Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts Hearing summary 29th November 1999 The Bristol Royal Infirmary Inquiry oral hearings this week centre on the evidence of Mr Janardan Dhasmana, former Consultant Cardiothoracic Surgeon, United Bristol Healthcare NHS Trust (UBHT). Mr Dhasmana began his evidence by commenting that paediatric cardiac surgery relied upon team work, he confirmed that he would meet with cardiologists to discuss each individual case. He then described his experience prior to his appointment in 1986 as a consultant in Bristol and compared the facilities there against those elsewhere at the time. During his time as a Senior Registrar at the Bristol Royal Infirmary (BRI) (1984-1986) he said that he recognised the need for a second paediatric surgeon to address waiting lists and to develop the service. He commented on the low number of referrals to the BRI in the early 1980s and discussed the restrictions on the paediatric cardiac service in terms of theatre time, beds and anaesthetic assistance and the disparate nature of the facilities including the cardiac intensive care unit (CICU) and the cardiac catheterisation lab. Mr Dhasmana then spoke about the concerns raised by Welsh cardiologists in 1987 regarding the Bristol service and the Bristol clinicians’ response to it. He commented on the difficulty in comparing individual centres performance and focussed on the establishment of the non-neonatal switch programme in Bristol and the ‘learning curve’ experienced by surgeons when introducing a new surgical procedure. Mr Dhasmana next spoke about clinical workload and the increase in referrals for adults resulting in restricted access to the CICU for paediatric referrals. He concluded by discussing the results of the non neo-natal switch programme. Mr Dhasmana’s evidence continues tomorrow. Mr Jardoslav Stark, Consultant Paediatric Surgeon, Great Ormond Street Hospital and Dr Eric Silove, Consultant Paediatric Cardiologist, Birmingham Children’s Hospital attended today’s hearing in their capacity as members of the Inquiry’s Expert Group.

FULL TRANSCRIPT

   1                    Day 84, 29th November 1999
   2   (10.35 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF: Good morning, sir. Sir, before we begin this
   6     week, which is dedicated to the evidence of Mr Dhasmana,
   7     may I deal with two or three matters which arise in the
   8     context of the conduct of the Inquiry as a whole?
   9          MR LANGSTAFF RE FUTURE PROGRAMME
  10   MR LANGSTAFF: Sir, I was hoping to look forward into next
  11     year when the Inquiry, of course, continues, and will
  12     continue to receive written evidence, but in particular,
  13     we, today, will be announcing by way of a press release
  14     details of the next phase of the work.
  15        Phase II of the Inquiry will look towards the
  16     future. It will examine the broader issues affecting
  17     the National Health Service and address the part of the
  18     Inquiry's terms of reference which requires you, as
  19     a Panel, to make recommendations which will help to
  20     secure high quality care across the NHS.
  21        With that in mind, there will be a number of
  22     seminars and I can announce first of all that the topics
  23     which have been chosen for those seminars have been
  24     informed partly by lessons which we have already learned
  25     or which are emerging from Phase I, from the oral

   1     evidence which we have heard since March.
   2        The seminar topics will take account of the latest
   3     research and thinking concerning the factors which
   4     determine the level of performance of organisations,
   5     both within the public sector and beyond. The first
   6     three seminars have been confirmed as follows: the first
   7     will be on Wednesday, 12th January 2000. It will take
   8     place here and it will have as its topic acute health
   9     care services for children.
  10        The second will take place in the National Liberal
  11     Club, Whitehall Place, London on 26th January next year,
  12     and it will be on the determinants of performance, the
  13     factors which determine the level of performance of
  14     organisations, including the public sector generally,
  15     and health care in particular.
  16        The third, at the Institute of Civil Engineering
  17     at 1 Great George Street, London, will concern itself
  18     with culture, the professional and managerial cultures
  19     and their impact on the quality of performance.
  20        There is a series of further seminars which I know
  21     are planned, and the details of which will be announced
  22     in due course.
  23        Individuals will be invited by the Inquiry to
  24     participate in specific seminars. All seminars are
  25     fully open to the public and to the media, and members

   1     of the public who would like to attend the seminars are
   2     asked to write to the Inquiry offices here in Bristol.
   3     For those who come without noticing the address, it is
   4     2-10 Temple Way and the postcode is BS2 0BY, or they may
   5     contact the Inquiry by e-mail at inquiry@doh.gov.uk,
   6     quoting Phase II, in order to reserve places, because it
   7     may well be that places for the seminars will be
   8     limited.
   9        The seminars will not themselves be recorded on
  10     LiveNote, as these proceedings have been, but a summary
  11     report of each seminar discussion will be published,
  12     together with the supporting papers.
  13        Can I move on to say that today we have also made
  14     public over 40 responses from individuals and
  15     representatives of local and national organisations, who
  16     have sent written comments to the Inquiry's Phase II
  17     consultation paper which was published earlier this
  18     year, and expressed our gratitude at the level of
  19     interest and the level of response which is, itself, an
  20     indication of the level of interest that there has been
  21     in responding to consultation.
  22        Phase I looks back, as we know, at how the
  23     services in Bristol were organised and managed from 1984
  24     to 1995, beginning with a broad view by setting the
  25     local scene in the national context, focusing closely on

   1     the local service with a detailed look at the paediatric
   2     cardiac surgical team between 1984 and 1995 --
   3   THE CHAIRMAN: Mr Langstaff, perhaps I can interrupt for
   4     a moment and make Mr Dhasmana aware of what we are
   5     doing? Sometimes on Monday mornings we have a roll call
   6     of things to be done or things that have been done and
   7     that is what we are doing right now. Forgive us for
   8     a little while longer.
   9   MR DHASMANA: Thank you, sir.
  10   MR LANGSTAFF: Just as Phase I looks back, Phase II looks
  11     forward to the future. We expect that it will be
  12     completed by April 1st 2000, with the Inquiry report
  13     expected in the late summer or autumn of next year.
  14        Sir, that is dealing with the future progress of
  15     the Inquiry in terms of hearings. May I also mention
  16     that over the last week or so there has been
  17     considerable interest expressed by a number of those who
  18     followed the Inquiry into the way in which the Panel and
  19     the Inquiry propose to deal with the difficult issue of
  20     morbidity.
  21        I think I last said something in some detail on
  22     this back in September of this year. I think two
  23     reassurances are needed: first of all, that I am
  24     conscious that we, presenting the evidence to you, have
  25     not lost sight of morbidity, although inevitably the

   1     emphasis of an Inquiry like this is sadly upon
   2     mortality. Secondly, would it be helpful if, later this
   3     week, I were to expand upon what I said in September and
   4     present you and the public with a fuller statement of
   5     how best the Inquiry can grapple with the uncertainties
   6     and difficulties of morbidity, so, as best it can, to
   7     honour its terms of reference and provide appropriate
   8     conclusions, if there are conclusions to be reached.
   9   THE CHAIRMAN: I think that that would be extremely helpful,
  10     Mr Langstaff, both to update us, if you will, as to what
  11     has been accomplished so far, and then to describe what
  12     work is in progress, bearing in mind that it must not be
  13     thought that December 16th, the end of the oral
  14     hearings, is the end of a period of time in which we are
  15     examining matters, taking further evidence and
  16     conducting further study. As you properly said and as
  17     we said before, this is such a complex area that it will
  18     take a period of time to unravel whatever we are able to
  19     unravel.
  20        So I think, if I may say so, a short statement
  21     from you towards the end of the week would, I think, be
  22     helpful to everyone, and be very welcome.
  23   MR LANGSTAFF: Sir, the last item perhaps of unfinished
  24     business, as it were, on the Monday morning roll call,
  25     is to ask whether the Panel has reached a view upon the

   1     application which was earlier made to it by Mr Lissack
   2     on behalf of the Bristol Children's Heart Action Group?
   3   THE CHAIRMAN: Thank you, Mr Lissack.
   4     CHAIRMAN'S STATEMENT ON APPLICATION TO RECALL WITNESSES
   5   THE CHAIRMAN: If I may, I will read out what I have in
   6     front of me. It is as follows:
   7        We refer to the application made by Mr Lissack on
   8     behalf of Bristol Heart Children's Action Group on
   9     October 12th, that four witnesses be called: that three
  10     of them, Mr Ross, Mr Barrington, Professor Berry, are
  11     recalled, and one, Mr Gray, called for the first time.
  12     We have examined the papers put before us and have
  13     reached the following view:
  14        First of all, it is clear that an error was made
  15     in the process of identifying those children from whom
  16     tissue had been removed with a view to advising
  17     parents. Given the scale of the exercise undertaken, we
  18     can see how it may be that error was probably likely,
  19     despite the hard work of Mr Barrington and Professor
  20     Berry. Nonetheless, such an error over such a sensitive
  21     matter was deeply unfortunate. It was probably
  22     inevitable that it would cause the distress which
  23     clearly ensued. Mr Barrington's apparent attempts to
  24     lessen this distress clearly failed. We do not feel
  25     inclined to criticise him.

   1        Secondly, we bear in mind that the question for us
   2     is whether calling or recalling the witnesses identified
   3     in the application will aid us in the fulfilment of our
   4     terms of reference. We feel, subject to one proviso, to
   5     which I will return in a moment, that we have as full
   6     a picture as possible of the practice in the past of
   7     removing, using and retaining tissue, both in Bristol
   8     and nationally. We also have a great deal of evidence
   9     on which we may call when giving our minds to
  10     recommendations for the future.
  11        The proviso relates to the precise purpose or
  12     purposes for which slides or other sections of tissue
  13     were taken in Bristol during the relevant years.
  14        Reference is made in the letter from the Trust's
  15     solicitors to "national guidelines", but these do not
  16     relate directly to the practice in Bristol. Thus,
  17     before reaching a final decision, we would be grateful
  18     to receive, as soon as possible, a statement from
  19     Professor Berry (rather than a letter from lawyers,
  20     which in our view would not be sufficient) responding to
  21     the matter we refer to as the "proviso".
  22        Once we have seen this and considered whether, in
  23     the light of what it says, further questions should be
  24     posed, we will announce our response to Mr Lissack's
  25     application.

   1        Mr Langstaff?
   2   MR LANGSTAFF: Thank you, sir. Sir, today we have
   3     Mr Dhasmana, we have as experts Mr Jaro Stark and
   4     Dr Eric Silove. Both Mr Stark and Dr Silove perhaps now
   5     need no introduction, having given evidence to us
   6     before, and they have been here on more than one
   7     occasion, but it would be convenient that once
   8     Mr Dhasmana has taken the oath, they should again be
   9     sworn. I suspect that their contribution today will not
  10     be very great because it is tomorrow that I shall be
  11     looking in some detail at cases which arise from the
  12     Case Note Review with Mr Dhasmana, and then I would
  13     anticipate that Mr Stark and Dr Silove will have rather
  14     more to say.
  15   THE CHAIRMAN: And I should welcome them and thank them
  16     again for being here.
  17   MR LANGSTAFF: Mr Dhasmana, would you stand to take the
  18     oath, please?
  19           MR JANARDAN DHASMANA (SWORN):
  20           Examined by MR LANGSTAFF:
  21     [Mr Jaroslav Stark and Dr Eric Silove, both sworn]
  22   Q. Mr Dhasmana, I wonder if we may have on the screen in
  23     front of you, please, the first page of your witness
  24     statement, WIT 84/1. There you give us your full names
  25     as Janardan Prasad Dhasmana. You have given us,

   1     I think, a number of witness statements, have you not?
   2   A. Yes, I did.
   3   Q. And the first witness statement goes from page 1 to 5
   4     and concerns your surgeon's log and year books, does
   5     it? Is that your signature dated 11th June at page 5?
   6   A. That is correct, sir.
   7   Q. At page 6, do we see the start of a statement regarding
   8     information systems, in particular two known as METASA
   9     and PATS, the Patients Analysis and Tracing System?
  10     Does that go to page 14, where we have, as an exhibit,
  11     a letter from Mr Hutter? Is that your second
  12     statement?
  13   A. That is correct.
  14   Q. At page 15 do we have a statement which concerns
  15     Issue M, audit? That, I think, including annexes which
  16     we have at pages 35, 37 and 39, 40 and finishes at the
  17     end of the annexes, does it, at page 40? That is the
  18     last, I think, of the annexes there on the screen. We
  19     may pick up your signature perhaps at page 33, which is
  20     dated 17th November.
  21   A. That is correct.
  22   Q. Page 41: do we have your statement on Issue B,
  23     structure, management and organisation of the Bristol
  24     Royal Infirmary and its Paediatric Cardiac Surgery Unit,
  25     and we see your signature at page 50, again dated

   1     17th November.
   2   A. That is correct, sir.
   3   Q. Page 51: your statement in relation to Issue C, the
   4     service, nature and outcomes, and your signature at the
   5     end of the annex, 61; page 54, your signature.
   6   A. That is correct, sir.
   7   Q. While I am on those statements, if I can take you to
   8     the very last line of page 52, you are dealing there
   9     with the date at which you stopped operating upon
  10     neonatal patients who needed an operation to transpose
  11     their great arteries. You say there that you stopped
  12     operating after a patient died in October 1992,
  13     following a successful operation after a second visit to
  14     Birmingham in July 1993. I think you mean October 1993,
  15     do you not?
  16   A. I apologise for these typographical errors.
  17   Q. It is surprising that in so many statements there are so
  18     few typographical errors, but we will try and pick them
  19     up.
  20        Can we then look at the next statement, which is
  21     page 62? Does this deal with Issue D, referrals? Can
  22     we scroll down, please? Your signature?
  23   A. Yes, sir.
  24   Q. There are annexes to that at pages 63 to 65. Your next
  25     statement begins at page 66, Issue E on pre-operative

   1     management of cases, which goes to page 68, where
   2     I think we have your signature.
   3   A. That is correct.
   4   Q. Then page 69, Issue F on management of surgery, your
   5     statement on that. And I think if you go to page 71, we
   6     see your signature to that statement, do we?
   7   A. Yes, sir.
   8   Q. There are annexes to that running from pages 72 to 86.
   9     Your statement on Issue G begins at page 87, Issue G
  10     being post-operative care. That takes us through to
  11     your signature at page 91.
  12        At page 92, Issue H, the split site. If we go to
  13     page 94, your signature to that, with annexes, as have
  14     already been indicated, by page 95 and beyond running
  15     through to page 102.
  16        Page 103, please: is that your statement on
  17     Issue I?
  18   A. Yes, sir.
  19   Q. If we go to page 104: your signature to that, Issue I
  20     being the treatment of families?
  21   A. Yes, sir.
  22   Q. Page 105: statement dealing with postmortems and
  23     inquests, Issue J. Does that finish at page 107 with
  24     your signature?
  25   A. Yes, sir.

   1   Q. Page 108: a statement on training and retraining.
   2     I think if we go through to page 115, we see your
   3     signature there?
   4   A. Yes, sir.
   5   Q. Page 116 is your statement on informed consent, Issue I,
   6     is it?
   7   A. Schedule L.
   8   Q. Schedule L, I am sorry. My fault entirely. Does that
   9     take us through to page 123, and at page 124, your
  10     signature?
  11   A. Yes.
  12   Q. With annexes from 125 to 132. Page 133: is this the
  13     statement that you give us on Issue N, the expression of
  14     concerns?
  15   A. Yes, sir.
  16   Q. Which takes us through to page 141 where we see your
  17     signature. There are appendices to that from page 142
  18     to 147.
  19   A. That is correct, sir.
  20   Q. I think you have, in addition, given as the Inquiry has
  21     progressed a number of comments, written comments, on
  22     the witness statements of others, and in particular, may
  23     we look, please, at WIT 80/10? This is your response to
  24     Dr Bolsin's statement to the Inquiry.
  25   A. Yes, sir.

   1   Q. And do we see your signature on that at page 12? We do
   2     not actually see your written signature there as it is
   3     typed, but nonetheless, this is a statement you put in
   4     by way of commentary, is it?
   5   A. Yes, sir.
   6   Q. In respect of the evidence of Mr Baird at WIT 75/22:
   7     your comments in respect of his statement. To page 24,
   8     where again, your signature is typed, but those are your
   9     comments on Mr Baird's statement, are they?
  10   A. Yes, sir.
  11   Q. On the witness evidence, the statement, that is, of
  12     Helen Vegoda, WIT 192/64, consisting of one page. That
  13     again is your signature, albeit typed?
  14   A. Yes, sir.
  15   Q. That of Helen Stratton at WIT 256/104 to 105. 104 is
  16     where it starts; 105 is where it finishes. In the
  17     first, I think, of two written comments on her
  18     statement, you say essentially that she did not raise
  19     the concerns that she expressed in her statement with
  20     you at any time?
  21   A. That is correct, sir.
  22   Q. And WIT 256/109, where you contrast what she had to say
  23     in her statement with, if we scroll down, what
  24     a Mr Gibbons had to say she said to Mr Gibbons. You
  25     signed that on 6th September 1999, did you?

   1   A. I cannot see "Mr Gibbons". (Words highlighted on
   2     screen).
   3   Q. You make the point there, I think, that what she said to
   4     a parent was the opposite of what she was saying in her
   5     statement about you.
   6   A. That is correct, sir.
   7   Q. You make comment, do you, on the statement of Mr Bryan
   8     at WIT 81, from pages 13 to 16. Beginning at page 13
   9     and then going on to page 16: this time signed, dated
  10     9th September. That is your first of two written
  11     comments in respect of Mr Bryan, and in this one you
  12     point out that he was the audit co-ordinator in cardiac
  13     surgery but did not express any concern to you about
  14     your practice as a paediatric cardiac surgeon.
  15        Then you go on to WIT 81/37, when you respond to
  16     his statement in respect of Issues M and N, and that
  17     ends, does it, at page 39, dated 8th October, signed
  18     only in typescript, but is that your comment on what
  19     Mr Bryan had to say?
  20   A. That is correct, sir.
  21   Q. You respond to what the Coroner, Mr Paul Forrest told us
  22     in his witness statement at WIT 308/4. Again, at the
  23     bottom is that your signature?
  24   A. Yes, sir.
  25   Q. To what Professor Angelini had to tell us at

   1     WIT 73/57, and if we go to page 62, your typed signature
   2     dated 11th October: is that your commentary on what
   3     Professor Angelini had to say?
   4   A. That is correct, sir.
   5   Q. Finally, in respect of the written evidence of Dr Monk,
   6     WIT 105/61, and that ends, does it, at page 62 with your
   7     signature?
   8   A. Yes, sir.
   9   Q. Is it the case, Mr Dhasmana, that you would wish the
  10     Inquiry to take your statements and your several
  11     comments as your evidence to the Inquiry?
  12   A. Yes, sir.
  13   Q. You will appreciate that I will not, therefore, ask you
  14     about all the details that you set out in those
  15     statements and comments, but in the questions that
  16     I have to ask, I shall to an extent be selective.
  17        Can I begin by asking you generally about your
  18     view of cardiac surgery? Would you say it was a team
  19     effort?
  20   A. Yes, cardiac surgery is a team effort.
  21   Q. Did you, when you operated in paediatric cardiac
  22     surgery, take a decision on your own to carry out and
  23     conduct any particular operation?
  24   A. I cannot remember every single instance.
  25   Q. Who would be involved, as you see it, in any decision to

   1     operate?
   2   A. We always had a combined paediatric cardiologist and
   3     cardiac surgeons' meeting on each case, whether in
   4     a formal manner in a room or an emergency situation by
   5     the bedside, or in the cath' lab or the echo facility,
   6     and the decision would be made for the patient's
   7     management after that.
   8        A number of times, when a formal meeting was
   9     taking place in the Children's Hospital, at that time my
  10     other cardiac surgical colleagues would also be there
  11     and other cardiologists would also be there, along with
  12     a person who was helping them with diagnosis, like
  13     a cardiac radiologist, and occasionally, an
  14     anaesthetist.
  15   Q. So sometimes the radiologist, sometimes an anaesthetist,
  16     always a cardiologist?
  17   A. The radiologist in the form of Dr Wilde or his team
  18     would always be there, because they were the ones who
  19     were really helping with interpretation of cine data,
  20     although of course cardiologists were taking part --
  21     taking the main role -- but the cardiac radiologist was
  22     always there. Dr Wilde was very keen on the cardiac
  23     side of the radiology, so he always made a point to be
  24     there.
  25   Q. You were appointed a consultant surgeon, were you, in

   1     1986?
   2   A. I was appointed --
   3   Q. -- with effect from?
   4   A. Yes, I started on 1st January 1986.
   5   Q. You were appointed in 1985?
   6   A. Yes, probably October/November.
   7   Q. When you began as a cardiac surgeon, did you have any
   8     responsibility, in particular for the facilities, the
   9     equipment and the staffing within which you had to
  10     operate?
  11   A. When I was appointed -- this was, you could say, an
  12     extra appointment; it was not to fill in a vacancy, and
  13     at that time the appointment was being made in a way for
  14     a person, really, to find his own place, his own
  15     mechanism, and to ask for what he wanted. So in a way,
  16     the facilities were there, but limited; you had to
  17     really expand on it.
  18   Q. Did you then have to work with what you had, or did you
  19     have much opportunity to influence the equipment, the
  20     staffing, the facilities around you?
  21   A. I am sure I had some input into getting some of the
  22     facilities and staffing around me.
  23   Q. May we have a look, please, at the GMC transcript for
  24     Day 42, page 19, page 20. At the bottom, you were asked how you
  25     felt about the paediatric work being done at Bristol.

   1     It is the fourth last line on the screen. You said that
   2     having worked in Great Ormond Street, having seen
   3     centres like Chicago and Alabama, you felt that "we were
   4     at a very low, primitive level, really", that is the
   5     term you used at the time, "either because of the
   6     facilities, or theatre, or ITU, or availability of
   7     beds."
   8        You expand by saying that you were not dealing
   9     with the more complicated problems, except as
  10     emergencies.
  11        Is that word "primitive" then a word you used to
  12     describe the Bristol facilities when you began in 1986?
  13   A. I am here talking of 1984 and 1985, when I was still
  14     Senior Registrar. There was only one surgeon doing the
  15     paediatric work, Mr Wisheart, and I thought for a centre
  16     to work in that type of facility with one surgeon
  17     working -- and if I remember it correctly, our ITU was
  18     not big enough, really, to accommodate more than one
  19     patient -- I may be wrong -- one paediatric patient at
  20     that time.
  21        You had to juggle with your adult list to fit in
  22     the paediatric cases, and I was uncomfortable with some
  23     of the waiting list that some of the children were
  24     really going through. In those contexts, I thought that
  25     Bristol could not be compared with the facility that

   1     I really had seen in, say, (?) or Alabama, or when
   2     I visited Chicago, and of course, in Great Ormond
   3     Street. Those were in the back of my mind, and that is
   4     why I used the term. Maybe "primitive" was a little bit
   5     too harsh on Bristol, really.
   6   Q. But it was a term you said you used at the time?
   7   A. Yes, I did.
   8   Q. And it is the term you thought appropriate at the
   9     GMC to describe it?
  10   A. Sometimes words do come out.
  11   Q. Do you want to stick by it now, or do you want to change
  12     that?
  13   A. I would say, if not "primitive", I would say it was at
  14     a lower level, really; it was not very high up, even on
  15     my scale.
  16   Q. "Primitive" gives one the idea that it was, as it were,
  17     at basement level by comparison with other centres, it
  18     was at a very low level. Is that what you meant to
  19     convey?
  20   A. I think I felt, you know, that until the time I was
  21     here, just starting, one surgeon for an active
  22     paediatric cardiac surgical unit, we could not call it
  23     a paediatric cardiac surgery unit. With my appointment
  24     there was some kind of redress in that situation.
  25   Q. We will come back to this page in a moment, but just

   1     picking up on what you say, that you could not really
   2     call it a paediatric cardiac surgical unit, could we
   3     look at DOH 4/28? Looking at the operations on the
   4     under 1s, we can see, if we look across the top line,
   5     "Open-heart surgery", that before 1985, the period we
   6     are looking at at the moment, the greatest number of
   7     operations performed in any one year appears to have
   8     been 14, on the under 1s?
   9   A. Yes, sir.
  10   Q. In that year, a total of 50 operations, including
  11     palliative and definitive closed surgery?
  12   A. Yes, sir.
  13   Q. 55, I am sorry. For a surgeon to develop expertise in
  14     a particular field, we have earlier in this Inquiry
  15     heard evidence that there is a minimum that the surgeon
  16     might expect to do in a particular area. Would you
  17     agree with that?
  18   A. If you are referring to the British Cardiac Society
  19     paper in the British Heart Journal, which appeared some
  20     time early in 1980, then I do, but at that time a lot of
  21     centres outside, I would say, GOS, Birmingham and
  22     Liverpool, probably were doing similar type of number,
  23     or may be slightly more.
  24   Q. But nonetheless, I think you are accepting that in the
  25     early 1980s, the number of operations performed by way

   1     of open-heart surgery was really very low indeed in this
   2     category of patient, under 1 year of age, for any one
   3     surgeon to develop an expertise in the complications
   4     that might be particular to that group?
   5   A. I would agree, yes, sir.
   6   Q. If we just for one moment look forward to 1988 and 1989,
   7     29 and 40, those operations by that stage were being
   8     split between yourself and Mr Wisheart?
   9   A. Yes, sir.
  10   Q. So on average, it would be 14 or 15 under 1s operations
  11     for you in one year in 1988, half of 29 being 14 or 15;
  12     and in 1989, the average would be 20 for each of you, in
  13     this particular group?
  14   A. Yes. Individually, I think we were still doing less
  15     than we should have been doing, yes.
  16   Q. So can I go back to GMCT 42/20? The top of the page,
  17     please? When you are appointed, it is not really, as
  18     you see it, a paediatric cardiac surgical unit because
  19     there is only one surgeon and presumably because the
  20     number of operations is far too low to justify calling
  21     it a specialist unit on its own merits. Would that be
  22     fair?
  23   A. I think I accept that, yes.
  24   Q. The aspects of what you then described as "primitive"
  25     are set out at the top of the page, where you are

   1     recognising, I think, shortcomings in the facilities or
   2     the theatre or the ITU or the availability of beds.
   3        Let me go through each of those in turn. So far
   4     as the facilities were concerned, what were the
   5     disadvantages, the problems, of the facilities in 1984
   6     and 1985 before you took up your appointment in 1986?
   7   A. At that time paediatric cardiac surgery in Bristol was
   8     being undertaken at two places: closed cardiac work at
   9     the Children's Hospital itself and the open-heart
  10     surgery at the BRI.
  11        In both places we were competing for space. In
  12     the Children's Hospital the paediatric unit had
  13     a theatre space of one and a half sessions a week, one
  14     week the whole day, another week half a day. In the
  15     BRI, in 1985/86, probably we were not doing more than
  16     five or six cases in the whole week, I think, so there
  17     was a limitation of theatre space; we could not really
  18     do any more, both on open and closed. That is for
  19     operating space.
  20        Similarly, beds: again, in the Children's
  21     Hospital you were competing with other very sick
  22     children in ITU to accommodate your post-operative
  23     cases, so you had to be careful about what you were
  24     operating, but fortunately, cardiologists were taking
  25     care of that by accepting patients from outside.

   1        In the general ward we were sharing a ward and
   2     a bed with a paediatric surgical team, and again, there
   3     were more than one or two paediatric general surgeons,
   4     paediatric ENT surgeons, paediatric cardiothoracic
   5     surgeons. They were all sharing the facility in that
   6     ward.
   7        At the BRI, before major remodelling was done in
   8     1988 the facility was limited both for adult and for
   9     paediatric cardiac in a way, in the old setup, so bed
  10     space was also limited, and of course, also theatre.
  11     ITU I think was probably four beds or five at that time,
  12     so we did not have a facility for a big unit in the
  13     South West region really, as it should be.
  14   Q. When you say that the bed space was limited, you are
  15     actually talking here, are you, of physical space for
  16     beds, as opposed to the staffing of beds?
  17   A. I am talking of physical space first, and the staffing
  18     level, of course, has increased a great deal after 1988,
  19     but before that, I think the staffing was probably all
  20     right for the beds we had, but we had very few beds.
  21        I do not know if people know the history of the
  22     Cardiac Unit in the BRI. This was supposed to be
  23     a nurses' sick room, before Mr Belsey took over that as
  24     a future Cardiac Unit. The history, at that day the
  25     Cardiac Unit being expanded over the year, expanding

   1     from a limited area to the huge facility now it is, and
   2     it is just because it was at the top of that six-floor
   3     building, you had to really expand at the expense of
   4     some other service, so you were competing for service
   5     against your other colleagues in the BRI. It was not
   6     always easy.
   7   Q. In terms of location, you have the ITU at the top of
   8     the building, as you have described. If it were
   9     necessary to carry out a catheterisation in the BRI,
  10     where were the catheter facilities?
  11   A. Historically, I think when I was Senior Registrar, the
  12     cardiac catheter facility was not in the BRI, it was at
  13     the Bristol General Hospital. Then they moved into the
  14     BRI probably late 1970s and it was in the basement; it
  15     still is, actually: the adult cardiac catheter facility
  16     is in the basement. The whole basement is the Radiology
  17     Department, so you could say it is part of their
  18     service, really.
  19   Q. So if it were necessary to carry out a catheterisation
  20     on a sick child, the child may have to go from the
  21     intensive care ward at the top of the building down to
  22     the bottom of the building for the investigation, and
  23     then up again back to the intensive care ward?
  24   A. If I could just correct you there, sir, these patients,
  25     these very sick babies, were admitted by cardiologists

   1     in the Children's Hospital, so they would -- I am
   2     talking now of before 1986, when I was Senior
   3     Registrar. If a child needed a catheter, he or she
   4     would be transferred from the Children's Hospital to
   5     this facility at the BRI, catheterised, and then back to
   6     the ITU in the Children's Hospital, where cardiologists
   7     and cardiac surgeons would make a decision what to do in
   8     their further management. Then, if somebody was
   9     requiring open-heart surgery, they would be moved to the
  10     BRI; if closed, then of course the Children's Hospital.
  11   Q. What about a child who is admitted as an emergency?
  12     Would he or she go to the Children's Hospital or the
  13     BRI?
  14   A. The cardiologist had total control of the children's
  15     admission, so no child would be admitted as an emergency
  16     at the BRI.
  17   Q. No child, at this stage?
  18   A. I mean, I think even now, any patient with a cardiac
  19     problem would be referred to the cardiologist,
  20     a paediatric cardiologist, and they did not have and
  21     they still do not have beds for children in the BRI.
  22   Q. So your recollection is that even the emergency cases
  23     would have to be admitted through the cardiologist at
  24     the Children's Hospital?
  25   A. With congenital heart defect, yes.

   1   Q. You say in the next sentence, going back to the
   2     transcript:
   3        "We were not dealing with the more complicated
   4     problems, except when they came in as an emergency".
   5        What point were you making there about the
   6     shortcomings of Bristol as a centre in 1984/85?
   7   A. I think this was because I had just returned from Great
   8     Ormond Street Hospital, having spent 13 months there,
   9     and I could see there almost every case was being
  10     tackled as it came and when it came. Of course, it was
  11     happening here also, but numbers were -- I do not know
  12     whether it was the referral or what -- numbers were very
  13     much fewer. I think my next sentence probably goes with
  14     what was the practice at that time with cardiac surgeons
  15     probably at most of the centres, that a lot of the
  16     repair was stage repair. You did a palliative
  17     procedure, and then, when the time came, the child
  18     became bigger, you went for full repair. That was quite
  19     accepted, and of course, centres like GOS and others
  20     were moving forward; there were fewer palliative repairs
  21     at that time. We were doing still quite a few
  22     palliative operations.
  23        I do not think there was any other complex
  24     procedure at that time. In my mind, of course, when you
  25     are talking about it in 1988 and 1989, you start

   1     thinking back and you think it is primitive, but
   2     probably if you put yourself back in 1986/85, probably
   3     there were no other complex procedures which were not
   4     being done in Bristol; it was just more palliation was
   5     being undertaken.
   6   Q. I think what you are saying -- tell me if I am right --
   7     is that whereas elsewhere in places like Great Ormond
   8     Street, you were conscious that the "landscape" was
   9     changing, surgeons were moving on to deal with
  10     conditions in a better, more effective way, by going for
  11     complex operations rather than two-stage or three-stage
  12     procedures, Bristol was lagging behind; is that the
  13     sense of it, or not?
  14   A. We were lagging behind in general terms, but we were
  15     not really sitting doing nothing; we were moving, but
  16     probably not at the same pace as others. I mean,
  17     Bristol moved, even during my Senior Registrarship, from
  18     Mustard to Senning; Bristol moved to some technique on
  19     AV canal; even the coarctation technique: they presented
  20     one of the earliest papers on failure of subclavian flap
  21     technique, which was happening in 1984/85. So we were
  22     not really lagging behind in a sense; we somehow were
  23     not at the same pace as these dedicated centres were.
  24        Of course, when you take up any new appointment,
  25     a new post, you are a little bit more ambitious, you

   1     want to go a little faster. That probably was at the
   2     back of my mind when I said what I said at that time.
   3   Q. You go on, I think, to deal with the cardiologists and
   4     how you saw them in 1984 and 1985. You describe them as
   5     "very cautious in taking up new operations and new
   6     techniques", and that if they had not seen it done for
   7     at least five years elsewhere, they would not give the
   8     okay for you to proceed in Bristol.
   9        That rather gives a picture of Bristol lagging at
  10     least five years behind the "cutting edge", anyway,
  11     elsewhere. Is that what you meant to say?
  12   A. That is correct, I did.
  13   Q. And not only is it what you meant to say, is it as you
  14     saw it and see it?
  15   A. I have to accept it now.
  16   Q. Can we have a look at UBHT 133/31? We had better go
  17     back so you can see where this begins, at page 29. It
  18     is a letter from a number of consultants at Bristol,
  19     dated 1987. The context, the first paragraph:
  20        "It has come to our attention that cardiologists
  21     in Wales have asked the cardiology group of the Royal
  22     College of Physicians to give a view about ..."
  23        It is in the context, as I understand it, of
  24     a number of Welsh clinicians wishing to develop their
  25     own services in Wales and therefore being critical or

   1     voicing criticism of the services in Bristol.
   2        Do you remember the period of time?
   3   A. I am not sure whether this is the same document.
   4   Q. Let us go down to the bottom of the page. "Firstly ...
   5     Secondly ..." and then we go over the page,
   6     "Thirdly ..."
   7   A. I am sorry, I cannot read that fast.
   8   Q. You can see that at the top of that page it talks about
   9     the Bristol paediatric unit being "subjected to
  10     a campaign of vilification. The word is chosen
  11     advisedly, which we find quite extraordinary and very
  12     sad. To illustrate this and without wishing to
  13     elaborate, the following is quoted from a document
  14     written under the auspices of the Welsh Heart Circle in
  15     Cardiff..."
  16        It goes on to quote a degree of concern about the
  17     standard of operations carried out at the receiving
  18     centre in Bristol.
  19   A. Yes, sir, I can see now.
  20   Q. If we scroll down, the view:
  21        "It is stressed that these sections form but
  22     part of a long and highly emotive plea for improved
  23     paediatric cardiac services in Wales, which we fully
  24     support, but nonetheless damning of Bristol for all
  25     that."

   1        If we can go over, can we scroll down? I am sorry
   2     for the flashing screen, Mr Dhasmana.
   3   A. I will have to get my glasses right.
   4   Q. If we go six lines down and highlight the words:
   5        "It seems therefore that this view is widespread
   6     and we believe based on ignorance of the facts, since
   7     there has been no recent inquiry into the actual status
   8     of the facilities (better than most, in our view) or the
   9     surgical results (which are at least equal to those
  10     achieved by other paediatric units)."
  11        You go on. I say "you" because if we go down to
  12     the bottom of the page, it carries your signature
  13     amongst others?
  14   A. Yes, sir.
  15   Q. If we go back up to that part, here, in August 1987,
  16     you were saying, in a letter responding to criticism in
  17     Wales, that the status of the facilities in Bristol was
  18     better than most, yet these are the same facilities you
  19     have been describing to us in 1984 and 1985 as meriting
  20     the word "primitive".
  21   A. Yes. One should really take those into different
  22     contexts, really, because my original sentiment about
  23     putting a word like "primitive" was with my reference to
  24     1984/85, now we are into 1987 and I have been in service
  25     for one year and in a way, we have got -- whatever

   1     comparator at that time was the UK Cardiac Register. If
   2     I remember it correctly, along with this letter there
   3     would have been a summary of results over the previous
   4     two or three years, really, compiled by my colleague,
   5     which I saw and agreed totally. They appeared to me
   6     almost on a par with the UK Cardiac Register. That is
   7     why I signed it.
   8   Q. There are two points being made. One is in relation to
   9     facilities. If you just read on:
  10        "The facilities or the surgical results which are
  11     at least equal to those achieved by other paediatric
  12     units."
  13        Could we highlight that, please?
  14        You are absolutely right in saying that this
  15     letter enclosed results. We see those at 133/35.
  16        If we take the comparison here, between Bristol
  17     1984 and 1986, this is drawn from the register?
  18   A. Yes, sir.
  19   Q. Open-heart surgery, over 1 year, Bristol, percentage of
  20     mortality is 7.9 compared to 1984 UK percentage of 6.9.
  21     Under 1 year, 26.5 which is 20 per cent higher than the
  22     UK 1984 average of 21.8, is it not?
  23   A. No, sir, it is only 5 per cent higher.
  24   Q. I am sorry, I agree, 5 per cent out of 100, but it is in
  25     a ratio of 5 to 4, which is where I was taking my 20 per

   1     cent from.
   2   A. Forgive me, if you just look at the number, in three
   3     years we are talking a total number of 49 cases, and to
   4     really base your statistical judgment on the 49 as
   5     compared to 431, any statistician would tell you there
   6     is not much difference between 21.8 and 26.5.
   7   Q. So if we go back from these statistics, bearing in mind
   8     the comparison is 1984 to 1986 Bristol, as against 84 in
   9     the UK. Can we go back to UBHT 133/31 and look again at
  10     the passage which we highlighted. On paper the results
  11     were not equal, were they, they were worse?
  12   A. I would not call it "worse", sir. We did admit, when --
  13     I think there were visitors from South Wales at that
  14     time who visited the BRI centre, both the BRI and the
  15     Children's Hospital. I was busy at that time in the
  16     operating theatre or something like that, but my
  17     colleague Mr Wisheart went along and talked to them, and
  18     I did have some type of reference to that meeting, that
  19     we did also admit that some of the complex cases
  20     probably that is where the mortality was higher than it
  21     was in other centres, but being small in number, we have
  22     taken a note and we are trying to improve, so in a way
  23     we admitted what was a shortcoming, but in a statistical
  24     sense, I would beg to differ that we were any worse off
  25     than the UK average, really.

   1   Q. I am interested -- I will push just a little on this.
   2     In first of all the comparison which you have seen
   3     accompanying this letter, 1984 to 1986 in Bristol, as
   4     against 1984 from the Cardiac Surgical Register, is it
   5     your impression, looking back on it now, that the 1980s
   6     were a time of considerable change and improvement for
   7     the better in terms of mortality throughout the sphere
   8     of cardiac surgical services in the United Kingdom?
   9   A. Paediatric cardiac surgery advanced a great deal in the
  10     1980s, almost in all the centres, but comparison with
  11     1984 was, because that must have been the most recent UK
  12     registered data we had, actually.
  13   Q. I am not criticising the comparison, because I think it
  14     must be right that that must be the latest figure
  15     available, but I am going to go on and ask about the
  16     conclusion drawn from it, because the sense, in 1987
  17     when this letter was written, would have been that
  18     throughout the rest of the United Kingdom, surgery was
  19     improving?
  20   A. Yes, sir.
  21   Q. And indeed, you yourself have said, "well, at centres
  22     like Great Ormond Street they were developing new
  23     techniques, we in Bristol were behind. They were
  24     improving; we were coming on behind, we were all moving,
  25     moving in the best direction for the patient." That was

   1     the general picture?
   2   A. Yes, sir.
   3   Q. So if you were comparing your results from 1984 to 1986,
   4     if they were to be the same as or at least as good as
   5     the United Kingdom results, you would expect on paper,
   6     after making due allowance for small numbers, the
   7     figure, the percentage, to be lower than that revealed
   8     by the United Kingdom statistics for 1984, would you
   9     not?
  10   A. I am sorry, I cannot get into your -- what you are
  11     really asking me.
  12   Q. If you are comparing a centre performing spot on the
  13     average for the United Kingdom, that centre, in 1986,
  14     should have a lower mortality than the average of the
  15     United Kingdom in 1984?
  16   A. Yes, but we are not getting 1986 data here, really.
  17   Q. You are getting Bristol data from 1984 to 1986?
  18   A. Yes, but again it is pooled, so we do not know exactly
  19     what was the 1986 data in this report. It is giving
  20     a pooled data, and I am sure it is because of the
  21     numbers, really, because we were doing such a small
  22     number, we could not get a meaningful answer. Supposing
  23     we are doing only 11 cases, one year you have two
  24     deaths, it is 20 per cent out of 10, or 1 death more
  25     could make it 30 per cent; one death less 10 per cent.

   1     It is such a dramatic change it looks, you know, on
   2     paper. So I cannot exactly say, and that is why,
   3     probably, it was pooled to give us some type of
   4     a definitive impression of what was happening.
   5   Q. It is very difficult when one is dealing with small
   6     numbers, is it not?
   7   A. Yes, sir.
   8   Q. If you take one operation, if only one is done and there
   9     happens to be a death in that operation, then the
  10     mortality rate on the crude figures is 100 per cent.
  11     But there is only one, and it may be the first of 100;
  12     the other 99 of which there is no mortality. So just
  13     taking a simple one operation does not tell you very
  14     much because of the low numbers. That is the point, is
  15     it not?
  16   A. That is the dilemma a surgeon faces almost all the time,
  17     yes.
  18   Q. And does that make it very difficult, then, to compare
  19     the figures for a unit doing as few cases as Bristol,
  20     with the national average such as you can find it to be
  21     from the register?
  22   A. I thought the UK average should be fair to compare it,
  23     because the UK average would have both. It would have
  24     centres doing a lot of more, and centres like us. So in
  25     a way, if you have an average, that should deal with

   1     best and the lowest, if you understand what I mean. So
   2     you can compare, if you are keeping pace with that, then
   3     probably, if you are not at the top, you are almost in
   4     the middle.
   5   Q. What I just want to take you back to is those words in
   6     the brackets. Did you draft this letter, or did you
   7     just sign it?
   8   A. I signed it, but --
   9   Q. Who drafted it? Do you remember?
  10   A. It must have been my senior colleagues. I was the
  11     junior most of that time.
  12   Q. Because if we look at the words which are "at least
  13     equal to those achieved by other units", am I right from
  14     the answers you have given me in thinking that whatever
  15     the statistical position was, that claim is an
  16     exaggeration in Bristol's favour, because what I think
  17     you are telling me is that the apparent -- the slightly
  18     higher mortality in Bristol might be explained by lower
  19     numbers, but you simply could not say because of the low
  20     numbers?
  21        What I am asking is how on that basis can one make
  22     it plain that it is at least equal?
  23   A. I feel, sir, I have already answered your question,
  24     really, because this line, if somebody read it, really
  25     says that we are on average, but at the same time we

   1     need to improve, we have scope to improve. It does not
   2     say exactly that we are at the top, but it really says
   3     that we are average. And I think when you are average,
   4     there is always scope to improve on it.
   5   Q. I think that Dr Silove -- Mr Stark would like to make
   6     a comment?
   7   MR STARK: I thought if I just can make a comment, because
   8     I agree with you and with Mr Dhasmana that some of these
   9     comparisons are obviously extremely difficult, but my
  10     own problem is when we are comparing data, say between
  11     Bristol and the Cardiac Register, the national averages,
  12     as you know, the statistical experts of the Inquiry
  13     considered all the data sources except Bristol to have
  14     certain problems.
  15        I have served on the Working Party of the College
  16     of Surgeons which collected data independently from the
  17     register, and I had an opportunity to discuss that with
  18     Dr Murray, who prepared the report on the Cardiac
  19     Register, and I hope I can recollect accurately for one
  20     year, and I believe it was 1988, so it is slightly
  21     outside what you are just discussing, but in that year,
  22     the register quoted the average in the country,
  23     mortality for open-heart procedure over 1 year being
  24     6.9 per cent, in 1988.
  25        Our Working Party had the figures independently

   1     collected. The best results were from Birmingham and
   2     GOS, which was 9 per cent and the other centres went
   3     from 9 per cent to 22 per cent, so there was no way that
   4     the national average was 6.9. I think this goes along
   5     with the statements, say, of the secretary of our
   6     society, Mr Keogh, that in general the Cardiac Register
   7     was very much under-reported.
   8        So that, for me, is a little bit of a problem when
   9     one compares this data. We take national averages as
  10     written in stone, and yet I think they are probably
  11     actually higher than what is stated.
  12   MR LANGSTAFF: I think the point which you are making is one
  13     which is drawn out in fact in the statistical reports,
  14     that there was or there is, for some units, a difference
  15     between that which they returned to the register and
  16     that which they gave to other sources.
  17   MR STARK: But if you have all the units well above the
  18     stated average, that obviously makes that average
  19     a little bit suspect.
  20   MR LANGSTAFF: But the problem, I suppose, would be for the
  21     unit itself looking for a national comparison, the only
  22     national comparison available to a unit would be the
  23     register, and that is why it was created, to give
  24     a national comparison. What I was exploring with
  25     Mr Dhasmana here, I think, was the claim in the text

   1     that the results for Bristol were at least as good as
   2     the results which, on paper, appear to be better,
   3     whether they were or not.
   4        So the only way one can make good the statement in
   5     the letter would be by a process of thinking around it
   6     and drawing in information from other sources, which is
   7     not obvious. I think you are agreeing with me on that.
   8   MR STARK: Exactly, yes.
   9   MR LANGSTAFF: Dr Silove?
  10   DR SILOVE: I was going to make a slightly different point.
  11     I think what Mr Dhasmana is trying to say is that
  12     perhaps what should have been in brackets there is,
  13      "which were not significantly different from other
  14     paediatric units".
  15   MR DHASMANA: That is right.
  16   DR SILOVE: I think if you look at the bare figures and
  17     analyse them statistically, he is probably right when he
  18     says that there is not a significant statistical
  19     difference. I think that this was a rather emotively
  20     written statement, perhaps, in the heat of the moment.
  21     You can see the great concern of the team in Bristol.
  22   MR LANGSTAFF: I am sorry to cut across you, Dr Silove. Let
  23     me just ask Mr Dhasmana this, before we have a break,
  24     because what you have touched on is the motive which
  25     goes behind the letter, which you may be able to comment

   1     on as one of the signatories to it.
   2        Is it right that because Bristol was put under
   3     pressure by comments from outside, that this letter was
   4     defensive and perhaps overstating the case for Bristol
   5     because it felt the need to defend itself?
   6   MR DHASMANA: I had a period of working in Cardiff for
   7     a period of my training. I have worked for one year and
   8     then as Senior Registrar for three months in Cardiff as
   9     part of my training. When I started there we had one
  10     cardiologist doing paediatric investigation and
  11     a surgeon who started, but somehow the programme --
  12     I was at a very junior level at that time, SHO, so
  13     I could not be very specific. The programme floundered.
  14        After that, when I went back there as a Senior
  15     Registrar, there was a feeling in Cardiff that they
  16     must -- that this is the only cardiac centre in the
  17     whole principality and if they had a fully-fledged adult
  18     cardiac centre, why should they not have a paediatric
  19     cardiac facility?
  20        I even applied for a job there in 1984/85, when
  21     they did advertise for a surgeon who could do mixed
  22     practise but I was unsuccessful, and the problem in
  23     a way was that there were too many cardiologists coming
  24     from different parts of the country running their clinic
  25     in Wales, and I felt they came out a bit more aggressive

   1     in 1986 in order to establish their unit. That is my
   2     personal feeling: to attack the nearest and closest to
   3     get their own service, really. And I feel that that was
   4     probably the emotive part behind all these things. We
   5     in Bristol always supported a move to Cardiff -- to
   6     facilitate their development of paediatric cardiac
   7     surgery, but at the same time, were anxious that we are
   8     so close by, there are not so many cases, we would have
   9     to support each other.
  10        But I feel the letter was a follow-up to what had
  11     happened before. This letter is addressed to the Royal
  12     College of Physicians, cardiologists, something happened
  13     before that. People really came up on television and
  14     things like that, and I think that was probably why this
  15     thing was put in emotive wording, but I am not
  16     sophisticated enough to put nice words like those,
  17     really; I am a bit crude.
  18   MR LANGSTAFF: Sir, unless there are further comments from
  19     my right, perhaps that would be an appropriate time for
  20     our first break?
  21   THE CHAIRMAN: Yes, thank you Mr Langstaff. Shall we say 15
  22     minutes, then, until 12.10?
  23   (11.55 am)
  24            (Adjourned until 12.10 pm)
  25   (12.10 pm)

   1   MR LANGSTAFF: I do not want to spend any more time on this
   2     letter, save for one thing: you said that at this time
   3     the feeling in Bristol was that it was not so good at
   4     the complex operations largely because you did not have
   5     enough of them; I think you were using words to that
   6     effect before the break?
   7   A. Sir, what I was really saying, that we have got scope to
   8     improve on that side really, you could not really
   9     analyse it in a manner as to deduce whether it was
  10     really bad or it is just because of number, as you have
  11     said.
  12   Q. When you yourself began in 1986, for those children who
  13     had the congenital condition of transposition of the
  14     great arteries with a VSD, would you have performed the
  15     Rastelli procedure?
  16   A. If it was indicated.
  17   Q. At some stage in 1988 you performed your first arterial
  18     switch operation on that class of patient, did you?
  19   A. Transposition of VSD, yes, I did.
  20   Q. Would you like to have a look, please, at what you said
  21     in respect of the starting up of a new operation in the
  22     GMC. It is GMCT 42/24, in the middle of the page. You
  23     say this:
  24        "The learning curve, people use this term without
  25     clear definition, nobody exactly knew what a learning

   1     curve was except for saying that whenever you start any
   2     new operation you are bound to have unfortunately high
   3     mortality and that is how it was known in the
   4     mid-1980s. No clear-cut detail of the learning curve,
   5     what to do and how to do it and how much time it takes
   6     was not known at the time except what people were
   7     mentioning when they were reporting on arterial switches
   8     and by the mid-1980s there were reports coming out that
   9     with mortality being say 30 to 35 per cent before, it
  10     was now coming down to under 20 per cent or something
  11     like that, that was understood to be, it is now getting
  12     over the learning curve."
  13        What you are talking about there, is it, is
  14     a surgeon or team having to come to grips with the new
  15     techniques that a new operation necessarily involves and
  16     improving with practice?
  17   A. I do not think any surgeon wants to be seen as in a way
  18     practising with his patients but that is the definition
  19     of "learning curve" known at that time.
  20   Q. Can I take you to something else that you said in the
  21     same context at the General Medical Council. We find it
  22     at GMCT 42/49, middle of the page. If we go overleaf,
  23     GMCT 42/50, at the top of the page, you are talking
  24     about the neonatal programme itself. You are saying:
  25        "Papers would come out with 4 of the first 10

   1     died and of the remaining 100, only 6 died. That is the
   2     type of thing they would put up now."
   3        Before you began your own series in 1988 of cases
   4     to operate by arterial switch on those children who had
   5     transposition with a VSD, you had looked into the
   6     literature, had you?
   7   A. Yes, sir.
   8   Q. What was your idea of the results that other centres
   9     were achieving using the arterial switch?
  10   A. I think that has probably been summarised in a statement
  11     like this.
  12   Q. We have both the non-neonates where you began and later
  13     on you went on to the neonatal programme in 1992, did
  14     you not?
  15   A. Yes.
  16   Q. You thought, did you, before you began that other
  17     centres performing the operation started with
  18     unfortunately higher mortality and then as they became
  19     more experienced in doing the operation their mortality
  20     levels reduced?
  21   A. I am afraid that was known in the mid-1980s, yes.
  22   Q. In 1988 when you began, there had, had there, been
  23     discussions between yourself and other colleagues about
  24     the decision to begin such an operation?
  25   A. Can I go into the background a bit?

   1   Q. Yes, please.
   2   A. Transposition of great arteries, I think my thinking
   3     changed when I spent a year in Alabama because until
   4     that time probably my knowledge of paediatric cardiac
   5     surgery was a bit superficial and I read more about it
   6     and I noticed that almost all other congenital heart
   7     defects were repaired and called cured, but the
   8     transposition of the great arteries in my mind was being
   9     palliated in almost all centres all over the world at
  10     that time.
  11        There were some centres which were starting to
  12     move in different directions and the patient was left
  13     with what I thought was a physiological operation, not
  14     an anatomical correction. You were accepting one
  15     mistake a child is born with by in my mind creating
  16     another error, you know, that is now an entry point and
  17     leaving the child with a non-physiological ventricle to
  18     support the body for the rest of life.
  19        When I did more reading there, especially in
  20     Alabama and I had an opportunity to go around other
  21     places, I noticed there was a disquiet about this
  22     operation. And of course before that, I mean
  23     transposition of great arteries is one condition. You
  24     could really say if you know the history of this you
  25     probably know the development of cardiac surgery.

   1        So in a way they started with one operation like
   2     the Mustard operation where a lot of foreign materials
   3     were used inside and children had problems because the
   4     heart would grow and the materials would not grow.
   5        Then Professor Senning from North European Centre,
   6     he came out with this where he used the patient's own
   7     material, so this was growing, so of course we had
   8     improved from the previous baffle operation of Mustard
   9     to a Senning operation using what you call a rotation of
  10     flap inside.
  11        Of course results were better but still it was not
  12     anatomical correction and those surgeons who were trying
  13     to do it had such a habitually high mortality at that
  14     time that somehow there was reluctance for cardiologists
  15     and cardiac surgeons at that time to accept it until
  16     papers started coming out that Senning and Mustard over
  17     a few years time or maybe later could run into further
  18     trouble and though this operation does carry a high risk
  19     in the beginning, it probably carries a better long-term
  20     course.
  21        That, in a way at that time in the University of
  22     Alabama they were not undertaking this operation, but
  23     this was being discussed in the tutorial and people were
  24     even seeing films of this operation being carried out by
  25     somebody else but of course Dr Kirklin, he liked to

   1     evaluate everything before really taking it on and that
   2     is the process he was in.
   3        Returning from Alabama, I got more interested in
   4     paediatric cardiac surgery and I was lucky to get an
   5     opportunity to work in Great Ormond Street Hospital and
   6     there I was exposed to arterial switch being performed
   7     and that was being performed in these type of patients
   8     who had transposition of great arteries with VSD, so in
   9     a way a different group than simple transposition and it
  10     was well-known in the circle that this is the group of
  11     patients who were -- operative repair, even with the
  12     conventional method at that time, maybe Senning with
  13     closure of VSD or Rastelli if there is some problem with
  14     pulmonary stenosis or something like that or further
  15     modification with conduit, they carry very high
  16     mortality.
  17        So that is why this was taken into this group of
  18     patients which could justify the high mortality expected
  19     at that time and Dr Quaegebeur at that time, I think he
  20     did a thesis and researched a bit, now Professor Yacoub
  21     at that time in Harefield, and Professor Yacoub would
  22     double up in this surgery, arterial switch, so he had
  23     experience and now he started this programme on return
  24     from England to Holland in 1977 and for the first 5, 6
  25     years he did it only in that group of patients who had

   1     VSD.
   2        When I was going around in various meetings,
   3     conferences, I was hearing, yes, arterial switch is
   4     a better operation, but it is better to start in this
   5     group of patients where mortality can justify doing it.
   6     Once you have learned the art of the surgery then it
   7     could be changed to a proper or simple transposition.
   8     So that was the thinking at the back of my mind. But
   9     I have been thinking about it since 1980 when I returned
  10     from America.
  11   Q. Against that background you were keen, were you, to
  12     develop the arterial switch operation in Bristol?
  13   A. Well, I told for any paediatric cardiac surgical unit
  14     this should be the operation of choice because that was
  15     the proper operation. As the name says, anatomical
  16     correction, yes, I was.
  17   Q. The cardiologists were not so keen, were they, at first?
  18   A. You are quite right.
  19   Q. How long did it take to persuade them?
  20   A. I was talking about it in the paediatric cardiological
  21     meetings every time a case where transposition would be
  22     referred, so in a way that was going on right from the
  23     very beginning when I started, but of course they were
  24     doing their own research and when they started getting
  25     information from their colleagues elsewhere that this

   1     operation was now being accepted, then they came round
   2     to my views by 1988.
   3   Q. How long, roughly, did it take you to persuade the
   4     cardiologists that they should agree that you should do
   5     an arterial switch operation in this group?
   6   A. I would say two years now, 1986/87.
   7   Q. You begin in 1986 as a consultant saying "This is the
   8     operation of choice" and it takes two years to persuade
   9     your colleagues that, "Yes, it is", and that they should
  10     agree to join with you in having that operation on their
  11     patients?
  12   A. I was also seeing their viewpoint which is very
  13     difficult to challenge really because here I was,
  14     a newly appointed surgeon who they had known for 5 years
  15     before as a Senior Registrar in their unit really saying
  16     "We should move forward in this direction", and they
  17     have this Senning operation going on very nicely with
  18     very good mortality. I think we had very good figures
  19     really, about 5 to 10 per cent, and why to change?
  20        Until that time, I think until the mid-1980s, the
  21     long-term outlook of Senning was not really universally
  22     known to be bad. I am not sure even now somebody would
  23     say, though maybe figures may be coming out now. So
  24     therefore really I mean I was putting my viewpoint but
  25     at the same time I could see why they were not so keen

   1     to change it and I think that is a good thing really.
   2   Q. What was Mr Wisheart's view?
   3   A. I do not think I can pinpoint a single person. At that
   4     time I felt that the cardiologists were the main people
   5     really dealing with it but I do not think Mr Wisheart
   6     had any definite views in 1986 or maybe until mid-1987
   7     about this operation.
   8   Q. If he had said "No, I do not think we ought to do that
   9     operation", is that do you think the decision the unit
  10     would have reached?
  11   A. I do not think I should speculate on something which
  12     has happened 10/12 years ago.
  13   Q. I am asking you really for your best view because you
  14     know the people, you know what they were like, you know
  15     how they behaved towards each other. If Mr Wisheart had
  16     wished not to do it, do you think it would have been
  17     done?
  18   A. I would have felt, you know, that I would have still
  19     stood at my corner really.
  20   Q. What about Mr Keen?
  21   A. Mr Keen was not doing any paediatric cardiac surgery, he
  22     had left in 1976 paediatric cardiac surgery.
  23   Q. He was still in the unit, and so he would have had no
  24     voice in a decision like this?
  25   A. He had no voice at the Children's Hospital because all

   1     these meetings were taking place at the Children's
   2     Hospital.
   3   Q. In 1988 when you came to do your first operation, you
   4     had never done an arterial switch operation before
   5     yourself, had you?
   6   A. No.
   7   Q. When was the last such operation at which you had
   8     assisted another surgeon?
   9   A. About 5 years ago, 5 years before 1988.
  10   Q. You referred in the GMC in the two extracts I have
  11     taken you to and elsewhere to a "learning curve". Did
  12     that mean you anticipated that out of the first few
  13     patients who came to you for corrective surgery of this
  14     sort a greater proportion were likely to die than would
  15     be the case later on when you had done a number of such
  16     operations?
  17   A. That is why I chose this particular pathology,
  18     transposition with VSD where the mortality was high
  19     whatever you did. Yes, I did anticipate that whenever
  20     you are starting a new operation, mortality would be
  21     higher than what you could achieve a few years later.
  22   Q. You were aware of this because you knew that the results
  23     in experienced hands were better than when those same
  24     hands had been inexperienced. Surgeons elsewhere doing
  25     it found their results had improved over a short period

   1     of time, over the learning curve, if you like?
   2   A. I understand now what you are saying. Yes, sir.
   3   Q. Where else in the United Kingdom were such operations
   4     being performed in 1988, as you now recall it?
   5   A. In 1988 not much was known about other centres outside
   6     three major centres, if you like, GOS, Birmingham,
   7     Liverpool, I am not sure whether they were doing it or
   8     not at that time. A colleague of mine was a surgeon at
   9     that time there but I am not sure whether she was doing
  10     it and I had come to know because Brompton had either
  11     just started or they were going on the same way in the
  12     transposition with VSD group, and that is the limit of
  13     my knowledge at that time of other centres in this
  14     country.
  15   Q. What was your understanding of whether the surgeons at
  16     Great Ormond Street, Birmingham -- you say you did not
  17     know very much about Liverpool and the Brompton --
  18     whether they had passed their own personal learning
  19     curves?
  20   A. Forgive me, but I did not know anything about it.
  21   Q. If they had been doing it for a while they must
  22     presumably have got beyond the learning curve?
  23   A. I do not think any of these centres in 1987/1988
  24     reported any of their results really. What you were
  25     hearing is what was being said in the cardiac courses,

   1     you know when you attended -- I mean on alternate years
   2     I attended congenital courses at the GOS or you went to
   3     Society meetings and things like that so what you would
   4     be hearing is what surgeons are talking to each other
   5     about, but there was no real figure being really
   6     publicised at that time.
   7   MR LANGSTAFF: Mr Stark, what was happening.
   8   MR STARK: I wonder if I can help you a little on this
   9     subject. I think the question of learning curves from
  10     what we already heard in this chamber before, it is
  11     a very difficult one and it goes back to the basics of
  12     training of congenital heart surgeons. We did not have
  13     data before 1997 but for the past two years, 1997, 1998
  14     and 1999, I have looked at the type of operations that
  15     the Great Ormond Street surgeons felt comfortable to let
  16     the Senior Registrar do under supervision. I just noted
  17     that the Senior Registrars did not do switch, did not do
  18     conduit, did not do Ross's (?) operation, truncus or
  19     total cavopulmonary connection; they may have done part
  20     of this operation, but not the whole thing.
  21        I think that is one aspect to consider. That it
  22     has been accepted in the past and it is still accepted
  23     that the newly appointed consultant so to speak has to
  24     learn "on the job" which is a difficult concept, but
  25     this is the fact.

   1        If I may I will quote just very briefly from the
   2     papers that my colleague, Dr Bull is preparing for
   3     publication, I think it will be available shortly, which
   4     I think would be of interest to the Panel.
   5        She analysed the three periods of treatment of
   6     transposition at Great Ormond Street. The first period
   7     was when we were doing Sennings and that was the period
   8     until 1985, because we too were quite late in adopting
   9     the new operation although in our centre it was more
  10     cardiologists who were pushing the surgeons so it was
  11     slightly reversed.
  12        Then the transition period from 1986 to 1992 and
  13     then finally entirely the switch period from 1993
  14     onwards. Dr Bull noticed one important thing: if you
  15     look at your results which until recently we did not
  16     know, we quoted always our results of Senning were
  17     excellent, about 2 per cent mortality but Dr Bull
  18     introduced a new concept, intention to treat and if we
  19     had an intention to treat this Senning, that we have to
  20     take into account the deaths that occurred before the
  21     operation, and the same with the switch.
  22        Taking this concept, our risk for transposition
  23     operation in the Senning area was not 2 per cent but it
  24     was actually 16 per cent and then during the transition
  25     due to the learning curve it actually went up to

   1     35 per cent and only after we accumulated more
   2     experience with switches it eventually came to
   3     5 per cent.
   4        This is our old figures, but if one takes some
   5     special cases like Mr Dhasmana mentioned, transposition
   6     and VSD, in 1997/98, our results for this group of
   7     patients, they are pretty good I think, 12 per cent, but
   8     last year because of the small numbers it jumped to
   9     29 per cent. So even at 1998/99 this is the mortality
  10     you can get.
  11        Again it is small numbers, it may be just one
  12     death that throws the percentages, so one has to view it
  13     with some caution.
  14   Q. May I ask you what your perception is of the number of
  15     centres in the United Kingdom doing the switch operation
  16     on the non-neonates, so the switch for transposition
  17     plus VSD, in 1988; were most doing it or not?
  18   MR STARK: I think I have to agree with Mr Dhasmana, we did
  19     not know. Actually we do not know today because the
  20     data are not available. If you ask me today of the 11
  21     centres in the UK I would say "Yes, Great Ormond Street
  22     and Birmingham". Because of my personal contacts I also
  23     know that it is done in Southampton and Brompton but
  24     I would not know any figures about other centres I am
  25     afraid.

   1   Q. Was there a feeling -- you can tell me, Mr Dhasmana --
   2     that this was an operation which other centres were
   3     doing, that there were good reasons for it as you have
   4     explained and this was part of the reasoning for Bristol
   5     taking on the operation?
   6   MR DHASMANA: In 1988 when I started in this programme I had
   7     a feeling that I was a bit late really in starting but
   8     I did not know exactly how they were doing except in
   9     talking to surgeons while attending these meetings.
  10   Q. The question then arises, if you were right in that,
  11     a bit late in beginning this operation, you were
  12     anticipating that in the hands of the Bristol unit, not
  13     only your hands but also Mr Wisheart who began the
  14     switch as well in this class of patient but the
  15     cardiologists, the nurses, the intensive care, the whole
  16     team, that in the hands of the team the chances were
  17     that children when you began the programme would die who
  18     would not die once the programme had been established
  19     and going for a period of time; is that right?
  20   A. The way I was seeing it in 1988 I can describe to you
  21     my feeling, at that time I did not think that both
  22     myself and Mr Wisheart would be part of it. I was
  23     thinking of myself in a way taking, you could say,
  24     a leading role in this and the rest of the team as I saw
  25     it I did not think would be any different because we

   1     were already dealing with that population, it is the
   2     same patient, transposition with VSD who --
   3   Q. Just to cut across you for a moment, what I was asking
   4     was whether it was the view of those concerned in the
   5     unit that when you first started children would probably
   6     die who, as the unit became more experienced in the
   7     operation, would probably with the same condition
   8     survive?
   9   A. I do not think it was expressed in those terms at that
  10     time for the unit really. Being self-critical,
  11     I probably was talking like that that probably that
  12     would happen when you start a new operation, but I was
  13     thinking of myself in a way. I at that time did not
  14     believe that the rest of the team, rightly or wrongly,
  15     would make much difference because this is the same
  16     group of patients they are dealing -- nurses are dealing
  17     with the same patients, cardiology staff would be
  18     investigating the same patients, similar patients, and
  19     the Senning with VSD repair or Rastelli operation is
  20     equally demanding in the operating theatre so nurses are
  21     already exposed to that. Coronary artery surgery is
  22     already being performed in the same theatre, nurses also
  23     know about the coronary artery techniques.
  24        So I felt, maybe I am wrong now, but that is what
  25     I felt at that time, that is most important, whether

   1     I am prepared and I felt I was prepared. The rest of
   2     the team I felt, you know, they probably do not need
   3     major retraining. But, yes, we had already gone on 2,
   4     3 years with an increased number.
   5        In 1988 the whole cardiac unit was remodelled.
   6     ITU space was enlarged, there were more anaesthetists
   7     now appointed. So I thought the unit was expanding or
   8     had expanded. It was my own preparedness I was looking
   9     at at that time.
  10   Q. If you had thought about it, you might have seen perhaps
  11     that because of the consequences of the learning curve
  12     as you described it to the GMC, that someone who had
  13     experience in the operation might well succeed in
  14     a difficult condition in the case of a patient who in
  15     your hands at the start might not survive the operation
  16     because of the underlying problems that the child
  17     suffered from and because of the lack of experience of
  18     the unit; did you think of that and express that at all?
  19   A. Again we had that problem. We are talking in 1999 about
  20     the problem as was being seen in 1986 to 1988. I have
  21     already mentioned in my statement on training and
  22     retraining which Mr Stark has also just mentioned, when
  23     you start as a consultant paediatric cardiac surgeon,
  24     a lot of operations you are doing for the first time.
  25        So you could really take that analogy to all those

   1     operations when you are starting, you know right in the
   2     beginning. You know if somebody else could have
   3     operated on, I wish that was possible and I wished
   4     nobody -- I mean I feel now -- I wish nobody has to
   5     operate on somebody for the first time but unfortunately
   6     that was the practice at that time and I was just
   7     keeping up with the practice.
   8   Q. Does it follow that, if you had thought about it, you
   9     might have said to yourself, "There is Mr Sethia in
  10     Birmingham [or whoever] by 1988; that there are
  11     experienced surgeons elsewhere in the country dealing
  12     with this sort of operation; that if I take the first
  13     10 cases that come to me and if they are operated on by
  14     him or by somebody else then more of those children will
  15     live than if I carry out the operation myself."
  16        If you had thought about that, one of the
  17     consequences nowadays might be to transfer the child to
  18     another centre so that the operation can take place for
  19     the benefit of the child in that other centre, might it
  20     not?
  21   A. That is the case in the 1990s, yes, but that was not the
  22     case in 1988.
  23   Q. It is a consequence of what you are saying that
  24     a deliberate decision was taken within the unit by the
  25     unit as a whole to carry out or begin a series of

   1     operations which would lead to the death of children in
   2     Bristol who would not necessarily die elsewhere; that is
   3     the consequence of the decision that was taken, is it
   4     not?
   5   A. Whenever you are put on any complex case anywhere there
   6     is always that possibility that the child could survive
   7     elsewhere, how do you know whether he is going to
   8     survive here or there unless you have got very clear
   9     guidelines? Unfortunately at that time there were no
  10     clear guidelines so almost every surgeon was really
  11     doing the best available practice at that time and this
  12     is the reason you have a whole team to decide on.
  13   Q. Can I break it down in stages, Mr Dhasmana, and approach
  14     it in that way? I think, but I would be grateful for
  15     your confirmation, that you are agreeing with me: that
  16     the effect of beginning a new operation for the first
  17     time, the switch is simply an example, in Bristol would
  18     be a deliberate decision which would inevitably lead to
  19     a greater number of children dying in Bristol than would
  20     die if they were operated on elsewhere in more
  21     experienced hands. That is the starting point. We will
  22     go on in a moment and look at the reasons why that
  23     decision was taken and why it fitted with the practice
  24     of the time. That I think is what you are agreeing to
  25     as a starting point, is it not?

   1   A. Forgive me, sir, I think you have a retrospective scope
   2     here really --
   3   Q. That may be so. Can we look at the reasons for a moment
   4     but can we agree the starting point and then look at
   5     whether that is purely looking at it through 1999 eyes?
   6   A. I think that is what, forgive me, you are using because
   7     at that time I could really narrate what was happening
   8     in 1988 and I insist on.
   9        Of course a lot of centres, I do not know how many
  10     centres really, sent their patients elsewhere or asked
  11     anybody else really to come and help with the new
  12     operation in the 1980s, I do not know. Maybe they are
  13     lucky or whatever is there, results improved and nobody
  14     knows about it. You have all the brilliant results of
  15     first class operations. Very few people really would
  16     mention, you know, 4 of the first 10 died like that.
  17     A lot of centres now report "We have got a brilliant
  18     result of this arterial switch starting from the period
  19     say 1984, 1985 to 1992 or 1993. They are not saying
  20     when they started. So we really do not know exactly
  21     what was happening at that time.
  22        I do know the GOS had a connection with a lot of
  23     centres and people were visiting. Yes, their surgeons
  24     used to visit each other and various things happened,
  25     but I do not know whether exactly that is true even in

   1     Birmingham. Mr Brawn started probably in 1988 or 1989
   2     in Birmingham. I do not know what happened there
   3     before --
   4   Q. He started October 1988?
   5   A. Yes, so really at that time I would say, except for
   6     centres in London, probably all surgeons, that is my
   7     feeling, they were experienced surgeons and they were
   8     doing things they felt they could really do and start
   9     with the new operation, and they did, and some of them
  10     not even assisted. At least here I had assisted in this
  11     operation in another centre.
  12   Q. Mr Dhasmana, do not please misunderstand the questions.
  13   A. I am sorry.
  14   Q. What I am seeking to explore with you is first of all
  15     the nature of the decision that was taken and secondly
  16     why in 1988 a decision like that was taken, how it could
  17     be taken and the circumstances surrounding it.
  18        Can I come back to the question which you have not
  19     yet I think agreed with me clearly, that is: that the
  20     consequence in the 1980s beginning any new operation in
  21     any one centre, is to expose the children undergoing
  22     that operation to a risk of mortality which would not be
  23     present in more experienced hands elsewhere doing the
  24     same operation?
  25   A. I think it is very difficult for a surgeon to really

   1     accept that he is exposing --
   2   THE CHAIRMAN: Mr Langstaff, as I understand
   3     Mr Dhasmana's answer, the premise in your question is
   4     one which I do not think Mr Dhasmana is able to grant,
   5     namely, that there were to his knowledge more
   6     experienced centres or he knew of the nature of that
   7     experience. I think that as I understand it is the
   8     answer. Therefore he cannot answer the question as you
   9     put it.
  10   A. I am grateful to you, sir.
  11   THE CHAIRMAN: I interject, I take no view, I am simply
  12     seeking to interpret what I hear and prevent you perhaps
  13     asking the question three more times to get the same
  14     answer three more times.
  15   MR LANGSTAFF: Thank you, sir.
  16        I had asked you what your perception was of
  17     whether Bristol were ahead or behind in developing this
  18     operation and your view, although you were not sure
  19     where else was performing it, was a number of other
  20     centres were and others you did not know about. But you
  21     made no inquiries I take it in 1988 as to who else was
  22     doing the operation?
  23   A. I made personal inquiries.
  24   Q. Of who?
  25   A. Surgeons and colleagues I am meeting in the meetings.

   1     So in a way you could really say almost all of them, you
   2     know, especially of my own, if you say age group or peer
   3     group.
   4   Q. When you first came to do the first operation of the
   5     arterial switch type the technique which you adopted,
   6     where did you derive that from?
   7   A. Mainly from Great Ormond Street but that was the same
   8     technique as you would be seeing in the books and by
   9     that time books had started really printing it out in
  10     the same way and also almost all publications at that
  11     time would come with techniques how to really do -- this
  12     was also a similar technique with Mr [now
  13     Professor] Yacoub, published in 1980. A similar
  14     technique was by Dr Jatene from Brazil in 1977/1978. So
  15     technique was there, I just took it on. It is not a new
  16     technique, I did not use any new technique.
  17   Q. Did the operation in a number of patients at any rate
  18     replace the Rastelli operation you had been doing?
  19   A. No. The Rastelli operation is a little different, not
  20     all patients with transposition of VSD would necessarily
  21     have the Rastelli operation. The Rastelli operation is
  22     when you are making an intraventricular tunnel, but in
  23     transposition VSD you could also do Senning and close
  24     the VSD. So it is not replacing Rastelli, it is
  25     replacing both of them.

   1   Q. The Rastelli operation you had not, I think, had a very
   2     great success with in Bristol, had you?
   3   A. You are quite right we have not done that many.
   4   Q. I think the first 5 died. Between 1986 and 1988 my note
   5     is that you did 7 operations of which --
   6   A. Are you talking of my surgeon's log?
   7   Q. Your surgeon's log?
   8   A. I cannot comment on it unless I have really seen it.
   9     One thing I would admit: that I did not do that many
  10     Rastelli operations.
  11   Q. Again, does the same process apply: that one would need
  12     to do a number of such operations to develop an
  13     expertise and technique in that operation?
  14   A. Very few surgeons in the world would have a long series
  15     of Rastelli operations, it is not one of the very common
  16     operations.
  17   MR STARK: Just a brief comment, switch did not replace
  18     Rastelli under any circumstances because the Rastelli
  19     operation is performed for the combination when you have
  20     transposition of ventricular septal defect and severe
  21     pulmonary stenosis, so it is an entirely different
  22     category.
  23        I want to make one more comment, if I may: this
  24     principle or this notion that if the surgeon does not
  25     operate on certain patients he has not done before, they

   1     would survive better in somebody else's hands. It is
   2     a very old problem and I personally have had to struggle
   3     with this on many occasions. For example, in the 1980s
   4     Dr Ebert from San Francisco published outstanding
   5     results of truncus operations which at that time there
   6     was something like 5 per cent and nobody in the world
   7     could really replicate it. Even today our results for
   8     truncus are in the region of 30 per cent mortality. So
   9     if we wanted to take this principle we would have to
  10     send all patients to him.
  11        Hypoplastic left heart, today every surgeon in the
  12     UK who operates on hypoplastic left heart should really
  13     send his patients to Michigan to Dr Bovey who has much
  14     better results than, again, anybody in this country.
  15        So you struggle with this. You know you are not
  16     happy to subject your patients to higher risk, but there
  17     are certain circumstances that obviously you cannot send
  18     all the patients to San Francisco, to Michigan and even
  19     in this country to a lesser extent it applies.
  20   Q. Part of what I was exploring with Mr Dhasmana was the
  21     various news behind and around the introduction of this
  22     particular switch programme in Bristol. I think I was
  23     going to link it with your own view as to the numbers of
  24     operations that were occurring in Bristol, which was
  25     small as you have already accepted?

   1   A. I agree, sir.
   2   Q. The chances, I suspect, would be that you would not
   3     anticipate, when you began the switch operation, would
   4     you, doing very many such operations over the next 2, 3,
   5     4 years?
   6   A. In transposition VSD group that is correct. But if that
   7     would have included simple transposition at the same
   8     time the number would have been bigger than what I have
   9     done.
  10   Q. If you anticipated that there would not be a very great
  11     number of operations, the opportunities to learn and
  12     develop would necessarily be compromised, would they
  13     not?
  14   A. Well I was not to know at that time because there was no
  15     type of definite time limit to the learning curve or
  16     whatever it was termed. Some people were picking it up
  17     very quickly, other surgeons were taking longer, we did
  18     not know how many you have to really do and my main aim
  19     was to really transfer this technique to all patients
  20     with transposition of great arteries and you could not
  21     transfer this one to all patients if you have not really
  22     so-called, you know, established the technique in this
  23     group of the patients because this is basically the same
  24     pathology, transposition, but with added problems and
  25     because of added problems they had a high mortality with

   1     other operations.
   2   Q. When you began you told us that you had asked other
   3     surgeons whom you had met about the operation. Did you
   4     take any steps to compare the way that Bristol was
   5     performing in the switch operation when you began it
   6     with the way that other centres in the UK were
   7     performing?
   8   A. You can not get data about the switch operation even
   9     now.
  10   Q. Not even by asking colleagues in other centres?
  11   A. Well unless you get something in writing I do not think
  12     you can really be pretty certain that you are getting an
  13     exact figure because the UK Register does not -- I do
  14     not know if it has changed now -- does not really put
  15     these conditions as per operation, it puts the
  16     transposition of great arteries and there is a lot of
  17     guesswork going on whether at that time they had switch
  18     or Senning.
  19        So in a way if you looked in the UK Cardiac
  20     Register you could not really say that your switch
  21     result was any inferior or at par with any other centre
  22     in the country.
  23   Q. You no doubt could ask the surgeon but what you are
  24     saying is you would not necessarily trust what a surgeon
  25     elsewhere said because he would talk up his results, he

   1     would claim more for himself than he was doing; is that
   2     the point?
   3   A. It is the human nature.
   4   Q. In developing or doing that operation you were
   5     performing that type of operation in Bristol for the
   6     first time. Other operations, let us take the
   7     hypoplastic left ventricle for instance: if a child
   8     presented in 1988 with such a condition, would they be
   9     operated on anywhere in the UK at that time?
  10   A. I do not think I can answer that because I do not know.
  11     Hypoplastic left heart at that time would in my mind, if
  12     I remember it correctly, be considered an inoperable
  13     condition.
  14   Q. When it became operable Bristol never did it, that
  15     particular operation?
  16   A. No.
  17   Q. Again perhaps if I can ask roughly: when was it that as
  18     you recollect it the hypoplastic left ventricle, left
  19     heart became operable in this country, roughly?
  20   A. I think Mr Stark has just mentioned this. Dr Bovey's
  21     paper and Dr Bovey's effort in this field which really
  22     has regenerated interest into hypoplastic left heart, my
  23     feeling is that somewhere in the 90s -- it could be mid
  24     1992 down -- a few centres, and I feel it was probably
  25     Birmingham which really took the leading role --

   1   Q. Can I ask you to pause there for a moment? Is that
   2     about right, as you recollect it?
   3   DR SILOVE: It is very interesting listening to
   4     Mr Dhasmana. Time plays very strange tricks with the
   5     memory, does it not? I think the hypoplastic left heart
   6     syndrome, Norwood operation started in Birmingham,
   7     I think the first one was done around 1992 or 1993 but
   8     I cannot really remember for sure.
   9   MR STARK: I think what I already mentioned last time here,
  10     we did not feel that the Norwood operation was really
  11     a good operation for patients because it was a series of
  12     about three operations and at the end one finished only
  13     with palliation, so we decided at Great Ormond Street to
  14     follow the Lomalinda in the United States' approach of
  15     transplantation. Then we realised in about a year or 18
  16     months we did not get a single suitable donor so we had
  17     to abandon this policy and then go in the way of the
  18     Norwood operation as the others.
  19   Q. When was that?
  20   MR STARK: I think it was about 92/93, but I would agree
  21     with Mr Silove I am afraid I do not want to put my head
  22     on the scaffold for it.
  23   Q. By 1992/1993, probably about that time elsewhere in the
  24     United Kingdom that such an operation was being done, it
  25     was not being done in Bristol and children with such

   1     a condition would be transferred, would they, to
   2     Birmingham or Great Ormond Street or to whoever was
   3     doing the operation?
   4   A. I am sure the cardiologists can answer that better,
   5     I was not asked. I have not been asked to see any
   6     patient with hypoplastic left heart, so there must have
   7     been some policy decision by a cardiologist.
   8   Q. Again although there was talk at one stage of possibly
   9     beginning transplantation in Bristol, any child who
  10     needed a transplant would not be dealt with in Bristol
  11     but would be transferred to a centre?
  12   A. That was purely adult, purely adult.
  13   Q. Any child needing a transplant would have the transplant
  14     done, what, at Harefield or --
  15   A. Harefield or the GOS and the Cambridge group, they
  16     combined at that time, in the beginning I think they
  17     were doing it in Papworth at that time, but later moved
  18     to the GOS when they had their own new set-up.
  19   Q. There were some techniques and some conditions that were
  20     regarded by the profession in the late 1980s and early
  21     1990s as requiring operation elsewhere?
  22   A. That is correct.
  23   Q. As you recollect it, what was the basis within the
  24     profession for saying "elsewhere can do it, we should
  25     not"?

   1   A. One, I think you know almost every cardiac surgeon --
   2     paediatric cardiac surgeon appreciated that you cannot
   3     treat everything. Hypoplastic left heart was in that
   4     category. If I am not mistaken, I think in the 1970s or
   5     early 1980s, termination was being advised if
   6     a diagnosis -- foetal diagnosis was certain about this
   7     condition.
   8        So in a way it was thought that probably there
   9     will not be enough numbers in any particular centre to
  10     double the facility to repair this condition which has
  11     more than one operation to correct or palliate the
  12     patient and therefore you will not get any satisfactory
  13     result to make any satisfactory conclusion about the
  14     operation. So this was one.
  15        The second was heart transplantation. There was
  16     a problem with a donor and also the number of patients
  17     per unit to really do this service and of course this
  18     was a very expensive service, transplantation.
  19        Third, I think we were going for tertiary
  20     referrals, when somebody was requiring or had multiple
  21     problems and we felt that probably the operation we were
  22     suggesting would carry very high mortality,
  23     cardiologists felt that they could probably get it or
  24     a second opinion at least from some other centre and
  25     centres like, you know probably at that time -- we are

   1     talking of mid-1980s and late 80s -- GOS, Brompton and
   2     Harefield were taken as a reference centre for us
   3     really. I am not sure whether I can add any more to
   4     that list.
   5   Q. I think you have mentioned facilities, numbers of
   6     operations and the third point you were making was by
   7     reference to tertiary referrals; expertise I think lies
   8     at the back of that. For three reasons: a lack of local
   9     facilities, a lack of numbers and possibly greater
  10     expertise elsewhere, some patients would be referred for
  11     particular conditions.
  12        Why did those reasons as you see it looking back
  13     on it, not apply to an operation such as the arterial
  14     switch when you look at the facilities and the numbers
  15     and the expertise that was available in Bristol in 1988?
  16   A. To answer that question one has to look at two things:
  17     one, the pathology itself. The pathology is
  18     transposition of great arteries which is not that rare
  19     as a hypoplastic left heart. I think Bristol probably
  20     were being served about 20, maybe -- I am just guessing
  21     it or approximating it -- about 20 cases a year with
  22     transposition of great arteries were referred to the
  23     Bristol paediatric cardiac unit, so it is a good number
  24     really.
  25        Second, arterial switch was now being established

   1     so you cannot have a cardiac service really and not deal
   2     with a condition which is not rare in the future. That
   3     is why really we had decided to develop the arterial
   4     switch programme at Bristol.
   5   Q. Following on from the second of those points that you
   6     make: it is arguing that the presence of a unit seeing
   7     itself as a unit meant that the unit had to do the full
   8     range of operations you would expect an ordinary unit to
   9     do; is that how I should understand your answer?
  10   A. I think you are correct, sir.
  11   Q. If you like the self-image of the unit as holding itself
  12     out as a paediatric cardiac centre itself created the
  13     necessity to do operations, some of which were quite
  14     complex but which you would expect that sort of centre
  15     to do?
  16   A. I felt it the duty of every unit to move forward in that
  17     direction with the means they have, yes.
  18   Q. It is a difficult question and it is one which others
  19     too will have to answer and some have tried: is that
  20     perhaps putting the idea of the unit as more important
  21     than the interests of the individual patient coming to
  22     the unit or not?
  23   A. It should not be like that because no surgeon would
  24     really leave the interests of the patient out in
  25     consideration of management of the patient under his

   1     care. That is most important, patient's own care. Of
   2     course you have to also develop the unit, it does come
   3     in the picture and the development of the unit does
   4     come, but patient's safety, no, you cannot compromise
   5     with that.
   6   Q. So you have a mixed approach: one is the development of
   7     the unit, the other is the benefit of the patient when
   8     you are considering operations and expanding the scope
   9     of operations. Obviously you want to treat people
  10     successfully who present with a condition?
  11   A. I think you have summarised it well.
  12   Q. So far as Bristol was concerned, you were a Registrar in
  13     Bristol, were you, in 1984?
  14   A. I was Senior Registrar.
  15   Q. That was when Bristol was first designated as
  16     a paediatric cardiac surgical centre dealing with the
  17     under 1s?
  18   A. I came to know when I returned from GOS really that
  19     Bristol has been designated now as a supra regional
  20     centre. So I was not here at that time one year I was
  21      -- for one year I was at Great Ormond Street Hospital.
  22     When I returned I was told that Bristol is -- either
  23     firm consideration or they got it changed, I cannot be
  24     certain of that.
  25   Q. Could Bristol or could any unit really be a paediatric

   1     cardiac surgical unit if it did not do the under 1
   2     operations, deal with that age group?
   3   A. I did not follow your question, I am sorry.
   4   Q. You are talking about the need to do certain operations
   5     because there was a unit, that is what units do, they do
   6     that sort of operation. Does the same reasoning apply
   7     to a cardiac surgical unit, could it do you think do any
   8     children's work if it did not do all children's work
   9     including the under 1s?
  10   A. You are asking about 1983 or you are asking about what
  11     concept now?
  12   Q. In the 80s?
  13   A. In the 80s for a supra regional centre I would believe
  14     that it should be able to deal with the problem,
  15     children faced with congenital heart defect, and come to
  16     you at that time and it is comparatively common.
  17   Q. Can I put the question a different way: if Bristol had
  18     not become a designated centre dealing with the neonates
  19     and infants in 1984, if it had not become such a centre
  20     would it realistically have done any paediatric work at
  21     all to speak of?
  22   A. It probably would not have appointed me.
  23   Q. Looking at the number of operations which we saw if you
  24     remember in the under 1 age group in the chart that
  25     I put on the screen, it is DOH 4/28. Given the 1983/84

   1     and 82, perhaps just to span the years of designation:
   2     10 operations in the open heart in the under 1s in 1982,
   3     4 in 1983, 11 in 1984.
   4        The very limited number of open heart operations
   5     then, facilities which you have described to us earlier
   6     today and which you have earlier called "primitive", one
   7     surgeon operating largely on adults but also on
   8     children, the great difficulties of the split site as
   9     you have described them, you may not want to comment on
  10     this but please comment if you can: do you think from
  11     what you know of the early 1980s that Bristol should
  12     have been designated at all to do neonatal and infant
  13     cardiac surgery?
  14   A. I do not think I am in a position to comment on that.
  15   MR STARK: Can I comment on that?
  16   Q. Yes, certainly.
  17   MR STARK: Sorry to barge in, but I was involved in the
  18     discussions about development of or recognition of supra
  19     regional centres. In the late 1970s we had 41
  20     departments doing some congenital heart surgery in the
  21     country. This is why when we saw the results in the
  22     Cardiac Register at that time some of the paediatric
  23     cardiologists and surgeons got together and recommended
  24     to the Department of Health that that should be
  25     concentrated in a smaller number of units.

   1        The profession actually recommended a much smaller
   2     number than the eventually recognised number which was
   3     9, we were talking about 6 in order that these numbers
   4     can be improved because when you look at other
   5     recognised supra regional centres from that time there
   6     were certainly others that did small numbers and there
   7     was already some evidence that with improved numbers you
   8     can get better results.
   9        So I think it goes sort of deeper, not only
  10     whether the Bristol should have been recognised or not
  11     but how many site centres one needs in the whole
  12     country.
  13   Q. The need to which you are referring is geographical, is
  14     it?
  15   MR STARK: The profession opposed that because we felt that
  16     the excellence of the centre and large numbers would be
  17     more important but then, as with many other specialties
  18     if you look at the intensive care of cleft palate or
  19     cleft lip, local political pressures sometimes prevailed
  20     and more units than was, from the medical point of view,
  21     optimum, were established.
  22   Q. That was a decision taken in the early 1980s. There had
  23     been recent decisions I think taken in Scotland?
  24   MR STARK: Yes, I was involved in the discussions. Scotland
  25     has two units, between the two of them though only 200

   1     cases of all age groups. So the professionals from both
   2     hospitals, that is Edinburgh and Glasgow, realised it
   3     was not a good situation and that the services should be
   4     concentrated in one spot. Obviously Glasgow surgeons
   5     and physicians felt it should be in Glasgow and the ones
   6     from Edinburgh it should be in Edinburgh so that was
   7     a little bit difficult.
   8        It was interesting that the patients who had
   9     a major say in these discussions and decisions, they
  10     suggested that they do not mind geographical position,
  11     they are prepared to travel any distance providing that
  12     the ultimately established unit would be first class.
  13     So I think the reference to geographical factors is
  14     probably not as important certainly as the profession
  15     would see it.
  16   Q. This was a case, was it, of the profession in the early
  17     1980s taking a view, be it administration, through the
  18     supra regional services advisory group recommending as
  19     we know 9 centres for designation on geographical
  20     grounds without asking the parents. What you are saying
  21     is that if they had asked the parents there may be no
  22     reason you know of to suppose that in 1983/1984 that the
  23     answer would be different than in the 1990s?
  24   MR STARK: I think so because in 1992 the supra regional
  25     services were re-evaluated by the working party of the

   1     College of Surgeons and this working party recommended
   2     some adjustments to de-recognise some units and
   3     recognise some new units but unfortunately the results
   4     of that recommendation to the Department of Health
   5     resulted in abolishment of the whole system which we
   6     considered rather unfortunate.
   7   Q. Again if I may before we have time for another break,
   8     Glasgow and Edinburgh are some 40 miles apart?
   9   MR STARK: Yes.
  10   Q. One might understand a parent in Edinburgh having
  11     a certain amount of local pride, particularly with the
  12     reputation that Edinburgh and Glasgow may have, but 40
  13     miles is only 40 miles.
  14        What considerations do you think might apply to
  15     parents from Cornwall, for instance South Wales, Avon
  16     who might have far greater distances to travel if the
  17     nearest available centre were Southampton, Birmingham or
  18     London.
  19   MR STARK: I think with the knowledge of results I think
  20     that the parents -- I can give you another example: for
  21     many years which were operating on most of the children
  22     from Bergen in Norway and they came with appropriate
  23     treatment, that is intubated, ventilated with a drip,
  24     accompanied by a nurse, by a doctor, in better condition
  25     than sometimes children from a 30, 40 mile radius who

   1     were just put into the ambulance and did not have this
   2     intensive treatment.
   3        I think, certainly in the 90s transport of
   4     patients, even long distances is not a problem. Perhaps
   5     Dr Silove can comment on that, but I believe the
   6     distances are certainly not as important as they were in
   7     the 1970s or 1980s.
   8   DR SILOVE: I can support that. We certainly have patients
   9     coming from abroad, transported in excellent condition
  10     and I support everything Mr Stark has said about that.
  11   MR LANGSTAFF: Sir, may we on that note of harmony have
  12     a break for until, let us say, 2.10.
  13   THE CHAIRMAN: Thank you Mr Langstaff. We adjourn now and
  14     reconvene at 2.10 pm.
  15   (1.30 pm)
  16            (Adjourned until 2.10 pm)
  17   (2.10 pm)
  18   MR LANGSTAFF: Mr Dhasmana, this morning, when I asked you
  19     if Bristol had not become a designated centre, would it
  20     realistically have done any paediatric work at all, your
  21     answer to me was, "It probably would not have appointed
  22     me".
  23   A. Yes.
  24   Q. You were a Senior Registrar when designation took place?
  25   A. Yes.

   1   Q. Was the post of a third surgeon -- Mr Keen, Mr Wisheart
   2     and another -- advertised before or after you heard
   3     about designation?
   4   A. I am sorry, I cannot follow. I mean, the post was
   5     advertised probably in 1985, was it not?
   6   Q. So that would be after designation?
   7   A. Yes.
   8   Q. So it would follow that designation would come first.
   9     Your appointment, as a consequence, second?
  10   A. Well, yes.
  11   Q. What other posts had you applied for -- consultant
  12     posts?
  13   A. I had applied for a number of posts.
  14   Q. Roughly how many?
  15   A. 13.
  16   Q. Let me just deal with this point that has been raised by
  17     others. On the interviewing committee when you were
  18     appointed there was Mr Wisheart?
  19   A. Yes.
  20   Q. Was he the senior consultant?
  21   A. No, Mr Keen would have been the senior consultant then.
  22   Q. Was he on the committee which appointed you?
  23   A. I do not remember now, but he could have been.
  24   Q. You had been Mr Wisheart's Senior Registrar?
  25   A. And also Mr Keen's. I was the only Senior Registrar

   1     they had at Bristol.
   2   Q. Did you feel, once you became a consultant, that you
   3     were still junior to Mr Wisheart?
   4   A. Well, I was junior consultant, yes.
   5   Q. So you felt junior to him?
   6   A. Junior to everybody.
   7   Q. If he had a view and you took a different view, you
   8     would expect his view to prevail, would you?
   9   A. Not always, no.
  10   Q. Normally?
  11   A. No. We always had a very healthy discussion on subjects
  12     and when I found that he was right, I accepted it. When
  13     he found I was right, he gave in.
  14   Q. If there was a disagreement between the two of you,
  15     which view, do you think, would be more likely to
  16     convince the department?
  17   A. Obviously when you start as a junior person in the
  18     1980s, you are a junior voice, really.
  19   Q. Can I turn from your appointment back to the time that
  20     the switch was introduced? Can we have a look at
  21     UBHT 190/8? This is your letter to Miss Stoneham, and
  22     you are saying, in the middle of that first paragraph:
  23        "The waiting list for some of the open-heart
  24     surgical procedures on congenital heart patients is
  25     still considerably high under my care. I hope with the

   1     expansion from July 1988, it will be possible to reduce
   2     some of the waiting list."
   3        Do you recall how long your waiting list was in
   4     April 1988?
   5   A. It is ten years now, but the waiting list in children,
   6     I never liked it anyway, so to me, any waiting list was
   7     long and of course must have been longer than that,
   8     really, because until the end, I never managed to reduce
   9     it under three or four months, which I am never happy
  10     with. So to my mind, any waiting list for a child is
  11     too long.
  12   Q. Again, concentrating on 1988, if I may, UBHT 162/84. It
  13     is a letter talking about the summer months going to be
  14     a bit difficult regarding experienced staffing of the
  15     Cardiac Unit, "the most difficult months will be July
  16     and August where we will not have Steve Bolsin,
  17     considerable consultant leave". And the writer is
  18     asking you to be patient and go carefully on workload
  19     until September.
  20        So there are pressures from management saying "You
  21     should not do as many cases as you are doing because we
  22     cannot cover them"?
  23   A. I do not think this is a letter from management. This
  24     is a letter from an anaesthetist.
  25   Q. Thank you; so pressures, anyway from your colleagues?

   1   A. That is correct.
   2   Q. Because of the difficulty of covering operations?
   3   A. Yes, sir.
   4   Q. So the waiting lists are high. There is difficulty
   5     with consultant cover. Can we look at