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 30th 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 this morning by discussing the introduction in Bristol of the arterial switch operation to repair transposition of the great arteries for neo-nates (children aged under 28 days). He commented on results he presented to the medical audit committee about the first arterial neonatal switches he undertook and went on to describe visits he made to Birmingham Children’s Hospital to observe Mr Bill Brawn, paediatric cardiac surgeon, performing the neo-natal correction. Mr Dhasmana explained that he had not been able to identify a reason for his higher mortality figures for early neo-natal arterial switches and was persuaded to resume the procedure in Bristol, whilst keeping it under review. However, he explained that he subsequently took the decision in 1993 to halt the neo-natal programme. Mr Dhasmana and the two members of the expert group then concluded the day’s hearing by discussing three individual cases reviewed as part of the Inquiry’s Clinical Case Note Review. Mr Dhasmana will continue to give evidence tomorrow morning. Mr Jaroslav 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 85, Tuesday, 30th November 1999
   2   (10.00 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF: Sir, I am sorry this morning's start has been
   6     delayed by about half an hour. Matters arose which
   7     necessitated conversations between the legal
   8     representatives and various interested parties and
   9     ourselves and can I once again thank them for their
  10     assistance in resolving a matter which had arisen.
  11          MR JANARDAN DHASMANA (RECALLED):
  12         EXAMINED BY MR LANGSTAFF (CONTINUED):
  13   MR LANGSTAFF: Mr Dhasmana, yesterday we were talking
  14     in the afternoon about the decision that was made to
  15     begin the neonatal arterial switch programme; do you
  16     recall?
  17   A. Yes, sir.
  18   Q. I was suggesting to you that when that decision was made
  19     you had had experience of some 14 operations in the
  20     non-neonates to resolve a condition of transposition and
  21     VSD and of the first 14 operations, 6 of the children
  22     had sadly died. I was pointing out to you that of those
  23     3 appeared to be in the younger age group.
  24        You I think were saying to me yesterday afternoon
  25     that there had been considerable discussion as to

   1     whether or not the neonatal switch programme should be
   2     begun. I think you indicated that discussion took
   3     a year or two before the programme itself started?
   4   A. The last few months of 1991 was what I was really
   5     saying.
   6   Q. That would be a year and a bit because you began the
   7     programme in 1992 -- it would be half a year?
   8   A. It would be about 3 months or 4 really, I would say.
   9   Q. Did you anticipate any technical difficulty in doing the
  10     arterial switch operation on neonates?
  11   A. That was a problem with neonates itself really where
  12     tissue would be friable, coronary arteries may be
  13     smaller and those were -- essentially those tore. The
  14     rest of the technical part I thought it would be the
  15     same as for older switches.
  16   Q. Is it right to regard the neonate as a different
  17     operation because of the size?
  18   A. Yes, sir.
  19   Q. Who was it in particular who supported your starting the
  20     neonatal operation, do you recall?
  21   A. You mean in the hospital?
  22   Q. In the hospital.
  23   A. I thought it was all the members of the group really,
  24     the paediatric cardiac group really, who included
  25     cardiologists as well as surgeons.

   1   Q. When you had done the operation for the best part of
   2     a year, by the end of 1992, you went to Birmingham?
   3   A. Yes, sir.
   4   Q. You went to Birmingham, as you tell us in your
   5     statement, because you felt you needed help with the
   6     operation?
   7   A. That is correct.
   8   Q. Why Birmingham?
   9   A. The last patient I operated on was September 1992 --
  10   Q. No, why Birmingham?
  11   A. It was not Birmingham I went to initially, it was the
  12     BPCA meeting at Birmingham in November 1992, which I was
  13     attending as a member. There I met a lot of my other
  14     colleagues, both cardiologists and paediatric surgeons
  15     and I discussed my problem with them, and one of the
  16     paediatric cardiologists from the Great Ormond Street
  17     Hospital then told me that they had a similar problem at
  18     Great Ormond Street Hospital and Mr Brawn was able to
  19     help really and "It would be a good thing if you talked
  20     to Mr Brawn". It so happened Mr Brawn was also
  21     attending the meeting, so I talked to Mr Brawn and also
  22     Mr Sethia. So it was following that meeting that
  23     I decided to go to Birmingham.
  24   Q. Had you known anything about the abilities of Mr Brawn
  25     and Mr Sethia before the meeting of the BPCA in

   1     November 1992?
   2   A. Mr Brawn was well-known in paediatric cardiac surgical
   3     circles so I knew that his results with arterial
   4     switches are very good.
   5   Q. Did you know that before you began the neonatal series?
   6   A. Yes, I did.
   7   Q. Why then, since you knew that he had a good reputation
   8     in the arterial switch series and since you knew that
   9     the neonatal operation might be rather different because
  10     neonates are very much smaller for the reasons you
  11     described, why is it that you did not go to seek his
  12     help and to watch an operation before you began the
  13     neonatal operation rather than after you had done
  14     a number?
  15   A. Yes. I think now I do ask that question to myself but
  16     at that time I was in a way full of confidence with my
  17     own work, with what I was achieving with arterial
  18     switches in older children and I felt that I was quite
  19     familiar with the neonatal arteries and tissues because
  20     I mean, all right, I had done only, as you found out
  21     yesterday, about 14 or 15 open neonatal or under 90 days
  22     operations. But I had done by that time about 75
  23     neonatal operations at the Children's Hospital and they
  24     were very complex coarctation repair, very minor shunt.
  25     That is again dealing with very fine vessels and you are

   1     joining them together. I was already familiar with
   2     coronary artery -- various patterns which you see in
   3     this condition and I had encountered them during my
   4     switch programme in older children.
   5        So I thought I was well equipped. I knew the
   6     tissue, I knew what I was going to do. I was already
   7     using my magnification and in a way I was familiar with
   8     coronary artery patterns so I did not think at that time
   9     that I needed any further exposure before starting the
  10     neonatal switch programme.
  11   Q. This is despite having waited for 4 years as it were
  12     since starting switch operations in order to move from
  13     the older age group into the younger age group.
  14        You did not feel it necessary to look and see how
  15     others managed, or handled the coronary arteries in the
  16     very young?
  17   A. No, while you are really in a way in this process, not
  18     really waiting, meaning that you sit doing nothing. It
  19     was a type of cautious wait and observation.
  20        You were doing things, you were reading material,
  21     you were attending various meetings where, all right, if
  22     you have not even assisted you were watching it on
  23     videos and other things people were presenting, and by
  24     this time, 1991, I had attended an ATS meeting in
  25     Washington, a whole day symposium was on paediatric

   1     cardiac surgery and two-thirds of it was devoted to
   2     arterial switches.
   3        So in a way I thought I was well equipped to deal
   4     with it. Just to me, or in my mind it was just age
   5     I was changing but not the operation.
   6   Q. You say you thought many times about whether you should
   7     have gone to see someone like Mr Sethia or Mr Brawn
   8     before beginning the neonatal switch. Admittedly that
   9     is with the benefit of hindsight. What answer had you
  10     given yourself?
  11   A. I mean at that time I would have said -- that is again
  12     hypothesis because again I did not go -- if I had gone
  13     I would probably have adjusted it or changed my
  14     technique in the same way as I did after visiting him.
  15   Q. After visiting him you made significant adjustments, do
  16     you think, to your technique?
  17   A. Well, it was more an organisation rather than my
  18     technique because in a way technique was basically the
  19     same. I was still using the trap door method of
  20     coronary transfer which was well documented, well
  21     recognised and that is what Mr Brawn -- I think he is
  22     still using it. I was using the Lecompte manoeuvre
  23     and was familiar with that. In a way the technical part
  24     was no different.
  25        I think it was more organisation because before

   1     I had a setup which was in a way not well rehearsed. If
   2     I was asking for something on the table, that was being
   3     relayed to somebody else to get it and then bring it.
   4     In a way I found that organisation was more important,
   5     how everybody dealt with it during this procedure. That
   6     is what I found very important.
   7        I did after that make sure that the nurses,
   8     perfusionists, anaesthetists also visited the centre and
   9     saw how things were being done.
  10   Q. Admittedly looking back on it you think that had you
  11     visited Birmingham 12 months earlier than you did there
  12     would have been changes to the pattern and organisation
  13     of the work along the lines of the changes that you
  14     introduced after having gone to Birmingham in December
  15     1992.
  16        When Messrs Hunter and de Leval came to write
  17     their report in 1995 you picked up I think on a phrase
  18     they used, talking about "institutional failure" or
  19     "multifactorial" reasons why the switch results might
  20     not be, were not as good as they had been in other
  21     centres.
  22        What do you think, again looking back at the early
  23     period of the neonatal switch, were the many different
  24     factors that went in to the results that you achieved?
  25   A. I think multifactorial is the right term and that

   1     probably explains everything, you know, not just
   2     surgeons, the whole team, everybody has to be geared up
   3     and move in the same way. I do not think I can explain
   4     that any better than the term itself really.
   5   Q. What factors do you now see as having played a part,
   6     factors that might perhaps have been changed had
   7     different views been thought at the time?
   8   A. There were quite a few things really when I looked in my
   9     whole neonatal programme, not just the first 5 really.
  10     I felt or I believed that incidents of coronary
  11     abnormality in my short series of 13 patients was
  12     comparatively higher than what had been reported in the
  13     literature. A lot of people do a lot of cases and then
  14     see one intramural artery and I saw two within the span
  15     of 13/14 cases.
  16        Out of a total experience of 38 switches which
  17     I have done, 17 had coronary abnormality of some sort
  18     which is higher than mentioned in the literature, which
  19     is usually 30 per cent in the literature.
  20        Also, I used to really say, but of course in
  21     scientific terms you should not be using the term,
  22     I felt I was unlucky to have been confronted with so
  23     many problems in the beginning of that experience and
  24     Mr Brawn pointed that out to me when I met him during
  25     work at a paediatric cardiac meeting in Paris and

   1     I talked to him about my problem.
   2   Q. Cutting you short: one factor was the slightly higher,
   3     17 as against say 13 -- a third -- incidents of abnormal
   4     coronary artery patterns in the children that presented
   5     to you.
   6        What were the other factors that you would
   7     identify as playing a part?
   8   A. I think that I noted more in the earlier part of my
   9     experience but some of it continued even later, like
  10     existing coarctation in patients who I was really
  11     operating for simple transposition. Or VSD, even though
  12     it was mentioned that it could be haemodynamically
  13     insignificant, and some of these coronary abnormalities
  14     I found out more on the table rather than described
  15     before. But I do admit that not all coronary
  16     abnormalities can be identified preoperatively.
  17   Q. Are you saying here that although not all coronary
  18     artery abnormalities can be identified preoperatively
  19     you felt that a number appeared for the first time to
  20     you on the table which, as you thought of it at the
  21     time, ought to have been picked up beforehand?
  22   A. That was my belief but I have been told that is not
  23     correct.
  24   Q. Let us explore that for a moment. Your belief would be,
  25     then, would it, that the cardiologist had not carried

   1     out a sufficient or sufficiently thorough investigation
   2     or had not accurately reported what that investigation
   3     showed?
   4   A. I was really commenting on them as a type of helpful
   5     criticism in order to improve further, I was not really
   6     criticising them.
   7   Q. I am not concerned with criticism so much as to
   8     establish the fact that this is what you thought should
   9     have been done.
  10   A. That is correct.
  11   Q. The consequence of a failure by the cardiologist, if it
  12     was, to identify coronary artery abnormalities before
  13     you discovered them on the table was, what, so far as
  14     you were concerned?
  15   A. It took me longer to correct in those cases really, just
  16     once -- I mean as I thought at that time I was probably
  17     taking a bit longer in these abnormal coronary artery
  18     patients trying to work out my programme on the table
  19     rather than having worked it out before.
  20   Q. If you had worked it out before, you would have been
  21     quicker?
  22   A. I would have saved a few minutes, yes.
  23   Q. And is time, as you see it, a matter of importance in
  24     such an operation?
  25   A. Well, I did not realise that at that time but looking

   1     back probably it mattered in the neonatal part of the
   2     switch. Because it did not matter too much to my older
   3     switches really, they were going very well with
   4     a similar percentage of coronary abnormalities in that
   5     group really, I never had any problem.
   6   Q. Looking back on it, you think the additional time you
   7     took because of the abnormalities that were presented to
   8     you on the table, having to think your way round them,
   9     think how to deal with them, may have had an influence?
  10   A. I am sure it did, I admit that.
  11   Q. We have heard in the Inquiry that the surgeon who has
  12     a lot of experience in dealing with a particular type of
  13     case may when he is presented with something unusual,
  14     something which he has not anticipated in advance, may
  15     be able to deal with it more quickly, more speedily
  16     because he has met that sort of problem before?
  17   A. I myself did the same in the last few cases. When I was
  18     presented with an abnormality I corrected them quicker
  19     than I was doing before. That is what I was talking
  20     about with the "learning curve". Everybody goes through
  21     that whether you are an experienced surgeon or not. You
  22     do, with your own experience, learn to really tackle
  23     sometimes these unexpected problems better than if
  24     somebody starts fresh.
  25   Q. We have looked at two of the factors: the slightly

   1     higher number of children presenting to you with
   2     difficult coronary artery patterns, abnormal; and
   3     secondly the failure as you see it of the cardiologists
   4     to tell you beforehand sufficiently in a number of cases
   5     that there were these problems so that your operation
   6     took longer and probably had an impact overall.
   7        What other factors do you think may have played
   8     a part?
   9   A. I feel as a surgeon Mr Brawn managed to have a better
  10     team to help him in the theatre than I managed here in
  11     Bristol.
  12   Q. What was it about his team that was better than your
  13     team?
  14   A. Well, he had a dedicated paediatric cardiac surgical
  15     assistant in a way. My assistant, even though he could
  16     be a Senior Registrar, may not be a dedicated paediatric
  17     cardiac surgical assistant, may not have seen that many
  18     paediatric cardiac surgical cases and I have no other
  19     option but to take his assistance at that time to help
  20     me.
  21        So in a way he would not automatically move in the
  22     same way or anticipate my move as it was being done in
  23     Birmingham. Similarly, nurses in Birmingham, they had
  24     almost everything ready on the table. They knew when he
  25     was going to require a suture, it was almost as if he is

   1     not looking, he is just doing that, he is getting it.
   2     I used to really say in theatre that "we are not running
   3     a relay service here" because that is what I was
   4     noticing. Most of the time I am saying "4 O" then
   5     somebody else is in 4 0 then somebody is getting from
   6     there and obviously by that time I would look at what is
   7     happening and this is all distracting.
   8        That was one of the problems, that sometimes some
   9     of the nurses in theatre were very uncomfortable with me
  10     because I did not like that type of -- it is not service
  11     to me, I thought it is service to the patient, and that
  12     was lacking and I think it was lacking because these
  13     nurses were on the same day dealing with an elderly
  14     gentleman, another person where probably such things do
  15     not matter that much at the time, but here it did.
  16   Q. Again you are picking up I think on two or three factors
  17     there: one is that the consequence of having a "relay"
  18     operation, one person turning to another to another to
  19     another, is a further delay in the time it would take
  20     you to complete your operation?
  21   A. That is correct, sir.
  22   Q. Secondly, it indicates that if you needed something very
  23     quickly you might have to wait for it and that is not
  24     a good thing?
  25   A. That is correct, sir.

   1   Q. Thirdly, it indicates, does it, that you reacted to the
   2     nurses, telling them off for running a relay operation
   3     for the reasons you have explained, which I think you
   4     have told us sometimes affected the atmosphere in the
   5     theatre?
   6   A. I am aware of that.
   7   Q. If you have an atmosphere in an operating theatre
   8     I suppose that the whole team does not function quite so
   9     well; it is inevitable, is it not?
  10   A. By "atmosphere" I do not really mean it should be
  11     pleasant with music going and all these things. I feel
  12     it should be professional and I felt it is not
  13     professional that, you know, things are not there.
  14     I mean the list is already out, you know what we are
  15     going to do. In a way it should be professionally ready
  16     for you and that is where my in a way criticism was.
  17        As far as the pleasantness is concerned, I was
  18     very pleasant outside operating time, but during the
  19     operating time, I did not want chitchat, I wanted things
  20     done and that somehow was not popular with many nurses.
  21   Q. So for the reasons you have given, you could be cross
  22     and irritable in the operating theatre, could you?
  23   A. I never realised that I could be, but yes, it would be
  24     seen that way.
  25   Q. If you were telling nurses off for a relay operation as

   1     you have described it, your need to do that would be
   2     a distraction, would it, of you from focusing upon the
   3     particular job that you had to do with the patient?
   4   A. I think when one uses the word "telling off", it sounds
   5     harsher than what it really was. I do not think I was
   6     "telling off" because when you are telling off that
   7     means you had stopped doing things, what you were really
   8     doing. I was not stopped from doing anything really,
   9     I was just in a way hurrying up, if you like. It could
  10     be seen that way, or it could be interpreted, but I did
  11     not realise I was telling anybody off.
  12   Q. But you said you found it distracting?
  13   A. To me, yes, because I am operating here, looking at
  14     this, and then I ask for a suture and it is not there.
  15     So it is not there. I look this way and you have got
  16     magnification on all those things, all focused. Then
  17     you go back on there, it takes a little time,
  18     a millisecond, but you have gone out from there. To me,
  19     especially when you are doing a very minute vessel,
  20     I think it is a little bit -- you know.
  21        But I did have actually a few nurses who were very
  22     good and mostly they used to work with me and I had no
  23     problem with that.
  24   Q. The assistant you described as not necessarily being
  25     somebody who had an interest in paediatric cardiac

   1     surgery, if you had hit a problem, something that you
   2     had to think your way round on the operating table, if
   3     you had an experienced assistant, is that the sort of
   4     thing you would discuss with such an assistant?
   5   A. I think most of the time you would discuss with your
   6     assistant for two reasons.
   7        One: sometimes, even the person is not
   8     experienced, can give you advice, you know, from his
   9     reading or literature; a lot of younger Senior
  10     Registrars, sometimes they know a lot more about what
  11     you are doing at that time.
  12        Second: when you are discussing you are not really
  13     in a way asking for the person's advice and help to you,
  14     you are also rehearsing in your mind what you are doing
  15     is correct or not, really. That is why I used to do
  16     that.
  17   Q. Was that as helpful with a Registrar who did not have
  18     the interest or the experience as it would be with one
  19     who did have an interest or/and experience?
  20   A. I felt it very helpful really in either case. But on
  21     the two occasions when I visited Birmingham there was
  22     not much chitchat really but probably things were very
  23     straightforward, there was no need for him to ask. So
  24     I did not see him really discussing that with his
  25     assistant or anything like that.

   1        But whenever I was doing it I felt, you know, that
   2     talking with my assistant helped me both ways, in
   3     devising my own plan, what I am really doing and
   4     sometimes getting some very helpful advice, yes.
   5   Q. What else would you say about the team that differed as
   6     between Birmingham and Bristol?
   7   A. I also felt that our anaesthetists did learn when they
   8     visited, even though they kept telling me that they have
   9     not really seen anything different, but I did notice
  10     with the changes which they accepted and they did.
  11        For example, before going to Birmingham we had to
  12     have the patients or neonates, especially younger
  13     children, in a way you could say with very good blood
  14     pressure before the move out from theatre and that
  15     really meant sometimes staying on bypass longer or
  16     adding more inotrope than you could have really done
  17     without.
  18        While at Birmingham -- I watched three operations
  19     on two occasions -- so in a way I saw that blood
  20     pressure was not essentially accepted or regarded as
  21     a very important thing, even 50 or 60 blood pressure was
  22     accepted as all right, if the filling pressure is all
  23     right, this heart is going to improve with the passage
  24     of time. I watched in ITU the first case, say about an
  25     hour, and within the next 40, 50 minutes this patient

   1     got better in ITU.
   2        So you did not really need to stay in theatre to
   3     wait for a patient to improve before transferring, once
   4     you are happy the repair has been done properly, the
   5     filling pressure -- Mr Brawn at that time, I may be
   6     wrong or I think it may have changed by now, but left
   7     atrial pressure was considered most important.
   8        That is all right. He said "Do not worry".
   9     I felt he was using more dilators to keep the body
  10     filled more than the heart. Before going to Birmingham
  11     we were filling the heart more but constricting the rest
  12     of the body really. I thought that was very good in the
  13     post-operative management and it did help us actually
  14     over the next few cases.
  15   Q. Again, the point you were making about keeping the child
  16     in theatre in Bristol when the child might not have been
  17     kept in theatre in Birmingham, would that extend the
  18     time the child would be on bypass for instance?
  19   A. Sometimes I had to keep them on bypass because we were
  20     not happy or not supposed to be happy to come off
  21     bypass, if you understand.
  22   Q. Having seen what they did in Birmingham you appreciated
  23     that with a different, a modified anaesthetic or
  24     post-operative approach you could come off bypass
  25     earlier?

   1   A. Yes.
   2   Q. Was there any other factor apart from the different team
   3     approach that you have described as between Birmingham
   4     and Bristol which you think, looking back on it, may
   5     have affected the surgery in Bristol?
   6   A. I do not remember at the moment, but maybe you will find
   7     out.
   8   Q. I am going to come to how you responded to the start of
   9     your switch operation and what it was that before you
  10     went to the meeting in November you have described of
  11     the BPCA inspired your first visit to Birmingham.
  12        Before I do that, may I ask our experts: here was
  13     a unit beginning a new procedure in some respects. How
  14     often was it that a surgeon who had not done
  15     a particular procedure, introducing it for the first
  16     time would, in the early 1990s, go, watch and observe
  17     another centre before beginning himself to do the work?
  18   MR STARK: I would not have information about that.
  19     I can only speak from personal experience and I think
  20     I would agree with what Mr Dhasmana said, you have
  21     various means, you go to the meetings where the videos
  22     are presented, sometimes you go to the surgeons to see.
  23     What you see sometimes is very good in a positive way
  24     because you think people are doing things better.
  25     Sometimes it is a negative way because you know which

   1     things you should avoid, what the other people do.
   2        So I think everybody would make an effort somehow
   3     to familiarise himself or herself with the procedure
   4     through the various means.
   5        I think as far as the question about the neonatal
   6     as opposed to the older children's programme, I think we
   7     discussed it briefly when we were here with
   8     Mr de Leval. There were basically two schools of
   9     thought. One which we have adopted at Great Ormond
  10     Street, that we would slowly reduce the age of the
  11     patients because there was a myth or feeling that things
  12     are more difficult in neonates. There was another
  13     school which was Dr Castaneda in Boston and subsequently
  14     one of his pupils, Dr Mead in Melbourne, who felt that
  15     perhaps it is easier to correct things in the neonates
  16     because you do not wait for the changes that the defect,
  17     with the passage of time, will inflict upon their heart
  18     or upon their lungs.
  19        Certainly from the technical point of view I think
  20     once we started doing more neonates one can easily say
  21     that the operation on neonates is easier because you use
  22     fewer stitches, the structures are smaller so you have
  23     to be accurate but while you may have to put into aortic
  24     anastomosis 30 stitches in a two-year old, you may put
  25     only 10 in a neonate. I think those were the two

   1     schools of thought, how to go about neonatal vis-a-vis
   2     older operations.
   3   Q. When you began the operations, the first neonatal
   4     arterial switch operation which you did I think you
   5     discovered there was an undiagnosed coarctation?
   6   MR DHASMANA: I found out later, you could say from PM
   7     really, postmortem examination.
   8   Q. So you performed the operation without knowing there had
   9     been an undiagnosed coarctation?
  10   A. On the table I did notice some difference of pressure
  11     because the arterial line was in the femoral monitoring
  12     line. When I was coming off bypass I had my needle in
  13     the aorta which I used to do a number of times just for
  14     the reason that we were using the technique at that time
  15     which you used to keep the periphery cooler but the
  16     heart fuller so you had a better pressure there. And
  17     I noticed some difference. But that I simply thought
  18     was just part as I had seen in a lot of other patients.
  19     The difference I think was probably not more than 15 or
  20     18 millimetres of mercury and I just felt at that time
  21     that that is not relevant.
  22   Q. The second arterial switch you did -- because the first
  23     5 all died, did they not?
  24   A. Unfortunately, yes, sir.
  25   Q. Did you think when you operated on the second that there

   1     might be a technical problem with the way you did the
   2     operation?
   3   A. No, because I looked at the postmortem examination and
   4     that filled me with confidence because both coronary
   5     arteries were widely patent, the patient did not have
   6     any problem attributed to coronary transfer. The
   7     problem here was very tight coarctation.
   8   Q. You told the GMC, I think, that your first reaction to
   9     that operation before you saw the postmortem report was
  10     to think there may have been a technical problem in the
  11     way in which you had conducted the operation?
  12   A. That is what you were talking about yesterday, my
  13     self-critical thing, anything which I had done, and if
  14     it does not go according to plan I questioned myself
  15     first and then look at others. I really kept asking
  16     myself "Did I do anything differently?" and before
  17     I could really see anything I thought "It must be the
  18     coronary artery which had probably caused the problem
  19     because this is a small baby and it is a possibility my
  20     stitches may not have been in the right place". But
  21     when I saw the postmortem examination then you could put
  22     a nice probe in there and the heart did not show any
  23     evidence of ischaemia, it in a way filled me with
  24     confidence.
  25        Until that time, yes, I always was questioning

   1     myself and I may have mentioned to somebody "I hope it
   2     is not the coronary artery", that type of question. But
   3     I thought every surgeon asked that question himself.
   4   Q. The lesson we may take from this is that you were not
   5     confident because this was only the second operation
   6     that you had done?
   7   A. This was the first.
   8   Q. You were not confident that you were necessarily
   9     doing the operation right, that you had to be reassured
  10     by other matters?
  11   A. I think everybody needs reassurance.
  12   Q. When Mr de Leval gave evidence to us he described as
  13     a matter of importance for a cardiac surgeon the feeling
  14     of confidence which such a surgeon has; is he right, do
  15     you think?
  16   A. It is very important when you are going in for surgery
  17     that you feel confident you can do it. I was confident
  18     when I did it. I raised the question in my mind because
  19     the child did not make it and I am asking that question
  20     to myself but when I saw the PM I was quite pleased that
  21     in a way my technique was fine. In a way you could
  22     really say I was back to my own self again.
  23   Q. Did you do the third and the fourth operations before
  24     you saw the PM on the second?
  25   A. No, the PM is usually -- I mean at that time the

   1     practice was that they would do the PM examination at
   2     the next available slot they can really fix it. If
   3     I have time, I am not operating, I would go and watch
   4     them and help him to really find, because a lot of these
   5     operations, the pathologists did not know the exact way,
   6     how things were done. Sometimes if I could not be there
   7     I could see the specimen, at my first available space
   8     really. It was sometimes in the evening, often 5.00 pm
   9     I went to their office and said "You examined that
  10     heart, can I examine with you?"
  11   Q. Let me move on a little: by the time you had done 5
  12     operations and the first 5 had died, what did you think
  13     about continuing with the programme?
  14   A. As I mentioned yesterday, every time a transposition was
  15     being referred we were always asking questions "How are
  16     we going? What we are doing?" All these patients, the
  17     first patient when this has happened I said "You know we
  18     missed coarctation, that is not a nice thing to miss".
  19     Of course an echo was done so in a way I do not know how
  20     we missed it, but sometimes you can and let us hope we
  21     do not.
  22        In a way we are asking questions but here the
  23     question was to improve the diagnosis, not to stop the
  24     programme.
  25        The second one, when I operated -- I am not sure

   1     but probably there was a technical problem on the table
   2     but I managed to in a way correct it. That did actually
   3     prolong the operation, the child took longer to recover
   4     and was recovering in ITU when he got into a septic
   5     state, and that was I would think a week or 10 days
   6     after that.
   7        So in a way in the second case there was another
   8     cause for failure --
   9   Q. Did you then go through each of the five cases and
  10     identify the individual causes and satisfy yourself
  11     about those causes?
  12   A. Yes, sir, I did.
  13   Q. Two questions really follow: you had had an experience
  14     in the first five cases of 100 per cent mortality. In
  15     the papers at the time, what level of mortality was, as
  16     you understood it, to be expected from the neonatal
  17     arterial switch?
  18   A. They were different papers at that time, a lot of papers
  19     coming out. As I mentioned before, I think yesterday,
  20     I was concentrating more on this North American paper
  21     which was really a type of study -- multi-centre study
  22     because, of course you know, papers were coming out from
  23     very good institutions and papers were probably coming
  24     out from not so good institutions.
  25        But this study was really a combination of all

   1     centres together and then analysing the results in a way
   2     that you can get some, what I thought, was sensible
   3     answer. On the basis of that I was expecting that
   4     mortality of 20 to 30 per cent in a centre like ours is
   5     probably expected in this type of operation.
   6   Q. In the middle of 1992, in May -- let us have a look at
   7     UBHT 61/165?
   8   THE CHAIRMAN: Mr Langstaff, as you are going through this
   9     I would like you to explore if you could whether there
  10     was any data which identified the results of the first 5
  11     or 10 as distinct from a longer series at this time.
  12   MR LANGSTAFF: This is a meeting in June 1992. If we look
  13     down at the bottom of the page as it is on the screen:
  14     results of the arterial switch operation by you, because
  15     Mr Wisheart had done three arterial switch operations
  16     I think, three or four, early on in the non-neonates and
  17     he had stopped?
  18   A. Yes, sir.
  19   Q. Why did he stop?
  20   A. I think the main reason was that, in a way centralise
  21     experience in one hand because after a few, or say 2 or
  22     3, he realised that it needed a lot more technical input
  23     from the person and it would be better if it is in one
  24     hand, because our total number, as we were talking
  25     yesterday, of transposition of every type in Bristol was

   1     probably not more than 20 in a year, that is maximum
   2     I would say. So he thought that one person -- it would
   3     be better in the hands of one person rather than both of
   4     us.
   5   Q. And better you than him?
   6   A. That was very kind of him to say that, I did not want to
   7     really put that in.
   8   Q. Because, as you would see it?
   9   A. I thought the word he used was "younger person could
  10     probably put more energy in it".
  11   Q. 61/165, your series: "Findings and observations.
  12     Mortality for TGA and TVSD switch" that is the
  13     non-neonates "similar to reported results particularly
  14     if consider his early experience". A higher mortality
  15     for multiple VSDs. You go on, down the bottom of the
  16     page: "Action taken/clinical changes instituted". There
  17     are these words "persevere with the arterial switch for
  18     the TGA/VSD", so you are going to persevere with the
  19     non-neonatal group. "Continue the programme of switch
  20     for TGA and IVS", that is the neonatal?
  21   A. Intact ventricular septum, yes, neonate.
  22   Q. "Aim for earlier repair when possible", to which group
  23     did that relate?
  24   A. Both.
  25   Q. "A careful search for multiple VSDs and coarctation",

   1     that is emphasising your experience, is it, with the two
   2     cases you have so far told us about where a coarctation
   3     was missed?
   4   A. Sorry, can I just explain further that answer to number
   5     3: "Aim for earlier repair when possible" is really
   6     following the second problem when in hospital. There
   7     was a higher mortality if a person or a child has been
   8     waiting for surgery in the hospital, admitted. That is
   9     why -- he is really saying that if we have got a patient
  10     here please operate on them sooner than what you are
  11     managing at this time.
  12   Q. Is it earlier in terms of the age of the patient or
  13     sooner after admission?
  14   A. I think when he asks us to operate on, that is what he
  15     really means.
  16   Q. When the decision has been made, to operate as soon as
  17     possible?
  18   A. Yes.
  19   Q. What we do not see on this sheet is any reflection of
  20     your telling the meeting about the results that you had
  21     had in the neonatal programme?
  22   A. That is not correct. If you follow, this is a summary
  23     sheet. There were five or six other pages because
  24     I presented data.
  25   Q. So you told them?

   1   A. Yes.
   2   Q. Did you also tell the meeting that in Birmingham on the
   3     neonatal switch hardly any patient died?
   4   A. That was at the end. It was a type of a meeting -- the
   5     meeting had almost finished. In a way we had done this
   6     --
   7   Q. The answer is "yes" you did say that?
   8   A. I did say that, yes.
   9   Q. Did you say to the meeting that Castaneda had reported
  10     results for the neonatal arterial switch of less than
  11     5 per cent mortality?
  12   A. That is correct, I did.
  13   Q. It follows that at this stage you knew that I think all
  14     the switches which had been done in Bristol by the team
  15     had died but elsewhere mortality could be between 0 and
  16     5 per cent?
  17   A. In some centres, yes.
  18   Q. Was there any discussion at the meeting as to whether,
  19     in the light of that, the results you were having
  20     required a review to see if there was anything you were
  21     doing as a team that needed to be changed in order to
  22     improve mortality or even to suggest "we should not be
  23     doing it"?
  24   A. I think there was actually. It was said that we would
  25     continue to deliver this programme and we would see it

   1     again in a few months time in one of these meetings,
   2     yes.
   3   Q. So people were concerned about whether they were doing
   4     the right thing by continuing to carry on the operation?
   5   A. With any programme you have to keep asking yourself that
   6     question, yes.
   7   Q. This was mid 1992. At this stage who was anaesthetising
   8     for the switch operations?
   9   A. By this time I think, we had only -- this is June 1992
  10     -- we started in 1988 when Dr Burton had retired, so
  11     Dr Masey being the main anaesthetist I would say.
  12     Dr Bolsin and Dr Monk, they took their turn when the
  13     rota was like that, but there were probably fewer with
  14     them, and some time in 1991 Dr Underwood came in and she
  15     showed more enthusiasm about paediatrics so I think she
  16     took a greater share of paediatric cases than doctor --
  17   Q. Had you got to the stage by now -- by the middle of 1992
  18      -- when, as it happened, only Dr Masey and Dr Underwood
  19     were actually carrying out the anaesthetic for the
  20     switch operations?
  21   A. I did not know that until December 1992.
  22   Q. By December 1992 you realised, did you, that the
  23     anaesthetists had agreed amongst themselves that only
  24     two would do it?
  25   A. I found out when I talked to Dr Bolsin, because in a way

   1     Dr Masey had gone to Birmingham with me. Dr Underwood
   2     was --
   3   Q. If you forgive missing the details: you spoke to
   4     Dr Bolsin in December 1992?
   5   A. That is correct.
   6   Q. What was he saying to you roughly?
   7   A. I was asking him to go to Birmingham to see the
   8     operation so that we can plan management.
   9   Q. And his response?
  10   A. His response was: that "Janardan, I tell you now Sally
  11     and Sue would really be dealing with these cases because
  12     we thought we would just leave -- we would let them
  13     concentrate on this problem because it is very
  14     technically demanding but of course I am willing to help
  15     if you want and I would make telephone calls", that was
  16     his last word.
  17   Q. Did you understand from what he was saying that he and
  18     Dr Davies were not prepared to anaesthetise for switch
  19     operations?
  20   A. Dr Davies was not even appointed at that time; Dr Davies
  21     was appointed in June 1993 or July 1993.
  22   Q. Did you understand that Dr Bolsin was not prepared to
  23     anaesthetise for switch operations at this stage or not?
  24   A. He did not put it in that way.
  25   Q. You told us that at the meeting there was discussion

   1     about keeping the switch programme under review, about
   2     whether the unit should continue to do it. Do you
   3     remember who it was who was raising those points at the
   4     meeting? Can we scroll back up to the top and see who
   5     was there?
   6   A. You can see it must be myself, Dr Jordan, Dr Joffe and
   7     Martin really. So we were all asking ourselves really.
   8     We did not feel any different from one to another, we
   9     worked as a team. So if there is a problem like that
  10     then they are the cardiologists who are referring, I am
  11     the surgeon who is operating, we are really in a way
  12     deciding that that is how we would really carry on.
  13   Q. How was it that you explained to yourselves at this
  14     meeting the difference in the results which Birmingham
  15     had and Castaneda had on the one hand for the neonatal
  16     switch and you were having in terms of at least the
  17     crude mortality data?
  18   A. By this meeting I am not sure I had done that many, only
  19     one probably was done, I am not sure. But we were
  20     looking because only one would have been discussed in
  21     this one, the first patient?
  22   Q. In terms of the comment "persevere with"; let us go down
  23     to the bottom of the page. The word "persevere"
  24     suggests there is an element which is less than
  25     enthusiastic to continue the operation. I think that is

   1     something of the reflection you are giving us, given the
   2     necessary concern to see whether the results were
   3     appropriate. Have I read that right?
   4   A. Yes, you have read it right. But if you look at it
   5     further, it says "for TGA and VSD". So what I have done
   6     on this one, I have presented all my experience from
   7     1988 until that time and in a way when we take overall
   8      -- probably by this time I would have operated on, say,
   9     12 cases or 11, I do not know, I have not got in front
  10     of me the paper which you are looking at.
  11   Q. If we go to GMC 8/22, are those the figures you
  12     presented to this meeting?
  13   A. Yes, there was some correction made to that but, yes,
  14     the total number was 16 and out of that -- that was the
  15     mortality as presented. Of course if one looks at it
  16     like that then it does look higher than the reported
  17     series and that is why you can really say that I in
  18     a way go according to year of operation. That was also
  19     a usual way of presentation in scientific papers at that
  20     time and that explains that most of these deaths
  21     occurred in the first 2 years of the programme. After
  22     that there was probably 1 death in the remaining cases.
  23   Q. Can we scroll down, but, sir, you will need to take it
  24     off the public screen. We see there the whole figures
  25     for the non-neonatal series, do we, up to this stage?

   1   A. Yes, sir.
   2   Q. If we turn over the page, page 23, this was the
   3     comparison you were making with the University of
   4     Alabama and Birmingham, was it?
   5   A. That was from the book which was at that time available,
   6     the 1986 edition of a book on cardiac surgery edited by
   7     Kirklin and Barrett-Boyes, yes.
   8   Q. The 1984 figures were unlikely to be very helpful, were
   9     they, looking at matters in 1992?
  10   A. For TGA and VSD this is the 1984 as it was available,
  11     but even in this country TGA and VSD was around 25 to
  12     30 per cent in most of the centres.
  13   Q. Those results for this country you did not show?
  14   A. Because they were not available, we were hardly getting
  15     any information from this country.
  16   Q. Can we scroll down the sheet? "CHSS North America, 1985
  17     to 1st June 1988". Again I do not know, does this
  18     relate to the arterial or the atrial switch, do you
  19     know?
  20   A. You have both there, arterial and atrial, both are
  21     mentioned. This is from 1985 until June 1988.
  22   Q. One can see there the survival rates?
  23   A. Yes.
  24   Q. 21 per cent in the arterial and 15 per cent in the
  25     atrial?

   1   A. You are talking of mid mortality.
   2   Q. You are quite right to correct me, I am sorry.
   3        Again 1988, 4 years earlier, was likely, was it,
   4     to indicate a higher mortality rate than one would
   5     expect in 1992?
   6   A. We know now, yes, but at that time I did not know that.
   7   Q. Was it not the view in 1992 that matters were developing
   8     fast in cardiac surgery?
   9   A. Yes, but as I said before, Britain as a rule is about 3
  10     or 4 years behind America in this type of surgery and
  11     probably Bristol was a few years behind the rest of the
  12     country.
  13   Q. So the papers you were summarising here and conducting
  14     the discussion in respect of the non-neonatal switch
  15     were both American, some at least 4 years old --
  16   A. Can I correct, sir? Even though this says "1985 to
  17     1988", this paper appeared in 1991 and 1992, so this was
  18     the most recent paper available at that time when
  19     I presented the data.
  20   Q. In North America the pattern of cardiac surgery was, was
  21     it, for a large number of units performing a small
  22     number of operations in each unit?
  23   A. No, I think you have another centre in mind. University
  24     hospitals in Northern America combined together to
  25     decide on what they were going to follow in future for

   1     the management of patients with the transposition of
   2     great arteries because here is a new operation come in,
   3     somebody is reporting brilliant results, is it really
   4     safe for everybody else really to take on?
   5        It was with that in mind that these university
   6     hospitals combined together to analyse their results in
   7     a way, what they call Congenital Heart Surgical Society
   8     of North America figures. I think in the beginning it
   9     was only arterial switches, I am not sure whether they
  10     had incorporated other areas or not, the experts may
  11     know more about it.
  12   MR LANGSTAFF: There is an appeal to expertise from
  13     Mr Dhasmana, can you help with the CHSS?
  14   MR STARK: I think a couple of points. Can we perhaps look
  15     at INQ 0070021 because I think that one problem -- and
  16     if we can enlarge the table, please -- this is the study
  17     of the same Congenital Society for the United States,
  18     the follow-up on the study that Mr Dhasmana quoted. The
  19     first author on this paper was Kirklin.
  20        I think the point I would like to make to put
  21     things into context: although the overall mortality for
  22     arterial switches at that time was 17.9 per cent,
  23     Dr Kirklin divided the institutions -- and they were all
  24     university teaching institutions -- into the low risk
  25     which is the first 7, whereas the mortality varied

   1     between 6 and 13 per cent, and then from institution age
   2     we have mortality between 23 and 80 per cent. The last
   3     four institutions were actually taken out of the study
   4     because their numbers were too small and they could not
   5     be taken into statistics.
   6        So I think the point I just wanted to make is:
   7     even at that time there was a variety of results between
   8     the centres.
   9   MR LANGSTAFF: In America?
  10   MR STARK: In America. I would assume purely from hearsay,
  11     and I am not sure if one should quote it, that the same
  12     existed in this country but we did not have hard data.
  13   MR LANGSTAFF: Was it a perception that the high risk
  14     centres (so-called) were those which did lower numbers?
  15   MR STARK: There was some indication. In the earlier
  16     report, not in this one but in the paper published 4
  17     years ago, they did a correlation between the size of
  18     the sample, of the number of patients operated, and
  19     there was a clear indication that institutions that did
  20     less than 10 switches during the study period -- which
  21     I believe was about 3 and a half years -- had
  22     a mortality of over 50 per cent while centres that had
  23     more than 50, and actually there were only two such
  24     centres in the whole study, their mortality was I think
  25     around 10/15 per cent but --

   1   Q. In that study itself there was an indication that not
   2     only experience but --
   3   MR STARK: Volume.
   4   Q. -- volume mattered in terms of producing results?
   5   MR STARK: Can I make one more comment? This is in response
   6     to the question by Professor Kennedy about whether there
   7     is evidence about the differences in early cases, the
   8     learning curve.
   9        Again, the evidence is very very limited but --
  10   THE CHAIRMAN: I interject to say I did not use the word
  11     "learning curve", those two words I would not use.
  12   MR STARK: Sorry. In the beginning of the experience there
  13     is some information, one is from the study by Muller.
  14     It is again North America but different institutions
  15     from the study presented here. He compared the first 10
  16     cases with the subsequent cases in about 15
  17     institutions.
  18        The interesting point was that the first 10 cases,
  19     the risk of infant switches was as high as 30, 50 and
  20     70 per cent in the three institutions. But to me what
  21     was more interesting, that although in the majority of
  22     institutions subsequently the mortality dropped, in some
  23     it remained the same and in others actually went up.
  24     They did not give an explanation for that.
  25        From our own experience at great Ormond Street --

   1     and I briefly mentioned it yesterday -- the transition
   2     period when we changed from the atrial switch to
   3     arterial switch was unfortunately associated with
   4     increased mortality. The mortality for the period of
   5     the atrial switch when we took into consideration even
   6     three operative deaths, as I mentioned yesterday, was 12
   7     to 15 per cent. During the transition it went up to 25
   8     to 30 per cent and that was in the years of, I think,
   9     1986/1991 and after 1992 when it was an entirely switch
  10     programme for all accepted neonates, from 15 per cent
  11     the mortality eventually went to 5.
  12        So this is what I tried to explain yesterday, what
  13     are the difficulties for the surgeon if he believes that
  14     the new operation is better; still during this
  15     transition period we were aware that we had more deaths
  16     than we would have had with the previous programme.
  17        The only other information I have is again from
  18     this study using some statistical evaluation, which is
  19     unfortunately above my head. Dr Kirklin estimated that
  20     the risk of the first switch in high risk units at that
  21     time would be 70 per cent and in low risk 30 per cent.
  22     But I am afraid do not ask me about statistics, this is
  23     a little bit high powered.
  24   MR LANGSTAFF: What I was going to ask you was whether it
  25     was your understanding that the definition of "high risk

   1     centre" was one which was given because of the results,
   2     in which case the argument you have just given may seem
   3     to be circular?
   4   MR STARK: It was given purely on the basis of the results,
   5     yes, because all those institutions had experienced
   6     surgeons. If you look at the end of this paper there is
   7     a list of institutions and surgeons and it basically
   8     reads as to who is who in congenital surgery in America.
   9   MR LANGSTAFF: Was there any attempt to analyse the reasons
  10     why -- apart from the number, the volume of operations
  11     done -- it should be that some centres were high risk
  12     and others low risk.
  13   MR STARK: There were many attempts to find out the
  14     mortality. For example coronary artery pattern was
  15     studied, age was studied, weight was studied but apart
  16     from the fact that it seems to be correlation, and
  17     strong correlation between the volume of cases and
  18     mortality, they did not come up with any conclusive
  19     answers.
  20   MR LANGSTAFF: Sir, perhaps that is a natural moment to have
  21     a break.
  22   THE CHAIRMAN: Thank you, let us say 15 minutes until about
  23     11.35 am.
  24   (11.15 am)
  25               (A short break)

   1   (11.35 am)
   2   MR LANGSTAFF: Mr Brawn had been to Bristol, had he, in
   3     about 1990 and discussed his mortality in the neonatal
   4     switch operation with you?
   5   A. To the meeting. He discussed the arterial switch
   6     experience. I am not sure whether it was very clear
   7     whether they were neonatal or his total experience.
   8     I am not sure, but yes.
   9   Q. And reported to you then that he was achieving
  10     a mortality rate of less than 5 per cent?
  11   A. 5 per cent, I think, was the term he used.
  12   Q. So when, if we go back to UBHT 61/165, we look at the
  13     findings and observations, "mortality for TGA plus VSD
  14     switch similar to reported results", the important word
  15     there is "reported", is it?
  16   A. No, TGA and VSD.
  17   Q. But you did not know, you say, whether what Mr Brawn was
  18     saying was for that operation?
  19   A. That is quite correct, because it was a type of slide
  20     presentation; there was no paper. Just a slide
  21     presentation. It was more a teaching -- I mean, if you
  22     want I can give you the background of that meeting,
  23     but --
  24   Q. No, I do not need that.
  25   A. No, okay. That was just a teaching presentation, and

   1     he was really giving the experience of arterial switch.
   2   Q. Can I ask you to focus on the next words which are
   3     used? Is this your writing or Dr Martin's?
   4   A. It is Dr Martin's writing.
   5   Q. What he has recorded is:
   6        "Similar to reported results, particularly if
   7     consider is early experience."
   8        What he appears to be saying is that it is similar
   9     to reports of early experience elsewhere, the
  10     implication being, it is not as good as reported results
  11     for places where a degree of experience has built up: is
  12     that the sense I should take from it?
  13   A. I do not think I can comment on that. That is somebody
  14     else's summary.
  15   Q. You were at the meeting. Was that the sense of the
  16     meeting?
  17   A. The sense of the meeting was very supportive, and
  18     agreeing with whatever I said at that time, that, you
  19     know, that was the experience in other centres, that is
  20     what I was achieving, and they thought that was
  21     similar. That is the impression I got from the meeting.
  22   Q. Was it raised at the meeting that your results were
  23     early results and therefore one might expect them to be
  24     poorer than results of centres with experience?
  25   A. No. I think, you know, quite clearly at that time there

   1     was no reservation about the word "learning curve"
   2     because that was being mentioned quite commonly in
   3     almost all medical meetings, whether cardiologists,
   4     cardiac surgeons, wherever, and if I recall it
   5     correctly, my initial experience was similar to the
   6     experience elsewhere because I had presented -- I mean,
   7     all right, those were the summaries which you see over
   8     the next few pages, but I would have presented that, we
   9     had had a paper where people had been really saying that
  10     out of this --
  11   Q. Again, I do not want to stop you saying anything that
  12     you particularly want to say, but may I cut you short.
  13     Are you saying that your experience that you presented
  14     was that of a, using the words at the time, "learning
  15     curve" and the results were appropriate for a learning
  16     curve?
  17   A. That is what I am saying, yes.
  18   Q. It follows that the results which you were reporting
  19     were appreciated to be higher mortality than those
  20     centres where the learning curve had been passed,
  21     because, as you have explained, you were in the process
  22     of the learning curve. That was the discussion, was it?
  23   A. I am very sorry, I cannot explain if I am not allowed
  24     to say the way I want.
  25   Q. I am not going to stop you, I am trying to help.

   1   A. Okay.
   2   Q. Please explain as you would wish.
   3   A. Thank you, sir. Here I was presenting my experience and
   4     I gave them my experience of 16 cases, as you have
   5     already seen. I am really telling them how the case
   6     progressed and what had happened in previous years, and
   7     while I am doing that, I am also telling them that
   8     similar things had happened in other people's
   9     experience. That is how I think, you know, everybody
  10     else is taking it. I cannot really explain any further
  11     why he has used a term, particularly considering --
  12     I mean, whether it is his early experience, whether he
  13     is calling up our early experience or early experience
  14     anywhere else, I cannot explain further on that.
  15   Q. Do you accept now what you accepted before the GMC, that
  16     you never really got beyond the learning curve so far as
  17     the arterial switch operation is concerned?
  18   A. I did not accept that to the GMC also. I accepted that
  19     it was in the neonatal programme. I was not able to
  20     transfer my experience from older switches to the
  21     neonatal switches. That is what I accepted.
  22   Q. Let me move on from here to the end of the year, to
  23     December. You kept the programme under review. You had
  24     had the experience you had at the neonatal switch
  25     deaths, and you recognised that you had a problem

   1     transferring the technique, or you think you had
   2     a problem transferring the technique, amongst the other
   3     difficulties you have mentioned, from the non-neonates
   4     to the neonates.
   5   A. I realised at the last operation, when I saw that the
   6     wound of the coronary artery anastomosis was not as it
   7     should have been.
   8   Q. That then caused you to raise the matter at the meetings
   9     as you told us in November, and to go to Birmingham in
  10     December. When you chose to go to Birmingham, did you
  11     think of asking either Mr Sethia or Mr Brawn to come
  12     down to Bristol and to assist you with an operation?
  13   A. I very clearly asked Mr Brawn if he would like to come
  14     to Bristol and help me with the programme here, yes,
  15     I did.
  16   Q. Was he willing to do so?
  17   A. No.
  18   Q. Did you ask Mr Sethia?
  19   A. Mr Sethia, when I talked to him later, he offered, but
  20     because I was already now connected with Mr Brawn, I was
  21     in a way happy to go along with Mr Brawn and in a way,
  22     did not go back to Mr Sethia.
  23   Q. At this stage, did you think of taking the advice of any
  24     other person with whom you had trained? I think you had
  25     trained with Mr Stark, had you not, at one stage?

   1   A. Yes, but I knew that Mr Stark is not doing neonatal
   2     switch at that time. I now have come to know, at the
   3     BPCA meeting, that Mr Brawn was helping people not just
   4     at the GOS, he has been to other places. So I thought
   5     here is a man who comes from the centre, which really in
   6     a way you could say his technique in the neonatal
   7     switch, that is from the Royal London Hospital, Dr Mee's
   8     clinic, well-known, and now I know that he has been to
   9     GOS, he has been to centres like Liverpool and
  10     Newcastle. So in a way, I felt quite happy to stay with
  11     him, really, and I did not really ask anybody else.
  12   Q. How many operations did you see him do in Birmingham?
  13   A. One.
  14   Q. You then came back to Bristol and put the lessons into
  15     effect?
  16   A. Yes.
  17   Q. You have told us about the lessons you learned having
  18     seen, I think, three operations, because that no doubt
  19     includes the operations you were later on to see in
  20     July 1993?
  21   A. Yes, but those lessons were learned after the first
  22     one. The second one, I did not basically see anything
  23     new, if you understand what I mean.
  24   Q. You have told us how you thought those lessons were to
  25     an extent effective?

   1   A. Yes, and also in the technique of my own work, if you
   2     understand. I think I mentioned a few in the
   3     beginning. Or not. I am not sure.
   4   Q. So you gained, yourself, in your technique. You gained
   5     in the manner of the matters we discussed this morning
   6     and tried to put those lessons into effect in Bristol?
   7   A. Yes. When I was leaving the unit, Mr Brawn also handed
   8     me over a video of the operation we watched at that time
   9     and advised me to study that at my leisure, at home, and
  10     then, when I am doing the next case, really. So in
  11     a way, here I have guidance with me for all the time, if
  12     you understand what I mean.
  13   Q. After that visit to Birmingham, what was the success
  14     like with the neonatal arterial switch?
  15   A. I think we had success with the first two.
  16   Q. What about after that?
  17   A. The third had an abnormal coronary arterial pattern
  18     which was not identified before. I tried to correct it
  19     but I was unsuccessful. Literature puts it very high
  20     risk probably at any centre.
  21   Q. So once again, you had a problem, did you, with the --
  22   A. Coronary artery.
  23   Q. -- not being identified to you beforehand?
  24   A. Not in that one, no.
  25   Q. What was it that made you go back to Birmingham for the

   1     second visit in July 1993?
   2   A. I lost two patients in succession and both of these
   3     patients had normal coronary arteries, so in a way, that
   4     raised doubt again in my mind that here I was, I did two
   5     successful operations, the third did not make it, but it
   6     was a highly abnormal coronary artery and probably could
   7     be explained in any centre. But the next one survived
   8     so I am still happy, I have got, you know, out of four,
   9     three survivals. And the next two did not, although of
  10     course, with one of them we did have evidence of
  11     myocardial infarction, but nevertheless, these two did
  12     not and they had a normal coronary artery.
  13        After the second of those two, I immediately rang
  14     the cardiologist concerned and said, "I am not doing any
  15     more now because there is something which it is obvious
  16     that if I still have not got it --", during this period,
  17     between 1992 and this time, July 1993, I had operated on
  18     about 7 or 8 older switches and they all survived. So
  19     that is why, really, I was very concerned that something
  20     is probably a little different in neonates which I have
  21     not still been able to transfer. That is what was quite
  22     worrying me.
  23        I told Dr Joffe that, "I am very sorry, it appears
  24     that I will not do any more neonatal switches".
  25        Do you want me to continue further?

   1   Q. Yes, please.
   2   A. He said, "Well, it so happens that I was going to get in
   3     touch with you". I said "What for?" He said "I have
   4     got another patient admitted with a similar problem".
   5        Then I narrated again what happened during the day
   6     in theatre and he I think tried to probably comfort me,
   7     saying "Let us just wait for the postmortem examination
   8     and then we can really --". I said, "Well, I am not
   9     taking that next case on".
  10   Q. So he was trying to persuade you to go on with the
  11     operation and you were unwilling to do so because you
  12     thought that your technique was not good enough?
  13   A. Well, you know, when you work with people for some
  14     years, sometimes you know a little bit more about them
  15     than they themselves know. I thought that probably he
  16     was thinking that "This man is again criticising
  17     himself, and probably at this time of night he should
  18     not be making this decision, he should be making it the
  19     next day after considering everything". But I was quite
  20     firm that I am not really taking that patient on.
  21   Q. What happened with that patient?
  22   A. He said "Well, what should we do?" I said "I tell you
  23     why not. We talk to Birmingham". He said "Well, why do
  24     you not do that?" So the next day I ring Birmingham,
  25     I ask for Mr Brawn. It so happened he was nearby, the

   1     secretary connected me to him, and I said -- he said "No
   2     problem, you know, bring the patient and I will operate
   3     here, and I tell you, I have got another patient here,
   4     so you will see two patients operated on the same day".
   5        So I arranged for that patient to be transferred
   6     to Birmingham Children's Hospital. Of course, when
   7     I say "I arranged", I am sure Dr Joffe did the rest.
   8     I told him that is what had happened. By this time,
   9     I talked to my anaesthetic colleague, I am not sure who
  10     helped me with the last operation but it must be the
  11     same one, or maybe Dr Underwood, and she was free, so
  12     I said "Let us go together and just see again. Maybe
  13     I may not be able to pick it up but you have watched me
  14     a number of times ..."
  15   Q. So you go?
  16   A. Yes.
  17   Q. Can I ask what you expected you might discover that you
  18     had not picked up on the first visit?
  19   A. What I noticed over these cases is that somehow, from
  20     outside and even when I have gone back in, the coronary
  21     artery looked in the right place. There was no obvious
  22     kink from outside. So I started asking myself whether
  23     what I called at that time the "lie", the way they are
  24     lying over the heart, have I got the angulation right,
  25     and maybe, technically anastomosis fine, and when you

   1     are looking at the postmortem, it looks fine, no
   2     problem, but the heart did not work. One of the things
   3     with anastomosis I think is the coronary artery, which
   4     I think is very important.
   5        Because that is focused in my mind, maybe the
   6     angulation, maybe the lie is important, I would say
   7     that. And of course, you know, it may be that I missed
   8     something in the technique, but mind you, as I said
   9     before, I had the video. Every time I would do the
  10     switch, whether older or on the younger, I watched that
  11     video. That video became part of my family, really.
  12     It was there.
  13   Q. Did you at that second visit to Birmingham discover
  14     anything you had not been doing technically beforehand?
  15   A. I mean, that is a very difficult question to answer,
  16     because frankly, I did, so in a way, I felt quite
  17     reassured in one way that I was not doing anything
  18     different causing a problem, but at the same time, I was
  19     not satisfied in my own self, so I asked Mr Brawn.
  20     I said, you know, I have been --
  21   Q. Can I stop you there? It may be that the answer you are
  22     about to give is an answer to my next question, but here
  23     you had been, before you went to Birmingham, just on the
  24     point of giving up the neonatal switch operation. You
  25     were going to give up because you thought for some

   1     reason or other, you could not do it, you could not
   2     translate the techniques you were using in the
   3     non-neonates to the neonates, and you wanted to avoid
   4     risk to patients and therefore you wanted, I take it, to
   5     give up operating on neonates with this particular
   6     operation.
   7        When you go to Birmingham and you discover, having
   8     watched two operations, that so far as you can see you
   9     cannot identify what it is, if anything, in your
  10     technique that may not be appropriate, are you not in
  11     the same position of saying, "Well, I must be doing
  12     something wrong but I do not know what it is?" Why then
  13     continue to operate after that?
  14   A. I think retrospectoscope is a very good thing. What we
  15     are talking about here, many things after and in a very
  16     cool environment, is different than what I was thinking
  17     on that day at that time. You know, in-between, I have
  18     also met Mr Brawn, in Paris, when we had another
  19     discussion and watched a number of operations there on
  20     video by different surgeons, so I also knew a few other
  21     techniques you do. So all these things were now at the
  22     back of my mind, and when I talked to Mr Brawn, I felt
  23     that this is something which really just takes a long --
  24     you keep on -- in a word, it comes on. But that was
  25     exactly what was in my mind and that is how

   1     I interpreted what Mr Brawn said to me: that this thing
   2     comes with experience and there would be no problem.
   3   Q. So you decided -- I want to see that this is right -- to
   4     have further operations on neonates after your second
   5     visit to Birmingham without having identified anything
   6     that you were doing wrong as a result of that visit?
   7   A. There was another factor in the middle, really. This is
   8     now July 1992 when I went to Mr Brawn --
   9   Q. 1993?
  10   A. Forgive me, you are quite right: July 1993, when I went
  11     to Mr Brawn again. Following that, I had in a way an
  12     older patient -- only three months older, really -- with
  13     transposition and VSD, who had a highly abnormal
  14     coronary artery, and I managed to repair it
  15     satisfactorily to its intramural coronary artery and we
  16     had the patient survive the operation, and quite well.
  17        So that also filled me with confidence, that here
  18     is very highly abnormal coronary artery pattern, which
  19     is known to be very high risk anywhere, so it brought my
  20     confidence back in, and then I go on summer holiday.
  21     The next patient was really, in a way, lined up for me,
  22     you could say, waiting in the unit on my return, and
  23     maybe in that environment, having gone on holiday after
  24     doing a very highly abnormal coronary artery operation
  25     successfully, having visited Mr Brawn again and seen

   1     that there was nothing wrong with my technique before,
   2     having seen other operations in Paris, I did not
   3     question other people, you know, putting the patient on
   4     my list on my first day return in a way.
   5        So going back into a neonatal switch, you could
   6     really say was somehow -- I just moved in again, but
   7     I do not think I can honestly say that we discussed in
   8     the same way as we discussed after the first stoppage.
   9   Q. What you have described is a process of getting your
  10     confidence back in order to go again with a neonatal
  11     arterial switch. I am interested in your logic, which
  12     was that watching Mr Brawn had not identified any flaw
  13     in your technique, and your worry had been that there
  14     was a flaw which you could not identify. Why did
  15     a continued failure, albeit watching Mr Brawn, to
  16     identify what the flaw might be, give you back
  17     confidence?
  18   A. I think it is the biggest confidence if you can very
  19     successfully repair a highly abnormal, which is almost
  20     considered universally a fatal abnormality.
  21   Q. What Mr Brawn said at the GMC was that if a surgeon can
  22     do a switch operation, he should be able to deal with
  23     coronary arteries, the two go together. Is he right?
  24   A. Well, that is accepted, really, yes. I mean, that was
  25     probably also at the back of my mind, really, having

   1     dealt with such highly abnormal coronary arteries.
   2   Q. And the problem you had had with the neonatal switch
   3     which made you go to Birmingham was not the abnormal
   4     coronary arteries, it was two neonates with normal
   5     arteries?
   6   A. That is right.
   7   Q. But you had nonetheless had your confidence restored for
   8     any neonatal switch?
   9   A. I had my confidence back then, yes.
  10   Q. Looking back on it, using the retrospectoscope, do you
  11     think you were justified in so doing?
  12   A. When, in 1999, I am looking back, probably not, but at
  13     that time, that is how I thought, and I had the full
  14     support of my team. I think that is probably then
  15     another factor, really, because that next case, the next
  16     neonatal switch, was all ready in the unit.
  17   Q. So you did it. When did you take the decision to stop
  18     doing neonatal switches?
  19   A. This patient survived, so in a way, I am feeling happy,
  20     you know, that I am back on the road. The next one
  21     comes and this was the same highly abnormal coronary
  22     arterial pattern, which I had repaired in a three month
  23     old child just a few months ago. So unfortunately,
  24     suspicion was raised but not confirmed pre-operatively.
  25     So when I see on the table and I look at this and I say

   1     no, not in that quick succession -- it was not a quick
   2     succession, but it was so soon after. Of course, this
   3     time my manoeuvre did not work out on this patient, and
   4     unfortunately, I lost that patient on the table.
   5        That was enough. I felt that I could not really
   6     now carry on whatever support I have here, because there
   7     is something which is not right with the neonatal
   8     switches, that at the moment I am not able to transfer
   9     my knowledge from older switches to neonates.
  10   Q. Whose decision was it that you should stop?
  11   A. It started from me, and I think it was stronger or -- it
  12     was I who refused, and after that a similar conversation
  13     took place and by this time, I think Dr Jordan was now
  14     retired so it would be Dr Joffe, and Dr Hayes had just
  15     joined the unit, so Dr Joffe really said almost the same
  16     thing again, "Janardan, you know, again, you are now
  17     too involved in this thing. Let somebody else review
  18     the whole experience and in a way, come out with some
  19     advice what to do for the future".
  20        I said, "Well, I am not going to do it. I am not
  21     going to take these patients on, but, yes, I agree with
  22     you, somebody else really should", and Dr Hayes in a way
  23     took it on herself to review the neonatal switch
  24     experience.
  25   Q. And as a result of that review by Dr Hayes, did that

   1     confirm your decision to stop?
   2   A. I had already stopped, really, because Dr Hayes wanted
   3     me to do a switch operation some time in late October,
   4     which I --
   5   Q. So it was Dr Hayes whom you referred to in your
   6     statement as being the cardiologist who wanted you to do
   7     another one?
   8   A. Yes.
   9   Q. And you refused?
  10   A. Yes.
  11   Q. Who knew of your decision to stop doing neonatal
  12     switches?
  13   A. Forgive me for mentioning, sir, here, but I have been
  14     reading the Internet and various things. I am quite
  15     surprised what I have heard. I thought people very
  16     close to me, both anaesthetic colleagues, they should
  17     have known because I had talked to them, and I am
  18     mentioning Dr Masey and Dr Underwood, that the neonatal
  19     switch programme was stopped.
  20   Q. None of the anaesthetists who have given evidence to us
  21     seem to have known that the programme was stopped,
  22     although they appreciate they were no longer
  23     anaesthetising for such operations.
  24        Did the cardiologists know you had stopped?
  25   A. Yes, obviously.

   1   Q. Because presumably they had to refer their children
   2     on, if they had a transposition case, to Birmingham?
   3   A. Yes, and they were still referring older switches to me.
   4   Q. Can you explain at all why it should be that the
   5     anaesthetists did not know or appreciate that you had
   6     taken this decision?
   7   A. I am quite surprised myself. I mean, I cannot really,
   8     in a way, explain why they are saying whether -- I mean,
   9     of course I did not put it on the notice board in a way
  10     for everybody to know that the neonatal switch programme
  11     had stopped in Bristol, but I thought everybody closely
  12     connected with me, especially with this programme, would
  13     have known my desire.
  14   Q. Did you mention that you were stopping to Mr Wisheart?
  15   A. Mr Wisheart had been very closely involved with --
  16   Q. It is a "Yes" or a "No", really. Did you mention it
  17     to Mr Wisheart?
  18   A. Yes, I did.
  19   Q. He was the Associate Director of Cardiac Surgery.
  20   A. No, at that time I was the Associate Director.
  21   Q. Of course, you began in January 1993, I am sorry. So
  22     you were the Associate Director. As such, did you have
  23     any responsibility to tell the team of decisions that
  24     had been made which might affect the team?
  25   A. I thought I did tell everybody in the team, really,

   1     including theatre nurses, that we are not doing neonatal
   2     switches any more.
   3   Q. How did you tell them?
   4   A. In a personal, informal manner, really. No written
   5     notice or anything like that.
   6   Q. So one by one in conversations?
   7   A. Yes. Because the last case, if I could find out who
   8     the anaesthetist was, I do remember, when we talked
   9     about it, the anaesthetist and the nurse, we all said it
  10     is not really -- I think the anaesthetist's words
  11     were ,"Back to the drawing board, Janardan".
  12   Q. Having given up the neonatal switch, you continued with
  13     the non-neonatal switch?
  14   A. Yes, sir.
  15   Q. If it is the case that anyone who does a switch
  16     operation should be able to cope with the coronary
  17     arteries, if that is true of both neonatal and
  18     non-neonatal switch operations, did your stopping the
  19     neonatal switch operations cause you to think at all as
  20     to whether you should have continued to do the
  21     non-neonatal operations?
  22   A. This question has always puzzled me because while I was
  23     having problems with the neonatal, I was carrying on
  24     doing successful older switches. During 1992/1993, or
  25     by the end of 1993, I would have done probably 12 or 13

   1     with only one death in that group, so it did surprise me
   2     and I did not have any real answer, but somehow I could
   3     not explain how I had a successful programme in the
   4     older age group but not in the neonatal group.
   5   Q. Did you at any stage take a decision to stop doing the
   6     non-neonatal switches?
   7   A. No.
   8   Q. Not at all?
   9   A. No.
  10   Q. Was a decision taken within the unit before the end of
  11     1995 to cease doing the non-neonatal switch?
  12   A. I am sorry, but you would have to explain a bit more --
  13   Q. I am sorry, can I repeat the question, because it is my
  14     fault. Was a decision taken within the unit before the
  15     end of 1994, to stop doing the non-neonatal switch?
  16   A. No.
  17   Q. I will come at a later stage in the questioning to ask
  18     you about the events that led up to the operation which
  19     you performed on Joshua Loveday in 1995, and that would
  20     involve looking at this later part of the non-neonatal
  21     switch programme. But before we leave this topic and
  22     go, bearing in mind the questions I have asked, to some
  23     of the cases that I particularly want to ask you about,
  24     were you aware during 1994 of concern being expressed by
  25     others, amongst them anaesthetists, about the switch

   1     programme you were then carrying on?
   2   A. Not in the first half.
   3   Q. Did you become aware, then, in the middle or later part
   4     of 1994 of such a concern?
   5   A. Dr Monk came to talk to me during the first week of
   6     July 1994.
   7   Q. Was he, as you saw it, expressing a view on behalf of
   8     all the anaesthetists?
   9   A. That is what he was doing, yes.
  10   Q. Did you work regularly, both as adult and paediatric
  11     surgeon, throughout 1993 and 1994, with all those
  12     anaesthetists?
  13   A. The two anaesthetists really joined only in July or
  14     August 1993. Dr Davies and Dr Pryn. Dr Davies was not
  15     primarily a paediatric anaesthetist; he had some
  16     experience during training and he was willing to help in
  17     the training --
  18   Q. Did you work with him?
  19   A. Dr Davies? Yes, at times.
  20   Q. And you worked with Dr Pryn?
  21   A. Quite often, yes.
  22   Q. And you worked with Dr Bolsin?
  23   A. Yes.
  24   Q. And Dr Masey?
  25   A. Yes.

   1   Q. And Dr Underwood?
   2   A. Yes.
   3   Q. And Dr Monk?
   4   A. Yes.
   5   Q. It would follow, from what you said, that none of them
   6     had expressed any concern to you that you understood at
   7     any rate as being concern about the switch programme
   8     until Dr Monk spoke to you at the beginning of July
   9     1994?
  10   A. That is correct, sir.
  11   Q. Do you find it surprising that you could work in the
  12     same theatre day in, day out with anaesthetists and not
  13     appreciate that they had concerns about a particular
  14     part of the work that you were doing?
  15   A. When I heard from Dr Monk, I could not believe it.
  16   Q. To what do you attribute, looking back on it, the
  17     absence of communication between the anaesthetists on
  18     the one hand and yourself on the other, so that you
  19     might become aware of that concern?
  20   A. That is what I am wondering even until now, really,
  21     because if I was not talking to anybody, then I could
  22     not really understand that, but I was talking to these
  23     gentlemen, and ladies, almost, if not every day, a few
  24     times a week. So I was in communication with them;
  25     I did not know of any reason not to talk to anybody.

   1     And I felt if there was any concern, they should have
   2     expressed to me before, in a way, going to their
   3     Director in a way which I thought probably is not right
   4     when we are so closely working together. So that is why
   5     I was surprised.
   6   Q. Again, that is a topic I will come back to. Since we
   7     have Mr Stark and Dr Silove here, can I turn from the
   8     questions I have asked thus far in relation to the
   9     switch operation in particular, and look at some of the
  10     cases which the Clinical Case Note Review have thrown up
  11     for our examination?
  12        May I begin -- I think you have the notes there --
  13     with the case of Ellie Brain. Sir, I should say, it is
  14     obvious from the fact I have used the name, that we have
  15     full consent.
  16   A. Thank you. Could I ask for your permission to use this
  17     file, because it has my quick reference and I can
  18     quickly turn the pages?
  19   Q. Please have anything you wish there. Ellie Brain was
  20     born, was she, on 3rd July 1988.
  21   THE CHAIRMAN: You need a bit of time to find your page?
  22   A. Yes, I am sorry.
  23   THE CHAIRMAN: Take whatever time you need.
  24   MR LANGSTAFF: While Mr Dhasmana is doing that, the
  25     particular interest which the Panel may have when the

   1     evidence is complete in respect of these cases should,
   2     I hope, exemplify aspects in the Brain case of
   3     pre-operative care and decision-making; in the second
   4     case to which I shall turn, the operation itself, in
   5     particular; and in the third, post-operative care. The
   6     fourth to which I shall pay regard will be the case of
   7     Joshua Loveday himself.
   8   THE CHAIRMAN: Thank you, Mr Langstaff.
   9   MR LANGSTAFF: So, Ellie Brain: was she born on 3rd July
  10     1988?
  11   A. Yes, sir.
  12   Q. Did she have a catheterisation at the age of 11 days?
  13   A. On 14th July 1988, yes.
  14   Q. She was suffering, was she, from a transposition of the
  15     great arteries?
  16   A. That is correct, sir.
  17   Q. So the question was whether or not she would be
  18     a candidate for the switch operation?
  19   A. Yes. This was in 1988, July 1988, and on the catheter,
  20     the patient was found to have a transposition of the
  21     great arteries and VSD.
  22   Q. Yes.
  23   A. Therefore, a decision was to be made, what we are going
  24     to do about it? That is what that meeting was about.
  25   Q. Yes. The decision which was taken, was it, following

   1     that catheterisation, was to list her for the switch
   2     operation?
   3   A. Yes. It is the Joint Cardiology Meeting. Can I refer
   4     to a page?
   5   Q. Yes, please.
   6   A. It is on page 67 on Medical Record No. 2420.
   7   THE CHAIRMAN: Mr Langstaff, you will help us while this is
   8     being found. Is this patient classed as a neonate, or
   9     not, because in 1988 --
  10   MR LANGSTAFF: No, she was not operated as a neonate; she
  11     was, of course, a neonate when the catheterisation was
  12     performed, and something may turn on that.
  13   THE CHAIRMAN: Thank you very much.
  14   MR LANGSTAFF: You are taking me to MR 2420/67, and we see
  15     there the --
  16   A. This is a Joint Paediatric Cardiac Surgical and
  17     Radiology Meeting, and there it lists "Dr Jordan,
  18     Dr Joffe, Dr Benatar, Dr Cormack ... and team."
  19        What we have done in these meetings,
  20     a cardiologist would present the clinical data, would
  21     present the echo picture, discuss the catheter finding,
  22     and the radiologist would help us to look at the
  23     cineangio.
  24        On the basis of that, we are really now writing
  25     here that the diagnosis of transposition of the great

   1     arteries and ventricular septal defect was confirmed.
   2        What we have noted is that this patient has
   3     pulmonary hypertension and if one looks in the -- let me
   4     finish the letter first: "... and pulmonary vascular
   5     resistance over systemic vascular resistance ratio 0.7.
   6     Angiography shows a single large very [peri]membranous
   7     VSD, and there was suspicion of tiny muscular VSD
   8     beneath it".
   9        With that, we were going to discuss, we were going
  10     to plan for this one --
  11   Q. Can I just stop you there? The position in general
  12     would be this, would it: that if there were pulmonary
  13     hypertension, then that might lead to reversible changes
  14     in the lungs, so one would need to operate sooner rather
  15     than later?
  16   A. That is correct, sir.
  17   Q. If there were no pulmonary hypertension in the lungs,
  18     a case of transposition with a VSD would normally wait,
  19     would it, and the first step would be a banding of the
  20     pulmonary artery, because otherwise the left ventricle
  21     would not develop the thick muscle it would need to pump
  22     the blood around the body when it became the systemic
  23     ventricle.
  24   A. I beg to differ there. I think it is a little bit
  25     different. When you have transposition with VSD, you

   1     already have pulmonary hypertension. These patients
   2     would normally have pulmonary hypertension. Either you
   3     repair it in a primary state at that time or you
   4     palliate -- and for palliation you are banding it -- and
   5     then you wait for child to grow to an age when you think
   6     you can repair it and then do the repair which you want
   7     to do, whether you do arterial switch or you do
   8     a Senning with VSD.
   9   MR LANGSTAFF: If I can ask you to pause there, Dr Silove,
  10     is there a problem if in fact the level of pulmonary
  11     resistance or hypertension is low, with the development
  12     of the left ventricle?
  13   DR SILOVE: Yes. I think -- may I answer that in a little
  14     more detail?
  15   MR LANGSTAFF: Yes, please.
  16   DR SILOVE: When there is a ventricular septal defect,
  17     Mr Dhasmana is quite right that it is usual that the
  18     pressure in the pulmonary artery and in the left
  19     ventricle will be high and will very often be at the
  20     same level as the pressure in the right ventricle, in
  21     transposition of course, which is the systemic
  22     ventricle.
  23        What happens if there is no VSD in the early
  24     neonatal period is that the pressure in the pulmonary
  25     artery falls quite rapidly. If there is a VSD, the

   1     pressure in the pulmonary artery tends to stay raised
   2     for a longer period.
   3        It is unpredictable, really, whether the pressure
   4     will fall for certain or not. What can happen is that
   5     the pressure can stay high, and it can stay high for
   6     many months, and that patient is then at risk of
   7     developing pulmonary vascular disease; the pulmonary
   8     vessels themselves can become diseased.
   9        On the other hand, the pressure or the pulmonary
  10     vascular resistance can fall, very often round about
  11     4 to 6 weeks of age, and you would then expect the left
  12     ventricular pressure and the pulmonary artery pressure
  13     to be higher than if there was no VSD, but it might not
  14     remain quite as high as the systemic pressure.
  15        If the pressure has fallen, reflecting a fall in
  16     the pulmonary vascular resistance, then the left
  17     ventricle is not having to work quite as hard as it
  18     would have to work if it was pumping against a greater
  19     resistance, and so it might not be quite so suitable for
  20     doing an arterial switch because it will lose some of
  21     the thickness of the left ventricular muscle.
  22   MR LANGSTAFF: In such a case, what is the appropriate
  23     surgical step? Is it to go straight to a switch, or
  24     not?
  25   DR SILOVE: Well, I think the conventional approach would be

   1     to do a relatively early arterial switch with closure of
   2     the ventricular septal defect. One can take the option
   3     of waiting, but if one waits, one has to consider
   4     whether one is going to band the pulmonary artery so as
   5     to protect the lungs from developing pulmonary vascular
   6     disease, and go for an arterial switch with closure of
   7     the VSD later, at which time you would then have to
   8     deband the pulmonary artery.
   9        The alternative strategy might be to leave the
  10     baby for a period of, say, two or three months, and it
  11     might be reasonable, say, to leave it for two months in
  12     the belief that the pulmonary vascular resistance will
  13     have remained high, and then do the arterial switch and
  14     close the VSD at that stage, but one has to be fairly
  15     certain that the pulmonary vascular resistance has
  16     remained high and that the left ventricular pressure has
  17     remained high in order for the left ventricle to be able
  18     to take over as the systemic ventricle.
  19   MR LANGSTAFF: In order to be certain, one needs to carry
  20     out what sort of investigation?
  21   DR SILOVE: One can very often get by with good
  22     echocardiography. One can look at the thickness of the
  23     left ventricle and the shape of the left ventricle, and
  24     if one has colour flow Doppler facility, one can get
  25     some estimate of whether there is purely shunting from

   1     the right ventricle through the VSD into the pulmonary
   2     artery, or whether there might be some bidirectional
   3     shunting. If one does not have echocardiography
   4     available, or if it is uncertain, then one probably
   5     needs to do a cardiac catheterisation nearer the time of
   6     the operation in order to be certain about the pulmonary
   7     artery pressure and the left ventricular pressure.
   8   MR LANGSTAFF: So what you are saying is that the critical
   9     aspect is the ability of the left ventricle to take over
  10     the systemic circulation, and that in order to satisfy
  11     oneself of that, one needs to have investigations nearer
  12     or at about the time of the operation, does one?
  13   DR SILOVE: I believe that is right. I think if you are
  14     going to do the arterial switch at the age of six weeks,
  15     there is probably no need to do further investigations,
  16     but beyond that time, you have to be fairly certain that
  17     you can expect there will still be a high left
  18     ventricular pressure.
  19   MR LANGSTAFF: Mr Dhasmana, do you want to comment on what
  20     Dr Silove has said? Please comment if you take
  21     exception to any of the points that he has made.
  22   A. No, I think Dr Silove has really described adequately
  23     the discussion on that day. It was exactly along those
  24     lines that we were talking that day, because this is the
  25     time, July 1988, when I had just started the arterial

   1     switch programme in older children. Though the
   2     pathology is the same, TGA with VSD, I was not very
   3     happy nor felt comfortable to transfer it to such
   4     a small child at that time.
   5        If I was not doing an arterial switch, conforming
   6     to my usual practice beforehand, I would have really
   7     gone for a PA band in this patient, but we had some
   8     problem with the PA band because by the time they
   9     waited, there was some further problem in the muscle,
  10     which did not help me when I tried to do a repair at the
  11     time. So I was not very happy on that.
  12        At the same time, I did not feel very comfortable
  13     in proceeding with arterial switch. Therefore, we were
  14     looking at some type of compromise for this child to
  15     reach -- I mean, there is no magic figure about it, but
  16     maybe at the back of my mind was that if three months
  17     had gone, probably the high risk period would be gone
  18     and we could do better with the arterial switch itself,
  19     really.
  20        That is how the discussion proceeded.
  21        What it did not go on was the mechanism of
  22     checking it, and of course, in pre-operative states I am
  23     very much guided by my cardiac colleagues, really. I do
  24     not think we made up our mind whether we would check
  25     anything at that time; we just simply took it on the day

   1     that I would do the arterial switch, but not now when
   2     this child is about three months of age.
   3   Q. One of the difficulties of taking pulmonary artery
   4     pressures of child who is 11 days old, as Ellie was at
   5     the date of her catheterisation, is that inevitably
   6     post-birth the lungs do have a hypertension which
   7     reduces over a period of time.
   8   A. That is physiological, yes.
   9   Q. So one would expect a catheter taken after 11 days to
  10     show relatively high pulmonary artery pressures, and one
  11     would anticipate, would one, taking your point,
  12     Dr Silove, that after a period of time that might -- one
  13     does not know -- reduce?
  14   DR SILOVE: Yes, that is right, it might. And it might
  15     not. But one has to find out.
  16   MR LANGSTAFF: It is common ground, I think, from what you
  17     were just saying, that in Ellie's case there was no
  18     further investigation?
  19   MR DHASMANA: Yes. I can see from the notes and, yes, there
  20     was none.
  21   Q. And I think we are agreed that there should have been?
  22   A. Well, now, looking back, yes, I do.
  23   Q. The reason why there was not, you say: this is something
  24     that we might have discussed in reaching the compromise
  25     that we did at the discussion, bearing in mind that she

   1     was a child who was young; we did not operate on
   2     neonates because they were too young at that stage, and
   3     it might have been suggested at that meeting that
   4     a further investigation was carried out and it was not,
   5     so that is part of the story why one was not?
   6   A. Looking back, yes.
   7   Q. Is it also part of the story as to why the further
   8     investigation that should have been carried out was not
   9     that the child was admitted for operation to the Royal
  10     Infirmary. The operation took place on 4th October
  11     1988. Is it part of the fact that the child went into
  12     the Royal Infirmary rather than to the place where --
  13   A. No, if people have made a decision on that day which
  14     child is to have a pre-operative catheter -- now with
  15     echo I do not have control because cardiologists, when
  16     they see these children in outpatients, they normally
  17     echo them. So I would not have questioned that one.
  18     But if there was a catheterisation to be done, then it
  19     would have been mentioned, "Admit to the Children's
  20     Hospital, catheter, transfer to BRI". That is how it
  21     would have been mentioned.
  22   Q. And because that was not done, she went straight into
  23     the BRI and straight into operation?
  24   A. That is correct.
  25   Q. So when you came to do the operation, you had no means

   1     of knowing, before you began, quite what the level of
   2     hypertension was, and therefore quite how able the left
   3     ventricle would be to take over the systemic flow?
   4     Is that right?
   5   A. I had relied on a patient who had a large perimembranous
   6     VSD and also a small muscular VSD underneath probably
   7     would have pulmonary hypertension, even at this time.
   8     My worry would have been more if the damage to the lung
   9     would not have become irreversible. Probably, when I am
  10     talking of the catheter, I am really talking of looking
  11     at that area rather than the suitability of this child
  12     for switch. I do not know what the experts would say.
  13   DR SILOVE: I think it is unusual for a baby to develop
  14     pulmonary vascular disease as early as three months of
  15     transposition, and I think it would be reasonable to
  16     proceed on the basis that there probably was no
  17     pulmonary vascular disease, but having said that, we do
  18     sometimes see pulmonary vascular disease very early in
  19     transposition with VSDs. It is an unknown, but I think
  20     the main reason for doing a cardiac catheter or some
  21     investigation -- a very good echo would probably have
  22     been a good substitute -- would be to try to get some
  23     confirmation that that left ventricle is likely to have
  24     a high enough pressure and be sufficiently thick-walled
  25     to take over the systemic circulation.

   1   MR STARK: I would agree completely with what Dr Silove
   2     said. Irreversible pulmonary vascular disease is very
   3     rare. I have seen it as early as six weeks, but it is
   4     very rare, so I think at three months I would feel very
   5     comfortable to operate. I think it is also very rare
   6     that the pressure with a large VSD would drop, but
   7     nevertheless, if one wants to be absolutely sure,
   8     I think one form of investigation or the other, echo
   9     certainly, should answer that perfectly well, or
  10     otherwise catheterisation. So I completely agree.
  11   MR LANGSTAFF: Would you normally expect, as a surgeon, to
  12     have a pre-operative echo or angiography?
  13   MR STARK: I personally would, but there are differences
  14     between surgeons. Some surgeons are happy to operate on
  15     the basis of echo only; some others require
  16     catheterisation. Some others may perhaps say that the
  17     previous one was all right, but I personally think one
  18     form or other of confirmation of this pulmonary arterial
  19     pressure is safer.
  20   DR SILOVE: I am sure we would have been happy with a good
  21     echocardiogram in this case, in Birmingham, but we
  22     certainly would have done an investigation.
  23   MR LANGSTAFF: Does this go so far as to say that in most
  24     cases where there is going to be a complex open-heart
  25     operation, one would expect to see some form of

   1     investigation appropriate to the operation at a time
   2     pretty close before the operation itself takes place?
   3   DR SILOVE: Yes, that is right.
   4   MR STARK: I think our cardiologists would perhaps routinely
   5     perform the echo the night before the surgery and
   6     discuss it with us, but, you know, our cardiologists are
   7     present on the premises, so that makes life a bit
   8     easier.
   9   MR LANGSTAFF: Do I take it that there was no routine
  10     practice of pre-operative echo or angiogram before
  11     complex coronary heart surgery?
  12   MR DHASMANA: That is correct.
  13   Q. And is part of the reason for that the split site, that
  14     the cardiologists were at one place and the operating
  15     theatre at another?
  16   A. That is also correct.
  17   Q. So one would not have the presence that Mr Stark has
  18     referred to on the ward the night before the operation
  19     as a matter of routine; it would have to be a matter of
  20     special request?
  21   A. Please correct me if I am wrong, but having worked in
  22     one hospital and visited the other, in both these places
  23     most of the patients are really admitted first under the
  24     paediatric cardiologist. They are almost worked out,
  25     so --

   1   Q. This is a question of looking at the team and not
   2     looking at individual responsibility?
   3   A. Exactly, so I am just saying that something comes
   4     naturally and routinely there which becomes a little bit
   5     more an "on demand" service in a centre like Bristol
   6     where you have a facility at two different places.
   7     Unless it has really been marked out right in the
   8     beginning, you do not get it unless you ask for it.
   9   Q. Thank you, Mr Dhasmana. Let us leave the case of Ellie
  10     Brain, unless -- perhaps it is convenient, as I deal
  11     with each these cases, if there are questions which the
  12     Panel may wish to address in respect of it --
  13   DR SILOVE: May I interject, please, sir? I think we should
  14     finish the story, if I may, about this particular
  15     patient. As it turns out, the left ventricle was able
  16     to take over the systemic circulation, as the evidence
  17     for that is that there was a blood pressure in the
  18     Intensive Care Unit post-operatively which was a very
  19     satisfactory blood pressure, and it showed that the left
  20     ventricle was performing as it should do. So although
  21     I am saying that measurements should have been done
  22     pre-operatively, fortunately the left ventricle was
  23     suitable for an arterial switch.
  24   MR LANGSTAFF: I think, if I can take, as it were, other
  25     questions that might arise on this, we can see from the

   1     medical notes that you quoted a risk for the operation
   2     of about 20 per cent?
   3   MR DHASMANA: I think in the notes it is a little bit
   4     different. In my hand it is written "15 per cent".
   5   MR LANGSTAFF: I am sorry, 15 per cent. What do you say
   6     about that as an estimate of risk, bearing in mind what
   7     one would have known about the 1988s?
   8   MR STARK: I think that every surgeon in every department
   9     has to have this a little bit on their own. I think at
  10     Great Ormond Street from the figures I quoted earlier,
  11     with transposition with VSD, at that stage we would have
  12     quoted high risk. I think in our hands the risk would
  13     be higher.
  14   MR LANGSTAFF: This is one of the very first operations that
  15     you were doing, was it not?
  16   MR DHASMANA: Yes.
  17   Q. And you would be appreciative that you had the learning
  18     curve anyway, to cope with. Do you think perhaps the
  19     15 per cent was overoptimistic?
  20   A. I now totally agree with you.
  21   MR LANGSTAFF: Sir, I am now going to go on to the second of
  22     our cases. I am in your hands as to whether it would be
  23     appropriate now we have gone, I think, about an hour and
  24     a quarter since the last break, whether it would be
  25     appropriate to break now or after the next case.

   1   THE CHAIRMAN: Why don't we break now until 1.30,
   2     Mr Langstaff?
   3   (12.50 pm)
   4            (Adjourned until 1.30 pm)
   5   (1.30 pm)
   6   MR LANGSTAFF: Mr Dhasmana, our next case is that of Ben
   7     Elliott. Ben Elliott, a little boy born on 8th October
   8     1989.
   9   A. Yes, sir.
  10   Q. And diagnosed fairly early on, no problem with that, as
  11     suffering from pulmonary atresia and VSD?
  12   A. That is correct, sir.
  13   Q. There is a catheterisation which takes place under
  14     Dr Martin on 13th October 1989, which showed
  15     I understand that the pulmonary arterial structures were
  16     hypoplastic with narrowing of the right pulmonary
  17     artery, separating its origin from the main pulmonary
  18     artery and the left pulmonary artery not being well
  19     seen.
  20   A. You are talking about Ben Elliott?
  21   Q. Ben Elliott. We pick that catheterisation up at
  22     MR 401/70 to 72.
  23   A. My fault because I was looking at the other catheter
  24     report.
  25   THE CHAIRMAN: Can we take the date of birth off?

   1   MR LANGSTAFF: We have full consent, of course. If we look
   2     at page 72 on the screen, the top of the page, that was
   3     the bit I was reading out to you:
   4        "the right pulmonary artery, separating its
   5     origin from the main pulmonary artery. The left
   6     pulmonary artery is not well seen probably due to some
   7     forward flow into the main pulmonary artery from the
   8     ventricular direction. This cannot be stated with
   9     absolute certainty but seems likely in the absence of
  10     alternative collateral supply into the left lung being
  11     shown."
  12        Measurements I think are attempted then and they
  13     showed that the pulmonary arteries were very small?
  14   A. That is correct.
  15   Q. Accordingly you saw Ben Elliott and made the decision,
  16     entirely appropriate, that there should be a left-sided
  17     shunt. That was performed on 14th October 1989.
  18     Thereafter the lad goes on fairly successfully into 1990
  19     until, at the age of 11 months there is a second
  20     catheterisation. That is what I think you must have
  21     been looking at before?
  22   A. Yes, page 30 I think.
  23   Q. If we can pick up that at page 49, that is where the
  24     catheterisation starts. We go over to page 50, can we
  25     scroll down, four lines underneath where it says "Right

   1     ventricle" we read:
   2        "The main pulmonary artery appears to have grown
   3     somewhat to a substantial size compared with the
   4     previous examination. The region of the proximal right
   5     pulmonary artery is not well seen and may well have
   6     increased in size but this cannot be stated with
   7     complete confidence."
   8        Underneath "Aorta": "The previous communication to
   9     the left pulmonary artery is better seen on this
  10     examination as is the opacification of the pulmonary
  11     artery itself. Again, the origin of the right pulmonary
  12     artery cannot be assessed adequately."
  13        What is apparent on the catheterisation is that
  14     there is an absence of information about the right
  15     pulmonary artery; that appears to be what it is saying?
  16   A. That is what it reads, yes.
  17   Q. Was there, at this stage, a choice of how one would deal
  18     with Ben's case?
  19   A. Ben was originally diagnosed to have pulmonary atresia
  20     with VSD and at that time we formed the view that the
  21     main pulmonary artery was either very tiny or
  22     hypoplastic. So the plan was to put a shunt in now, see
  23     him later and then decide for the future. That is why
  24     this catheter was done. On this catheter we really saw
  25     that a window -- I mean diagnosis is not exactly

   1     pulmonary atresia now because there is some
   2     communication between the right ventricle and the main
   3     pulmonary artery though it is very tiny.
   4   Q. Stop there for a moment: the main pulmonary artery would
   5     not have grown unless it was getting some blood in?
   6   A. From the shunt.
   7   Q. From the ventricle or from the shunt?
   8   A. Not exactly. From both really, from the ventricle as
   9     well as from the shunt but if it is true pulmonary
  10     atresia then it is from the shunt.
  11   Q. But there appeared to be some communication?
  12   A. Tiny communication, as it says here. I thought I saw
  13     somewhere "tiny communication".
  14   Q. I think it is there somewhere but --
  15   THE CHAIRMAN: Fourth line of the paragraph beginning "Right
  16     ventricle": "Tiny pulmonary artery communication...".
  17   A. So once we have that picture, of course what is
  18     described here is not exactly the same as you see on the
  19     Senning. When you look at the Senning film you are
  20     seeing the pulmonary arteries on either side and you
  21     then have a little better idea about the size than what
  22     is described because size has not been described
  23     anywhere in this report. So we would have actually, we
  24     used to have a ruler there in the same room and of
  25     course magnification, how much magnification as compared

   1     on the X-ray film.
   2        We would then have measured the pulmonary artery
   3     on either side and decided what we are going to do and
   4     we would have done that, it just somehow was not
   5     mentioned in any letter or even in our joint cardiology
   6     meeting except saying "It appears suitable for repair".
   7   Q. There is no record of that having been done, you are
   8     right. The choice in a case such as this would be,
   9     what, to go for repair?
  10   A. To go for one stage repair now.
  11   Q. Or?
  12   A. Or do another shunt, you know, to make it grow any
  13     bigger and then decide whether we can do a repair in
  14     a conventional manner, that is establishing direct
  15     communication between right ventricle and pulmonary
  16     artery or if it is true pulmonary atresia, fixing with
  17     a conduit outside.
  18   Q. Critical to the decision might be an idea of the size of
  19     the pulmonary arteries?
  20   A. Yes.
  21   Q. This picks up a point which you may have seen in the
  22     transcript where Ben Elliott's case was discussed
  23     earlier.
  24   A. I have seen that.
  25   Q. Dr Silove was making the point that size is important

   1     and there appeared here to be a difficulty with
   2     identifying the right pulmonary artery and he was
   3     suggesting various cardiological techniques that might
   4     have been adopted.
   5   DR SILOVE: Yes, I mean the original angiogram had not been
   6     made available to me and I was just going by the report
   7     I had read and, as you have said, there is nothing in
   8     the report to say that the pulmonary arteries had
   9     actually been measured. It seems to me as if you are
  10     agreeing with my own sentiments, that it is very
  11     important to measure the size of the pulmonary arteries
  12     in order to assess whether they would be suitable for
  13     a complete repair.
  14   A. That is what I was trying to explain, sir.
  15   MR LANGSTAFF: In any event, the decision is made because of
  16     the review that takes place that Ben is suitable for
  17     a one-stage repair?
  18   A. That is what I considered, yes.
  19   Q. The parents, Mrs Elliott, you have read her statement
  20     and you have responded to it on an earlier occasion.
  21     She recollects being in some uncertainty about what
  22     operation was proposed and at one stage thought there
  23     was to be a shunt until the night before the operation
  24     when the consent form was signed when you explained to
  25     her that it was a repair rather than a shunt.

   1        I do not know whether you recollect dealing with
   2     Mrs Elliott at all, do you?
   3   A. I cannot recollect in certain terms but all my patients,
   4     I would not have listed them for surgery unless I have
   5     talked with them in outpatients and I had talked to
   6     Mrs Elliott in outpatients.
   7        I think Mrs Elliott got confused between what she
   8     had heard from Mr Wisheart when she came to the clinic
   9     earlier when somehow she saw Mr Wisheart. That was very
  10     soon after the first shunt when the diagnosis was still
  11     pulmonary atresia. So Mr Wisheart explained to her how
  12     this would be managed in future and exactly that is what
  13     he said, as you have mentioned, that the next operation
  14     could be the shunt, and then when he grows further
  15     because he is thinking of pulmonary atresia, he is
  16     really thinking that this patient is going to need
  17     a conduit and probably a shunt on one side would not be
  18     big enough to really take it any further because they
  19     tend to get narrow or the artery gets bigger and they
  20     become less efficient and you have to provide another
  21     shunt. The child had grown to an age when you can fix
  22     an extracardial conduit because that would be a size
  23     which could go on for a few years, otherwise you keep
  24     replacing it.
  25   Q. You think that is a product of that conversation which

   1     probably took place between Mr Wisheart and Mrs Elliott.
   2        Can I ask you about one thing --
   3   A. Can I add one sentence to that one: I think after that
   4     one, I really talked to her; somehow she remembered
   5     Mr Wisheart's conversation more than mine, for whatever
   6     reason.
   7   Q. One of the things she recollects is this: she recollects
   8     your saying -- it may have been you, it may have been
   9     Mr Wisheart -- that there would be an operation to
  10     extend the artery which she remembers being described as
  11     an umbrella-type treatment. That description would be
  12     appropriate to catheterisation, would it not?
  13   A. That cannot be from the surgeon. She must have now been
  14     confused with the cardiologist saying some time in
  15     outpatients, I do not know, because I have not got any
  16     notes, but I have seen her statement where she mentioned
  17     umbrella. What she is really talking of, what I think,
  18     I may be quite wrong on that, but angioplasty may have
  19     been mentioned by somebody, I do not know who, that the
  20     pulmonary artery, if it is tiny -- the pulmonary valve
  21     area could be enlarged. But certainly no surgeon,
  22     neither Mr Wisheart or myself, would have mentioned
  23     that.
  24   Q. In any event, if we move on to what happens: Ben is
  25     admitted in 1991 for an operation, he is discharged

   1     because he is suffering from respiratory infection, not
   2     a problem but undoubtedly distressing for the child.
   3     Then on 4th June 1991, Ben now being 20 months of age,
   4     admitted for a total repair?
   5   A. That is correct, sir.
   6   Q. Can we have a look at the operation note, which is
   7     MR 213/23. We can see what was attempted, the "total
   8     repair including the transanular patch reconstruction of
   9     the main pulmonary artery and origin of the left,
  10     ligation and division of the left-sided Goretex shunt",
  11     that is the earlier shunt that had been done.
  12        If we scroll down, the findings, you describe both
  13     the pulmonary arteries there as "comparatively narrow
  14     especially at the bifurcation, admitting only 6 Hegar on
  15     either side".
  16        That struck you, did it, as narrow for a child of
  17     his age and size?
  18   A. I think 6 Hegar meant 6 millimetres really. For a child
  19     of this size I would say it was at the lower level on
  20     the range. We had -- I do not know now, it has probably
  21     changed to a different theatre, but in the theatre we
  22     had a normal RAM with a -- supposedly sized for a child
  23     of that age, weight and body surface area; we called
  24     that Lev's table, this is from Chicago, Morris Levy. So
  25     we would have consulted that and on the basis of that

   1     I would have said that it is probably at the low area --
   2     smaller side, but it was not that we could not correct
   3     it because the problem here I was seeing was right at
   4     the bifurcation, at the origin of the two arteries, not
   5     the periphery.
   6   Q. If that is something which, if you had known the size
   7     before you had started, would it or would it not have
   8     made a difference?
   9   A. 6 millimetres would not have made any difference in my
  10     opinion to proceed with total repair.
  11   Q. You go on dealing with the procedure. Can we go
  12     overleaf? Can we go back to page 23? That should be
  13     easier to read. I know sometimes I have been told by
  14     members of the public that documents are not easy to
  15     read. I try and make it better by reading out the parts
  16     which matter most.
  17        You describe here how the operation proceeds. At
  18     about the black dot which we see on the right-hand side,
  19     you describe the pulmonary arterial orifices being
  20     enlarged at the bifurcation, "the peripheral pulmonary
  21     arteries still appearing narrow", is the way you put it,
  22     "admitting only 7 Hegar".
  23        You go on, three lines further down, "though the
  24     patient was weaned off cardiopulmonary bypass, the right
  25     ventricular pressure was suprasystemic ... This

   1     improved after an hour but still the right ventricular
   2     pressure was systemic ..."
   3        What was the problem? Presumably there was some
   4     obstruction, was there, to flow?
   5   A. I think I remember, going through this which we have
   6     here, when I have enlarged the pulmonary artery by using
   7     the patient's own pericardial patch and it has gone
   8     right up to the bifurcation which includes the origin of
   9     the two arteries, so the bifurcation patch is somewhat
  10     like this, it is not exactly (indicating).
  11   Q. You are describing a T shape?
  12   A. Yes, not exactly a T. You could say a truncated T. But
  13     what I was now saying, the pulmonary arteries were
  14     almost a similar size from there on to the hilum. Of
  15     course I could not take any major repair extending that
  16     any further because to my mind it would have taken much
  17     longer and probably I would not have achieved or may not
  18     have got the satisfactory result which I did not know at
  19     that time.
  20        So I accepted that. Looking at it of course the
  21     ventricular pressure which was 75 in the beginning which
  22     was higher than the aorta which is about 120. I mean we
  23     have a formula we call P-RV-LV. It means the pressure
  24     in the right ventricle/left ventricle, and you compare
  25     it, is more than one and it is probably -- it is around

   1     the 1.1 or 1.2 figure which is quite high.
   2        Now I wait for a while. If it had not come down
   3     it would have certainly caused me anxiety but because it
   4     came down, and now if you are looking, the aorta is 75
   5     and the right ventricle has come down to 70. All right
   6     it is systemic, but if you transfer it in the same way
   7     it is not now 0.95 or 0.9 so it has come down from that
   8     level to the 0.9 or 0.95 level.
   9   Q. Both ventricles are equal pressure when it is measured
  10     at that stage?
  11   A. Yes, but you know they are not simultaneous pressure,
  12     you have not got three needles at the same place, you
  13     are measuring one after the other, because you cannot
  14     explain a left ventricle pressure of 70 and an aortic
  15     pressure of 75. So it appears that the aorta, and
  16     probably the left ventricle when it was measured,
  17     probably were of the same pressure because you cannot
  18     have an aortic pressure of 75 if the left ventricle
  19     pressure is not 75.
  20        You have got a right ventricle pressure of 70 so
  21     we now know this is lower than the systemic pressure.
  22     But of course 70 is not a usual right ventricular
  23     pressure so I have accepted. So in technical terms
  24     I have written the systemic pressure, but if you
  25     transfer in the P-RV-LV value it is now 0.9 or 0.95, so

   1     it has come down to that level. In a way I now know the
   2     obstruction is not at the central level. If there is an
   3     obstruction it could be either in the peripheral
   4     pulmonary artery or it could be in the lung itself, I do
   5     not know.
   6        I wait further because now do I accept it or do
   7     something more about it? That is why if you go further
   8     down you see what next I have done. One of the things
   9     is, you have to think of taking a load off this right
  10     ventricle because we know the right ventricle pressure
  11     at that level would not be very good for this patient,
  12     in short or long-term or whatever we call it.
  13        So I have to go in to do something about it, take
  14     the load off. Before I do I just want to make sure if
  15     there is something else happening in between the two
  16     ventricles. So I take the sample out from the left
  17     atrium and I get an oxygen saturation of 100 per cent
  18     and at the same time the arterial saturation which the
  19     anaesthetist has taken is only 80 per cent. So that
  20     means there is some intracardiac shunt, which is all
  21     right, it is not big but I did not want it big really,
  22     I felt you know that there is some shunt so either it is
  23     because of a residual leak, something -- small VSD,
  24     sometimes you can miss it especially when you have
  25     a situation like extreme tetralogy here, tetralogy with

   1     extreme pulmonary stenosis or in pulmonary atresia or
   2     there could be leaking from my patch or suture holes.
   3        So that made me feel that probably I do not need
   4     to really go back and make another hole because there is
   5     a hole there which should take the load off the right
   6     ventricle.
   7        I also know from the published literature and from
   8     all the surgeons and cardiologists that in these
   9     situations right ventricular pressure does come down
  10     with the passage of time. I keep reading and I have
  11     a reference even in the Kirklin book where it describes
  12     the chapter on tetralogy of Fallot, describes special
  13     circumstances and it mentions in the section of
  14     pulmonary atresia with tetralogy of Fallot that you can
  15     accept P-RV-LV of even 1.2 but watch these patients in
  16     the post-operative period and come back if you have
  17     trouble or P-RV-LV does not come down.
  18        With that thing in my mind I accepted this.
  19   Q. What I think you are saying is that if you had not
  20     thought there was a residual hole in the ventricular
  21     septum you would have gone into the heart and created
  22     one in order to relieve the pressure?
  23   A. That is what is in the back of my mind, that is why
  24     I took these blood samples, yes.
  25   Q. The starting point is the need to relieve the pressure

   1     and a decision that a hole in the ventricular septum is,
   2     as you saw it, necessary in order to ensure that the
   3     child has a reasonable chance of survival?
   4   A. Yes, sir.
   5   Q. Because without it the child's chances would be much
   6     poorer though not necessarily minimal?
   7   A. That is correct, sir.
   8   Q. Whatever you would have done, bearing in mind the
   9     problems of the pressure of the one ventricle as against
  10     the other, it would need to be kept by yourself or by
  11     somebody else in intensive care under very careful
  12     review because it might be necessary to go back into the
  13     heart to take further surgical steps to relieve the
  14     pressure?
  15   A. That was the idea, yes, sir.
  16   Q. May I ask, gentlemen: first of all the starting point is
  17     right, is it, that there was plainly a need to relieve
  18     the pressure in the right ventricle?
  19   DR SILOVE: I am sure that is correct, yes.
  20   MR LANGSTAFF: Again, one cannot, can one -- one would not
  21     wish to fault the decision to go back in and create
  22     a hole if there had been no hole in the ventricle; that
  23     would have been entirely appropriate?
  24   DR SILOVE: I am speaking as a cardiologist. I think that
  25     would be the right strategy, but I am sure Mr Stark --

   1   MR LANGSTAFF: Mr Stark, is that right?
   2   MR STARK: It is right. If the pressure remains
   3     supra-systemic I think one should make sure that there
   4     is a hole. If there was no proven hole by the
   5     saturations as described I think I personally would have
   6     gone back to make a hole, if the pressure remains
   7     supra-systemic.
   8   MR LANGSTAFF: One would need, for the hole to be
   9     effective, to have some reasonable assurance, would one,
  10     that the haemodynamics were such that the hole made
  11     a difference?
  12   MR STARK: Basically one is looking for creating a shunt,
  13     that means a child from 100 per cent saturation would go
  14     down say to 80 per cent and from the supra-systemic
  15     pressure, the pressures in the two ventricles will be
  16     equalised, that I think would be the confirmation that
  17     the hole is effective, yes.
  18   DR SILOVE: Also as a cardiologist, I am very curious to
  19     know why the right ventricular pressure is so high.
  20     Clearly there is some obstruction to flow, there is some
  21     increased resistance to flow at some level. As
  22     a cardiologist I would like to know at what level that
  23     is. Is it at the outflow of the right ventricle, is it
  24     in the pulmonary artery itself, is it where the
  25     pulmonary artery divides into right and left or is it

   1     beyond that? As a cardiologist my instinct would be to
   2     say: "What are the pressures in the pulmonary arteries?"
   3     but I am not sure that is necessarily a surgical
   4     approach.
   5   MR STARK: This was one other question I wanted to ask
   6     Mr Dhasmana. This is obviously a difficult situation
   7     because one would have expected the pressure to come
   8     down. Was it customary in this situation for your
   9     cardiologists to be in the operating room and discuss
  10     the steps that should be taken, for example whether one
  11     should re-open the ventricular septal defect because
  12     certainly I think in our setting this is what would have
  13     happened, we would have called the cardiologist to the
  14     theatre and discussed it together.
  15   A. No, there was no customary practice for a cardiologist
  16     to be in theatre when we were operating on children.
  17   MR STARK: This is because again they were in another place?
  18   A. Distance and then because there were -- this is 1989 --
  19     of course we had now three cardiologists.
  20   MR LANGSTAFF: This is 1991, the operation?
  21   A. Yes, we had three cardiologists but they were still
  22     also doing clinics in different places and sometimes
  23     there could be only one paediatric cardiologist during
  24     the day and looking after you could say Bristol. So he
  25     could be in the Children's Hospital. Of course on paper

   1     we always had this facility, "Send for us and we will be
   2     there" and they used to be, but probably somehow in the
   3     back of our mind was it would not be easily available.
   4   MR LANGSTAFF: Dr Silove, suppose you had been the
   5     cardiologist called and appreciating all the
   6     difficulties of looking at this with hindsight, if you
   7     were called to an operation which had proceeded as the
   8     note shows us and asked to discuss it with the surgeon,
   9     what do you think you would probably have recommended?
  10   DR SILOVE: The surgeon and I would have had a discussion
  11     and I would have said to him "Are you absolutely certain
  12     there is no obstruction either at valve level where you
  13     have put the patch on the pulmonary artery or where the
  14     pulmonary artery divides? Can you perhaps put
  15     a catheter up there and measure the pressures?" Usually
  16     the surgeon will say "I will do that" or "I will try
  17     it".
  18        I think this is a good example of team effort
  19     where the cardiologist and the surgeon work together in
  20     discussing something.
  21   MR STARK: I think it is exactly what our cardiologist would
  22     have suggested, yes, what Dr Silove says.
  23   MR LANGSTAFF: Suppose you do not get resolution of the
  24     problem in that way. Obviously you might do, but you
  25     might not. What about the size of the hole in the

   1     ventricular septum?
   2   MR STARK: I think it would have depended on what I said
   3     are the criteria for efficiency. If it showed that the
   4     arterial saturation dropped and the pressure from
   5     supra-systemic came to systemic, this is what we set out
   6     to achieve, I would be happy. If this was not achieved
   7     I would think about making the hole bigger.
   8   A. Can I come in?
   9   MR LANGSTAFF: Yes, please.
  10   A. Here we have already got an 80 per cent saturation so
  11     that pressure had already come down in the right
  12     ventricle so I felt we have already achieved by making
  13     a hole really.
  14   Q. The child then, if we can leave the operation, goes from
  15     the operating theatre into the ITU and remains stable
  16     for 4 hours and then Ben deteriorates, requiring
  17     increasing support and sadly dies at 5.00 in the morning
  18     on 5th June.
  19        Dr Silove, do you have a comment about the care on
  20     ICU and what should have happened as you see it, bearing
  21     in mind what Mr Dhasmana has said about the need to keep
  22     this situation under careful review?
  23   DR SILOVE: I think if this had happened in our institution
  24     the cardiologist would have been on the Intensive Care
  25     Unit fairly soon after the patient got back and would

   1     have done an echocardiogram. This is 1991, we had
   2     colour flow facilities at that time.
   3        We would very carefully have assessed, firstly the
   4     function of the two ventricles, secondly, we would have
   5     assessed whether there was any evidence of obstruction
   6     to flow into the pulmonary arteries which one could do
   7     with echocardiography and, thirdly, we would have
   8     probably tried to assess how much shunting there was
   9     from right ventricle to left ventricle through the
  10     residual ventricular septal defect and we would probably
  11     have been closely involved with the further observation
  12     of the patient and if there was any sign of
  13     deterioration would almost certainly have repeated the
  14     echocardiogram later on.
  15        There would have been a dialogue going on all the
  16     time between the cardiologist and the surgeon. I am not
  17     saying the cardiologist would have been in the ITU all
  18     of the time, but there certainly would have been this
  19     dialogue and the facility to do these ultrasound
  20     investigations.
  21   Q. We have an operation after which the death occurs at
  22     5.00 in the morning following deterioration during that
  23     period. Would it be likely that in many units there
  24     would be a cardiologist around dealing with a case such
  25     as Ben's in those hours?

   1   MR STARK: I seem to be agreeing too much with Dr Silove, it
   2     starts worrying me, but I think it is very important
   3     because, especially in Fallot's tetralogy there is
   4     a situation we call "restrictive right ventricle". In
   5     simple terms, if the child's heart does not perform
   6     after open heart surgery, the first step is to increase
   7     volume and the second step is to give drugs, so-called
   8     catecholamines to improve the performance of the heart.
   9        If you have this restrictive physiology, it is not
  10     the pumping of the ventricles, but it is the relaxation
  11     of the ventricle and in that situation, instead of
  12     giving catecholamines you actually give vasodilators
  13     which improve the situation almost paradoxically because
  14     you lower the blood pressure but you improve the flow
  15     and that can be only done on the basis of
  16     echocardiographic investigation. So in this situation
  17     certainly we would do immediately the echocardiogram and
  18     our cardiologist would be there and perhaps this would
  19     alter our strategy.
  20   MR LANGSTAFF: You would have done this in 1991.
  21   MR STARK: Oh, yes.
  22   MR LANGSTAFF: There is no record in the notes of
  23     a post-operative echocardiogram having been done, is
  24     there?
  25   A. I -- having seen that -- know it was not done.

   1   Q. You know it would not have been done?
   2   A. Having seen the notes, I have seen very carefully and
   3     I know there is no record of this being done.
   4   Q. Is the point which is made by both Mr Stark and
   5     Dr Silove a good one: that in order to manage Ben's case
   6     effectively one would wish to have a post-operative
   7     echo?
   8   A. That should happen, but that was not routine at Bristol
   9     at that time.
  10   Q. Again we come back to the problems we identified
  11     earlier, do we, the problems of the availability of
  12     cardiologists?
  13   A. I think this case also -- I tend to have some memories
  14     of bad cases. We returned from theatre about 6.00/7.00
  15     in the evening. Again, as I said I sat around for about
  16     1 hour and it looked very good. I came back about 11.00
  17     and I was totally surprised that he looked so ill in
  18     front of me. Of course you know the problem with the
  19     unit, it could be highlighted now here that there was --
  20     we could really say that we almost, what we call, near
  21     misses, we failed to identify near misses here.
  22        When I saw him he was very sick and I had now in
  23     front of me a child fluid overloaded. I think by this
  24     time we had -- this red herring of chest infection
  25     somehow came in because anaesthetists managed to find

   1     some thick mucous plug at the end of the operation or
   2     mentioned to the mother or whoever was there and was
   3     being treated on the line of infection, which did not
   4     make sense to me when I came back and of course you know
   5     we got a child fluid overloaded.
   6        I now started on PD to get rid of fluid really but
   7     he kept deteriorating and finally died. Unfortunately,
   8     looking back, it would have been so good if we had
   9     somebody to have examined with the echo but at that time
  10      -- I could also take partial blame that I did not
  11     insist on somebody coming at 1.00 in the morning to come
  12     and do the echo, but that means calling somebody from
  13     another hospital with another facility and the usual
  14     thing. But I take my share but I do feel that that
  15     should have been done, yes.
  16   MR STARK: Can I ask through you one question: Mr Dhasmana
  17     mentions a fluid overload which obviously in this
  18     situation is very difficult. I just wanted
  19     clarification because in some of the transcripts of your
  20     talks with the anaesthetist it seems there was
  21     a protocol in ITU how to handle, for example fluids, and
  22     it also seemed that some of the senior members of the
  23     teams were even not aware of this protocol which to me
  24     gave an impression that, you know, there were perhaps
  25     some problems. Because if it then leads to the fluid

   1     overload then obviously even the result of the best
   2     operation can be compromised. Can you comment on that?
   3   A. Yes, protocol has always been there in the unit, we
   4     always had that protocol. I was quite surprised to read
   5     that in the transcript the person concerned did not know
   6     about it. Obviously he did not pay any attention to
   7     it. But protocol was there. The other two
   8     anaesthetists, they appeared in June and July 1993, so
   9     I do not think I should really say anything about them,
  10     but others should have known.
  11        I know Dr Masey and Dr Underwood they used to
  12     stick to the protocol and also when I used to leave the
  13     ward, I used to leave a lot of notes. You will find the
  14     post-operative first sheets would be always in my hand
  15     saying how much fluid to be given. So I would write
  16     that but what would happen sometimes, when there is more
  17     drainage from the chest drain and various things, people
  18     would just replace it if you have somehow not specified
  19     and you are not there really.
  20        This patient when I came back, CVP was 20 or 25,
  21     and in a way I am now really telling them that you did
  22     not need to replace losses, whatever was there, if you
  23     have high CVP. But sometimes you cannot keep repeating
  24     that thing every day and unfortunately that does happen
  25     from time to time even probably in all units.

   1   Q. You were there in the early evening and you came back at
   2     11.00 and were astonished at the deterioration. Who had
   3     been in charge of the child in the intervening period?
   4   A. In a way, a resident SHO there but also my Registrar, he
   5     should have been around or would be around and similarly
   6     the Anaesthetic Registrar also in the same position.
   7   Q. None of them had called you to discuss with you the
   8     deterioration in the condition?
   9   A. No, but that could be again -- this is the problem when
  10     you have a set pattern of some consultants doing these
  11     things, sometimes people wait, "well, he will be coming
  12     back in half an hour anyway". Sometimes what looks more
  13     important in retrospect may not have looked important to
  14     them but that is what always used to worry me and I have
  15     always been very much concerned about these near misses,
  16     about which I was not that knowledgeable at that time,
  17     until recently, after Mr De Leval's report really.
  18   Q. Again, perhaps with the dangers of thinking back on it,
  19     this was a case in which it was important, once Ben had
  20     left the operating theatre, that a review should be kept
  21     because there had been the difficulties of the pressures
  22     in the two ventricles and we had agreed I think that
  23     there was a need to keep his case under careful review
  24     because there might be a need to go back in and create
  25     a larger hole in the VSD, presumably, to relieve the

   1     pressure?
   2   A. What looks a fair time interval now probably may not
   3     have sounded that much to them because I would have left
   4     say at 8.00 and then I was back in at 11.00. Maybe to
   5     them it did not look that way and I also probably did
   6     not anticipate for my part that it could happen like
   7     that and I -- it is possible I may not have left a
   8     message that very clearly marked them.
   9   Q. Again with the dangers of hindsight, that is a message
  10     which if you did not leave it but you might have done,
  11     should certainly clearly have been left?
  12   A. Yes.
  13   Q. If you did leave it then the Senior House Officer or the
  14     Registrar in surgery or anaesthetics it would appear did
  15     not take sufficient notice of it to bring you back
  16     sooner when something might have happened. I do not
  17     know, suppose you had been called back at 9.00, would
  18     you, do you think have called for an echo perhaps?
  19   A. I think probably if I was not confronted with fluid
  20     overload which really just put me off course really
  21     I would have asked to do the echo. But having seen the
  22     fluid overload my first priority was to get rid of this
  23     fluid.
  24        But if I had seen him not doing well, his drop in
  25     blood pressure, saturation and things like that but not

   1     overloaded, I would have definitely asked for duty
   2     echo. But here I appeared at a wrong time and probably
   3     what was a wrong track.
   4   Q. Was it a difficulty of the Intensive Care Unit at this
   5     time, 1991, that no one had overall charge of the ICU?
   6     You as a surgeon had responsibility for the surgical
   7     aspects of your case as we understand it, the
   8     anaesthetists would have responsibility for the
   9     anaesthetic aspects and I think there may be in some of
  10     the evidence we have heard something of a grey area
  11     where one stopped and the other started?
  12   A. There was no continuity of care, that is the word I was
  13     putting really.
  14   Q. Do you want to comment on that?
  15   DR SILOVE: I do not know if I want to comment on that
  16     particular point. There should of course be somebody
  17     who is in overall charge of the management of the
  18     patient and people need to channel their questions about
  19     how to manage the patient through that person.
  20        I wanted to raise an additional point about the
  21     question of doing echocardiograms on the Intensive Care
  22     Unit: from what I understand, especially from what
  23     Mr Dhasmana has said today, there just was not the
  24     culture of the cardiologists being available on the
  25     Intensive Care Unit on a regular basis to do

   1     echocardiograms, is my understanding. They might have
   2     done it sporadically and occasionally.
   3   MR LANGSTAFF: "On demand" was the expression Mr Dhasmana
   4     used earlier.
   5   DR SILOVE: "On demand". I think the problem here is that
   6     one needs to have echocardiograms done on almost every
   7     patient on the Intensive Care Unit. If you are going to
   8     get benefit from doing echocardiograms on patients who
   9     are very sick, you have to know what a patient's
  10     echocardiogram looks like when he is doing well, in
  11     other words a patient who is doing well, you need to
  12     know what that echo looks like so that you have
  13     something to compare it with when you have a patient who
  14     is doing badly.
  15        It really boils down to a culture of having
  16     someone available on the Intensive Care Unit at any time
  17     for any of the patients. I can see how very difficult,
  18     or virtually impossible this must have been with the
  19     cardiologists in one hospital and the patients in an
  20     Intensive Care Unit at another hospital.
  21   MR STARK: It is well-known after open heart surgery, the
  22     child comes from the operating room and maybe in good
  23     condition and it is usually 4 to 6 hours later then that
  24     the water which accumulates in the heart, in the lungs
  25     causes some deterioration. This is why I would

   1     100 per cent agree with what has been said. If you do
   2     routinely an echocardiogram when the child comes from
   3     theatre, then when the child deteriorates you know
   4     whether the problem was there already or whether it is
   5     a new problem.
   6        The second point I would like to make: if you want
   7     to interpret the echo, it is not only just to put the
   8     transducer on the chest, you have to do it often. If
   9     you do a one-off investigation, similarly like one-off
  10     operation, you are not very good at it. Particularly in
  11     the ITU where the window -- that is the way you look at
  12     the heart -- is limited because you have dressings, you
  13     have drains so I think the routine approach really is
  14     the answer.
  15        Again, I agree with what Dr Silove said: in the
  16     situation in Bristol where the cardiologists were placed
  17     in another place, it must have been extremely difficult.
  18   MR LANGSTAFF: Do you want to comment on that at all?
  19   A. Looking back, no.
  20   Q. At the time or at about that time, very shortly after
  21     this, you went off to Birmingham to see Mr Brawn and the
  22     setup there. Was it your impression that at Birmingham
  23     when you looked at it there was a culture of
  24     post-operative echo?
  25   A. I did not see any echo being done, but I did not stay

   1     that long.
   2   Q. So there might have been, but you cannot say?
   3   A. No, that is true. But I knew at GOS, when I was there
   4     in 1983 there was a very active Senior Registrar,
   5     Dr Smallhorn, he had walked with a huge machine. In the
   6     evening I would be on and various things and I used to
   7     feel so relieved really seeing him when examining
   8     patients. Of course, that was at the back of my mind
   9     and I asked for it a number of times but somehow we
  10     could not really get that thing going.
  11   Q. Whom did you ask?
  12   A. I asked -- I think Bristol, somehow BRI, there was
  13     a Cardiac Radiology Department, it is quite strong in
  14     a way, they control a lot of cardiac imaging. Of course
  15     there is an echo facility in the BRI but that is under
  16     the auspices of Cardiac Radiology. So if you have to
  17     really ask for an echo, you call them.
  18        I did not like calling them unless it was Dr Wilde
  19     or Dr Murphy who were doing it because they were the
  20     ones who really did that often and knew. So a number of
  21     times I would wait for, if I know that they are not on,
  22     I would wait for our Paediatric Cardiologist to come
  23     around and ask them to do it. Of course they had to --
  24     I think we had a machine in the ward, I think in 1991 we
  25     probably had a machine in the ward, then they would do

   1     it. But if they were not there then we had a problem.
   2   Q. What you are describing is almost a turf war between the
   3     cardiac radiologists who appeared to have been regarded
   4     as responsible for cardiac echos. The cardiologists
   5     were able to help you because they could interpret and
   6     do the work.
   7        You were saying this to me in the context of my
   8     question, which was: whom did you ask for the machine
   9     you have described; I do not think you have answered
  10     that?
  11   A. Starting from that cardiac radiology, and of course you
  12     know we had a problem because that echocardiogram
  13     machine could be going anywhere, so we really decided to
  14     have one in the ward itself. The funding was really
  15     arranged by two or three sources: South West Children's
  16     Heart Circle put money in it; Mr Wisheart, he had his
  17     own discretionary fund, he put some money in it and
  18     I put some money in it and that is how we got that
  19     machine and also, even the ECG machine in the ward.
  20        So a lot of things were being done from other
  21     sources and once that machine was there then our
  22     paediatric cardiologists could really do echos more
  23     often than they were doing before.
  24   Q. When did you get that machine?
  25   A. That is what I was trying to remember and I am sorry,

   1     I cannot recall the exact time but it could be around
   2     that time.
   3   Q. What I suggest is that overnight perhaps you think
   4     again, if you can, as to when it was that machine came
   5     and let us know.
   6        Before we have a break because I think it is
   7     probably time to have a break before we deal with the
   8     third of the cases I wanted to ask you about, you
   9     mention asking a number of people for this equipment.
  10     Obviously eventually you got it with the funding from
  11     the sources you have described, but before they provided
  12     the funding, who had you asked?
  13   A. I think my communication would have been to Dr Wilde in
  14     a way, how to improve the echocardiographic service in
  15     the unit because I was very keen on getting that and
  16     there had been quite a few correspondence between myself
  17     and Dr Wilde and of course Mr Wisheart also in between.
  18        Mr Wisheart I knew was a very keen supporter of
  19     this idea, so there was no problem amongst surgeons
  20     because we all wanted that. The only problem was
  21     somehow funds to get that machine in the unit.
  22     Paediatric cardiologists were very happy to do the
  23     examinations, but their machine was in the Children's
  24     Hospital and they could not carry it all the time.
  25   Q. Before we finally leave Ben Elliott's case -- we are

   1     almost at the end of it -- there are one or two matters
   2     I want to discuss with you. You came at 11.00; you
   3     thought you were managing a problem of fluid overload;
   4     you were not I think there when Ben finally died in the
   5     morning?
   6   A. No.
   7   Q. How long do you think you stayed after coming at 11.00?
   8   A. Maybe about an hour, it is the usual -- midnight, you
   9     know.
  10   Q. Again since the picture that is painted by the notes
  11     I think is one of steady deterioration, is it not?
  12   A. I think I had a very experienced Senior Registrar at
  13     that time so in a way -- it could have been Mr Waterson
  14     who is now a consultant elsewhere in paediatric cardiac
  15     surgery and I was quite pleased to leave. In a way
  16     I think by the time we left I already had a chat with
  17     the parents and I showed my great pessimism at the way
  18     things had gone and felt that probably now -- not much
  19     I can really now do: "Hope he settles on PD and then we
  20     will decide what to do next day". That is really how
  21     I left it at that time. Unfortunately he kept
  22     deteriorating.
  23   Q. Mr Waterson, had he been in the operating theatre with
  24     you?
  25   A. I am not sure. Can I look? No. I saw it, it is

   1     Mr Jack Taff who then moved to Birmingham and he is now
   2     a cardiac surgeon somewhere in Bombay.
   3   Q. Was it Mr Waterson who was the Senior Registrar on duty,
   4     on call for the ICU or not, do you remember?
   5   A. I am not sure now, I have not seen his name. But it was
   6     during that time. This chap was also very good and
   7     I had full confidence in him and he was a very keen
   8     paediatric cardiac --
   9   Q. You expressed your pessimism to the parents you have
  10     told us and that was before you left in the evening?
  11   A. That is correct.
  12   Q. They have said -- it is obviously their perspective --
  13     that when they were told by another doctor on the
  14     Intensive Care Unit that you had gone home, they felt
  15     you had as it were washed your hands of Ben; that is the
  16     description they use and you have seen that in
  17     Mrs Elliott's statement?
  18   A. I have seen that.
  19   Q. Again, you had continuing responsibility as the surgeon
  20     for Ben; you had an operating list, did you, the next
  21     day?
  22   A. Not necessarily because, as I said yesterday, usually
  23     there used to be a gap of a day between two -- my
  24     operating slot used to be, I do not know whether this
  25     patient was operated on Thursday or Tuesday, 4th June

   1     1991. If it was Tuesday then the next lot would have
   2     been Thursday. If it was Thursday then it would have
   3     been either Friday -- yes, it could have been Friday but
   4     I am not sure.
   5   Q. If you were pessimistic and had expressed that to the
   6     parents, although you might not use the same words had
   7     you, do you think, in your own mind perhaps washed your
   8     hands of Ben? There is a difficult situation, you are
   9     pessimistic; do you remember how you felt?
  10   A. I am sure the nurses would tell you that I have never
  11     washed my hands of any patient right up to the end. Of
  12     course you have to be realistic about situations, you
  13     can do only this much and after that you know things
  14     only -- only if things improve.
  15   Q. The other matter I want to explore with you from what
  16     the parents recall -- WIT 227/15, the bottom of the page
  17     and it is something which I ought to give you the
  18     opportunity of dealing with orally. You have submitted
  19     some written comments on this but what is said is that
  20     after Ben died the parents came to see you. Under
  21     paragraph 62 there is a talk about which operation was
  22     selected. Mr Elliott asks you why you have closed the
  23     shunt off and I think the explanation for that
  24     surgically would be that that is essential if the
  25     operation is to be done on bypass?

   1   MR STARK: Yes, you cannot go on bypass without closing the
   2     shunt.
   3   MR LANGSTAFF: Therefore Ben could not have relied after
   4     that on the shunt. There is a comment which he and
   5     Mrs Elliott recall you having said, that you would not
   6     have had a two stage operation you would rather have one
   7     stage because "such a course of action would not be
   8     cost-effective"?
   9   A. I think I have answered that in my statement if you want
  10     to flash that one, you would see it. Because cost has
  11     never come in my mind in treating any patient, adult or
  12     child. "Cost-effective" is not the word I would have
  13     used. I do not know what I would have said, but not
  14     "cost-effective".
  15   Q. WIT 227/23: this is your response. You have never used
  16     the term "cost-effective" in deciding against any
  17     operation in cases of sick patients, and you say you:
  18     "Would have made a note of the conversation if there
  19     were any cause of annoyance during that meeting".
  20   A. I have always -- when the parents have left in some type
  21     of way which I thought was an unsatisfactory manner,
  22     I have put it down in the notes and there is no such
  23     mention in the notes.
  24   Q. The more general point emerges really: to what extent
  25     did considerations of cost come into the question of

   1     whether you chose to operate and, if you did choose to
   2     operate, whether you would operate by one method or
   3     another?
   4   A. As I have said before, nothing.
   5   Q. Sir, may we, having dealt with the case of Ben Elliott,
   6     now perhaps have a break and then turn to look at the
   7     next case from the Case Note Review which will be that
   8     of Joseph Good?
   9   THE CHAIRMAN: Reminding ourselves always of the purpose for
  10     looking at these cases, as we need always to remind
  11     ourselves. Let us now take a break for 10 minutes, that
  12     is just after 2.50.
  13   (2.40 pm)
  14               (A short break)
  15   (3.05 pm)
  16   MR LANGSTAFF: Can I, Mr Dhasmana, turn to the case of
  17     Joseph Good?
  18   A. Yes.
  19   Q. Joseph Good was a boy born on 16th June 1990.
  20   A. Yes, sir.
  21   Q. Who was referred from Rotherham to Swansea by
  22     a paediatrician, suffering from a number of problems,
  23     most of which were not cardiac problems, but amongst
  24     them, Fallot's tetralogy.
  25        He was first seen, I think, in the clinic in

   1     Haverfordwest by Dr Jordan from Bristol on 26th March
   2     1991, when he would have been just over 9 months of
   3     age. He came in for a cardiac catheter on 23rd May
   4     1991, and on 24th May 1991, then aged 11 months, he had
   5     a cardiac catheter under Dr Jordan at the Bristol
   6     Children's Hospital.
   7   A. That is correct, sir.
   8   Q. That showed, did it, that the main pulmonary artery was
   9     hypoplastic, and the origin of the left pulmonary artery
  10     was completely obstructed proximally. It emerged,
  11     I think, that the left pulmonary artery did not arise
  12     from the main pulmonary artery, but came off a patent
  13     ductus.
  14   A. That is correct, sir.
  15   Q. The catheter was therefore done at an appropriate time
  16     and produced quite a lot of detailed information, did
  17     it, about the condition of Joseph?
  18   A. That is correct, sir.
  19   Q. There was, then, a meeting -- let us have a look at the
  20     medical note which is MR 1732/38. We see who is there:
  21     both the surgeons -- this is the joint cardiology
  22     surgical meeting at which the case was discussed.
  23        Can we look down? Joseph Good, tetralogy of
  24     Fallot with disconnected left pulmonary artery filling
  25     via the ductus, as we have described. It was agreed

   1     that Joseph needed to have the left pulmonary artery
   2     joined to the right or main pulmonary artery and the
   3     establishment of a central shunt. It needed to be done
   4     on bypass because the left pulmonary artery takes
   5     a considerable amount of blood because it would be very
   6     difficult to obtain an adequate side bite on the right
   7     pulmonary artery.
   8        That is the plan, then, of action.
   9        Would it have been easier, do you think, to have
  10     gone for a Blalock-Taussig shunt, or not?
  11   A. I am not sure I understand your question that well. If
  12     somebody would ask what you really mean by
  13     a Blalock-Taussig shunt, are we talking of sites or --
  14   Q. On the left side.
  15   A. This is the patient who has a catheter diagnosis of
  16     tetralogy of Fallot with hypoplastic pulmonary artery,
  17     and disconnected -- the term we used, non-confluent
  18     pulmonary arteries -- where the blood supply to the
  19     lung, the one I could really see, was really coming out
  20     from the ductus. The ductus itself was narrowing. So
  21     the problem, as I see it, it was more on the left side
  22     than on the right side. The right side already had
  23     a dubious blood supply; I do not know how much was
  24     coming from it. So in a way, my anxiety really would be
  25     to preserve the blood supply to the left lung, because

   1     here the patient was just living on -- if we look at the
   2     catheter report on page 39 to 43, it does say the PVA is
   3     narrowing.
   4   Q. Do you want the last page of that? That is the first
   5     page of the catheter report. We can go through to the
   6     last page if you want, which has the report on it,
   7     I think?
   8   A. I think the number on mine does not match with what is
   9     on here.
  10   THE CHAIRMAN: You take the time and find the page that you
  11     wish. Perhaps we could take it page by page?
  12   A. It says here "filling from small patent ductus
  13     arteriosus", but when you looked you could see there was
  14     a narrowing right in the beginning so here I have
  15     a child who is now 18 months old or something like
  16     that -- no, it is about a year old when it was being
  17     discussed, and the blood supply, what I was really
  18     saying was, from the duct with now the small patent
  19     ductus arteriosus. So in my mind the urgency here was
  20     to deal with something on the left side, not on the
  21     right, and the left I was looking for. Because this is
  22     the only blood supply this patient was getting, I could
  23     not really do a Blalock-Taussig shunt in a classical
  24     manner, because you have to put a clamp on the pulmonary
  25     artery. The only supply I had, if I put a clamp on, the

   1     child may not survive. That means to do this one,
   2     I have to really do it on bypass.
   3        At that time, the heart and lungs are being looked
   4     after by the machine when I have a clamp on and I am
   5     doing things. Because I am going to use bypass,
   6     I thought why do I not also at the same time try to
   7     establish continuity, if I could. That is the reason
   8     I decided -- when I say I "decided", of course, you
   9     know, I am using the term here "I" but it was the whole
  10     team. We decided that if I am going to use bypass, then
  11     that is what I would do.
  12        If, as you say, a Blalock-Taussig shunt was being
  13     considered, then yes it could be done in the usual
  14     manner, but to me, that was not the right treatment at
  15     that time.
  16   Q. You have explained the reasons why you went for the
  17     central shunt.
  18   A. No, I did not say that until now. What I really said,
  19     that in a way, establish a shunt, I did not say
  20     "central" shunt until now. I said I would use bypass
  21     to establish the shunt. And of course, when I am doing
  22     that, then I could connect it. But just by connecting,
  23     it would not increase in size unless I put a shunt on.
  24        I felt at that time we have got the pulmonary
  25     artery, and it is possible that I would be able to fix

   1     a central shunt. So that is where the decision of
   2     central shunt came in, after connection and doing all
   3     these things.
   4   Q. The operation then takes place on 9th January 1992.
   5     The child by now is 18 months of age. The report is at
   6     MR 1732/25 and we see what took place: the disconnection
   7     of the left pulmonary artery from the aortic arch; the
   8     re-anastomosis to the main pulmonary artery and the
   9     insertion of the central shunt consisting of 5 mm
  10     Goretex.
  11        If we go down and have a look at what takes place
  12     during the operation, the main pulmonary artery, under
  13     "Findings", very narrow. The left pulmonary artery
  14     markedly narrow in the beginning. The procedure: you
  15     describe bypass. We can go over the page, and pick it
  16     up on the second line towards the end:
  17        "During a period of circulatory arrest, the left
  18     pulmonary artery was ligated at its origin in the aortic
  19     arch and opened in its proximal portion where it was
  20     very narrow. The fibrous connection was excised. The
  21     main pulmonary artery was opened in its distal part.
  22     Continuity between the main pulmonary artery and the
  23     left established posteriorly by joining in end to end
  24     anastomosis, causing quite a bit of tension, so the
  25     anterior wall was formed by inserting a Goretex patch".

   1   A. Yes.
   2   Q. Just stopping there, this is a frequently encountered
   3     problem and solution, is it, Mr Stark?
   4   MR STARK: Yes, it is, because I would just comment on the
   5     approach. I agree, in my view this would be an optimal
   6     approach because when the ductus supplies the left
   7     pulmonary artery, which is discontinuous, it has
   8     a natural tendency to narrow. If it narrows and
   9     occludes, some tissue of the ductus extends to the
  10     pulmonary artery, which also narrows, so supposing you
  11     have done the shunt on the right, this left pulmonary
  12     artery can become so small that it may not be salvagable
  13     after one or two years. So this is why I think this
  14     approach is preferable and because the distance may be
  15     long, sometimes it is quite a lot of tension. You want
  16     to avoid tension because that would cause subsequent
  17     stenosis, so you may just anastomose the big wall and
  18     put the patch on anteriorly.
  19   Q. The difficulty with is that as you put tension on
  20     a vessel, so you make it a bit thinner, do you?
  21   MR STARK: I am not sure about the pathological mechanism,
  22     but if you have tension on the vessel, whether it is
  23     a coarctation, whether it is a pulmonary artery, it
  24     tends to get stenosed.
  25   Q. Therefore you need the patch?

   1   A. Yes.
   2   Q. What we read on to see is -- this is looking just above
   3     the black hole, the black mark on the right-hand side:
   4        "The patient was weaned off cardiopulmonary bypass
   5     with minimal problem, but there was considerable oozing
   6     from the mediastinal dissection, and also from the PDA
   7     reconstruction suture line which required a considerable
   8     amount of effort by use of haemostatic agent and the
   9     insertion of a few stitches before bleeding was
  10     minimised and the chest was closed in layers in our
  11     usual method."
  12        The problem then here was at this stage bleeding,
  13     was it?
  14   A. Can I go back a bit? I have read the transcript also,
  15     that is why I think I feel that I must explain it a bit
  16     more here. The impression is being given from this
  17     description here as if the whole anastomosis or the
  18     graft after the anastomosis was under tension. No.
  19        If that tube, after you have dissected it or
  20     detached it from the undersurface of the aorta, excised
  21     the fibrous part and if I had just pulled it together,
  22     then it would have been very tense and instead of a tube
  23     it would have been stretched out. So that is why the
  24     term is being used a "tension".
  25        Instead of using that way, if I had opened it as

   1     a flap and fixed it like that, it is a type of a -- I do
   2     not know how to describe that, but the front open and
   3     the rest of the patient's own tissue back, but the
   4     tension is now gone, so the rest of the anastomosis,
   5     once you have inserted it, it is sitting comfortably.
   6     Maybe my use of English language is not very good here,
   7     but the "tension" was really meant to explain the
   8     problem which I had in the beginning, if I would have
   9     brought it together as a tube to use the left pulmonary
  10     artery as such. But by modifying the technique,
  11     I relieved the tension, so at the end there was no
  12     tension.
  13        That is why I wanted to clarify, because from the
  14     transcripts, it gives the impression as if the whole
  15     anastomosis at the end was under tension. I do not
  16     think any surgeon -- and of course I quite agree with
  17     the transcript on that day, that tension is bad news and
  18     no surgeon likes to have tension in an anastomosis,
  19     whether it is in the gut or the blood vessel.
  20        So I did not accept tension at the end.
  21        Of course, the bleeding here, coming to your main
  22     question now, is really because that part of the ductus,
  23     I had detached it, it had by this time become partially
  24     calcified. I think you can see at the top of the report
  25     it does say. So when you put a stitch in there, if

   1     I put a buttress and various things, they tend to cut
   2     through, so it took me quite a bit of time to control
   3     that bleeding. That is what I am talking of,
   4     mediastinal bleeding. That is the section you cut out
   5     in the mediastinal, to separate it, detach it and
   6     repair: that is where they are bleeding from. Once you
   7     have put in a buttress, you are really saying ooze is
   8     coming out, and sometimes you just have no other option
   9     but to wait for the other haemostatic agent for some
  10     time before you think you are ready to close.
  11   Q. So you have explained the wording that you used in the
  12     operation note, and that is helpful, and I think
  13     confirmed the question that I was asking you. But tell
  14     me if I am right or not, that by the end of the
  15     operation, the problem that you were faced with with the
  16     patient was that there was bleeding?
  17   A. There was bleeding, yes.
  18   Q. And that meant, did it, that ending the operation took
  19     rather longer than it might have done, because you
  20     obviously wanted to resolve the bleeding before you
  21     closed the chest?
  22   A. Yes. The term I have used here is "minimised" it. That
  23     means I am not totally happy, but it has settled down
  24     and I feel confident that I can close it.
  25   Q. So there is still bleeding going on, but it is at such

   1     a level that you feel happy or at least content that the
   2     operation should now finish and the child go through to
   3     intensive care?
   4   A. Yes.
   5   Q. I think we see in intensive care, if we go to the
   6     notes at MR 1731/33, and scroll down, please, that in
   7     intensive care, having come out of the operation at
   8     about a quarter to 5, by 5.30 it is described as "oozing
   9     plus plus" from the drains, so there was a quantity of
  10     blood coming out of the drains, was there?
  11   A. That is correct. Again, responding to the transcript on
  12     that day, I think one of the things mentioned was, we do
  13     not see a real drainage in mls. You have here, on
  14     page 7 --
  15   Q. Let us look at page 7, and can you tell us the hour you
  16     want to enlarge the line of?
  17   A. You can see the patient has come to ITU, say, about
  18     5 o'clock, it says at 1700 hours, and then on this side
  19     the drain. The patient has the mediastinal train, left
  20     pleural drain and right pleural drain, and you can see
  21     the mediastinal drainage is quite significant in the
  22     first few hours, really.
  23   Q. Just have a look if we go, please, scroll across 1700,
  24     and it is the mediastinal ... can we enlarge that, at
  25     all? So you are saying there, there was quite a volume?

   1   A. Yes.
   2   Q. In the intensive care, I think a number of efforts were
   3     taken to try to control the oozing, the bleeding?
   4   A. Yes. Now, there were a few things in my mind. If this
   5     patient, not bleeding before, or I was confident that
   6     I closed the chest in a manner that is haemostatic,
   7     I would have been now thinking about, you know, "Well,
   8     about 10 per cent, 20 per cent of blood volume is being
   9     lost; better go in". But I have already spent a lot of
  10     time in theatre watching the bleeding and minimising it,
  11     and I know where it is. That is what I was thinking at
  12     that time. It is in the area where the more stitches
  13     you put in, the more holes you are going to make in the
  14     aorta and it is going to make it worse.
  15        So I said, all right, get the blood tested for
  16     clotting and various things, and also I am starting
  17     Trasylol; you can see here I gave Trasylol Aprotinin
  18     just as another mechanism to control bleeding, and the
  19     blood result you can see on pages 88 and 89.
  20   Q. Thank you; that is page 88.
  21   A. We can see the APTT is very high, 84 a second, and there
  22     is a normal range there. So in a way, now I am working
  23     on trying to improve the clotting mechanism; I am giving
  24     protamine and plasma, I have already given Aprotinin,
  25     and of course once you start these manoeuvres, it looks

   1     quicker here but it does take hours, sometimes, so two
   2     or three hours is gone.
   3        I am worried because quite a bit of blood has
   4     already drained down by this time but I know that the
   5     APTT is very high. I go in and I put more stitches but
   6     it is more troublesome, so I wait for the thing to
   7     settle down. You can see the second reading on 89, it
   8     has come down, but it was still high, 63 or something
   9     like that, but I thought things were improving and the
  10     bleeding has, in a way, after two or three hours,
  11     settled down. There was not much coming out now from
  12     the pleural drains, so I thought, it is getting better,
  13     hold tight, we are not going to get anything by taking
  14     him back to theatre, and that was the reason I did not
  15     take him back to theatre, which I would have done in
  16     other circumstances by this time.
  17   Q. As it happens, at 7 o'clock the following morning the
  18     bleeding is recorded as having settled. We pick that up
  19     on page 34 --
  20   A. Forgive me, but it has settled long before that.
  21     I mean, that is the morning round when the junior doctor
  22     comes. He makes the first note at 7 o'clock in the
  23     morning he says "bleeding settled" and big exclamation
  24     mark --
  25   Q. He says "At last"?

   1   A. Yes, whatever, sometimes, but if you look in the chart,
   2     you can see that the bleeding really has settled down by
   3     11 o'clock at night, really. There is hardly any
   4     drainage after that, on page 0007.
   5   Q. So back to page 7, if we go back to that for the
   6     moment. We can see that the bleeding settles?
   7   A. Yes, after that, you know, hardly any from 11 o'clock
   8     onwards, so after, in a way, five or six hours, bleeding
   9     has really stopped, not 7 o'clock in the morning, as the
  10     impression one gets from the transcript.
  11   Q. Thank you. What then I think happens is that there is
  12     an echocardiogram performed by the x-ray department,
  13     which you pick up at page 105.
  14        Here we do have a post-operative echo, and it is
  15     performed by Dr Murphy?
  16   A. Dr Paula Murphy is very experienced and she is a cardiac
  17     radiologist.
  18   Q. She is one of the two you mentioned earlier?
  19   A. Yes, and I trusted her more than a few other people.
  20   Q. I am tempted to ask you whom, but ...
  21   A. Well, just the same thing as I said yesterday: younger
  22     people have a newer technique, sometimes, with respect,
  23     tend to outdo their senior colleagues, and I think Paula
  24     Murphy is very good. She now runs the MRI setup,
  25     really, and almost all congenital heart disease

   1     patients, they go to her.
   2   Q. Dr Silove, at this stage what did it seem to you, from
   3     your review of the notes -- you have listened to the
   4     explanations we have had from Mr Dhasmana, which have
   5     filled in some gaps in the transcript in the notes.
   6   DR SILOVE: Yes. The question is, why was the
   7     echocardiogram done? I am not sure, but I think that
   8     the BRI page 34 might give us some clue to that. I am
   9     sorry, before you wipe that off --
  10   Q. We will come back to 105. Let us go to 34.
  11   THE CHAIRMAN: I think we need a slightly more exact
  12     reference.
  13   MR LANGSTAFF: It is page 34 of the same series
  14     [MR 1731/34]. It is 10.1.92: "Echo, no pericardial
  15     effusion, good ventricles."
  16   DR SILOVE: Somewhere, I think a little further down on the
  17     page, just about there, the second last line, it tells
  18     us CVP 18 to 20, i.e. high".
  19        That is central venous pressure, and I think the
  20     central venous pressure was high earlier than that, and
  21     before the echocardiogram was done, and if we just
  22     scroll up again, up the page to where the echo was, the
  23     first comment that is written there is "no pericardial
  24     effusion", so I think the echo was done in order to
  25     exclude the pericardial effusion because the CVP was

   1     high.
   2        That seems to be the explanation.
   3   MR DHASMANA: If I could come in here, I think since then
   4     I have looked a little bit more in my own diary, and
   5     this, the main operation, was done on a Thursday. In
   6     1991/92, at that time I was doing a few adult cases on
   7     Fridays, so I would be going down to theatre. I come in
   8     the morning; I quickly go around my patients, and
   9     I would have seen this patient, although it is not
  10     written, and I would have said, "Well, this is the
  11     patient which I had a problem in theatre with the
  12     bleeding, drained quite a lot over the first few hours,
  13     it settled, looks okay, but could you please get an echo
  14     done today, just to make sure that inside there is no
  15     major collection?"
  16        So it was not in a way echo done to assess the
  17     cardiac thing, but I asked them, I said "You will not
  18     get routine echo done unless you ask for it", and
  19     I would have asked them to get an echo done, because
  20     I know I would have done that.
  21   Q. So you ask for an echo yourself to satisfy yourself that
  22     there is no large collection of blood inside?
  23   A. That is correct.
  24   Q. And that is very much, I think, what you, Dr Silove, had
  25     anticipated was a reason, at any rate, for the echo?

   1   DR SILOVE: The reason I am suggesting that is because
   2     I notice there is a report of the CVP being 18 to 20,
   3     and it is sort of in the context, in this note here at
   4     12 midday, it is the second last line, it says "CVP 18
   5     to 20" and the line above that says "echo excludes
   6     pericardial collection", and CVP they regard as high; it
   7     is indeed high.
   8        It seems to me as if the reason the echo was done
   9     was because there was a high CVP, but maybe I have
  10     misinterpreted that. It seems to fit together in the
  11     note here.
  12   Q. We have had Mr Dhasmana's explanation of why it was
  13     done.
  14   DR SILOVE: The radiologist has said, no pericardial
  15     effusion, and has also said, good ventricle function.
  16   Q. Just pausing there for a moment, can we go back to the
  17     radiologist's report in full, because we only have
  18     a note there. The report is at MR 1731/105. What she
  19     says about the ventricle, the left ventricle, is
  20     "contracts well"?
  21   DR SILOVE: Yes. The point is that if there is a high
  22     CVP, there are several possibilities: the one is that
  23     there is compression of the heart caused perhaps by
  24     a pericardial effusion. That can cause a high CVP.
  25     Another important cause is that there might be poor

   1     ventricular function; if there is ventricular failure,
   2     that can cause a high CVP. The third possibility is
   3     that there is volume overload.
   4        I seem to recall that there was also a note that
   5     there is a tendency to low arterial pressure. Maybe if
   6     we could just go back to page 34, because I think that
   7     is where I read it. 10-1-92, 12 midday, this boy has
   8     problems "(1) tendency to low arterial pressure," which
   9     clinically is associated with severe hypoxia with
  10     saturation and dropping to the 50s, and again, lower
  11     down on that page, the third last line says "echo
  12     excludes pericardial collection" and CVP 18 to 20.
  13        So putting together low arterial pressures and
  14     a high CVP, one is possibly thinking of the high
  15     possibility of cardiac compression, and that would be
  16     a good reason for doing an echocardiogram. You want to
  17     know whether there is likely to be compression of the
  18     heart by an effusion, and you also want to know whether
  19     the left ventricular function is good.
  20        But here we have good left ventricular function in
  21     the face of a high CVP, so it makes it seem as if there
  22     might be cardiac compression.
  23   Q. Just pausing there; Mr Stark?
  24   MR STARK: I think this is actually the first time I would
  25     slightly disagree with Eric. I think we have good left

   1     ventricular function, but for my money, the right
   2     ventricular function was not described in great detail.
   3     I think the CVP would be a function of the right
   4     ventricle, not the left ventricle function. So in the
   5     absence of bleeding for the last six hours and absence
   6     of effusion, I must revise my earlier assessment of the
   7     situation. I think I would be not thinking about
   8     tamponade so highly, but rather more about this right
   9     ventricular restrictive physiology I described earlier,
  10     which could occur just as a consequence of bypass, which
  11     could explain the high CVP.
  12   DR SILOVE: It is wonderful to have a disagreement! If
  13     you look at the second line from the top, it says "good
  14     ventricles", plural, and my interpretation of that was
  15     that both ventricles were contracting well.
  16   MR STARK: On the echo report, where it says "right
  17     ventricle", I do not think the description is good
  18     enough for me. I do not think we should bother too much
  19     with our arguments.
  20   MR LANGSTAFF: Anyway, the question is not so much who is
  21     right about what the radiologist saw and described; it
  22     is really a question about what should be done. Is
  23     there disagreement as to what should be done? Do you
  24     want to come in on the disagreement and give us a third
  25     view.

   1   MR DHASMANA: If I could, it is not a third view. I was
   2     looking for in a way an ITU chart which records pulse,
   3     blood pressure, CVP, continuous ongoing monitoring. It
   4     is usually found in the notes, but I have tried the
   5     notes, the copies sent to me before; I could not find it
   6     myself, also. But I do feel that they were not at the
   7     same time. Echo was done first.
   8        This patient deteriorated around 11 o'clock and
   9     you see reference to that in my discharge letter to
  10     patient GP -- I am sorry, I am using "discharge" letter,
  11     my summary letter. MR 1731/52. It says the patient
  12     there deteriorated by 11 o'clock in the morning, and of
  13     course at that time, because I was in theatre, I could
  14     not possibly be called, and Mr Wisheart was -- because
  15     on the Friday morning he always used to makes rounds, so
  16     he was available and he would have been called to see
  17     the patient. That is his notes at 12 midday, seeing the
  18     patient on my behalf.
  19   Q. So going back to page 34 --
  20   A. So therefore I am really saying the echo was done when
  21     the patient was not in that bad situation, and was done
  22     because I requested in the morning, and then he
  23     deteriorated and of course Mr Wisheart had now seen him,
  24     but maybe, you know, he had seen this patient and was
  25     told echo was just done and nothing was seen, or --

   1     I mean, Dr Murphy, one of the things was that, even
   2     though the typed report as you have seen, she tended to
   3     write in the note, so we really knew what was
   4     happening.
   5   Q. Her note, to be fair, is dated the 16th, whereas the
   6     written note is on the notes and is dated the 10th?
   7   A. But the typed note does say it was done on 10-1-92.
   8   Q. Yes.
   9   A. I was hoping she would say what time it was done,
  10     really, but that was not mentioned.
  11   Q. We can see, I think, that it must have been done some
  12     time between 7 o'clock and 12 o'clock?
  13   A. Yes. I mean, I feel that it was done before Mr Wisheart
  14     saw the patient and the patient deteriorated, but I feel
  15     that probably was done when the patient was not that
  16     poorly.
  17   Q. What I want to explore, whichever of you may be right,
  18     is, given that one has a child whose CVP is high,
  19     indicating high venous pressure, with ventricle function
  20     which is reported by an earlier echo as having been
  21     good, with a tendency to low arterial pressure, but high
  22     venous pressure, what would go through your mind as
  23     being the next step to take?
  24   DR SILOVE: I think that cardiac compression has not been
  25     absolutely excluded by these investigations. The

   1     finding of no pericardial effusion does not exclude the
   2     possibility of cardiac compression because you do not
   3     need a huge amount of blood or clot -- you do not need
   4     enough to be able to see it on the echocardiogram; it
   5     could still be enough to compress the heart.
   6        I think that it would have been prudent to open
   7     the chest and at least suck out the pericardial space
   8     and hope that that is going to relieve any pressure, at
   9     least, find out whether there is compression of the
  10     heart.
  11   MR LANGSTAFF: Mr Stark?
  12   MR STARK: If I was at the bedside at 12 o'clock, I think
  13     I would feel that probably the right ventricular
  14     malfunction was more likely because this would have
  15     involved using pressure reducing gauges like
  16     nitroglycerine or sodium nitroglyceride, I think I would
  17     re-open the chest to exclude tamponade and also observe
  18     the heart while I was giving these drugs, so I think
  19     generally in this situation I have a long threshold for
  20     opening the chest, but the tamponade would not be on the
  21     top of my list, but despite that I think I would have
  22     opened it.
  23   Q. It is a question of what action to be taken, rather than
  24     what you discover if you take the action?
  25   MR STARK: As I said, I would give nitroglycerine, but

   1     probably at the same time, or shortly afterwards,
   2     I would tend to open the chest.
   3   DR SILOVE: I think we are both --
   4   MR LANGSTAFF: Could I ask you to pause for a moment and
   5     ask Mr Dhasmana what he would have done if he had been
   6     there. You were not, because you were operating, but if
   7     you had been there, what do you think you would have
   8     done? Do you think you would have opened the chest, or
   9     not?
  10   MR DHASMANA: It is very difficult for me to comment on now,
  11     because I know what I saw on the postmortem day, and of
  12     course, you know, with that thing in my knowledge,
  13     I cannot really get that out of my system to comment on
  14     what I would have done. But, having struggled with him
  15     in theatre, and then tried to control bleeding, no doubt
  16     tamponade would still have been in a way high on my
  17     list.
  18        Having said that, I did see the patient after.
  19     Why did I not do it then? So I do not have an answer to
  20     that. Obviously you could say my colleague has already
  21     seen and it makes it very sensible I just accepted it,
  22     but maybe because I know the postmortem finding and I do
  23     not really somehow minimise the amount mentioned there,
  24     I feel that, yes, tamponade should have been
  25     considered.

   1   Q. Are you of the same mind as Mr Stark, that where you
   2     have a situation like this, that you have a low
   3     threshold when it comes to re-opening the chest and
   4     having a look?
   5   A. Basically I would feel almost all cardiac surgeons
   6     have.
   7   Q. As it happens, we know that it was not done and we know
   8     what was revealed at that postmortem, and as you say, it
   9     is difficult to analyse this case now in that
  10     knowledge. But at 12 midday it was Mr Wisheart who was
  11     there, not yourself. He was not, I think, then
  12     thereafter, to see the effects of the regime that he was
  13     suggesting.
  14        Again, do we have the same difficulty that there
  15     was no continuous care regime in the ICU to look at the
  16     different possibilities and take a consistent and more
  17     careful perhaps approach to each patient, because of the
  18     difficulties we have been discussing?
  19   A. You mean in the form of an intensivist, somebody there
  20     all the time keeping a continuous watch on that
  21     patient?
  22   Q. Someone of that nature?
  23   A. Yes, because I must have seen the patient when I came
  24     back from theatre, because there is an entry that day
  25     and the day thereafter, that I have seen the patient, so

   1     I am really doing it. But of course it is not the same,
   2     it comes to that window; if you miss the window, you
   3     miss it, because by the time, really, the next day, this
   4     patient is now requiring very high ventilatory
   5     pressure. He had leaked out from both lungs. When you
   6     have that situation, then, you know, you just have to
   7     wait. You have probably missed the window.
   8        I mean, I have another suggestion, just to throw
   9     it in here. I do not know, I mean, in that case of
  10     course the postmortem finding is a little bit different:
  11     central shunt of 5 mm Goretex. Here you have got a high
  12     CVP; you have a lower oxygenation and you have
  13     decreasing blood pressure requiring very high
  14     ventilation. Could it explain that too much blood was
  15     going to the lung? If too much blood was going to the
  16     lung, then it is not a tamponade.
  17   DR SILOVE: I think that is a very reasonable suggestion
  18     as well. The only thing against it is that the left
  19     ventricular function appeared to be good at the time,
  20     and if there is too much blood coming back, going to the
  21     lungs and too much blood coming back from the lungs to
  22     the heart, you expect to see perhaps dilatation of the
  23     left atrium and left ventricle and perhaps the left
  24     ventricular function will not be so good.
  25        It is impossible to know just what the problem was

   1     and we cannot say for certain that the patient
   2     deteriorated because there was cardiac compression. We
   3     do not know whether there was cardiac compression.
   4        I think all that I am suggesting and what Mr Stark
   5     is probably suggesting, and what I think Mr Dhasmana is
   6     agreeing with, is that if the chest had been explored,
   7     you might have found that there was tension -- you might
   8     have found there was compression of the heart and it
   9     might have improved, but I am not saying that it would
  10     have.
  11   MR LANGSTAFF: Can I pick up that because you appreciate
  12     the purpose of looking at the Case Note Review is not to
  13     resolve to the last dot and t how a particular child
  14     died and whether, in a clinical negligence case, there
  15     would be a finding one way or the other, but to use the
  16     cases to explore the adequacy of care involving the
  17     whole of the aspects of care that it allows us to
  18     examine.
  19        Looking back over the three cases which we looked
  20     at so far -- we will come to Joshua Loveday tomorrow --
  21     does it perhaps seem to you that when you were operating
  22     in this particular setup, that you might have been
  23     operating, as it were, with one hand tied behind your
  24     back because of the deficiencies of the system within
  25     which you had to do it?

   1   A. I think if I was thinking that way, I should not have
   2     been really carrying on, so obviously I was not thinking
   3     like that, because, I mean, you are now seeing the
   4     patients who have got into trouble but completely
   5     ignoring the patients who have gone through that unit,
   6     and have survived the operation, even a very critical
   7     operation, both adults and children. So I was not
   8     totally unhappy with what was happening in the
   9     post-operative care unit.
  10        We are talking of 1991. Only one unit in the
  11     country at that time, to the best of my knowledge, had
  12     round-the-clock intensivists or something like that. We
  13     did not have that service, so we have to really put that
  14     time-frame in the picture.
  15        We called an echo examination here, instead of
  16     calling four hours later, the next day, so we are doing
  17     it but maybe not in the same order. So I would not
  18     think that I am operating with one hand tied behind my
  19     back; I would not. At the same time, I was aware that,
  20     yes, I have to watch everything very carefully because
  21     there is here an absence of round-the-clock senior
  22     cover.
  23   MR LANGSTAFF: The mention of clock, sir, brings me to the
  24     question of time. It is now coming up to 5 to 4. Would
  25     this be an appropriate time, since we have completed

   1     a third of the cases, to adjourn until 9.30 tomorrow
   2     morning?
   3   THE CHAIRMAN: Yes, Mr Langstaff. Shall we do that?
   4     I understand we also have to thank very much Mr Stark
   5     for his being here and helping us. We are as ever very
   6     grateful to you. You help us enormously by your
   7     presence. Thank you.
   8        So I say we adjourn until 9.30 tomorrow morning.
   9     Good afternoon, everyone.
  10   (4.00 pm)
  11     (Adjourned until 9.30 am on Wednesday, 1st December
  12     1999)
  13
  14
  15                I N D E X
  16
  17
  18     MR JANARDAN DHASMANA (recalled)
  19
  20        Examined by Mr Langstaff (continued) ........ 1
  21
  22
  23
  24
  25

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Published by the Bristol Royal Infirmary Inquiry, July 2001
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