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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?