I think if the data was strong enough at the time
7 it was produced then it would recruit people to it, yes.
8 Q. Focused as it was, for the reasons you have told us,
9 upon the surgeons?
10 A. Yes.
11 Q. It was never, I suspect, going to be easy within any
12 department to identify as it were individuals as
13 responsible for something which might be the result of
14 all sorts of other factors playing together?
15 A. Yes.
16 Q. You knew from the outset because that is the particular
17 data you were collecting, that might be the result, that
18 is what you suspected was the result?
19 A. Yes.
20 Q. Looking back on it, I appreciate from 1999 hindsight,
21 it would have been best, would it, do you think, to get
22 the anaesthetic department as a whole or at least an
23 official group within the Trust agreeing the parameters
24 of the study, if you like designing the study that you
25 are about to embark on?
0110
1 A. It might have been difficult to do that and I think that
2 for me the urgency was to find the data. You have to
3 remember, we have moved on from 1989 where the mortality
4 in Bristol was twice the national average. We have not
5 seen any perceptible improvement, we still have
6 concerns, we have expressed them to the Director of
7 Anaesthesia, we have expressed them to the Professor of
8 Anaesthesia, we are still seeing concerns.
9 The urgency was not necessarily to get a colleague
10 or group together to decide what the data collection
11 would be, the urgency was to decide if there was
12 a problem because continuously throughout this period
13 the conveyor belt of paediatric cardiac surgery was
14 operating on children and the suspicion and the concern
15 was that some of these children were dying
16 unnecessarily.
17 So, yes, in an ideal world in ideal circumstances,
18 that is what you would do: key stakeholders, several
19 meetings, decide what you are going to do, let us do
20 it. That was not necessarily an appropriate course of
21 action in Bristol because of patients' safety.
22 Q. I want to explore that a little, if I may. The
23 consequence of the approach you took then was that the
24 design of the study, if you like, planning of it was not
25 something which was shared by many other than by
0111
1 yourself, Andy Black and with the tacit encouragement of
2 Professor Prys Roberts?
3 A. Yes.
4 Q. What you are recognising: in an ideal world it would
5 have been shared with -- the anaesthetic group?
6 A. I think in an ideal world we would have sat down with
7 all the participants, including the surgeons. As I have
8 tried to suggest, this was such a sensitive and prickly
9 issue in this institution it was never going to be
10 possible to do that.
11 For whatever reason, whether they had been
12 intimidated, whether they had been bullied as I had,
13 I was not always going to get the support of my
14 paediatric cardiac anaesthetic colleagues.
15 Q. Did you know when you began the data collection exercise
16 that you were unlikely to have the support of your
17 anaesthetic colleagues?
18 A. As I said earlier, I hoped that if I produced results
19 which mandated action I would be able to recruit them to
20 the action that was required and that could have been no
21 action, we must now support the surgeons in everything
22 that they do. That was one end of the spectrum. The
23 other end of the spectrum was, can we identify
24 procedures which we think are dangerous in this
25 institution?
0112
1 Q. That presupposed that presenting anaesthetic colleagues
2 with data "Look, I have collected this data, I have had
3 it analysed, it is my private effort or my private
4 effort with Dr Black" was ultimately going to carry
5 sufficient conviction to get you down the road to the
6 full survey, the full analysis that you were looking
7 for?
8 A. Yes, I hoped it would be able to drive us towards an
9 open review.
10 Q. One of the reasons that you have given for taking it,
11 pushing it forward yourself with Dr Black was that the
12 reception of paediatric cardiac surgical results was
13 what you called a "sensitive and prickly issue"?
14 A. Yes.
15 Q. Who, as you saw it, had the particular sensitivities and
16 was prickly about it?
17 A. I think at various times almost everybody in the
18 institution. I think the particularly sensitive people
19 were Mr Wisheart who, as I said, got angry when this
20 subject was raised, whether it was the perfusionists
21 saying "Can we get involved in an audit of bypass times
22 for paediatric or cardiac surgery?", whether it was
23 nursing staff, whether it was me, whether it was other
24 cardiac anaesthetists. I think that in Dr Monk's
25 evidence there is a distinct sensitivity about
0113
1 disrupting relationships with paediatric cardiac
2 surgeons.
3 Q. That is only though, it would seem, a surgeon's
4 problem. At this stage, although that was inevitably
5 your focus because of the way in which you had first
6 been alerted to it and had gone through the process you
7 have described of as it were excluding your own
8 performance as a reason for the results and therefore
9 inevitably because of your part in the chain focusing on
10 the surgeon. Academically, philosophically it could
11 have been anyone anywhere in the chain or a number of
12 factors in combination, it did not have to be the
13 surgeons?
14 A. Absolutely.
15 Q. If that is the case, why should the surgeons have
16 necessarily been so prickly and sensitive about it?
17 Might it not have been presented in the way your adult
18 review was, "Let us have a look at the results to see if
19 we can improve them, identify what may be going wrong
20 with a view to getting them better", a straightforward
21 audit almost?
22 A. Yes, I think the prickliness and sensitivity antedates
23 the data collection by several years from 1990. There
24 was a prickliness and a sensitivity about it and
25 I detected that in my colleagues as well. I think
0114
1 approaching the surgeons about this problem which may
2 not have been their fault, it may have been entirely
3 anaesthetic, it may have been that the mortality was
4 entirely in the hands of one anaesthetist, Steve Bolsin,
5 and he perhaps should give up paediatric cardiac
6 anaesthesia.
7 If that had been the result that had come out
8 I would have been prepared to do that or retrain or
9 whatever, but whenever you mentioned paediatric cardiac
10 surgical outcomes with the surgeons, there was
11 a defensiveness or an angriness or a failure to address
12 the issue.
13 Q. The failure to address the issue we looked at yesterday,
14 and it would appear from the documents we have up to the
15 end of 1992 anyway that there is recorded repeated
16 dealing with the issue of improving outcomes.
17 So far as the sensitivity goes, we have yet
18 I think to discuss Mr Dhasmana, apart from in general
19 terms, his retraining for the arterial switch which
20 must, therefore, have caused him some concern and
21 sensitivity on that?
22 A. Yes.
23 Q. The sensitivity, as you described, would seem to be the
24 process you might expect of everyone saying "We do not
25 seem to be getting the results we would like to have, we
0115
1 are not doing as well" and obviously uncomfortable about
2 that. You were sensitive about it, were you not?
3 A. I was concerned about it, yes. I was not sensitive. If
4 somebody had come to me and said "Steve, I have just had
5 a look at my switches, they are awful" I would not have
6 said "Do not mention the switch, go away", I would have
7 said "This is interesting. Let us go and have a look at
8 some more information".
9 If you went to a colleague about it, it was like
10 a taboo, it was something you just did not mention, it
11 was like family planning with your mother, you do not
12 mention it. It was a taboo subject, "You do not raise
13 this issue with paediatric cardiac surgeons in this
14 institution" and calling it sensitivity, calling it
15 prickliness, calling it whatever, that is what it was,
16 it was not a subject you talked to the surgeons about.
17 Q. Could you, do you think, not have persuaded everyone in
18 the light of the results there were to have embarked
19 upon an exercise to find out really why the results were
20 as they were and whether they might be improved?
21 I think we have to look at the stage beyond mid 1992,
22 have we not, because up to that stage you agreed with me
23 yesterday that it appeared the appropriate steps were
24 being taken, albeit at meetings you were not present at?
25 A. Yes, but we also agreed that by mid 1992 the 1991
0116
1 results were going back up again to twice the national
2 average mortality, although we have not seen the
3 evidence of that yet. But there were still concerns in
4 my mind and I found that this subject was very difficult
5 to raise with everybody. I do not know whether they had
6 been got at. I was certainly encouraged not to raise
7 this subject with the surgeons again. I do not know if
8 everybody else was as frightened as I was of raising the
9 subject. I cannot explain why people would not do it
10 but I know there was a reluctance to address this issue
11 in this unit. It may have been because the results were
12 bad.
13 Q. Having started as you did the data collection and the
14 analysis exercise you have described, did you tell for
15 instance Dr Clements that you were engaged upon
16 something of this sort?
17 A. Yes, I have seen Dr Clements' statement and I think
18 I did mention it to him, although I cannot remember the
19 conversation in detail.
20 Q. His recollection is that what he said to you is that as
21 a first step, having been told of your data, you should
22 recheck your data and verify those with your colleagues
23 in cardiac anaesthesia, if you like getting ownership of
24 the process because that would be important?
25 A. Yes.
0117
1 Q. Earlier on the whole business of going it alone had
2 attracted criticism after the letter you wrote to
3 Dr Roylance and the meeting of the anaesthetists, which
4 basically, as I understand your evidence, said "Do not
5 do it alone, Dr Bolsin -- Steve -- let Dr Williams and
6 Dr Monk handle it for you"?
7 A. Yes.
8 Q. There was a willingness at any rate at that stage for
9 Dr Williams and Dr Monk to handle the general issue for
10 you. You had your concerns resurfacing in 1992 because
11 of the results as you understood them?
12 A. Yes.
13 Q. It was not, was it, I expect you will agree as a matter
14 of fact, necessary that you and Andrew Black should do
15 it privately; do you agree with that or not?
16 A. It certainly was not necessary for us to do it
17 privately, neither did we do it privately.
18 Q. By "privately" I mean the two of you?
19 A. I see what you mean.
20 Q. Not involved in a secret, clandestine, whatever
21 discussion you had elsewhere, but to do it on your own
22 privately rather than involving the anaesthetic
23 department, is the point I am on.
24 A. I would not have excluded the other members of the
25 anaesthetic department. Cedric was involved. It was
0118
1 not -- yes, I agree with you.
2 Q. If it was not necessary to do it privately, using
3 "private" in the way I mean it, for what reason did you
4 not actually involve the other anaesthetists?
5 A. There was not anything for them to do. We were
6 collecting the data. Andy had the computer programme,
7 he entered the data, he analysed it. The time to
8 involve them was when we had some results.
9 Q. They might have planned the campaign, if you like, with
10 you. They might have said, you come to them and say
11 what are the several meetings there were of the
12 anaesthetists, you could have said to them "I have got
13 a concern, I think I ought to explore this concern, I am
14 not happy about this and I think we ought to collect
15 some data on this". If they had said "No", okay, you
16 know where you are?
17 A. Yes.
18 Q. But that actually never happened?
19 A. (Witness nodding).
20 Q. If they had said "Yes", you would then have had the
21 support of all the anaesthetists?
22 A. Yes.
23 Q. It would have been as it were an anaesthetic effort?
24 A. Yes.
25 Q. And the overall input into what might be the factors
0119
1 would be all the greater, you would all contribute their
2 ideas even though you might have the effort of
3 collecting the data, might you not?
4 A. Yes.
5 Q. If you had done it that way, the result perhaps might
6 have been that a set of data would have emerged sooner
7 which had the support of the anaesthetists which could
8 then have been taken forward perhaps earlier than it
9 was?
10 A. I think that is possible and I think it would have been
11 a lovely way to have done it. I think the practicality
12 was that this was all in the summer 1992. The Oxford
13 interview as I remember it was in July 1992. I came
14 back from holiday not having obtained the Oxford job.
15 We then set about collecting the data. I suspect there
16 were not all of the paediatric cardiac anaesthetists
17 actually in the department for several months because we
18 would have been staggering our annual leave through the
19 summer months and we were conscious of the fact we
20 wanted to get this done within the university summer
21 holiday in order to get the vast majority of the data
22 collection done. It is possible that although that
23 would have been an ideal way of doing it, it was
24 practically never likely because the anaesthetists would
25 have been on holiday.
0120
1 Q. At what stage did you actually tell your colleagues that
2 you were not doing it, albeit privately?
3 A. I could not put a date on that. I think I would say to
4 people "I am still concerned". I cannot put a date on
5 that.
6 Q. What we know from others who have given evidence to us
7 both in writing and orally is the first time the data
8 appears to have been shown round to anyone may have been
9 September 1993 and afterwards. The reason I pick
10 September 1993, that is what Professor Angelini has told
11 us was when he first saw the data.
12 As I understand what you are saying, he was the
13 first or one of the first persons to whom you had shown
14 it. I do not know whether that is right or not?
15 A. I think Sally Masey was actually the first of the
16 paediatric cardiac anaesthetists to see the data because
17 Andy had literally got it hot off the printer and Sally
18 was in the department and he asked her for her comment
19 on it, unsolicited, which I think gives a measure of the
20 openness with which we were doing it in that Andy got
21 the data. His first contact was not "Steve, do you
22 think you ought to show this to your colleagues?" it was
23 "Sally, what do you think of this?"
24 Q. At the moment I am not concerned with making a comment
25 as to "open" or "closed" or "private" in that sense.
0121
1 What I am looking at is the question of as it were
2 ownership of the project.
3 What Dr Masey has told us is that she first knew
4 of the data collection when Dr Black showed her some
5 figures and I think she was a bit taken aback that the
6 figures had been collected by you and he without her
7 knowing of it.
8 A. Yes, I was using her to date it because you were saying
9 when was the first date.
10 Q. That would be about the spring of 1993?
11 A. That is what I thought, yes.
12 Q. She said "I believe spring 1993, it was some time in
13 1993". That was her evidence to us.
14 A. I believe it was spring 1992 as well.
15 Q. 1993?
16 A. 1993 as well.
17 Q. Who after her do you recollect having shown the figures
18 to?
19 A. I cannot remember a sequence of showing people the
20 figures. I think I would have gone through the process
21 of tidying it up, producing the significance levels
22 rather than the chi-square number.
23 Q. The box of the lines rather than the --
24 A. Yes, the box data as opposed to the plain data and then
25 I would have shown it to my colleagues.
0122
1 Q. Certainly Dr Monk remembers there having been
2 a discussion about the data.
3 A. Yes.
4 Q. There are a number of recollections along the lines that
5 you showed data to individuals and said "Here is some
6 data; what do you think about this?" or words to that
7 effect.
8 A. Yes.
9 Q. You are saying "Yes". That may either acknowledge the
10 fact we have had that evidence or that is what happened.
11 A. Yes, I showed people the data and said "This is the data
12 that Andy Black and I have collected, what do you think
13 about this?"
14 Q. Did you suggest in that conversation what they ought to
15 think about it?
16 A. I did not want to direct anybody into any specific
17 actions. For me this was data that gave rise for
18 concern. I think by -- I am trying to think when
19 Dr Pryn and Dr Davies started at the BRI.
20 Q. Mid 1993?
21 A. Yes, I had given up my major paediatric cardiac
22 anaesthetic commitment in that I had given up my Mondays
23 when I operated with James and he did his children and
24 I was now concentrating much more on adults. So in
25 a way I was showing it to the people who were now the
0123
1 primary contributors to the paediatric cardiac
2 anaesthetic service.
3 Q. Essentially saying to them as you describe it: "Here are
4 figures I have collected, have a look at that and over
5 to you", that sort of thing or what?
6 A. I would have said "I think these are quite worrying;
7 I think we should be doing something about it, what do
8 you think?" We were now looking for the ownership, the
9 sort of collective, collaborative approach.
10 Q. Dr Monk recalls that he had looked at the data and he
11 had certain problems with it, essentially some of the
12 matters you and I went through before the lunch break --
13 A. Yes.
14 Q. -- which you frankly accept there were problems with the
15 data in the sense of it could be better, but it was the
16 best you could do?
17 A. Yes.
18 Q. He, amongst others, I think was very concerned about the
19 VSD figures which did not seem to him to be right, he
20 has told us?
21 A. Yes, I mean there is an element I think of a post-hoc
22 analysis there because that was certainly never clearly
23 expressed to me. I think if it had been at the time it
24 would have been in the statements.
25 Q. It may have been thought but not said?
0124
1 A. Possibly, yes.
2 Q. He tells us that he was encouraging you to present the
3 data formally to a meeting of the anaesthetists and that
4 he actually thought you had agreed that would be a good
5 way forward?
6 A. I do not remember ever being asked to do that and
7 certainly it would have been an extraordinary meeting
8 because as paediatric cardiac anaesthetists we did not
9 really meet much as a group. I think there is evidence
10 in the transcripts that we used to meet in corridors and
11 in coffee rooms but not really together formally as
12 a group, and certainly to meet with an overhead
13 projector or a slide projector and a series of results
14 would have been extraordinary for that group.
15 Q. What he told us, and I will select quotations from his
16 actual evidence to us.
17 A. Yes.
18 Q. He says:
19 "The audit I got from Steve was not verified";
20 you decide what he meant by that, that is what he said.
21 He "showed it to other colleagues who felt that the VSD
22 data in particular was not accurate and their opinions
23 as to what the data meant varied".
24 That I suppose is understandable in the nature of
25 the process of showing the data as figures to
0125
1 individuals, presenting it saying: "There are some
2 figures I have collected, they look worrying, what do
3 you think about it" on an individual basis?
4 A. Yes.
5 Q. Again there may be an element of post-hoc about this,
6 but in retrospect what was called for was a general
7 meeting to get a consensus about it; those are my words
8 not Dr Monk's?
9 A. I do not remember the calling of a general meeting or
10 a consensus meeting. I never made overheads of that
11 data. Andy was never approached to address a meeting
12 and explain the data. As I say, a meeting of just
13 purely cardiac anaesthetists in the presence of an
14 overhead projector would have been extraordinary at that
15 time. My intention in passing it on to Chris Monk was
16 to go through the blueprint for action which was to
17 share this data with my clinical director and say
18 "I think we have a clinical problem here, over to you
19 on this one, I am not going down this route again and we
20 have already established that there is a precedent for
21 directors of anaesthesia taking this data across to the
22 surgeons".
23 Q. What he told us was this:
24 "The other cardiac anaesthetists were similarly
25 shown the data in coffee rooms et cetera. What I wanted
0126
1 was to produce a forum where initially the cardiac
2 anaesthetists spoke about the data, and I asked Steve
3 and we discussed the need to present the data to the
4 cardiac anaesthetists and he appeared to agree with me
5 but we did not manage it. [You agree, you certainly did
6 not manage it] We had meetings and Dr Bolsin did not
7 come or did not --
8 "Question: "Did not come?
9 "Answer: Did not come because we would have these
10 meetings ad hoc, not ad hoc but as planned as we could
11 within work time when somebody was not doing a general
12 list, I was not away at a meeting, somebody else was not
13 away on holiday and you try to get everyone together to
14 talk about it. Yes, that conversation did not occur.
15 So at the time and much later we never had a joint
16 opinion on what the Bolsin/Black audit actually meant."
17 Later on I asked him whether it was right that the
18 data was never discussed collectively by anaesthetists
19 at any rate before the middle of 1995. He said:
20 "It was not presented in a formal way which would
21 enable us to discuss it. It was discussed at an
22 individual level which does not give you a corporate
23 decision."
24 A. I think that as a Director of Anaesthesia if he was that
25 concerned he should have called the meeting and put down
0127
1 the agenda and said "this is what you do Steve".
2 I think he has completely abdicated his responsibilities
3 as a clinical director in an organisation which is
4 supposed to have a very flat structure. I find that
5 incredible.
6 Q. Stripping the comment away for a moment: did he or did
7 he not suggest to you that it would be appropriate to
8 present your data to a meeting of the anaesthetists?
9 A. I do not think so because if he had said that I would
10 have prepared overheads and I would have been prepared
11 to go to a meeting that anybody arranged.
12 Q. He has suggested that there were meetings and you did
13 not come?
14 A. What sort of meetings has he suggested there were?
15 Q. He is talking about meetings of the anaesthetists as
16 I understand his evidence. I have read you out the
17 passage and you will have to rely on that.
18 A. Yes, I mean they were not formal meetings. Certainly
19 I never received a request to present this data to the
20 paediatric cardiac anaesthetists.
21 Q. What sort of formal request would you look for? Is it
22 not good enough for the director to say: "Look, Steve
23 I think you ought to present this data to us so we can
24 have a collective discussion about it and take a
25 collective view"?
0128
1 A. I used the word "formal" because you used it in the
2 context of the meetings that I was expected to present
3 the data at. If somebody had said to me: "Steve will
4 you present this data on Tuesday morning", I would have
5 said "fine, if I am not busy I will come to do that".
6 It sounds to me as if the meetings which discussed the
7 audit data were not that organised and therefore it
8 would have been very difficult for me to have turned up
9 on an ad hoc basis in a coffee room somewhere else to
10 discuss the data.
11 Q. I want to see whether there is, at the end of the day,
12 a disagreement between you and Dr Monk on this issue:
13 whether he did or whether he did not suggest to you that
14 it would be a good thing for you to present the data at
15 a meeting of anaesthetists generally?
16 A. He may have suggested it would be a good thing and
17 I would have said "arrange the meeting and I will
18 present the data".
19 Q. There is no disagreement as to his suggesting it. He
20 says there were meetings and you did not come; is he
21 right about that?
22 A. There may have been meetings, but I am not sure that
23 they would have been meetings at which I expected to
24 present the data.
25 Q. Does it come to this then: he was saying to you "Steve,
0129
1 you should present this data at a meeting of
2 anaesthetists". He then arranges a meeting of the
3 anaesthetists, not necessarily with one item on the
4 agenda: 'Steve Bolsin's Data' but a meeting of the
5 anaesthetists to which you would be invited to come.
6 You do not actually come so there is no discussion, but
7 he thinks to himself "I have invited Steve Bolsin to
8 come and present his data"; there is the opportunity, it
9 does not happen.
10 You for your part are sitting there thinking "no
11 one has actually asked me to present my data formally as
12 the item on the agenda, therefore I shall not prepare
13 for it therefore I will not go to a meeting specifically
14 to say it" and, as it happened, did not go to meetings
15 at which it might have been said. Is that the way one
16 reconciles these two accounts?
17 A. The first thing is that I am not sure there were any
18 meetings of the paediatric cardiac anaesthetists that
19 were organised in advance, certainly in advance enough
20 for me to prepare the overheads and attend the meeting.
21 Secondly, I am not sure that that was ever an
22 expectation that I had.
23 Q. You had the data as you have shown us in the tables?
24 A. Yes.
25 Q. And the tables were on paper?
0130
1 A. Yes.
2 Q. And the paper was produced by computer?
3 A. Yes.
4 Q. And the copy could be printed off or photocopied?
5 A. Yes.
6 Q. So you would not actually need an overhead?
7 A. No, you could circulate papers but I had circulated
8 papers to my colleagues. I mean Chris Monk had a copy
9 because he tells us that he took it to the library to
10 look --
11 Q. So if everyone had a copy what was the problem, unless
12 it was simply that you did not get to an anaesthetists'
13 meeting at which it might have been done; what was the
14 problem with the anaesthetists together discussing the
15 data?
16 A. I think that would have been highly appropriate. I am
17 not sure those types of meetings were ever arranged at
18 the time we are talking about.
19 Q. Do we leave it like this: you had data in a form which
20 could have been appropriately discussed at a meeting.
21 That, as it happens, you did not take any initiative to
22 go to a meeting of anaesthetists to discuss it?
23 A. Yes, I think that is a fair summary.
24 Q. Professor Angelini told us he got the data in about
25 September 1993. Again the question is asked, and we
0131
1 have already been over the ground and I do not want to
2 waste time: having collected the data, having shown it
3 round in the form in which it was on paper to the
4 anaesthetists -- we are looking I think just at the
5 first data set, are we not, because the other two, the
6 switch and the AVSD had not been produced in 1993?
7 A. No, they were produced in 1994.
8 Q. You did not show that data to any cardiologist nor to
9 either of the two paediatric cardiac surgeons?
10 A. No.
11 Q. Why did you choose to speak to Professor Angelini about
12 it?
13 A. I felt that -- and I discussed it with Andy Black and we
14 both felt that the peculiar sensitivity of the surgeons
15 may have been related to the fact that there is, as you
16 may or may not know in medicine, rivalry between
17 specialist groups. There is a particular rivalry
18 between surgery and anaesthesia because probably they
19 work so closely together. Surgeons do not like to be
20 told what to do by anaesthetists and anaesthetists do
21 not like to be told what to do by surgeons and it is
22 legendary and it exists.
23 Q. This was part of the problem on the ICU, was it?
24 A. It certainly was reflected as part of the problem on the
25 ICU, yes.
0132
1 Under those circumstances the anaesthetists who
2 had the data, and I believed my clinical director was
3 taking this data in the established pattern to the
4 people who we had the concerns about and no action was
5 being taken and the background is that children were
6 still being exposed to risk.
7 We said "perhaps it is because this source of
8 information is anaesthetic that the surgeons will not
9 act on it, perhaps if a surgeon comes with data and says
10 'look guys, you know as well as I know there is
11 a problem here, we must sit in a dark room or quiet room
12 and sort this out and we will deal with this problem
13 ourselves and we will be seen to have done it ourselves
14 and there will not be any question of anaesthetists
15 telling us'", we thought that might be a way of solving
16 the problem.
17 Q. The "we" here is?
18 A. We the surgeons.
19 Q. No, the "we" who wanted to achieve this result?
20 A. It was Andy Black and myself. We were very worried.
21 Q. At some stage you spoke, did you, to Dr Ashwell?
22 A. Yes.
23 Q. Was that in December 1993?
24 A. Yes, it was.
25 Q. Can we have a look at her letter to you, it is UBHT
0133
1 61/265? The first paragraph:
2 "You spoke to me in confidence last Thursday, by
3 complete coincidence John Farndon spoke of the same
4 matter to me."
5 You have, for very understandable reasons,
6 interpreted that I think on a number of occasions as
7 meaning that Professor Farndon himself had concerns
8 which he independently expressed to Dr Ashwell?
9 A. Yes.
10 Q. You do not know, of course, how it came about that
11 Professor Farndon and Dr Ashwell spoke?
12 A. No.
13 Q. Therefore you would accept, would you, their joint or
14 similar recollection that in fact, despite what the
15 letter says, it was Dr Ashwell who approached
16 Professor Farndon and not the other way around?
17 A. Yes, I understand that.
18 Q. Can we scroll down? She enclosed to you guidance. Tell
19 me, had you actually given her the data?
20 A. I do not know, I cannot remember. I suspect I probably
21 would not have done.
22 Q. You had expressed concerns generally to her?
23 A. Yes.
24 Q. For what purpose; why involve her?
25 A. I think at this stage I was looking for any red alarm
0134
1 button which could prevent what I believed was happening
2 in the hospital I was working in, which is that children
3 were dying unnecessarily. I was prepared to go to
4 anybody within the profession who I thought could
5 prevent that happening.
6 Q. One of the easiest ways to press the red alarm button
7 would be for you to as it were stage a sit down strike,
8 saying: "Look, I am not going to do any more of these
9 operations because I have this information and I do not
10 think it is proper for me as a doctor to do any more
11 operations unless and until it is properly explored,
12 this information"?
13 A. You have to remember that by the end of 1993 I had given
14 up the vast part of my paediatric cardiac surgical
15 commitment.
16 Q. The "vast part"?
17 A. I was only working on some Thursdays, which was when
18 some paediatric cardiac operations were being done. So
19 I was doing much less paediatric cardiac anaesthesia at
20 the end of 1993 with the advent of Steve Pryn and
21 Ian Davis into the department than I was before then.
22 Q. But you were still doing it?
23 A. I was doing occasional ones and I had discussed with my
24 director of anaesthesia, my thesis was: if there is
25 a problem with these operations, you cannot do them
0135
1 under local anaesthetic, we would just withdraw the
2 service for the operations that we think are high risk
3 and that was my thesis.
4 Q. So far as you were concerned you did not do it?
5 A. I personally did not do that. I cannot remember when
6 the last fatal operation that I anaesthetised for
7 a child in the BRI was.
8 Q. You go to Dr Ashwell to ask for what, for advice?
9 A. Yes, Dr Ashwell had been involved with Andy Black and
10 myself in developing the Association of Cardiothoracic
11 Anaesthetist National Database Collection and had been
12 very helpful in the field of audit and was a Department
13 of Health official of some seniority who I hoped would
14 be able to advise me on what I found was a particularly
15 difficult issue to get action on.
16 Q. This is, as we see, her advice, is it?
17 A. Yes.
18 Q. The Three Wise Men procedure was what she was steering
19 you towards. What did you do in response to that?
20 A. If I could come back a little bit, the first paragraph
21 here reassured me enormously. I had been to
22 Professor Farndon at the end of 1993 and I had given him
23 the results in the same way as I had been to Professor
24 Vann Jones and Professor Dieppe and others.
25 I had evidence here, although you have told me
0136
1 that it was incorrect in fact, that a Professor of
2 Surgery in the BRI was concerned enough to raise the
3 issue with a senior medical officer at the Department of
4 Health. So I was reassured that actually there was
5 going to be some quite quick action here. Here was a
6 very senior figure in the hospital seriously concerned
7 enough to go to the Department of Health. So I was
8 reasonably reassured, but I was also put in the
9 direction of the Three Wise Men procedure and
10 I discussed that with Dr Sheila Willatts who was
11 a member of the Council of Royal College of
12 Anaesthetists.
13 Q. And anyone else?
14 A. I cannot remember whether I showed this to anybody else.
15 Q. The BMA?
16 A. Possibly the BMA, I am not sure who I might have shown
17 it to at the BMA or when.
18 Q. Did someone give you some advice that to go to the Three
19 Wise Men might expose yourself?
20 A. Certainly, yes. That is why I mentioned Sheila Willatts
21 because I showed this to Sheila Willatts and she
22 obviously realised the seriousness of activating the
23 Three Wise Men procedure and she said: "Wait, I will
24 talk to somebody", I thought it was at the Medical
25 Defence Union but I am not sure, and she either gave me
0137
1 a telephone number to ring or she arranged for me to be
2 in the department when somebody telephoned from the --
3 I thought it was the MDU -- and we had a long
4 conversation about the Three Wise Men procedure and
5 whether it applied in this case.
6 Q. The effect of the advice was that you thought that was
7 a blind alley?
8 A. No, I was advised that it would not be a suitable course
9 to pursue.
10 Q. On 10th February 1994, it is UBHT 61/270, you wrote back
11 to Dr Ashwell?
12 A. Yes.
13 Q. Can we have a look at that letter? It thanks her for
14 the letter. You say this:
15 "Professor Farndon, Professor Angelini and myself
16 have made considerable progress with the matters of
17 concern that we discussed. There is now in place
18 a programme for the appointment of a new paediatric
19 cardiac surgeon and a commitment from the highest levels
20 of the Trust to improve and maintain performance. There
21 would seem to be little benefit from any further
22 investigation from your end at this stage although this
23 should not be ruled out if words are not converted
24 speedily into actions.
25 "I am most grateful to you ..." et cetera.
0138
1 What you are doing as far as Dr Ashwell is
2 concerned is signing off in effect?
3 A. I do not think the last sentence of the first paragraph
4 is a sign-off, is it? It is saying "watch this space".
5 Q. The last paragraph is talking about your own audit, is
6 it not?
7 A. No, sorry, the last sentence of the first paragraph:
8 "There would seem to be little benefit at this stage";
9 but I am not ruling it out, am I?
10 Q. You are not ruling it out?
11 A. And all we have so far --
12 Q. Let me put the questions. You are not asking her to do
13 anything more, are you?
14 A. No, certainly not at that stage.
15 Q. You were thanking her for what she has done?
16 A. Yes.
17 Q. And you are saying that everything seems to be going
18 forward as you would wish?
19 A. I think it is actually even more specific than that.
20 What I am saying is that we have some words of agreement
21 but we have not yet got the actions which is what I am
22 waiting for.
23 Q. The matters you think are going to sort out the problem
24 you specifically refer to, the appointment of a new
25 paediatric cardiac surgeon, number 1?
0139
1 A. Yes.
2 Q. So you thought that had been agreed and was going to
3 make a difference?
4 A. Yes.
5 Q. We know that something of that sort had been agreed,
6 having announced the September previously that this was
7 going to be sought?
8 A. Yes.
9 Q. Something that everyone in the unit had been looking for
10 for some time?
11 A. Yes.
12 Q. "The commitment from the highest levels of the Trust to
13 improve and maintain performance." On the face of it
14 that is just words, what did you understand that meant
15 in practice?
16 A. I think in practice what that meant to me was that we
17 were not going to be doing any more dangerous operations
18 and I think that links with the last word of the last
19 paragraph which is the actions that I expected were that
20 we would be not doing dangerous operations.
21 Q. Where do I find that?
22 A. Sorry, we have a "commitment from the highest levels of
23 the Trust to improve and maintain performance". At the
24 end of the first paragraph, those would be the actions
25 that I wanted, that we would not be doing dangerous
0140
1 operations.
2 Q. Who was it, as you understood, who had agreed at this
3 stage that there were not going to be any more dangerous
4 operations?
5 A. I think that was probably through Professor Angelini.
6 Q. Which operations, given the concentration of your data
7 source on tetralogy of Fallot, VSD and AV canal, which
8 operations did you think were the dangerous operations
9 that were then to be avoided?
10 A. I think on the basis of the data that we had, it would
11 have been: AV canals, tetralogy of Fallot and then
12 probably the switch operation as well which was not in
13 the Bolsin/Black data analysis but was certainly in
14 operation, about which there were concerns within the
15 unit not with just me.
16 Q. Can you tell me why you describe "a commitment from the
17 highest levels of the Trust" in your letter when you
18 would have known, I take it, there was no decision as
19 such minuted anywhere to stop any operation of any kind
20 at this stage?
21 A. No, I would not have known of those decisions but I did
22 have from Angelini reports that he had raised the matter
23 with the chairmen of the Trust and the Chief Executive
24 of the Trust and I think that is where my phrase
25 "highest levels of the Trust" is derived.
0141
1 Q. Can I ask why in this particular letter you did not say
2 "and the Trust has agreed not to perform a number of
3 operations" or "operations X, Y and Z"?
4 A. Because I was not privy to the details of that
5 information, but I had understood from Gianni that he
6 believed he had received assurances that the Trust was
7 not going to undertake operations X, Y and Z which had
8 higher mortality rates than we would have expected.
9 Q. I think it is probably time, Dr Bolsin for the next
10 break.
11 THE CHAIRMAN: Shall we take 15 minutes, 2.45.
12 (2.30 pm)
13 (A short break)
14 (2.50 pm)
15 MR LANGSTAFF: Did Professor Angelini talk to you about the
16 conversations he had had with Dr Roylance, then?
17 A. Yes, he did.
18 Q. In talking to you about Dr Roylance's attitude and
19 approach, did you get the impression at all that
20 Dr Roylance's view was, "what is a problem for the
21 clinicians is for the clinicians to sort out"?
22 A. I actually think that emerged later. We are talking now
23 about February 1994, is it? We got up to the Ashwell
24 reply.
25 Q. We are talking about the time between your letter to
0142
1 Dr Ashwell and her reply, during which you understand
2 from others that the problem has been sorted?
3 A. No, I think that is an exaggeration of what I put in the
4 letter. People have said that they are prepared to
5 commit to a solution, but they have not actually enacted
6 that solution, I am sorry.
7 Q. I am sorry if my shorthand was unintentionally too
8 short. My fault.
9 A. Yes, okay. So Professor Angelini had spoken to the
10 Chairman, he had spoken to the CEO and I think he had
11 written to them as well. He had spoken to John Farndon
12 and he had spoken to James Wisheart.
13 Q. Back, then, to the question which I was asking you: did
14 you understand at all that Dr Roylance's essential
15 approach might have been "what is a problem for the
16 clinicians is for the clinicians to sort out"?
17 A. I am not sure that that emerged in the conversations
18 I had with Gianni at that time, but I certainly knew
19 that Gianni was having conversations with several people
20 and they were trying to sort out solutions at that time.
21 Q. He told you, you told us, that the commitment from the
22 highest levels of the Trust, that is the Chairman and
23 the Chief Executive, was to stop doing particularly
24 dangerous operations?
25 A. Yes. I think that is my expansion on what I had written
0143
1 in the letter. The commitment from the highest levels
2 of the Trust was that there was a problem and they would
3 try and deal with the problem. My solution to dealing
4 with the problem was that we would stop doing the
5 dangerous operations. Whether the highest levels of the
6 Trust had committed to that solution or not, I do not
7 know, and I think that is probably why I put in that
8 caveat at the end of the first paragraph.
9 Q. So let me have it clear: what you were told by Professor
10 Angelini was not that the Chief Executive or the
11 Chairman of the Trust was saying, "Very well, we
12 acknowledge a problem; we shall not do the dangerous
13 operations"?
14 A. They were not saying that, no.
15 Q. It is "Okay, there is a problem; we will take
16 appropriate steps"?
17 A. Yes.
18 Q. Nothing more than that?
19 A. That was, I think, what I was hearing from Gianni at the
20 time.
21 Q. What Professor Angelini indicated to us in his evidence
22 when he came to tell us about this meeting was --
23 A. Which meeting?
24 Q. The meeting with Dr Roylance -- was this --
25 A. Can I ask, were there not more than one, or was it just
0144
1 one?
2 Q. It was the meeting at this stage. There were two
3 meetings. I shall quote you the transcript. There was
4 one between himself, he reported, and Dr Roylance, and
5 one with Dr Monk in attendance as well.
6 A. Yes.
7 Q. He was asked:
8 "Did you show Dr Roylance the Bolsin data?" Which
9 is the Bolsin/Black figures.
10 Answer: No, I do not think I did. Certainly we
11 never discussed anything in detail. I am pretty sure
12 that both of us did have the data with us, Monk and
13 myself, when we had the meeting with Roylance, but we
14 never went through any specific data, the reason being
15 that the attitude of Dr Roylance was, 'This is a matter
16 for the clinicians'. Effectively, he was saying, 'I do
17 not want to know anything about this'."
18 A. Right.
19 Q. That is what he has told us was the result of the
20 meeting.
21 A. Yes.
22 Q. The indication he gave us was that he did not get very
23 far.
24 A. Yes. What was the date of that meeting, please?
25 Q. Two meetings between the end of 1993 and March 1994.
0145
1 A. Okay. And another meeting, just to link up with the
2 "highest levels of the Trust", was there another
3 meeting with Mr Durie, or possibly Durie and Masey,
4 or --
5 Q. Forgive me, Dr Bolsin, I appreciate you may wish to
6 ask me questions, but the role here is that I ask the
7 questions and you give the answers as best you can.
8 A. I understand.
9 Q. What I am asking you is what was reported by
10 Professor Angelini to you.
11 A. Yes.
12 Q. I am telling you what Professor Angelini has
13 indicated to us, which does not appear to square with
14 the report that you recollect that he gave to you.
15 A. Yes.
16 Q. The reason for my putting Professor Angelini's
17 account -- after all, you were not at the meeting with
18 Dr Roylance -- is whether, having heard what he told us,
19 you think that you may, in attempting to recollect what
20 was behind your letter to Dr Ashwell, have been mistaken
21 in recollecting the information that Professor Angelini
22 was telling you?
23 A. I think, in helping to provide that answer and producing
24 an interpretation, the highest levels of the Trust would
25 have meant that I knew that Professor Angelini had
0146
1 spoken to the Chairman of the Trust Board and the Chief
2 Executive. If he had only spoken to one of those
3 people, then I would have said the name of the person
4 that he had spoken to. So I think I am saying that he
5 had spoken to both of those people, and I think that
6 what I am also saying is that they have given
7 a commitment to the identification of the problem, and
8 that we are waiting for action to deal with that
9 problem.
10 Q. Commitment to the identification of the problem?
11 A. They have agreed that there is a problem and we are now
12 looking to a solution, which is the actions.
13 Q. So the reflection that Professor Angelini was giving
14 you -- this is a comment which you should feel free to
15 make a contribution to, if you wish -- but what it
16 appears Professor Angelini was telling you was different
17 from what he has told us was said to him, because
18 essentially he was telling us Dr Roylance was saying,
19 "Not a matter for me, a matter for the clinicians, they
20 can sort it out".
21 A. But he was saying, they recognised there was a problem;
22 "What we have to do now is produce the actions which
23 will be the solution".
24 Q. I see. So how does one get from an acknowledgment of
25 a problem as you recollect it to a commitment from the
0147
1 highest levels of the Trust to improve and maintain
2 performance?
3 A. That is the implementation of the solution.
4 Q. But the solution had not been agreed: problem
5 identified; nothing more than that?
6 A. Yes, and in terms of the words, they had agreed they
7 would address the problem, that we had not got any
8 actions, which is what I was hoping would be speedily
9 produced.
10 Q. This letter is 10th February 1994.
11 A. Yes.
12 Q. Do you recollect, at all, when it was in relation to
13 this letter that you had the report back from Professor
14 Angelini as to his conversation with Dr Roylance?
15 A. I would have been in contact with Professor Angelini
16 several times a week, and we would have discussed this
17 problem a lot. It was something that was --
18 Q. That is not actually the question. The question is,
19 are you able, with the help of the --
20 A. No, it was an evolving process. What you are looking
21 at here is a conglomerate amalgamation of information
22 coming from different sources. At one point Gianni
23 would have said, "I have spoken to the Chairman, he
24 accepts there is a problem". At another point he would
25 say "I have spoken to the CEO. He also accepts that
0148
1 there is a problem but we have to sort it out". I don't
2 know, he might have said "We have his support", or
3 something.
4 So I am putting together a whole series of
5 meetings into one paragraph, a Department of Health
6 official that I have expressed a concern to, and
7 saying, "We seem to be going in the right direction.
8 If what people are saying happens, we will not need to
9 get back to you".
10 Q. You spoke to Dr Ashwell in December 1993?
11 A. Yes.
12 Q. Professor Vann Jones -- I should have put this
13 chronologically, it is slightly out of sync' -- records
14 you came to his office on 16th November 1993?
15 A. Yes.
16 Q. You are talking to him about results?
17 A. Yes.
18 Q. Why did you go to him?
19 A. He was the Director of Cardiac Services at that time.
20 Q. And he was a cardiologist, was he?
21 A. Yes, he was an adult cardiologist.
22 Q. Just by the way: you have spoken to us about
23 anaesthetists and the problems of the sensitivity there
24 may have been with them in respect of the results of the
25 performance of the surgeons?
0149
1 A. Yes.
2 Q. Did you show any of the data that you showed to the
3 anaesthetists to the cardiologists?
4 A. When you say "the cardiologists", do you mean --
5 Q. Those cardiologists engaged in paediatric cardiac
6 surgery.
7 A. No, not the paediatric cardiologists, no.
8 Q. Why not?
9 A. I hardly ever met them, to be quite honest with you.
10 Q. So it must follow that you never sought them out to
11 give them the data?
12 A. No.
13 Q. Did you seek out Professor Vann Jones?
14 A. Yes.
15 Q. And he was a cardiologist not engaged in paediatric
16 cardiological services?
17 A. Yes, that is true.
18 Q. Did you give him the data?
19 A. Yes.
20 Q. To keep?
21 A. I believe I gave him the data, because my usual
22 practice at that stage was to put data into a clear
23 plastic envelope and then hand it to people after I had
24 spoken about it.
25 Q. You had a number of copies run off, did you?
0150
1 A. Yes. It was several pages, was it not, that had the
2 tabulated boxes?
3 Q. Yes, and these would be the Mark II version that
4 appears, a more understandable version?
5 A. Yes.
6 Q. Even if one still needed to sit down and explain it?
7 A. Yes, but can I say, he was the Director of Cardiac
8 Services and the Director of Cardiac Services included
9 cardiac surgery, which included paediatric cardiac
10 surgery, so he was the line manager directly above the
11 paediatric cardiac surgeons.
12 Q. Actually, in November 1993 there was no Director of
13 Cardiac Services; I think that began in April 1994.
14 A. Is there a shadow --
15 Q. There was a shadow director?
16 A. Well, he was the shadow director of the shadow
17 Directorate of Cardiac Services.
18 Q. So as it happened, when you went to see him, he had
19 no authority except in shadow form?
20 A. He was a "shadowy figure"!
21 Q. I think the transcript ought to have that as a flash of
22 humour, so there is no misunderstanding!
23 A. I am sorry, yes. He was only shadow director. I am
24 sorry.
25 Q. Did he query with you the results of the VSDs?
0151
1 A. I cannot remember him doing that, but I cannot exclude
2 the possibility he might have said "The VSDs do not look
3 too good", or something like that.
4 Q. He has told us that he knew, even then, that is when the
5 figures were first presented to him on 16th November
6 1993, that the results on the VSDs could not be true.
7 That is the way he put it.
8 A. Yes. He certainly did not give me that impression when
9 he saw the data.
10 Q. Did you talk through the data with him?
11 A. Yes.
12 Q. And were you expressing, do you think, any urgency to
13 him?
14 A. I think I was expressing concerns about these
15 operative groups and the problem in paediatric cardiac
16 surgery.
17 Q. So does it follow from your last answer that he may be
18 right when he says to us, as he did, that as he saw it,
19 "There were no concerns of urgency such as, 'We must do
20 something about it, it is terrible, these particular
21 figures'. The only sense of urgency from Steve was", he
22 says, "if I remember rightly, that Bristol below the
23 national average was underlined for the four
24 operations. He talked it through and then he left".
25 A. I think I would have been using the kinds of words and
0152
1 phrases you have seen in some of my communications up to
2 now: "We need to address this problem, I think it is
3 serious, I really do have some concerns about this".
4 I think we are looking at the culmination now of
5 repeated concerns being expressed. I do not think you
6 would get from my activity up until now, that I would
7 not have been seriously concerned with him. Exactly how
8 urgently I would have said he had to solve the problem,
9 I do not think I would have given him a time-frame.
10 Q. What Professor Vann Jones also told us was that, because
11 he could see one set of data, the VSD, was, as he called
12 it, "blatantly flawed" -- those are the words he used to
13 us -- he actually wanted some further clarification of
14 that information, where were the data and all the other
15 operations that were going on. Do you recall that part
16 of the discussion with him?
17 A. I do not remember him asking for all the other data.
18 It would have been very easy to go back to Andy Black's
19 database and just print it out and give it back to him.
20 If he had asked for it, I could have produced it for
21 him.
22 Q. It may be this further recollection by him prompts you:
23 "I asked Steve as I recall to go at least away
24 and check his VSD figures".
25 A. I do not remember being asked to do that.
0153
1 Q. When you left, did you take a copy of the data back with
2 you?
3 A. No, I would have --
4 Q. Did you leave it with him?
5 A. It would have been my practice to leave the data with
6 the people, so they could check it as Chris checked it
7 in the library.
8 Q. "It would have been my practice" is the sort of language
9 one uses trying to recollect what one actually did
10 without knowing?
11 A. Yes.
12 Q. It is sometimes a figure of speech, and you have used
13 it a number of times, I think, to mean "I did" do X and
14 Y. Let me tell you that we have had evidence from
15 Professor Vann Jones that you did not leave the data
16 with him; that he handed it back to you and you took it
17 away. In which sense did you mean to use the "I would
18 have"? It is your normal practice but you cannot
19 remember on this occasion, or "I definitely did?
20 A. I cannot say I definitely did, so it would have been the
21 former.
22 Q. It follows if that is what Professor Vann Jones says
23 with certainty, it is something you would, even though
24 it is different from your usual practice, accept?
25 A. Yes. I would have made up the data, put it into a clear
0154
1 plastic folder and taken it over to his office with the
2 intention of leaving it with him for further study. My
3 hope was that he would take this data to the surgeons.
4 It would have been extremely unlikely that I would then
5 take it away, because he would not then have any data to
6 study or take on.
7 Q. I follow your intention.
8 A. Yes. I cannot say with certainty now, I accept that.
9 Thank you.
10 Q. The meeting with Professor Vann Jones was in November;
11 the meeting with Dr Ashwell was in December and
12 in-between the meeting with Dr Ashwell and the letter
13 that you wrote back to her, there was, as we have heard,
14 a meeting on 20th January 1994 in level 7 of the
15 University. Do you recollect that meeting?
16 A. Yes, I do.
17 Q. WIT 80/119, please. Line 23. Leave the date for
18 a moment:
19 " ... a clinical audit meeting was held.
20 I believe this was the meeting at which Mr Wisheart
21 presented informal data relating to the Fontan
22 procedure. Mr Dhasmana was not able to attend ...
23 because he was operating and no other data for the unit
24 was presented. We were never presented with the data
25 Mr Dhasmana 'would have presented at that meeting' and
0155
1 there appeared to be a distinct unwillingness to share
2 outcome results. Mr Wisheart made general reassurances
3 that the performance of paediatric cardiac surgery in
4 the unit was improving. No figures were provided to
5 support this assertion."
6 A. Yes.
7 Q. Leaving the date aside, that is this meeting that
8 I would date 20th January 1994.
9 A. I think your dates are much more likely to be correct
10 than my dates.
11 Q. Because that is what you recollect now I have prompted
12 you on the date as having happened at that meeting in
13 Level 7.
14 A. Yes.
15 Q. Because what you have got down, 2nd June 1994, is
16 supposed to be the Level 7 meeting?
17 A. Yes. My recollection of 2nd June was produced when
18 I prepared this statement. I had no documents to
19 corroborate the meeting and it was being produced --
20 Q. If you had no documents to corroborate the meeting, why
21 on earth did you put a day of the week, a date and
22 a month which in fact was six months out?
23 A. There may have been another meeting in my diary, or in
24 my Filofax, which you have had copied to you, which
25 I may have misinterpreted as being that audit meeting.
0156
1 Q. So it is not quite right to say you did not have
2 documents; you did have documents, you were working off
3 them and you misattributed?
4 A. Yes, "misattributed" would be a good word, because I am
5 not sure that I necessarily have in my Filofax an audit
6 meeting dated 20th January.
7 Q. You recollect, I suspect, having been asked quite
8 a number of questions at the GMC about this particular
9 meeting?
10 A. This is the January meeting?
11 Q. The January meeting.
12 A. Yes.
13 Q. The date being 20th January. I think, to be fair to
14 you, there was some concern and discussion as to whether
15 it was the end of 1993, January, possibly March 1994, so
16 there was a degree of uncertainty, and we have been able
17 to narrow it down to 20th January.
18 A. Yes.
19 Q. But it is perhaps a small example of, would you permit
20 me to call it -- tell me if I am wrong, please, if you
21 do not agree -- a certain carelessness about dates when
22 making up your statement?
23 A. I think there are a couple of possibilities. One is
24 that it may be one of those transcription errors of the
25 dictating machine I used to prepare this statement which
0157
1 has taken whatever I said and made it look formal and
2 a spell-check certainly would not pick that up. The
3 other is that I may have had in my Filofax an audit
4 meeting dated for 2nd June, but I am not sure. I do not
5 have my Filofax for 1994 with me.
6 Q. We have it at WIT 80/183. I do not want to waste more
7 time on this point than it deserves, but it is fair to
8 you that I should put it. You are right, of course,
9 2nd June, "Cardiac audit meeting, 1400 hours". The
10 meeting at level 7 was an evening meeting, was it?
11 A. I think it was late afternoon. I could not give you
12 a time. Can I just ask, I know I am not supposed to,
13 but is there a reference in my Filofax to a 20th January
14 meeting?
15 Q. We do not have the diary for that date, I am afraid,
16 so I cannot help you.
17 A. I am sorry, in that case I have misattributed the one
18 audit meeting, the cardiac audit meeting I actually have
19 in my Filofax for that year to be the one we are now
20 talking about.
21 Q. At any event, we are now looking at it properly in the
22 chronology. At that meeting, Mr Dhasmana is supposed to
23 present the results of the unit but he is operating so
24 he does not?
25 A. Yes.
0158
1 Q. And the meeting is there. Everyone goes to Level 7.
2 That is unusual, is it?
3 A. Yes.
4 Q. So there was particular interest in the results?
5 A. Yes.
6 Q. Particular interest by you, because you had been
7 carrying out your work with Dr Black and you had shown
8 that to some of your anaesthetic colleagues?
9 A. Yes.
10 Q. There had been no discussion of those figures as yet,
11 collectively?
12 A. No, not a collective discussion of those figures,
13 I agree.
14 Q. The cardiologists had not been around for you to show
15 the figures to, otherwise you would have done?
16 A. I am not necessarily sure I would have shown it to the
17 paediatric cardiologists, and it comes to the prickly
18 sensitivity, taboo nature of outcomes from paediatric
19 cardiac surgery.
20 Q. So why would you not have shown it to them?
21 A. I would have left this data with my Clinical Director
22 and I would have expected him to have then taken it
23 across to the directors or the clinicians involved,
24 because that was the pattern that was agreed after the
25 initial very threatening response that I got to raising
0159
1 concerns about paediatric cardiac surgery outside the
2 unit in 1990.
3 Q. So not your job to take it up with the cardiologists,
4 is what you are saying?
5 A. Or the cardiac surgeons, correct.
6 Q. That would be the job of the Director, and that would
7 be representing the anaesthetists' views, presumably?
8 A. Hopefully, yes.
9 Q. Because again, slightly hypothetical, but let us suppose
10 there had been a meeting of the anaesthetists at which
11 all the anaesthetists except for yourself said "This
12 data is rubbish" -- excuse the shorthand. Suppose that
13 had been the outcome of the meeting, they did not agree
14 with the data, you would not expect the Director to take
15 it forward?
16 A. No, I think I would have expected him to come back to me
17 with that opinion, and then --
18 Q. You would be there to listen to the discussion?
19 A. Hopefully, yes.
20 Q. So you formed your own view, but there would have to be
21 a collective meeting of the anaesthetists first, at
22 a necessary stage, I think is what you are suggesting?
23 A. Yes.
24 Q. So here was Mr Wisheart coming forward, presenting the
25 results of Fontan operation?
0160
1 A. Yes.
2 Q. Discussion about those results?
3 A. I am not sure. I can remember a few figures being put
4 up on what I think was a whiteboard, but I am not sure
5 there was an enormous amount of discussion.
6 Q. And open to you, had you wished, to say, "Look, we, the
7 anaesthetists, have a bit of concern about the overall
8 outcomes. Can we have a fuller review? We were going
9 to review the figures here today. We have not had them
10 because Mr Dhasmana is elsewhere, can we be circulated
11 because we are concerned from individual experiences
12 that something may need to be improved"?
13 A. Yes. I mean, we specifically, or I specifically did not
14 have any concerns about the Fontan procedure, because we
15 had audited the Fontan procedure.
16 Q. But the purpose of the meeting would be to look at the
17 results generally?
18 A. Yes.
19 Q. If you had a general concern, which you say you did --
20 A. Yes.
21 Q. -- why not raise it at that meeting in some appropriate
22 terms?
23 A. I think I was still expecting concerns about results to
24 be raised directly with the surgeons by those people who
25 were empowered to do so, and that was really the
0161
1 Clinical Director and possibly Professor Angelini.
2 Q. Do you remember the minute, your own minute of the 1991
3 meeting?
4 A. Yes.
5 Q. The minute that resulted in your being told not to
6 minute any more?
7 A. Yes.
8 Q. It records you as having said "this vindicates the
9 vigilance of the anaesthetists"?
10 A. Yes.
11 Q. Taking the lead on making that point?
12 A. Yes.
13 Q. Nothing, do I take it, inhibited you, or would have
14 inhibited you, from making a point about the need for
15 vigilance, for data, for looking at improved outcomes,
16 and so on?
17 A. No. I think you do not understand the background to
18 what had happened up until then. There was an awful lot
19 that would have inhibited me from raising those general
20 concerns in a forum which included Mr Wisheart, who was
21 by now, I suspect, either the Chairman of the Hospital
22 Medical Committee or the Medical Director of the Trust.
23 During that time, I had been accused of being
24 a troublemaker, of rocking the boat, of not being part
25 of the loyal membership of the organisation, and I was
0162
1 feeling particularly isolated, professionally, in the
2 Department of Anaesthesia. In order to reduce that
3 perception of me, I was expecting other people at
4 academic, professorial or directorate level, to deal
5 with the problem of paediatric cardiac surgery.
6 I had had an awful lot of problems raising the
7 issues of paediatric cardiac surgery within the
8 organisation, and I think I was responding to an earlier
9 retort to keep my head down.
10 Q. You say -- I think this is the first time we have heard
11 it -- that you felt isolated as a member of the
12 Department of Anaesthesia?
13 A. Yes, I think so.
14 Q. You say that you were accused of being a troublemaker?
15 A. Yes.
16 Q. By whom?
17 A. I think that was a general impression I was getting
18 from, for example, when I was talking to the
19 perfusionists and getting data from them, they were
20 saying, you know, "This is not going to go down well; we
21 know that they do not like people looking at their
22 records; we know that they do not like people looking at
23 their outcome data", and I think that the unsaid
24 impression I was getting from people like the Director
25 of Anaesthesia and others was "That this is a problem
0163
1 for anaesthesia in dealing with this issue, and
2 actually, the problem may be Steve Bolsin; it may not
3 be --
4 Q. Can I just stop you there? If it was an unsaid
5 impression, then no-one actually called you
6 "troublemaker"?
7 A. I am trying to think when that might have emerged.
8 Certainly I was feeling uncomfortable with the
9 persistent raising of paediatric cardiac surgical
10 outcomes as an issue within this organisation.
11 Q. Forgive me, I may have a suggestion which may be
12 wrong; if it is, tell me. Did it arise, that expression
13 "troublemaker", "rocking the boat" from a document you
14 had read last night, which we cannot I think refer much
15 further to because it is a statement circulated for
16 comment in advance of publication to this Inquiry from
17 a witness who, I can tell you, it is hoped may be
18 called?
19 A. No. I would have to say that that statement which I did
20 read last night just --
21 Q. I do not want you to go into the details of it. I am
22 just asking you if that is where those words come from?
23 A. No, those words --
24 Q. Let me then move back to the question. The
25 "troublemaker": who called you "troublemaker"?
0164
1 A. I think that in terms of "troublemaker" that may not
2 be the correct word, but I think that I was hearing the
3 word "trouble" being used about my concerns being
4 repeatedly raised about paediatric cardiac surgery.
5 Q. Who was using the word "trouble" in connection with
6 you, about whom you knew at this time?
7 A. I think that certainly the perfusionists would have
8 said, "This could cause trouble, raising these
9 concerns --
10 Q. This "could" cause trouble?
11 A. Yes.
12 Q. That is not the same as having a report given to you
13 that somebody is saying, "Bolsin is trouble".
14 A. Yes. I think that one of the concerns of Chris Monk in
15 raising the issue of paediatric cardiac surgery within
16 other directorates within the hospital was that the
17 perception was that if anaesthesia were to continue with
18 this, then anaesthesia would be seen as causing trouble
19 for other directorates, and that was reflected back on
20 me.
21 Q. He spoke to you, I shall suggest, because we have had
22 evidence from him -- I do not have a case for him, but
23 that is the evidence he has given us -- that he spoke to
24 you after speaking to Mrs Maher, or Mrs Maher spoke to
25 him, and that I will date, I can tell you now, later
0165
1 than this meeting --
2 A. Yes.
3 Q. -- and said something to the effect of, "You are dealing
4 with it inappropriately by going to her rather than
5 taking it through the anaesthetists"?
6 A. Yes.
7 Q. So I ask you to think again: is it right that you
8 understood at the time of this meeting, 20th January
9 1994, that Chris Monk was calling you and your
10 activities "trouble"?
11 A. I think probably for me to say that definitely at this
12 time that had been said may not be true, but certainly,
13 I was aware of a groundswell within the department or
14 possibly the organisation that this was seen as
15 troublesome activity. I am going to have to think about
16 how that came about, and where that impression came
17 from, because I am not sure I can necessarily pin it
18 down now, but it was certainly an awareness that I had.
19 Q. I will ask you about it tomorrow, and you will have the
20 chance to think about it overnight, but perhaps you can
21 help me with the other phrases. What about "rocking the
22 boat"?
23 A. I think that any activity like this -- I think that
24 Brian Williams mentioned that to me when I first
25 produced my letter --
0166
1 Q. You remember how you put it: you had been accused of
2 rocking the boat?
3 A. But I had been accused of rocking the boat in 1990,
4 so there was evidence that this was how the organisation
5 saw raising questions about paediatric cardiac surgery
6 as far back as 1990.
7 Q. Had there been any episode since 1990 when you recollect
8 being accused of rocking the boat?
9 A. Between 1990 and this meeting, possibly not, but I do
10 not think the perception that I had been rocking the
11 boat had gone away, if you see what I mean.
12 Q. The context of the question, to which you gave that
13 response to me, was if you had felt free in 1991 to
14 raise the issue, after the 1990 events, to raise the
15 vigilance of the anaesthetists and drawing attention to
16 the mortality figures and so on, put your head above the
17 parapet, as it were, then why did you not do it at this
18 meeting here in January? You said, "I did not
19 understand what had actually been happening because you
20 had been accused of being a troublemaker and rocking the
21 boat", and your best recollection at the moment -- you
22 may come back to it in the morning if you have missed
23 something that helps prompt your recollection -- but
24 your best recollection is that the words "troublemaker"
25 were not actually said, that you had an impression that
0167
1 activities such as you were engaged on might be
2 troublesome, but you cannot ascribe that to anyone in
3 particular, and no-one accused you of rocking the boat
4 after 1990, so it follows that had not been the
5 development?
6 A. Yes. There were also two very different meetings.
7 I think the meeting in 1991, at which I had been
8 prepared to say that the "vigilance of the
9 anaesthetists" was something sitting in an armchair,
10 much more informal.
11 I think in a formal meeting, such as the one on
12 level 7, I was much less prepared to raise formal
13 criticisms of the paediatric cardiac surgery mortality,
14 which as I have said was a distinctly prickly subject
15 within this organisation.
16 Q. I am surprised at that, because we have heard expressed
17 to us in the Inquiry the idea that if you are sitting
18 drinking someone's wine and eating their biscuits,
19 drinking their coffee and eating their biscuits, it is
20 more difficult to criticise them than if they are in
21 a formal meeting. Do you want to comment on that?
22 A. Saying this indicated the vigilance of the anaesthetists
23 in keeping their morbidity and mortality data is not the
24 same as raising a service problem of mortality in that
25 unit in a formal setting.
0168
1 Q. And help me with this: you say you felt isolated in the
2 anaesthetic unit?
3 A. Yes.
4 Q. Is that a reflection of the way you felt your
5 relationships with other anaesthetists were going, or
6 what?
7 A. I think it was in relation to a lack of support for an
8 approach to the data that I was producing within the
9 unit, so that having produced data, having circulated
10 data, having shared it with people, having put it up to
11 Director level, there was still no formal or informal
12 agreement that this was data that needed to be acted on.
13 Q. Is your perception that that was so perhaps part of the
14 reason why -- I can understand why it might be -- you
15 had never yourself, at a meeting of the anaesthetists as
16 such, presented that data?
17 A. We are coming back to the issue that we had before the
18 break. There were no formal --
19 Q. The question is rather different. The question is: did
20 you think that if you had presented the data to the
21 anaesthetists at a meeting, they would have said, "This
22 is not good enough, you have got to go away, think
23 again", and rejected it?
24 A. I do not think so, because if the request had occurred,
25 I, with Andy Black, would have gone and explained the
0169
1 data to them. I think I would have recruited Andy to
2 the data and said, "This is the data; we have done this,
3 this is how --" because they would have asked me
4 questions about how it was analysed, how it was
5 collected.
6 Q. And you could not have answered it?
7 A. Yes, and I would have needed Andy. One of the routes
8 for the paediatric cardiac anaesthetists was in fact to
9 ask Andy whether he would do what they say they asked me
10 to do.
11 Q. So at this stage, anyway, you felt on your own?
12 A. Yes, relatively isolated, I think I would say. I was
13 not part of the mainstream opinion which was prepared to
14 accept the performance of the unit as it stood. I was
15 actually standing slightly aside from that opinion, and
16 saying, "I think we have a serious problem; I think it
17 could be very serious and I think we should be doing
18 something about it".
19 Q. So you had a feeling, at this stage, that if you had
20 pushed the issue -- let us suppose that you had said
21 something at the meeting of 20th January 1994: "These
22 data are unacceptable, we have to stop and do something
23 urgently about it", something along the lines, "We have
24 to stop this operation or that operation" --
25 A. No, I think we have already agreed that the reason for
0170
1 the data was a full and open review.
2 Q. I am sorry, would you just listen to the question? Do
3 not anticipate, please.
4 A. I am sorry.
5 Q. Suppose that at that meeting you had said words to the
6 effect, "This data is disturbing, we must do something
7 about it and I propose X and Y"?
8 A. Yes.
9 Q. That you had not had any full support.
10 A. I am not sure I would not have had support. I would
11 have been worried about the consequences from other
12 people.
13 Q. Both Dr Pryn and Dr Monk seem to recollect that at
14 this meeting, 20th January 1994, it was not just the
15 Fontan results which were presented, that in fact the
16 results for the unit were presented, even though they
17 might not have been presented as Mr Dhasmana might have
18 wished. Are they right or are they wrong about that?
19 A. As I remember the Fontan results, I do not remember the
20 whole results of the unit.
21 Q. Might they have been presented?
22 A. It is possible, but I just remember Mr Wisheart
23 standing and writing figures down, and I think it would
24 have been almost impossible for him to have written down
25 all the results of the unit.
0171
1 Q. Had you wished, and had you not felt vulnerable as
2 a result of the influences you told us of, you could,
3 I take it, have presented the data?
4 A. Yes, I could if I had wished.
5 Q. And if you had done, you would have urged the meeting
6 to carry out a full and thorough review?
7 A. Yes. I think my hope was that this meeting was going to
8 be the full and thorough review that we had been aiming
9 at for a long time, so to a certain extent, although it
10 had taken a long time and we had had our data for about
11 two years, my hope was that by going around the various
12 routes that we had gone to, we had actually now achieved
13 the full and open review that certainly I, and I think
14 Andy working with me, had always wanted.
15 So I expected at this meeting on 20th January, it
16 was actually the goal, the destination that our data was
17 the signpost towards.
18 Q. Did you contribute to the meeting at all?
19 A. No, I was very disappointed that we were not at this
20 destination.
21 Q. So you have a very disappointing meeting on
22 20th January?
23 A. Yes, in terms of data, yes.
24 Q. Does it seem to you that the unit is moving forward or
25 moving in any direction that you would wish it to go at
0172
1 that time?
2 A. I, at that point, did not have any reassurance that the
3 problems within the unit of certain operations with high
4 mortality were being addressed, and my concern was that
5 they were continuing and persisting, and we were
6 continuing to expose children to this excess risk. That
7 meeting did not reassure me that that was not happening.
8 THE CHAIRMAN: May I come in for a moment, Dr Bolsin, you
9 may be able to help me. The picture that you are
10 drawing is, as I understand it, one of a relatively
11 young, as you were and in my case still are, consultant
12 who is somewhat isolated from colleagues in so far as he
13 has a set of views which, for whatever reason,
14 colleagues are not entirely adopting. You are nervous
15 because of having been "hit on the head" last time you
16 put your head above the parapet -- my language, not
17 yours. Here you say you sit in this meeting and you are
18 frankly, using your words, worried about the
19 consequences from other people if you were to say it.
20 I am just wondering why you might think, if I am
21 right that your major concern was with what Mr Wisheart
22 might say or do, why do you think that Mr Wisheart had
23 begun to -- again, I will use a very colloquial term --
24 take agin' you?
25 A. I think partly because I had not stopped raising the
0173
1 issue of paediatric cardiac surgery. I believed that
2 Brian Williams had spoken to him after 1990, after the
3 Roylance letter, about paediatric cardiac surgery, and
4 would have said that there are concerns within the
5 Department of Anaesthesia and it would have been easy to
6 have followed the trail to me.
7 I think that I had also expressed concerns to
8 other people, including Professor Vann Jones, including
9 Professor Farndon, whom we did not mention earlier on,
10 and including Professor Angelini, and I had anticipated,
11 and expected, that those people had all gone to
12 Mr Wisheart. I had also spoken to Professor Monk, and
13 I expected that he had gone to Mr Wisheart with the
14 results, and continued to express concerns, and that
15 those concerns were coming from me.
16 I think that that, on its own, would have been
17 a contravention of what I was told not to do in 1990,
18 and that was what concerned me.
19 Q. That is very helpful, thank you. So do you see 1990,
20 let us call it the "minutes incident", as a kind of
21 watershed of falling-out, or was there a period when
22 something happened before, or something happened
23 afterwards, which would make you be seen as a rebel
24 rather than a colleague?
25 A. I think that there was an incident before the minutes
0174
1 of the meeting. I think the minutes incident was
2 actually 1991 --
3 MR LANGSTAFF: Yes.
4 A. -- 1990 was the Roylance letter and a red-faced
5 Mr Wisheart talking very angrily to me about the
6 consequences of taking incidents outside the unit.
7 We are talking about 1990. In 1991 I then produced some
8 minutes at which I suggested that the Anaesthetic
9 Department taking an interest in outcomes, reporting
10 back and expressing concerns is useful, and I am told
11 that is not what we are supposed to be doing, I am not
12 to take minutes any more, so I have got confirmation of
13 a similar attitude and I am continuing to do what I have
14 been advised by somebody who, at that point, was the
15 Associate Director of Cardiac Surgery; he has now become
16 the Chairman of the HMC. He will become the Medical
17 Director of the Trust and he is also going to be
18 a candidate for the Chief Executive of this
19 organisation, and I personally did not want to formally
20 and openly cross the path of that person. I was,
21 6 feet 6 though I am, frightened of doing so.
22 Q. Just one matter which arises from that: you say that
23 what you were frightened of was putting your head --
24 this is a colloquial rendition -- "above the parapet"
25 because of the threats Mr Wisheart had made to you after
0175
1 the 1990 letter to Roylance?
2 A. Yes.
3 Q. You were afraid of being seen, therefore, to be, shall
4 I use the word, "a troublemaker"?
5 A. Yes.
6 Q. What you said in the answer to the Chairman is that you
7 thought you were being seen as just that, because it was
8 known, you thought, that you had repeatedly raised and
9 were continuing to raise, concerns, putting your head
10 above the parapet?
11 A. Yes.
12 Q. If in fact you thought that your head was above the
13 parapet, then why was there any further reason for
14 remaining silent at the meeting in January 1994, because
15 the damage had already been done, as you saw it, had it
16 not?
17 A. I think it was a question of whether you were raising
18 your head above the parapet openly in this forum, or
19 whether you were doing it behind the shadow of your
20 director, the Clinical Director of Cardiac Services, the
21 Professor of Cardiac Surgery or the Professor of
22 Surgery, and I think although it was possible for people
23 to trace the paper-trail back to me and say, "Gianni,
24 you are just showing me Steve Bolsin and Andy Black's
25 data", I think I felt more comfortable providing other
0176
1 people with the data so that they could confront people
2 and I was not prepared to confront people.
3 Q. So, put pithily, the difference in your mind was between
4 being seen to be putting your head above the parapet, as
5 opposed to being known to be putting your head above the
6 parapet?
7 A. Yes.
8 Q. The last matter I want to deal with today is the dinner
9 which came at Bistro 21, and again, let me find where
10 you deal with this in your account. It is WIT 80/118 --
11 THE CHAIRMAN: Mr Langstaff, I just wondered, I was thinking
12 in terms of rising around 3.45 today in terms of the
13 stenographers and others. Is this a matter we can
14 finish today, or shall we start with it tomorrow?
15 MR LANGSTAFF: I think we can probably usefully deal with it
16 this evening, and then anticipate what will happen
17 tomorrow. It will take, I suspect, no more than 10
18 minutes, if that is acceptable.
19 What you say in your statement, line 19, is that
20 in 1993 there is a meeting in the restaurant near the
21 hospital. You have been asked, I think, extensive
22 questions about this particular incident at the GMC.
23 A. Yes.
24 Q. When the date was suggested to you as being 5th April
25 1994?
0177
1 A. Yes.
2 Q. And again, the fact that that date had been put to you
3 repeatedly had obviously slipped your mind when you came
4 to write your statement?
5 A. Yes.
6 Q. But there was only one meeting, was there, at Bistro 21?
7 A. Yes.
8 Q. The date we have is either the 5th or preferably, we
9 think, the 13th April. It does not make any difference
10 which it is.
11 A. Not at all, no.
12 Q. April 1994, for the purpose of chronology.
13 A. Yes.
14 Q. There had been, before this, the meeting that you
15 described, 20th January, the letter back to Dr Ashwell,
16 saying the management -- we have seen the quote, I am
17 not going to requote it.
18 A. Yes.
19 Q. And this is the next significant event, is it? This
20 comes, as I understand it, before the conversation you
21 had with Mrs Maher?
22 A. Yes.
23 Q. What was the purpose of going to the meeting?
24 A. This meeting?
25 Q. This meeting, this dinner, let us call it.
0178
1 A. I think Chris Monk invited me to attend the meeting.
2 I think it was at relatively short notice, and my
3 understanding was that we were going to address some of
4 the issues in cardiac surgery and probably paediatric
5 cardiac surgery.
6 Q. Why the four of you?
7 A. To be quite honest with you, I have not thought about
8 that. I assume it was because we all had an interest in
9 paediatric cardiac surgery.
10 Q. Was it perhaps because Dr Monk is the Director of
11 Anaesthesia, Mr Wisheart is the Medical Director and has
12 obviously an input into cardiac surgery, was, had been
13 the Associate Director of Cardiac Surgery?
14 A. Yes.
15 Q. Professor Angelini had been a surgeon whom you had
16 talked to about your concerns and because you were known
17 to be expressing or promoting concerns?
18 A. It is certainly possible that those are the reasons,
19 yes.
20 Q. If that is possible, did you know, at this stage,
21 whether Mr Wisheart had seen your data?
22 A. No. I assumed he had, because when I had given it to
23 Dr Monk, he had said, "Right, I will take this on", and
24 Professor Angelini had said, "I will show the
25 appropriate people this data".
0179
1 Q. So your understanding was, "Mr Wisheart has a copy of my
2 data and knows it has come from me"?
3 A. Yes. He may well have known that it came from myself
4 and Andy Black, yes.
5 Q. So there you are, at the meeting, at the dinner: called
6 to discuss your data and the conclusions to be drawn?
7 The way forward? What?
8 A. I am not sure. I think it was paediatric cardiac
9 surgery and adult cardiac surgery.
10 Q. Did you in fact discuss it?
11 A. It was a very unusual meeting because if the agenda or
12 the purpose of the meeting was as you suggest it, the
13 first two courses were spent in small-talk, talking
14 about nothing really to do with cardiac surgery at the
15 BRI, and only latterly did we get into any conversation
16 about cardiac surgery at the BRI at all.
17 Q. Is that a reflection of awkwardness in grappling with
18 the subject, bearing in mind that there may be different
19 perspectives on it?
20 A. Yes, I think it was the taboo nature of the subject.
21 Q. So there you are circling around the issue in the first
22 two courses?
23 A. Yes.
24 Q. Talk being whatever it was, Manchester United and so
25 on. When did you get to grips with the subject? Did
0180
1 you ever?
2 A. I did not want to raise it, and I do not think I did
3 raise the subject.
4 Q. Why not?
5 A. Because I felt very uncomfortable raising this subject
6 with that company. I would raise it with --
7 Q. That is what you were there for, was it not?
8 A. I was not sure that the purpose of the meeting was for
9 me to raise the subject in front of that company. I had
10 already raised the subject with Dr Monk and I had
11 already raised the subject with Professor Angelini, and
12 I would have been happy to contribute to a debate if
13 they raised the subject and it impacted on the data that
14 I had collected or the views that I held.
15 Q. So you thought you were there to contribute to
16 a discussion, but not to begin it?
17 A. Yes, very much so. I was not prepared to initiate
18 a discussion on the basis of what had happened up until
19 this meeting.
20 Q. So if someone had said, "Do you have any concerns about
21 paediatric cardiac surgery?" looking at you or Professor
22 Angelini, you might have responded to it?
23 A. If the issue of concerns about paediatric cardiac
24 surgery would have been raised, I would have expected
25 either Professor Angelini or Dr Monk to have taken the
0181
1 lead and said, "Well, actually now you come to mention
2 it, we do have a problem and I do not know, Steve,
3 whether you would like to come in on this one and tell
4 us about your data collection?"
5 Q. What Dr Monk has suggested to us he said -- because he
6 told us you were getting frustrated that by the end of
7 the evening nobody had grappled with the subject which
8 he had arranged the meeting for --
9 A. It was a very difficult subject to grapple with.
10 Q. His recollection is that although he does not recall the
11 exact words, he said words to the effect of:
12 "Do you have any difficulties with the paediatric
13 cardiac services?"
14 May I tell you that in comments he has given us,
15 Mr Wisheart says he said words to the same effect, "Do
16 you have a problem with paediatric cardiac services?"
17 Did one, or the other, or both say that to you and
18 Professor Angelini, or you or Professor Angelini?
19 A. I think the question, if it arose, would have arisen to
20 the table, so that one person would have been speaking
21 to three others, and I would not have responded to that;
22 I would have contributed to it, but I would not have
23 responded to that --
24 Q. Can I take it in stages. Was the question asked?
25 A. Possibly.
0182
1 Q. If it was asked, why did you not respond?
2 A. I would have contributed. I did not want to raise the
3 issue of me being the prime mover in concerns about
4 paediatric cardiac surgery. That was why I was going
5 through every other route possible to press alarm bells
6 to get somebody to come and deal with the issue of
7 paediatric cardiac surgery.
8 Q. So Professor Angelini, someone you were on friendly
9 terms with, shared your concerns?
10 A. Yes.
11 Q. After the dinner, did you say to him, "Gianni, for
12 goodness sake, why did you not respond to that
13 question? It was not for me, I am a junior consultant,
14 but you are a Professor, why did you not say something?"
15 A. Yes.
16 Q. Did you say that to him?
17 A. No, I thought in a sense the question in my mind was
18 redundant, in that, at that stage, I believed that both
19 Chris Monk and Professor Angelini had raised the issue
20 with Mr Wisheart so that the issue of concerns was one
21 that was current within this group, within that group;
22 it was not really a question of saying, "Is there
23 a problem?", it is a question of what we are going to do
24 about the problem.
25 Q. Forgive me, if words to the effect of, "Do you have any
0183
1 problem with ...", or "Are there any difficulties with
2 paediatric cardiac services?", something like that was
3 said, and you do not necessarily accept it but you
4 cannot deny it, then that would have shown that the
5 person asking the question either wanted there to be
6 a general discussion, or did not accept that there were
7 any legitimate concerns or problems?
8 A. I am sorry, can you just repeat the question?
9 Q. We have, really, to a quarter to four, so let me just
10 ask you this question and leave it if necessary, to
11 finish this off tomorrow morning, although I think we
12 have pretty well finished it now.
13 The meeting, you are going to tell me, I know,
14 ended without any discussion actually taking place?
15 A. Yes.
16 Q. If a question were asked, as it is suggested to us and
17 you cannot deny was asked, like "Are there any
18 difficulties?" and so on, "What is the problem?", why
19 did it not lead to a discussion there and then?
20 A. I am not sure, because Dr Monk was aware of my concerns
21 and Professor Angelini was aware of my concerns. I was
22 aware of my concerns. I thought that Mr Wisheart was
23 aware of the data, and I would have expected a meeting
24 like this to have been dealing much more with solutions
25 than with whether or not there was a problem.
0184
1 As far as I could see, the data coming from the
2 unit already recognised that there was a problem. My
3 data confirmed the data that recognised that there was
4 already a problem. We should not have been talking
5 about whether there was a problem, "Do you have any
6 concerns?"; we should have been talking about, "What are
7 the solutions to the problems we know exist within this
8 unit?" and the director should have been very much aware
9 of that.
10 Q. The solution you had in mind was the need for an
11 immediate, thorough investigation and review?
12 A. Which we had been promised in January when Mr Dhasmana
13 was due to present the data and he did not -- I am
14 sorry, I interrupted you, I must not.
15 Q. Would not this meeting have been an ideal opportunity,
16 bearing in mind your concern for little children in the
17 unit, to press the case for just such a review?
18 A. Yes.
19 MR LANGSTAFF: Sir, tomorrow morning we begin at 9.30.
20 Anyone who expects Dr Bolsin to continue straight on
21 will be perhaps surprised to know that in fact at 9.30
22 we shall interpose the evidence of Mrs Hill, because she
23 is a bereaved parent and it is appropriate that she
24 should know when she starts and we expect that her
25 evidence will finish round about 10.30, and that will
0185
1 leave us quite sufficient time to complete the very
2 helpful evidence that Dr Bolsin has been thus far able
3 to give us.
4 THE CHAIRMAN: Yes, thank you for that. So we adjourn now
5 until 9.30 tomorrow morning. Good afternoon, everyone.
6 (3.50 pm)
7 (Adjourned until 9.30 am on Thursday, 25th November
8 1999)
9
10
11 I N D E X
12
13
14 MR LANGSTAFF:
15 Clarification of scope of the inquiry
16 in the light of recent media reporting ...... 1
17
18 DR STEPHEN BOLSIN (recalled):
19 Examined by MR LANGSTAFF .................... 4
20
21
22
23
24
25
0186
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001