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 1st December 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 working relationships between clinicians involved in the diagnosis, treatment and aftercare of babies and children born with congenital heart defects. He commented on the collection of data relating to surgical outcomes and identified the sources of data used during the 1980s and 1990s. He spoke about responsibilities for completing data entries and commented on the suitability of the data sources for recording information about paediatric cases. He related the audit data collected in Bristol to figures published in the UK Cardiac Surgical Register. He commented on the use made of this comparative data when the Bristol service was reviewed by the Welsh Office following concerns raised about the Bristol mortality figures by Welsh cardiologists in the mid 1980s. Mr Dhasmana confirmed that he was unable to compare case mix between Bristol and other centres providing a complex paediatric cardiac surgical service. He went on to focus on the development of audit and the co-ordination of audit activity between surgeons and cardiologists in the late 1980s and early 1990s. He discussed the issue of communications between surgeons and anaesthetists and discussed concerns raised about the switch programme by his anaesthetic colleagues stating that he was not aware of their dissatisfaction until mid 1994, several months after he had stopped performing neo-natal switches. Mr Dhasmana concluded by saying that following his appreciation that concerns were being expressed about his practice he agreed not to schedule future switch operations without discussing the case with the cardiac anaesthetists. Mr Dhasmana’s evidence concludes tomorrow. Tomorrow afternoon the Inquiry will hear from Mr Stephen Willis from Devon and Mrs Rachel Ferris, General Manager, Cardiothoracic Services, UBHT. Dr Eric Silove, Consultant Paediatric Cardiologist, Birmingham Children’s Hospital, attended today’s hearing in his capacity as a member of the Inquiry’s Expert Group.

FULL TRANSCRIPT

   1               Day 86, Wednesday, 1st December 1999
   2   (9.40 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF: Good morning, sir.
   6          MR JANARDAN DHASMANA (RECALLED):
   7         EXAMINED BY MR LANGSTAFF (CONTINUED):
   8   MR LANGSTAFF: Mr Dhasmana, yesterday when we went through
   9     the three cases we have looked at so far, we will come
  10     to the case of Joshua Loveday rather later today, you on
  11     a number of occasions were making the point that the
  12     cardiologists were not present as often as you would
  13     have wished in the Royal Infirmary either
  14     preoperatively, postoperatively or for that matter,
  15     although you did not say it, I suspect intraoperatively?
  16   A. That is correct, sir.
  17   Q. That would make it difficult, I suspect -- tell me if
  18     this is right -- for the service to operate as a team as
  19     you would most wish?
  20   A. Looking back, yes.
  21   Q. Can we have a look at a letter sent by Mr Wisheart? It
  22     is UBHT 195/2. It is dated 3rd April 1992. Before
  23     I come to the text, yesterday we spoke about your going
  24     to Birmingham and how you wanted to take along members
  25     of your team and you took an anaesthetist on each of the

   1     two occasions you went. You encouraged Dr Bolsin to go
   2     but he said "I am not doing this operation, it is
   3     Dr Underwood, Dr Masey". You took along nurses and
   4     a perfusionist?
   5   A. I did.
   6   Q. Did you ask any cardiologist to go?
   7   A. Yes, I did. I did and they said, "What we will do, we
   8     will make telephone calls and we will find out. We know
   9     from our own experience and what I talked to others that
  10     nothing different is being done in these patients than
  11     what we are doing, but I would make telephone calls and
  12     I will let you know if there was any change".
  13        I believe they did, but I did not get any
  14     information that they did go and visit that centre just
  15     for this reason. They may have visited their colleagues
  16     in the course of meetings and various things, but I --
  17   Q. It might be right to say that they, the cardiologists,
  18     made no special effort in the way that the
  19     anaesthetists, the nurses and the perfusionists had done
  20     and you had done?
  21   A. I think that sounds as if, you know, there was any
  22     drawback on their part but I was quite happy with their
  23     answer and I thought they must know what they are doing.
  24   Q. This is a letter on the screen which Mr Wisheart was
  25     writing to Professor West, the Medical Postgraduate

   1     Dean. It arose in the aftermath I think of a visit by
   2     Dr Shinebourne dealing with the accreditation of Bristol
   3     for a Senior Registrar post?
   4   A. Yes.
   5   Q. He was suggesting that there should not be such
   6     accreditation following his visit.
   7        What Mr Wisheart wrote -- can we scroll down?
   8     "Paediatric cardiac surgery is carried out by
   9     Mr Dhasmana and myself. I would like to make a number
  10     of points: (1) the cardiologists and cardiac surgeons
  11     work in the closest co-operation in the assessment,
  12     decision making and management of the children both
  13     before and after surgery. The development of the
  14     paediatric cardiological services both medical and
  15     surgical have progressed in the last decade on the basis
  16     of the closest possible co-operation."
  17        The first sentence suggesting that cardiologists
  18     and cardiac surgeons "work in the closest co-operation"
  19     in preoperative and postoperative management both before
  20     and after surgery is not the picture that you were
  21     giving us yesterday, is it?
  22   A. I think one has to really look at the context in which
  23     this letter was written and I know very well why it was
  24     written and when it was written. I think one should
  25     also see that what I am talking about now is looking

   1     back, comparing with centres like GOS, Birmingham and
   2     other places but of course we were running the service
   3     at that time, as somebody would say, and what we were
   4     looking at, that no decision in the cardiac surgery was
   5     being made without talking to cardiologists. They were
   6     part of the decision making. They were in a way
   7     involved with management.
   8        But of course because of the physical problems of
   9     distance and also their number, one has to remember at
  10     that time the paediatric cardiological service in
  11     Bristol was only consultants, there were no other staff,
  12     they did not have junior staff, they had a rotating
  13     SHO --
  14   Q. Can I ask you to stop there for a moment? What you said
  15     to me in answer so far I think is two things: first, you
  16     began by saying -- these are my words but I think
  17     reflecting what you are saying, "This may not be
  18     strictly accurate but you have to look at the purposes
  19     for which this letter was written"?
  20   A. That is correct.
  21   Q. The second point you were making is: "Well, it is not so
  22     badly inaccurate because ..." and I think you were going
  23     to say "every surgical decision involved a cardiologist
  24     and people were doing the best they could in the
  25     circumstances" and at that stage you had no measure of

   1     comparison because you did not know until you looked
   2     back on it how that compared with elsewhere.
   3        Have I reflected your answer thus far?
   4   A. I think you have, yes.
   5   Q. The first point, "it is not strictly accurate but one
   6     has to look at the purposes of the letter" may mean, may
   7     it, that Mr Wisheart here was putting forward a view
   8     which was inaccurate or exaggerated a point because it
   9     suited the purposes of the unit to do so?
  10   A. I would say it was not inaccurate because we were, if
  11     you look at it you could compare paediatric service with
  12     the adult service. We definitely had a better
  13     co-operation from paediatric cardiologists in every
  14     aspect of the patient management. The purpose was quite
  15     right really because both Mr Wisheart and I were really
  16     worried that we do not have that much paediatric
  17     cardiologist cover for our patients and we knew it would
  18     be possible only if we had another human being in that
  19     speciality to help us.
  20   Q. Is this why, if you look at point 4, you are doing your
  21     best to try and get a Surgical Registrar to help so you
  22     have a bigger cardiological presence; is that the aim?
  23   A. Not Surgical Registrar, Paediatric Cardiology Registrar,
  24     yes, Senior Registrar.
  25   Q. The point of the letter is to achieve an object?

   1   A. That is correct.
   2   Q. And the object was to relieve the difficulties that you
   3     were experiencing, you and Mr Wisheart?
   4   A. Yes.
   5   Q. Really is it fair or unfair to say that point 4, the
   6     purpose of the letter to obtain a Senior Registrar
   7     appointment in paediatric cardiology, is because without
   8     it one could not say or continue to say what is said in
   9     paragraph 1, that there was close co-operation before
  10     and after operations?
  11   A. If one looks at that sentence again, it is not exactly
  12     saying it is in Bristol, it is giving you a type of
  13     principle of paediatric cardiac service really that
  14     paediatric cardiologists and cardiac surgeons everywhere
  15     work in close co-operation and probably that is what we
  16     need more. I think that letter should be interpreted in
  17     both ways. It points out the deficiency and it also
  18     really says what we should have.
  19        There is a background there because I know
  20     Dr Shinebourne, when he came in he was very upset that
  21     he could not meet us and that was physical presence
  22     really, he was taken by car from one place to another so
  23     he got the impression that they are two distinct
  24     hospitals. So we were very disappointed that we did not
  25     meet Dr Shinebourne but we were trying to in a way now,

   1     we felt, correct what was a shortcoming from our part
   2     really to help in this venture.
   3   Q. The second point I want to pick up from yesterday,
   4     moving on from this letter, is in relation to equipment
   5     because you on a number of occasions were commenting
   6     upon the equipment that was or was not available.
   7        We heard from nurses in this Inquiry, the
   8     reference is Day 32, page 80, that there was no
   9     maintenance or renewal programme for equipment on BRI
  10     Ward 5. Are you able to comment on that or not?
  11   A. I think I can comment on a bit of it because I was
  12     actually Chief Director during part of this. UBHT did
  13     or does, I am sure it still has, a department called
  14     "MEMO". As the name says, medical equipment
  15     maintenance organisation. I had a feeling they were
  16     going round and looking at this but one thing one has to
  17     really take into perspective: every piece of equipment,
  18     whatever you are seeing today, 10 months from now would
  19     be considered -- well, we should have better. There was
  20     that feeling going on all the time and of course if you
  21     had more money you could always replace them. So MEMO,
  22     they were there but probably you could say there was not
  23     uniform satisfaction about the standard of equipment
  24     which I am not going to question too much about because
  25     I know that was there.

   1   Q. The third and perhaps the last set of issues I need to
   2     pick up with you from yesterday is the question of your
   3     idea of the team which operated on children as part of
   4     paediatric cardiac surgical services. Who in your view
   5     was part of the team? Who constituted the team?
   6   A. You asked me a question at the Children's Hospital; do
   7     you mean Children's Hospital or do you mean the BRI?
   8   Q. In the services in both hospitals.
   9   A. As I mentioned before, any child with cardiac services
  10     or with a cardiac problem would be admitted by the
  11     cardiologist so they were the first part of the team
  12     really, the cardiologists. Then of course
  13     investigation, then the radiological department was
  14     playing a role quite strongly until the cardiologists
  15     took over quite a bit of it themselves really.
  16        Third, in a way anaesthetists. Fourth our own
  17     junior staff on both sides and then nurses and
  18     supporting team of physiotherapists and other people who
  19     helped these patients recover.
  20        There was trouble on both sides because, as
  21     I mentioned in one of my statements, we had a split
  22     service not just between BRI and Children's Hospital but
  23     also in the cardiac surgery itself, that we were doing
  24     closed cardiac work at the Children's Hospital and open
  25     heart surgery at the BRI. So if you were doing closed

   1     cardiac -- do you want me to go on?
   2   Q. Please.
   3   A. Closed cardiac work we were doing at the Children's
   4     Hospital, as far as surgeons were concerned I was the
   5     only surgical person there, there was no junior cover
   6     there for me to call it my own team but of course I used
   7     to get help from cardiologists. That was possible once
   8     they had more of their junior staff in the form of
   9     Senior Registrars and some SHOs.
  10   Q. But not possible while there was not a Senior Registrar?
  11   A. Exactly. So I used to sometimes say -- well, most of
  12     the time -- take my own Registrar, I would say to the
  13     Surgical Registrar from the BRI who was not at that time
  14     involved in theatre, "Could you please come and give me
  15     a hand with this operation?" In a way that was the
  16     shortcoming there, that surgical staff was not there.
  17        Of course at BRI there was a problem with medical
  18     staff, cardiological staff. So we had a problem on both
  19     sides.
  20   Q. If one focuses upon surgical services, both closed and
  21     open, the surgeon plainly is a central figure because
  22     I suppose that unless the surgeon is willing to do the
  23     operation it will not take place. Is it, looking back,
  24     the position that the surgeon would take overall
  25     responsibility for the patient under the team? Would

   1     somebody else as you see it take responsibility for
   2     that? Was it shared and if so, how? There are three
   3     questions in that. Let me break them down and ask you
   4     each individually.
   5   A. I can answer them one by one, if you like.
   6   Q. Please.
   7   A. One, I would say a cardiac surgeon is different from
   8     other surgeons because other surgeons can get a case
   9     directly from a patient's GP. You do not need to have
  10     anybody else to make a decision and you can really just
  11     take a patient on and it is you who is responsible.
  12        In cardiology, in both sides, adult and paediatric
  13     but more important paediatric, the surgeon does not get
  14     the case directly. Cases are referred to the
  15     cardiologist. He is investigating, he is examining; he
  16     knows what service he has; he has one or two surgeons he
  17     can refer the case. That is why joint cardiological
  18     meetings are important and a decision then is made what
  19     are we going to do and who is going to do it and when
  20     you are going to do it.
  21        After that decision is made then the case is
  22     really referred on to the surgeon or the surgeon takes
  23     over. But the primary decision for the management of a
  24     patient, I would feel and strongly believe, is a joint
  25     decision of everybody concerned with the child's

   1     welfare.
   2   Q. If one looks at the preoperative period, as you see it
   3     that is partly the responsibility of the cardiologist
   4     until one comes to the question of what operation should
   5     be performed; that is a discussion between the
   6     cardiologist and the surgeon, is it, a joint
   7     responsibility at that stage?
   8   A. Yes, sir.
   9   Q. The surgery itself, is that, would you say, a joint
  10     responsibility between those involved or is that really
  11     the responsibility of the surgeon, the surgical phase?
  12   A. Then again here cardiac surgery is different from other
  13     forms of surgery because in other surgery once the
  14     patient leaves the theatre and is extubated you have
  15     really just the surgeon and nobody else. But in cardiac
  16     surgery, right at the time of surgery there are three,
  17     four distinct teams involved in the patient's
  18     management.
  19        Somebody is looking after perfusion. Somebody is
  20     looking after anaesthesia, which is not just putting the
  21     patient to sleep but also making sure that the patient
  22     really is being looked after during perfusion in the
  23     same way by keeping an eye on drugs and various
  24     management and also these patients are not immediately
  25     extubated so the patient is still recovering from

   1     anaesthesia, is still requiring breathing support and
   2     various things, so anaesthetic cover continues in the
   3     postoperative period.
   4   Q. I had, I hoped, restricted the questions I was asking to
   5     the operation itself.
   6   A. Yes.
   7   Q. It is difficult I know because the one shades into the
   8     other. I will ask you in a moment about postoperative,
   9     if I may. So far as the operation itself is concerned.
  10   A. I have talked about perfusionists, I have talked about
  11     anaesthetists and I also talked about the nurses because
  12     they play a very important role here. Operations are
  13     varying, it is not a similar type of operation,
  14     especially in paediatrics.
  15        You do not have a huge number of one particular
  16     type of operation going on and on and on every day. You
  17     could have one day ASD, another day VSD or the same day
  18     a tetralogy and ASD or some other combination. So
  19     nurses are also quite an important part of this group.
  20   Q. Does any one of those disciplines coordinate the
  21     activities of all those particular parts of the overall
  22     team?
  23   A. It is very good on paper really that somebody should
  24     coordinate but it just functions without somebody taking
  25     the role of coordinator. What you do, you publish the

   1     list, the list goes to theatre or the sister in charge
   2     and then it is taken and then the list is also
   3     publicised so the anaesthetists know, the perfusionists
   4     know from there and it is taken as if it is coordinated
   5     that way.
   6   Q. The individuals who would work with you on a particular
   7     case would be on a rota which may or may not coincide
   8     with your rotas, you may be working with different
   9     people on similar operations over the weeks?
  10   A. Yes, that is correct.
  11   Q. Within the operation itself, we heard as you will have
  12     seen from the transcript, some concern in one case about
  13     the replenishment of cardioplegia, there being in that
  14     particular case no note that cardioplegia had been
  15     replenished after half an hour and the time on, when it
  16     was needed, was about an hour and a half long.
  17        A decision such as that, we were given to believe
  18     the anaesthetist might say to the surgeon "Shall I give
  19     some more cardioplegia?" or the surgeon might call to
  20     the anaesthetist "Can I have some more cardioplegia?"
  21     What is your perception of how that worked?
  22   A. Thank you for giving me that opportunity because I saw
  23     that transcript and it made me feel very uncomfortable.
  24     I could not believe that I would have had a patient on
  25     the table without cardioplegia for one and a half

   1     hours. There is something missing somewhere. Either an
   2     entry has not been made -- most probably an entry has
   3     not been made because I do make a point of giving
   4     cardioplegia at frequent intervals.
   5        One has to make a little observation here:
   6     a 30 minute rule applies to the heart, which is almost
   7     at normal temperature. It is mostly with the adult
   8     patients who are treated at 32 degrees or 37 degrees
   9     Centigrade. Most of the paediatric patients, they are
  10     cooled down to 25 to 20 degrees Centigrade so you do not
  11     necessarily need to stick to the 30 minute rule, but
  12     definitely not 65 minutes, as you have mentioned. It
  13     would not be exactly on 31 minutes that cardioplegia
  14     would be going, but some time around then. Because
  15     there is no real time known, a lot of work has been done
  16     but there is still no clear-cut ruling on this except
  17     for the general arbitrary line that after 30 minutes you
  18     must start looking for a region to give cardioplegia.
  19        In the paediatric practice anaesthetists used to
  20     give cardioplegia. In a lot of centres, perfusionists
  21     give it in the machine and in a way in both of these
  22     situations, both of these groups, they ask the surgeons,
  23     after about 30 minutes gone, 35 minutes gone, "Do you
  24     want me to give cardioplegia?" I am sure, the surgeon
  25     at that time is just concentrating on that and time

   1     sometimes you do not notice at that time.
   2   Q. Again asking you to pause, if you do not mind, what you
   3     are saying I think is that because of your focus upon
   4     the intricacies of the surgery, you would expect to be
   5     reminded by the anaesthetist, that would be essentially
   6     his job, or the perfusionist, to tell you "The time is
   7     now ready for a fresh cardioplegia" and no doubt if that
   8     reminder came you would say "Yes, go ahead" or whatever?
   9   A. That is correct. What they would say, to give
  10     cardioplegia you have to stop at that time, do nothing
  11     else until cardioplegia has been given. So they would
  12     ask you and of course you are not going to put a big
  13     argument up at that time, and you say "Yes, please give
  14     it". Though I do know that --
  15   Q. Is that the way it usually worked with you at any rate,
  16     that they would suggest and you would then find a quick
  17     and convenient moment to stop, cardioplegia is applied
  18     and then you continue?
  19   A. Both anaesthetists who have worked mostly with me on
  20     paediatric, they were very particular about that and
  21     I am quite surprised there is no mention in the notes
  22     about cardioplegia. I would feel there is some omission
  23     in an entry but it is not possible and I can really say
  24     that for a person not to be given cardioplegia for one
  25     and a half hours, I just cannot believe it.

   1   Q. On the face of it, it is very surprising and one would
   2     certainly expect an anaesthetic record in surgery to be
   3     complete, would one not?
   4   A. I cannot complain about others' records because I found
   5     the surgical records are not very good sometimes, so
   6     I am afraid record-keeping is not a very good thing in
   7     human nature unless you are doing auditing or accounting
   8     or some other job like that.
   9   Q. When surgery is being conducted the anaesthetist has not
  10     the same hands-on role as the surgeon and is expected to
  11     enter the charts as he goes along, is he not?
  12   A. It should be.
  13   Q. I have not yet asked you about the postoperative phase,
  14     let me do that now.
  15        You were going to say until I cut you short that
  16     the anaesthetists had a part to play post-operatively.
  17     We have seen that from various sources, as well as the
  18     surgeon. Very much later on in Bristol anyway the
  19     intensivist who might be an anaesthetist by training --
  20     and I think the way the intensivists began in Bristol
  21     was by an expansion of the anaesthetic sessions to cover
  22     the ICU, was it not?
  23   A. That is correct, sir.
  24   Q. Apart from the anaesthetist and the surgeon and the
  25     intensive care nurses, did anyone else have

   1     a responsibility as you recollect it for the
   2     postoperative phase?
   3   A. I think you have counted the major groups.
   4   Q. The anaesthetist would be concerned with matters such as
   5     fluid levels, drug administration, ventilation
   6     primarily, would he?
   7   A. They would be concerned -- I think fluid management was
   8     a type of joint concern really and from my previous
   9     experience at other centres and my training, I was a bit
  10     more on restricting fluid so I used to control the fluid
  11     regime as much as possible, but of course anaesthetists
  12     would be really a very guiding influence on that and
  13     also the drugs.
  14   Q. What was the dividing line between the responsibilities,
  15     if there was one, of the anaesthetists on the one hand,
  16     the surgeon on the other and perhaps the nurses in the
  17     third corner?
  18   A. There was no clear-cut demarcation line except that as
  19     being a surgeon of the patient concerned I used to
  20     always take myself as providing some type of continuity
  21     for that patient to make sure things are moving in the
  22     right direction.
  23   Q. Looking at the input from the various different teams,
  24     what if any measures did you take or did the unit take
  25     to make sure that each part of the team responsible for

   1     the ultimate outcome for the patient was performing
   2     adequately?
   3   A. I thought I was trying to get the communication right
   4     but it appears it was not very good, communication
   5     amongst the staff. As a result I used to put in a lot
   6     of presence there just to make sure that what we talked
   7     about in the morning was being carried out during the
   8     day. What we are talking about in the evening would be
   9     carried out in the night; what we left in the night was
  10     carried out for the remaining part of the night because
  11     the rest of the staff were moving or changing. So the
  12     communication was not very good and I used to find that
  13     sometimes that could create confusion especially amongst
  14     nurses really because it is possible a different set of
  15     doctors may have advised differently on the same line
  16     because, as you know, for any management there could be
  17     more than one way of dealing with the problem.
  18   Q. So far as the nurses are concerned, in the Intensive
  19     Care Unit at Ward 5 of the BRI was there from time to
  20     time a shortage of paediatric trained nurse cover?
  21   A. The problem with the BRI, because it is a place in the
  22     hospital where it is mainly an adult service, so
  23     whenever we wanted to recruit a paediatric trained nurse
  24     in the cardiac surgery, we were not very successful
  25     because nurses who were trained in children's care, they

   1     are in high demand everywhere and there is a shortage in
   2     almost all hospitals so obviously they get absorbed
   3     there quickly. If somebody lives, say in Bristol or
   4     other places and having been trained in paediatric, they
   5     did not feel that they wanted to look after adults when
   6     a child is not being looked after in ITU.
   7        So we had a very real problem in recruiting a pure
   8     paediatric trained children's, intensive care nurse in
   9     our cardiological department. However, we had some very
  10     good, very dedicated nurses. They by their own effort,
  11     by their own experience and by going to the Children's
  12     Hospital, they doubled up their expertise as to get my
  13     confidence that I was always happy for them to look
  14     after my patients.
  15        But because of this we had a core group and there
  16     were a small number of nurses who I would feel happy to
  17     leave my patients with, and that used to cause some
  18     problems and that is where the term 'shortage' really
  19     comes, because of course you know sickness or illness,
  20     nobody can really foresee those things.
  21   Q. Did nurses have to be recruited from the bank from time
  22     to time for ICU work?
  23   A. Unfortunately, yes.
  24   Q. And you say "unfortunately" because?
  25   A. Because sometimes what we would do, we would get nurses

   1     who are intensive care trained but probably in
   2     a different field, not even cardiac surgery. So when
   3     they come in we would move them to look after the HDU
   4     side and some suitable nurse from HDU would be moved
   5     into ITU, so it still needed adjustment of nurses in the
   6     unit but that was in a way the best we could really do
   7     rather than postpone the case and postpone again.
   8   Q. Going back to the question of the teams or the groups
   9     that formed part of the overall team --
  10   THE CHAIRMAN: Mr Langstaff, I wonder if we could ask
  11     Dr Silove whether experience of bank nurses and so on
  12     was common in his experience, whether in Birmingham or
  13     elsewhere.
  14   DR SILOVE: I think there has always been a very major
  15     problem in recruiting nurses for intensive care. It is
  16     common -- it has been common throughout the country for
  17     intensive care beds not to be fully staffed and I am
  18     sure bank nurses have had to be recruited from time to
  19     time in most places.
  20        May I just say something else, may I go back to an
  21     issue that Mr Langstaff was raising a little earlier on
  22     this morning: you were focusing on the word
  23     "co-operation" between cardiologists and cardiac
  24     surgeons and I wanted to say that from the perspective
  25     of doing the clinical case note reviews, the teams of

   1     experts considered there was good co-operation between
   2     the surgeons and the cardiologists, the cardiologists
   3     were not being unco-operative by not going to the BRI,
   4     we perceived there being geographical constraints which
   5     might have made this extremely difficult.
   6        In a number of comments coming from the teams of
   7     experts about the management of patients at the
   8     Children's Hospital, they actually praised the
   9     management on the Intensive Care Unit and there was
  10     a perception that the cardiologists were much more
  11     closely involved with the management of patients at the
  12     Children's Hospital, presumably because that is where
  13     they were.
  14        But I do not think we should start getting the
  15     feeling that the cardiologists were being
  16     unco-operative. Mr Dhasmana said earlier on in this
  17     hearing that when he asked cardiologists to come to the
  18     BRI they came.
  19   A. Yes, they did.
  20   DR SILOVE: But it was difficult to find them.
  21   MR LANGSTAFF: I think one of the points that you said
  22     earlier to us arising out of the Clinical Case Note
  23     Review was that a number of teams had commented upon the
  24     absence, not the lack of co-operation but the absence of
  25     cardiologists on the ICU at the BRI and a number of them

   1     had said "where is the cardiologist?"
   2   DR SILOVE: That is absolutely right and I agree with that
   3     point and we commented on that in a number of cases
   4     yesterday. The only word that I am trying to have
   5     removed from this is the word "co-operation".
   6   MR LANGSTAFF: You are concentrating on attitude rather than
   7     performance?
   8   DR SILOVE: Yes.
   9   MR LANGSTAFF: That is a fair point, is it, Mr Dhasmana:
  10     that the attitude was entirely right, performance in the
  11     way one would hope and expect was lacking?
  12   A. This letter itself shows really that the problem was
  13     identified and we were all working together to move to
  14     that direction. We had all accepted and agreed that
  15     there should be a more physical presence of paediatric
  16     cardiologists by themselves in a way and they themselves
  17     realised that, the only thing was it was not possible
  18     a number of times.
  19   Q. I was going to ask you about how the component parts of
  20     the team were able (if they were) to evaluate their own
  21     contribution to the overall outcome. The first question
  22     that arises: we know the anaesthetists had audit
  23     meetings of their own, was there any form of review so
  24     far as you know of the cardiologists as a separate
  25     group, the perfusionists and the nurses?

   1   A. I cannot follow the question, you said "separate
   2     group"?
   3   Q. We have identified a number of component parts: nurses,
   4     anaesthetists, perfusionists, cardiologists, surgeons in
   5     creating an overall outcome for the patient in cardiac
   6     surgery. The unit as a whole looked at its figures and
   7     we will have a look at that in a moment or two. Before
   8     we get to that stage, I am just asking how the
   9     performance of the separate groups was assessed, if it
  10     was; was there any process of doing so?
  11   A. There were audit processes in every group really. We
  12     cardiac surgeons had our own audit which we used to call
  13     monthly morbidity/mortality meetings. We had our yearly
  14     audit where we would present a whole year's figure. We
  15     would have a teaching session during which our junior
  16     staff would present, say, a periodical audit for
  17     a particular problem.
  18        Similarly when you use the term "cardiology" I was
  19     a bit confused whether you meant adult or paediatric
  20     really because both of them had a separate group really,
  21     but paediatric cardiology also had their audit which --
  22     we were a part of it, paediatric cardiac surgeons used
  23     to really go to that periodic cardiology audit meeting
  24     which became more formalised once they increased their
  25     consultant number from two to three when Dr Martin came

   1     along, and it was supposed to be a monthly audit
   2     meeting. It did carry on. Somehow it lapsed somewhere
   3     in 1990 and 1991 sometime and then he got it back again
   4     in 1992. So there was a cardiology audit which was a
   5     combined paediatric cardiac services audit.
   6        Perfusionists by themselves did not have any audit
   7     but they used to in a way -- I think it became more
   8     formalised once the children moved to the Children's
   9     Hospital but before that there was no real audit in the
  10     name of perfusion because they did not take perfusion by
  11     itself as separate from cardiac surgery, if you are
  12     auditing cardiac surgery you are auditing the whole
  13     thing.
  14   Q. When you came as surgeons, either separately or with the
  15     paediatric cardiologists, to look at your results what
  16     available data was there to you, first of all to
  17     establish your own results and, secondly, to compare
  18     them with the results of any other group or centre?
  19   A. In the beginning it was all, you have to collect data
  20     yourself from registers, books, make your own -- I mean
  21     we all from our training really have had a logbook which
  22     we continued with that. So we used to keep a record
  23     there.
  24   Q. Can I identify the sources and then we will ask about
  25     each of them in turn if I need to. The first is logs?

   1   A. Yes.
   2   Q. Surgeons' logs; what else?
   3   A. Then I -- and I am not sure whether my colleagues, but
   4     I am sure some of them did -- also had a record of the
   5     whole year's work really in a way in a folder which
   6     would have an operation note, discharge summary and
   7     relevant cases, postmortem findings in patients where
   8     unfortunate events has taken place. So that I would
   9     have, which I used to call a year book but probably not
  10     everybody called it that way, but they were there 1985,
  11     1986, 1987, like this.
  12        Of course the hospital had its own medical record
  13     and sometimes we had to really go back to them to get
  14     things verified. So that was the case mostly during the
  15     1980s. I am not sure at that time there was any
  16     computer in true form.
  17   Q. In the 1990s?
  18   A. In the 1990s we started computerising things and I think
  19     there was one system, we tried it but it failed because
  20     it was a very complex system, METASA source it was
  21     called. We then change to the PATS system which was
  22     more compatible with cardiac surgery because in way
  23     Americans, they were well advanced and they had
  24     developed it. So we took it from there.
  25        Our society accepted it so in a way to us it felt,

   1     you know, it would be reasonable really to adopt this
   2     system and then we do not have to really separate or
   3     make an extra effort to fill in the UK register really.
   4   Q. In the 1990s, did you continue to keep your logs?
   5   A. Yes.
   6   Q. Did you continue to keep your year books?
   7   A. Yes.
   8   Q. And you had in addition the PATS system; that is the
   9     Patient Analysis and Tracing System?
  10   A. Yes.
  11   Q. Which replaced the METASA system?
  12   A. Yes, I do not know the full form now, I have forgotten.
  13   Q. Did you have any other source of data for your own
  14     figures?
  15   A. For my own figures?
  16   Q. For the figures, the surgical figures of the unit?
  17   A. It is not coming to my mind at the moment, but ...
  18   Q. We have heard from cardiologists that they kept
  19     a register which they called the South Western
  20     Congenital Heart Register?
  21   A. Yes.
  22   Q. Was that something they kept to themselves?
  23   A. I knew that Dr Jordan -- this was known to be
  24     Dr Jordan's brain child and he was very keen on it and
  25     almost all children would have a type of sheet in the

   1     case notes saying "South West Congenital Heart Surgical
   2     Register" or some type of that name.
   3   Q. I think I do not need to ask you about the details of it
   4     because we have those. Did you use that particular
   5     register to produce your own figures at all?
   6   A. No, I did not use that.
   7   Q. I want to look at each of those to some extent in
   8     a little more detail. The second part of the initial
   9     question I asked was: what (if any) comparison data was
  10     available to put Bristol's figures, results, outcomes in
  11     context?
  12   A. The only comparator which I can really name is the UK
  13     Cardiac Register.
  14   Q. The surgeons' logs, looking at those first; they would
  15     be completed by you personally, your own log that is?
  16   A. Yes.
  17   Q. You would put in to the log, the record: the name of the
  18     patient, the hospital number?
  19   A. Yes, I think it must.
  20   Q. Date of the operation?
  21   A. Can I just explain that, it probably would come better?
  22   Q. Please.
  23   A. I did not want it to be too complicated, I simply wanted
  24     a type of what I have done and what was the outcome in
  25     this patient. So in a way I can quickly fill in and get

   1     the quick glance back type thing, what I have done in
   2     the past.
   3        I would ask my secretary to type in the
   4     demographic data which I used to call, the patient's
   5     initials or name would be there. Initially date of
   6     birth was not there, she used to put in the age at that
   7     time in months or the year and the hospital number. She
   8     would just put in the diagnosis as we have got it from
   9     the cardiologist and sometimes she would put down
  10     a little bit more on haemodynamic data which I told her
  11     not to bother because most of the time I thought they
  12     were not correctly put in.
  13        So they were the typed part you know in the
  14     beginning. She would also mention the operation that
  15     was carried out and after that I used to fill in and
  16     I used to really -- I was interested in what was
  17     happening, whether they were discharged or not
  18     discharged, what had happened and then follow the
  19     information which I would get from the cardiologist,
  20     a copy letter and I would just summarise that. So that
  21     is how it was.
  22   Q. The logbook was actually compiled by your secretary?
  23   A. The initial entry, just the demographic data, the rest
  24     of it was in my own hand.
  25   Q. When you say you were looking at the outcome, were you

   1     able in every case, and did you in every case follow-up
   2     whether there had been survival or mortality within
   3     a 30-day period?
   4   A. That is a very good question and I cannot answer that in
   5     every case I have that answer.
   6   Q. So far as the 30-day figure itself is concerned, did you
   7     yourself regard that as being of significance or not?
   8   A. Yes.
   9   Q. Why? If, for instance, someone died following surgery
  10     at 31 days, they would not be within a 30-day mortality
  11     obviously. Did you regard it nonetheless as important
  12     for your own figures to have a cutoff at 30 days?
  13   A. I think here 30-day mortality came from the UK Cardiac
  14     Surgical Register because that is what they were asking
  15     for so we had to in a way put in an entry from our
  16     logbook or whatever information we had to satisfy that
  17     one.
  18        To me personally, if a patient died in hospital,
  19     whether the BRI or the Children's Hospital, it was
  20     a hospital death and that did matter to my own record.
  21   Q. Whenever it happened?
  22   A. Whenever it happened, if it happened in hospital, yes.
  23   Q. Suppose that a child had stayed in hospital for 6 weeks
  24     after operation, a prolonged stay on ICU, and then had
  25     finally succumbed; would that be in your log as a death?

   1   A. It would be in my log as a hospital death, yes.
   2   Q. What (if any) note did you make about apparent morbidity
   3     following operation?
   4   A. I am afraid morbidity is not very well recorded because
   5     as I said before the logbook was not supposed to be
   6     a detailed note really, otherwise I would have been in
   7     the same trouble like any record now because they are
   8     not completely filed you have to really then have
   9     a check point at every entry point, so there was no
  10     entry point for morbidity. At that time mortality was
  11     the thing which I was looking for. But in some patients
  12     who stayed in hospital longer and there was a problem in
  13     the hospital I was concerned about, I have listed as
  14     much as I could.
  15   Q. At some stage you did I think indicate a figure as to
  16     your expectation of the morbidity following operations.
  17     In fact it is in your statement, if we look at
  18     WIT 84/53. You say:
  19        "As regards to morbidity, there was no data
  20     available to me from any other centre in the country to
  21     be used as a comparator. At some of the courses ...
  22     incidence of neurological changes following open heart
  23     surgery... were discussed and wide ranges were
  24     mentioned, for example, psychiatric and behaviour
  25     changes in as many as 25-30 per cent of cases and gross

   1     motor changes in 5-15 per cent."
   2        The only comparator you say you had was locally
   3     with your colleague Mr Wisheart although no comparative
   4     figures were collected and you believe you did not
   5     compare unfavourably against Mr Wisheart?
   6   A. That is just an impression.
   7   Q. If you were to estimate now -- and it is a question you
   8     may want to think about overnight, and tell us if you do
   9      -- if you wish to estimate now what you think the
  10     percentage of neurological complications, renal
  11     complications respiratory complications may have been in
  12     the cases in which you dealt, what sort of percentage do
  13     you think you would put on it, appreciating you have no
  14     detailed data to make the estimate?
  15   A. That is why I am saying neither can I estimate at this
  16     time nor tomorrow because I do not have any data with
  17     me.
  18   Q. You cannot give a rough figure?
  19   A. I cannot really unless somebody sat with all those 1800
  20     cases and looked at the notes and compiled it because
  21     that data is not there.
  22   Q. Going back to the first of the data sources you mention,
  23     your log; turning to the second, the year book: you kept
  24     a year book, did Mr Wisheart?
  25   A. I cannot comment on that. I believe I have followed his

   1     practice so if I was doing it I am sure he was doing it,
   2     whether he continued to do it I am not sure.
   3   Q. At some stage Mr Wisheart kept a year book, whether he
   4     went on doing it you do not know?
   5   A. No.
   6   THE CHAIRMAN: Stepping back one moment to the reference to
   7     morbidity, Mr Langstaff. I know you are going to say
   8     something tomorrow about this, but I wondered whether we
   9     could ask Dr Silove to comment on Mr Dhasmana's answer.
  10   DR SILOVE: I think Mr Dhasmana's experience is probably the
  11     same as most other centres, in that figures for
  12     morbidity have not really been well collected. The only
  13     figures that seem to be collected are those of mortality
  14     and I am not really sure how well those figures are
  15     collected, but morbidity is something which people have
  16     begun to write about more in the last 5 years or so, but
  17     there is very little information available
  18     unfortunately.
  19   THE CHAIRMAN: Would you like to tell us why that may be the
  20     case?
  21   DR SILOVE: I suppose it is a matter of having somebody to
  22     do the work of writing it down and people have not
  23     actually bothered in the past to consider that to be
  24     a factor that needed to be written down. I do not
  25     really know the explanation, sir, it is so difficult

   1     going back in time. We are aware that many patients in
   2     the immediate postoperative period have minor
   3     neurological problems, some have more major problems,
   4     there does not appear to be any significant audit method
   5     of finding out how many patients actually have
   6     neurological or renal problems or any other morbidity
   7     problem.
   8   MR LANGSTAFF: I wonder if I may push you a little on that:
   9     in some textbooks would one find an estimate of the
  10     extent to which there might be, for instance,
  11     neurological damage following operation?
  12   DR SILOVE: There will be information in some textbooks
  13     which will be drawn from published articles and you will
  14     see a great range in figures. I cannot quote you
  15     precise figures at the moment, I do not have them in my
  16     head but you will see figures ranging from 5 per cent
  17     right up to 25 per cent for morbidity and it is very
  18     difficult to know what reliance one can place on various
  19     figures.
  20   MR LANGSTAFF: Is any attempt made in the articles from
  21     which those percentages (wide as they are) are drawn, to
  22     attribute those percentages to any particular cause?
  23     For instance, it appears to be generally accepted -- and
  24     tell me if this is wrong -- that the period of time on
  25     circulatory arrest or time on bypass has an adverse

   1     implication in terms of morbidity; is that a matter
   2     which the articles -- from where the figures come?
   3   DR SILOVE: There are attempts to link it to length on
   4     bypass and I do not believe there is any strong
   5     correlation. Again, I must plead some ignorance on
   6     this. I have not studied that particular subject
   7     carefully.
   8   MR LANGSTAFF: Dealing with that issue for a moment, if
   9     I may. You were accepting yesterday that the length of
  10     an operation probably had an adverse effect. The longer
  11     the operation the more likely there would be some
  12     adverse effect on the child concerned. First of all --
  13   A. Can I just?
  14   Q. Yes, please.
  15   A. I am not sure we did talk on this yesterday, did we?
  16   Q. You mentioned the view that the length of time in
  17     operation might have an adverse impact. If necessary
  18     I can look back at the transcript and pick it up. What
  19     I am exploring with you is that concept anyway, is it
  20     right?
  21   A. I think it has been -- I do not know whether I can put
  22     a little philosophical view on something the Chairman
  23     asked me before, forgive me.
  24        Because this has also bothered me for a long time,
  25     that in a way we get mortality but we do not get too

   1     detailed morbidity from different centres. I asked that
   2     question to a great mentor of mine for whom I have a lot
   3     of regard, Dr Kirklin. He told me the way he sees it,
   4     that the cardiac surgery developed a great deal. The
   5     initial question in everybody's mind was to get that
   6     patient better, survive the operation. It is only
   7     recently that we have come to a stage because we are
   8     using a cardiopulmonary bypass, a different machine
   9     which itself causes damage to the blood cell, you do not
  10     use this device in any other type of surgery. That
  11     machine itself causes a problem.
  12        So in a way you are adding a problem or the
  13     machine may be causing a problem. It is now, with
  14     modification, with further advances the machine is
  15     getting safer and safer. So now because the machine is
  16     getting safer and safer we should now be looking at
  17     whether now the surgery itself is adding something
  18     because until now we had a machine to blame.
  19        So that is why morbidity, in my mind -- and I may
  20     be wrong -- is late in coming, but it is coming now
  21     because now people are reporting almost, you know,
  22     a very acceptable mortality from cardiac surgery, even
  23     sometimes no different than major general surgery. So
  24     this is the time to look for morbidity. So that I feel
  25     is probably the cause in late appearance of morbidity

   1     data.
   2        Most of the morbidity data which is appearing is
   3     now appearing in the same way, first, in the most major
   4     problem which is neurological and that is why a lot of
   5     research is now being undertaken. Until now very much
   6      -- research was more on correcting the problem but not
   7     looking into the complication. Now they are looking and
   8     they are doing research and that is where the figures
   9     are coming.
  10        About the length of operation and association with
  11     bypass: there is a general feeling, because you have
  12     a patient on drugs or anaesthesia for a longer period so
  13     obviously a person probably would have a problem. But
  14     we have all seen that sometimes after a long operation
  15     a patient makes a miraculous recovery, and sometimes a
  16     straightforward operation, a very short bypass, we have
  17     a series of problems.
  18        So there is an impression that probably a long
  19     operation and a long bypass leads to the problem, but at
  20     the same time people do have views that a long operation
  21     and a long bypass, unless it is unduly long, probably
  22     does not have any significant effect on outcome this way
  23     or that way.
  24   DR SILOVE: I agree with everything that Mr Dhasmana has
  25     just said and I do not believe there is any clear

   1     evidence, there is no clear evidence that length of
   2     bypass is definitely related to morbidity. It is an
   3     impression, as he says.
   4        Just to take this a step further: many of the
   5     cases where there is a long bypass because I think --
   6     I am not a surgeon -- but I think the surgeon is
   7     deliberately prolonging the bypass time after having
   8     done the operation to give the heart a rest, to allow
   9     the heart to recover before taking the patient off
  10     bypass and letting the heart take over.
  11        To take it just a stage further than that, there
  12     is a form of bypass called -- which is a sort of
  13     a partial bypass really -- ECMO which is Extracorporeal
  14     Membrane Oxygenation where the patient is connected to
  15     a bypass machine often for weeks and weeks and I do not
  16     believe there is any strong evidence that that prolonged
  17     period of perfusion, using the oxygenator is responsible
  18     for morbidity.
  19   MR LANGSTAFF: When was ECMO introduced?
  20   DR SILOVE: I suppose probably about 7 or 8 years ago, I am
  21     not sure about that.
  22   A. The mid 1990s, 1994/1995.
  23   MR LANGSTAFF: Did they use it in Bristol?
  24   A. Now they are using it, they did not have it before.
  25   Q. Not in the period with which we are concerned in the

   1     Inquiry?
   2   A. No, it is very recently.
   3   Q. So far as the cardiopulmonary bypass is concerned, you
   4     agree then with what Mr Dhasmana was saying: it does
   5     damage the blood inevitably as part of the process?
   6   DR SILOVE: Yes, it does.
   7   MR LANGSTAFF: Intuitively, I think is what you are saying,
   8     the view is that the longer the machine is used the
   9     greater the damage is likely to be?
  10   DR SILOVE: Yes, perhaps more important than the length of
  11     bypass, though, might be the cross-clamp time of the
  12     aorta when there might be -- mind you that really
  13     affects the myocardial function more than anything
  14     else. When there is total circulatory arrest for a long
  15     period of time that could cause neurological damage but,
  16     as Mr Dhasmana was pointing out, these babies and
  17     children are usually cooled down to about 20 to 25
  18     degrees Centigrade which should protect the brain quite
  19     significantly for periods of, say, an hour of
  20     circulatory arrest.
  21   MR LANGSTAFF: The words you are using are "protect
  22     significantly", it would suggest that --
  23   DR SILOVE: There is great anxiety that prolonged
  24     circulatory arrest can cause neurological damage, that
  25     prolonged bypass might cause neurological damage but

   1     there is no very hard evidence.
   2   MR LANGSTAFF: The intuitive feeling that length of time on
   3     bypass -- the length of circulatory arrest may cause
   4     damage, the longer it goes on the more the problem might
   5     be -- has that been a general view of cardiologists and
   6     cardiac surgeons since surgery on bypass was introduced?
   7   A. Paediatric cardiac surgery, especially paediatric
   8     cardiac surgeons have been very much interested in this
   9     field, really. Yes, they have always kept an eye on
  10     this and know what Dr Silove has just said.
  11   MR LANGSTAFF: Is there anyone who expresses the view that
  12     it does not matter?
  13   DR SILOVE: No, I do not believe there is.
  14   MR LANGSTAFF: We have rather gone out of the way of my
  15     asking you about the sources of data in a discussion
  16     which was necessary and followed from the Chairman's
  17     question. It is perhaps appropriate, then, to have
  18     a break before we return to the question of data sources
  19     and analysis.
  20   THE CHAIRMAN: 15 minutes until 11.00.
  21   (10.45 am)
  22            (Adjourned until 11.00 am)
  23   (11.05 am)
  24   MR LANGSTAFF: The year books, Mr Dhasmana: what additional
  25     information, over and above your logs, did your year

   1     books give you?
   2   A. It had a copy of the operation note, so it would have
   3     the detail of the operation, the findings, what I have
   4     done, who anaesthetised and the usual data there, and it
   5     would have a discharge summary which I used to write
   6     myself in the 1980s, but of course once the computer
   7     came in it became a bit more regimented. So that would
   8     have more information, and it would have some mention of
   9     morbidity, because I always wanted to give that
  10     information to the GP, so if I had done the discharge
  11     summary myself, I would have mentioned that.
  12   Q. The METASA system you say essentially was not
  13     satisfactory and it was replaced?
  14   A. Well, only I could complete it; nobody else could,
  15     really, because it needed a lot more information, and it
  16     was very time-consuming, so I and sometimes, you know,
  17     my other consultant colleagues if they had time, they
  18     could do that. But if you relied on juniors to do it,
  19     it did not work out.
  20   Q. So do I take it from that that the information contained
  21     in it would be to an extent unreliable and to an extent
  22     inconsistent?
  23   A. That is correct.
  24   Q. The patient analysis and tracing system: that, I think,
  25     related to operations from April 1992 to January 1996,

   1     so far as we are concerned.
   2   A. I think that is right.
   3   Q. It was a spreadsheet?
   4   A. It was a spreadsheet you needed to fill in, and again,
   5     this thing would change. Initially, the SHO at the time
   6     of admission was supposed to be filling in demographic
   7     data and some of the symptoms and haemodynamic data and
   8     the surgeon after he had finished the operation would
   9     fill in the rest, but the haemodynamic data was not
  10     always filled completely, so some time later it was
  11     changed that the surgeon would fill in the haemodynamic
  12     data and the operation findings himself.
  13        One has to realise that the PATS system was not
  14     geared up to deal with paediatric information, except
  15     diagnostic information and things like that, it is
  16     basically more adult orientated, so even though we
  17     adopted it, I still would not call it a very
  18     sophisticated technique for data collection in
  19     paediatric cardiac surgery.
  20   Q. It was supposed to fill in the diagnosis for paediatric
  21     cases?
  22   A. That is correct.
  23   Q. The work done on the PATS system which the Inquiry team
  24     has done reveals that there were no entries in respect
  25     of diagnosis prior to August 1994; thereafter, only

   1     about four entries in the diagnosis field, which
   2     suggests a lack of completeness by whoever was supposed
   3     to fill in the diagnosis.
   4        Was that appreciated?
   5   A. It was very well appreciated because in a way the PATS
   6     system wanted one diagnosis and it was not easy in a lot
   7     of children to put in one diagnosis. Most of these
   8     patients had multiple problems. That is why I was
   9     saying that, you know, the PATS system was not really
  10     geared for the paediatric system. That is why, when
  11     I came to know about another system, I applied to join
  12     that one.
  13   Q. I am told, and you have a chance to agree or disagree,
  14     that the completion of some of the items on the
  15     spreadsheet was, as described to me, "spasmodic". Would
  16     that be a fair description?
  17   A. If you are talking of all five surgeons, then yes.
  18   Q. So in terms of giving information to you, it was not
  19     a very reliable source of information?
  20   A. For paediatrics I never considered the PATS system
  21     reliable, no.
  22   Q. So in terms of preparing the figures for audit, you
  23     would be back relying upon your surgeon's log?
  24   A. My surgeon's log and the secretary who was keeping the
  25     year book and monthly operation in a way, she used to

   1     record that.
   2   Q. The problem with the comparison, the Congenital Heart
   3     Register, is, is it, that you had no idea how it was
   4     going to be filled in at other centres?
   5   A. That is correct.
   6   Q. And am I right in thinking that the data you had for
   7     comparison purposes came to you after the year end,
   8     after analysis, and therefore you had already produced
   9     your own internal next year's figures by the time you
  10     got the national figures for the year before?
  11   A. That is correct. Most of the time it used to be two
  12     years behind.
  13   Q. But the general view would be, would it, that the
  14     figures, albeit two years behind, looked at over
  15     a number of years, would enable one to determine
  16     a trend?
  17   A. That is what we used to believe, yes.
  18   Q. And the figures produced by the national register would
  19     be in relation to diagnosis rather than operation?
  20   A. That is correct, sir.
  21   Q. So you would be able to look at what information you
  22     had internally on diagnosis, if you had that
  23     information, to compare it with the outcomes for that
  24     diagnosis nationally, but the information you had from
  25     your surgeon's log was not diagnosis, it was operation.

   1   A. Yes. So, I mean, I knew what was the diagnosis, and now
   2     I know from my own data what operation I have done, but
   3     to fill in, I would fill in as per the diagnosis.
   4   Q. So when you made the returns to the national register,
   5     you filled in as per diagnosis, and not as per
   6     operation?
   7   A. That is correct.
   8   Q. So we may see, if we look at the figures, a difference
   9     between the operations conducted on the one hand and the
  10     diagnosis which might suggest a different type of
  11     operation on the other?
  12   A. That is correct.
  13   Q. When you were Associate Clinical Director, did you, do
  14     you think, have any responsibility to provide the audit
  15     figures then produced -- this would be 1993 onwards --
  16     to the Trust for annual review?
  17   A. No.
  18   Q. Who did?
  19   A. I think initially it was Mr Hutter and then some time in
  20     1994 -- around that time, it changed to Mr Bryan.
  21   Q. And both of those were adult surgeons?
  22   A. Yes.
  23   Q. Purely?
  24   A. Yes.
  25   Q. So who had the responsibility of conveying to the Trust

   1     from January 1993 onwards the paediatric figures?
   2   A. The paediatric figures were part of the unit figure --
   3     open-heart surgery.
   4   Q. So Mr Hutter and Mr Bryan?
   5   A. Yes.
   6   Q. And they would have to get the figures from you, would
   7     they, or Mr Wisheart, or both of you?
   8   A. Yes.
   9   Q. In 1987, can we have a look, please, at UBHT 194/22?
  10     You joined with your colleagues in writing to the editor
  11     in respect of a BBC Wales television programme. We can
  12     see from the first paragraph that "certain allegations
  13     were made about the standard of paediatric cardiac
  14     surgery in Bristol".
  15        Do you recollect there being such a TV programme?
  16   A. You remember, I think the first day you showed me
  17     another letter --
  18   Q. I did.
  19   A. -- and it is all related to the same thing.
  20   Q. The figures that you then had available were at
  21     UBHT 55/8. That is the 1984 to 1986 figures.
  22   A. That is correct, sir.
  23   Q. Tell me, looking at this form -- this is a typed form
  24     we have -- when would the figures have been presented in
  25     this typed form?

   1   A. I am not able to follow your question.
   2   Q. What we are looking at is a page, a typed page. It is
   3     a document which has come to us in the Inquiry as
   4     a typed page.
   5   A. Yes.
   6   Q. Somebody obviously prepared the figures and produced
   7     them --
   8   A. Yes.
   9   Q. -- in this form. Do you know who did?
  10   A. It is my colleague, Mr Wisheart.
  11   Q. Did he type them up personally? Did he have his
  12     secretary do it?
  13   A. No, he must have a secretary to type it.
  14   Q. Did you, in the department, in the unit, see
  15     a handwritten version of this before it was typed? Was
  16     it presented to the unit in this form, or are we looking
  17     at a document which was sent off to somebody else, such
  18     as the register?
  19   A. I used to do my own mostly in hand and then I would give
  20     to Mr Wisheart my figure and he would collate it, so
  21     I would not really have an opportunity to see his own
  22     hand, unless, you know, he has given it to me, and
  23     I would see this typed version coming out at the end,
  24     really.
  25   Q. So you would go through your own logs, work out your

   1     own figures, give your figures to him, he then produces
   2     a typed result?
   3   A. That is what I would see, yes.
   4   Q. So this is what you knew about the unit?
   5   A. Yes.
   6   Q. If we look across the first line, "open-heart surgery
   7     over 1 year", 7.9 per cent is the percentage of deaths
   8     in Bristol between 1984 and 1986. The comparison with
   9     the UK 1984, 6.9, so Bristol is one percentage point out
  10     of 100 higher there. Under 1 year, 26.5 compared to
  11     21.8 nationally.
  12        We have been through these figures before, a 5 per
  13     cent difference or a ratio of 5 to 4 there, and the
  14     closed-heart figures show Bristol with a lower mortality
  15     in over 1 year and virtually identical in under 1 year.
  16     Overall, closed-heart, better than the national average
  17     by 5.7.
  18        The grand total at the bottom is pretty much
  19     identical.
  20        Can we go back to the response to the editor,
  21     UBHT 194/22? The second paragraph:
  22        "The outcome for operations in children in this
  23     unit during the period 1984-86 is equivalent to the UK
  24     national results in 1984 (latest available data) and
  25     better for certain conditions. This is true for both

   1     open and closed-heart surgery ..."
   2        Again, repeating the question which I asked you on
   3     the first day, it is not, is it, entirely accurate to
   4     say that the figures for open-heart surgery in the
   5     younger children was equivalent to the UK national
   6     results for 1984, given the difference between the
   7     figure for Bristol and the figure nationally, a ratio as
   8     I have said to you, of 5 to 4?
   9   A. Well, I said on that day, and I am saying it again:
  10     statistically, they are equal.
  11   Q. Is it the position, if one saw the same pattern repeated
  12     year after year after year, so that year after year
  13     after year Bristol were at the 26 per cent level; that
  14     the UK was at the 21 per cent level -- make it easier,
  15     25 and 20 per cent -- that then the fact of repetition
  16     would inevitably make one query why it should be that
  17     Bristol was consistently producing a figure less than
  18     the national results?
  19   A. I would agree with you.
  20   Q. So what is essential for small numbers such as this is
  21     to see the pattern over a period, is it?
  22   A. That is correct, sir.
  23   Q. That is the only way, is it, that one can really adjust
  24     for the effects of small numbers, because otherwise what
  25     one is looking at may simply be that year, that is how

   1     the figures work out; the next year it may be very
   2     different?
   3   A. That is the problem with small numbers, because if you
   4     are doing say only 10 to 20 cases a year, then just one
   5     case this way or that way could make 10 per cent
   6     difference, and you can see the difference is 5 per
   7     cent, so you cannot really make any valued judgment on
   8     just simple figures.
   9   Q. Shortly after this, we have heard that representatives
  10     from the Welsh Office -- I think it is actually at the
  11     end of 1986 -- came from Cardiff to Bristol -- and
  12     Dr Lloyd reported on that visit at Welsh Office document
  13      WO 1/263. I will show you the first page of it. That
  14     is the first page of her report. It sets out the
  15     background.
  16        WO 1/265 , 266 is the page I want to ask you about, at
  17     the bottom. She has described a visit by herself and
  18     others to Bristol.
  19        In the middle paragraph:
  20        "Both consultant paediatric cardiologists and one
  21     of the consultant surgeons accompanied us while
  22     inspecting Bristol Children's Hospital ..."
  23        It talks about the development of the new
  24     paediatric cardiac catheter suite.
  25        Were you the consultant surgeon who accompanied

   1     her around?
   2   A. No, I was not.
   3   Q. That was Mr Wisheart.
   4        "We were unable to obtain from the DHSS who do not
   5     hold figures broken down by units any figures on outcome
   6     by centre. We did, however, raise the question of
   7     outcome with Bristol staff. They put to us the accepted
   8     point that outcome is influenced greatly by case mix.
   9     They were quite open in quoting outcomes for some of the
  10     commoner procedures they undertake. They see a gradual
  11     improvement in these as expertise grows and specialist
  12     equipment becomes available. For most of the more
  13     commonly occurring conditions their figures compare well
  14     with other centres. They acknowledge that surgeons in
  15     different centres develop special expertise in rarer
  16     conditions and that outcomes may therefore vary greatly
  17     for these between centres."
  18        At this time, then, what Mr Wisheart and the
  19     cardiologists appear to have been saying to Jennifer
  20     Lloyd was that the outcome is influenced greatly by case
  21     mix. The suggestion, I think, seems to be, if you take
  22     some difficult cases, you cannot expect such a good
  23     result as you would if you took some easier cases.
  24        Was there, as you see it, any particular
  25     difference between Bristol and its case mix in 1986/87

   1     from the case mix you would have expected in any other
   2     centre?
   3   A. It is difficult for me to comment, because (1) I have
   4     not seen this letter before; (2) I am not the one who is
   5     talking; (3) I do not have the detail of the operation
   6     results of different types so I cannot really comment on
   7     what was the case mix talked about and at that time,
   8     I was still working in Bristol when I was Senior
   9     Registrar and got the consultant's job in Bristol, so
  10     I cannot really comment on what was happening
  11     elsewhere.
  12   Q. So for your part, you cannot help at all on whether
  13     Bristol's case mix seemed, to you, to be unusual,
  14     because you had no point of comparison?
  15   A. That is correct.
  16   Q. Can we then move on from 1986 to 1987. UBHT 126/13.
  17     This is the annual report. Is this the first formal
  18     annual report that there was?
  19   A. Probably you are right, but maybe before I have not
  20     seen it.
  21   Q. Can we go to page UBHT 126/18? If we look at where it
  22     deals with the results, it is the third line. In fact,
  23     I will take the whole of the top paragraph:
  24        "A summary of the types of surgery performed
  25     between 1984 and 1987 and the results are contained in

   1     table 3. Mortality is attributed to surgery if it
   2     occurs within 30 days of the operation. These results
   3     are virtually identical to those obtained
   4     nationally ..."
   5        If we want to find the results we would go,
   6     I think, to page 11 [UBHT 166/11], where the mortality,
   7     the over 1 year is 8 per cent, broken down, simple,
   8     moderate, complex. We can see there the figures 1.9,
   9     6.5 for moderate, 23.7 for complex, and under 1 year
  10     27. The total mortality for open operations, 11.3.
  11        If we go on to 1988, it is UBHT 126/3 for the
  12     report, and that is the covering sheet. Can we look at
  13     page 12, please.
  14        Here we have the open-heart surgery reviewed for
  15     a four year period. This is an attempt, is it, to get
  16     a reflection of the difficulty that we mentioned
  17     earlier: if we look at it in isolation, there are small
  18     numbers and we get no picture of the trend or how the
  19     results compare with the national results?
  20   A. I think this was trying to get some type of statistical
  21     verification, if we still could get it. That was the
  22     idea, yes.
  23        I am a bit confused, because I thought the
  24     previous one had mentioned 1984 to 1987, and we still
  25     have the same year, or am I wrong? It was previously

   1     1984 to 1986.
   2   Q. We can go back to the previous table which is at
   3     UBHT 126/18. I am sorry, that is the wrong reference.
   4     Can we go back to the previous table?  166/11, I think,
   5     was the sheet I took you to.
   6   A. Yes. I think I am right, because I noticed there it was
   7     saying 1984 to 1987, so there is some -- I think because
   8     this is a year book of 1987, so it should be before
   9     1986, here.
  10   Q. I think the results are there set out looking at all
  11     three years, if I am not mistaken. If one looks at the
  12     number of cases just to resolve this, take a like, focus
  13     on the under 1 year, for instance.
  14   A. These numbers are a little different than the numbers in
  15     the other ones.
  16   Q. The point is, I think, this must be a three-year period,
  17     because of the number of under 1 year cases, so you are
  18     quite right; we are looking here at the three-year
  19     table. Can we then look, please, at UBHT 126/12? It
  20     says "(figures for a four year period, 1984 to 1987, in
  21     parentheses)", which may be four years if they are not
  22     financial years?
  23   A. At that time they were not financial years, so it
  24     probably is a four year period.
  25   Q. We then have the figures for the year 1988 compared with

   1     the figures for the previous years.
   2   A. I am sorry, I do not have it.
   3   Q. If you look at what it says at the top of the page, the
   4     figures for the four year period are in brackets so the
   5     four previous years are in brackets; 1988, not in
   6     brackets.
   7        If you look at the open-heart surgery, 29
   8     operations performed in the under 1 age group. If we
   9     just put a yellow bar, please, across that line, the
  10     29 patients, the number of deaths are quoted, the
  11     percentage of deaths is calculated, 37.9 per cent, and
  12     the comparison, the previous four years, 27 per cent.
  13        Was there, do you recollect, any discussion about
  14     those figures?
  15   A. I am sure there would have been, but I go on the same
  16     way, because here we can see 29 and 11, so just one
  17     death this way or that way could make that difference
  18     again and that is how probably it could have been
  19     explained. Again, probably it could be explained more
  20     if individual cases were really looked at.
  21   Q. So on the face of it, unless there is an explanation
  22     which relates to an individual case, the figures would
  23     be disturbing, would they not, because they indicate
  24     that the unit was actually performing less well in 1988
  25     than it had done for the previous four years, and you

   1     would expect an improvement, would you not?
   2   A. I have always been uncomfortable with these figures, and
   3     I have mentioned a number of times that these figures
   4     should always be given with the confidence level,
   5     because that is how Dr Kirklin used to tell us, 70 per
   6     cent confidence limit. Then you really know where you
   7     stand and you can make a value judgment. That is why
   8     I would have seen the figure. I would have said it
   9     looks high but we need further explanation before we can
  10     say anything more.
  11   Q. Was there any discussion at the time of how this
  12     compared to the United Kingdom's figures?
  13   A. I am sure there would have been. I do not have a clear
  14     feeling, but I personally would have thought that
  15     probably, yes, we did realise that it was slightly
  16     higher than the UK Cardiac Register -- this within
  17     brackets is not the UK Cardiac Register, really, it is
  18     our own figure.
  19   Q. It is your own figure for the previous four years.
  20   A. Yes, I am sorry.
  21   Q. This report tell us you two things: first of all your
  22     own results within that particular year, and you point
  23     out that there are small numbers, have on the face of it
  24     got disturbingly worse?
  25   A. Yes.

   1   Q. And secondly, one would need to make a comparison of
   2     figures like this to see how Bristol related to the rest
   3     of the United Kingdom?
   4   A. That is correct.
   5   Q. One of the difficulties you have told us, of course, is
   6     getting the United Kingdom figures for the comparative
   7     years. One can only, perhaps, pick that up in
   8     retrospect.
   9        If we go to UBHT 55/88, this is from your own
  10     unit's 1990 report, and it is reporting the figures for
  11     UK 1984 to 1988. You have told us that you got those
  12     figures really two years after the event, but we can
  13     just pick up for a moment 30-day mortality under 1 year
  14     of age, 1984 to 1990, within the UK as reported through
  15     the register, 21.2 per cent.
  16        Can we go back, then, to the previous sheet,
  17      UBHT 126/12?
  18   A. But before you go back here, this is the year we were
  19     really pleased about that, because our result was --
  20   Q. I am going to come to that, by all means mention it
  21     now. As it happens, we can see from this sheet, if we
  22     go back to UBHT 126/12, please, if the national figures
  23     had been available they would have been 21.2 per cent?
  24   A. In fact, that was not a national figure for 1988. That
  25     is what I was trying to point out at that time, because

   1     that was a combination, a four year figure, really, and
   2     somehow we got in a UK figure 1984 to 1988 all combined
   3     together, so you have a combined mortality of 21.2 per
   4     cent mentioned there, which I am a bit surprised at
   5     because normally we get annual figures, so I do not know
   6     how that figure is mentioned that way. But, yes, that
   7     is not a 1988 figure, 21 per cent.
   8   Q. No, it is a four year figure, 1984 to 1988, 21.2 per
   9     cent. Here, the 27 per cent is a four year figure,
  10     1984 to 1987, and we have 1988 added at 37.9.
  11   A. But then you can see 27 and 21 will not be much
  12     different, if you are looking that way, but 37.9, yes,
  13     there must have been some worry amongst us that the
  14     mortality is slightly higher.
  15   Q. Do you recall any such worry being expressed and
  16     discussed at the time?
  17   A. I think I expressed in the following year, in 1989, if
  18     you look, I was quite worried at that time and I did say
  19     that our results on mortalities are higher.
  20   Q. Let us have a look at 1989. The report is at
  21     UBHT 167/72 and the page we need to look at is
  22     UBHT 55/80.
  23        So here for 1989, under 1 year of age, 37.5 per
  24     cent. And closed 3.4 per cent, open 10.9, closed 2.4.
  25        Was that, as you recollect it, at all worrying,

   1     given that it came after the 1988 figures that we have
   2     just been looking at which you recognise were worse,
   3     higher, than the figures for the four years previously,
   4     and appear to be quite different from the UK national
   5     figures?
   6   A. Yes, I did, and I pointed out that it is high and at
   7     that time I also said that looking back, our previous
   8     results on all these things point that our under 1 year
   9     of age group is not doing that well, and we must look
  10     into it. It was following that that there was an audit
  11     meeting for under 1 years in 1990.
  12   Q. Again, so that we can look at the two sides of the
  13     service, both over 1 and under 1, that is 1989. If we
  14     go to page 81 [UBHT 55/81] there is a comparison made
  15     between Bristol on the one hand and the United Kingdom
  16     1988 figures on the other. This time, I think, the 1988
  17     figures were produced a year after the event, so there
  18     is only a year's gap there.
  19        If we look at the under 1 line, if we just
  20     highlight that, we are looking now at quite a number of
  21     patients, are we not, between 1984 and 1988 on the
  22     left-hand column, 103 patients, an overall percentage
  23     mortality rate of 30.1 per cent. In 1989 we can see
  24     another 40 patients, percentage mortality 37.5. The
  25     total, 143 patients in the five-year period, giving

   1     a mortality rate of 32.2 per cent over that entire
   2     five-year period?
   3   A. That is correct, sir.
   4   Q. Compare that with the United Kingdom for 1988. That
   5     should be better than Bristol in 1984, 1985, 1986 and
   6     1987, but the percentage from the 708 patients reported
   7     through the register is quite definitely lower than the
   8     figure for Bristol.
   9   A. I agree.
  10   Q. How long does one have to have a series, a pattern of
  11     figures, for a small unit such as Bristol?
  12   A. I felt this was long enough, really, to need to look at
  13     what we are doing. That is why we called for that audit
  14     meeting.
  15   Q. Just summarising, at this stage these figures called for
  16     action?
  17   A. That is right.
  18   Q. If we can just look at the over 1 year group, and just
  19     concentrate on the total line, please, the percentage
  20     there, 8.9 per cent, comparing with the UK for 1988 of
  21     6.9 per cent, is not so much out of step as the
  22     under 1s, but the number of patients is rather bigger,
  23     is it not?
  24   A. Yes. I think it just shows a little bit of a trend, but
  25     my concern more was under 1s rather than over 1s.

   1   Q. So that being the 1989 figures, there was an audit
   2     meeting, was there, in March 1990. We pick that up at
   3     UBHT 61/126.
   4        We have looked at this before. When the results
   5     were produced, you had concern; did others have
   6     particular concern?
   7   A. I know that I had concern but I cannot really recall if
   8     anybody else had said that. I am talking about at that
   9     time, I am having difficulty to separate myself from
  10     what I know now from what I knew at that time.
  11   Q. Shall we look at what the minute says? First of all it
  12     deals with VSD. Can we scroll down so "VSD" is at the
  13     top? There is an examination of the VSD deaths. Do you
  14     recall how long the meeting took?
  15   A. It would have taken more than an hour, but probably not
  16     longer. You could say people would be going back to
  17     their work so the meeting would have started -- it used
  18     to be Monday morning. It started at 8 o'clock and then
  19     people would start getting a bit restless after
  20     a quarter past 9, so it probably would have gone on
  21     maximum to half past 9.
  22   Q. Then the Senning results, which are reported as being
  23     good, and some discussion of that?
  24   A. I think on VSD results, that in a way we identified
  25     a problem, when we looked at the number of cases

   1     together, that the problem appeared to be post-operative
   2     pulmonary hypertensive crisis, and somehow we had to
   3     really tackle that, so that was one thing identified.
   4   Q. Can we scroll down? TAPVD.
   5   A. Yes, and that was the next group identified. Under 1,
   6     most of the patients who got into trouble had the TAPVD
   7     and that is why the in next group tested, 3 patients out
   8     of 5 died.
   9   Q. The last paragraph on that page:
  10        "Agreed there should be a low threshold for
  11     cardiac catheter study in children that were relatively
  12     well and not in the unstable obstructed group."
  13        What is being said there?
  14   A. I am trying to remember what we were discussing at that
  15     time. I think Dr Martin had just joined so our
  16     echocardiographic service was getting in a way more, you
  17     could say with an infusion of new blood, more modern.
  18     Until that time, we were getting very concerned that
  19     sometimes we were not getting the right or correct
  20     diagnosis, and obstructions were being missed.
  21   Q. So this goes back to something which we demonstrated
  22     yesterday as a problem, that it might be that the
  23     information available to the surgeon when he came to
  24     operate was not as complete as the surgeon would hope.
  25   A. Well, yes.

   1   Q. Can we go overleaf? Again, scroll down so we have AVSD
   2     at the top of the page, please. AVSD was reviewed.
   3     "Other operations": there is no reflection there, in
   4     the "other operations" as such to the arterial switch
   5     programme which you had started, but that is because
   6     that was in the over 1s at this stage.
   7   A. When we looked yesterday, there were very few under 1s,
   8     really, and one is mentioned here, one due to
   9     interoperative bleeding in a child having an arterial
  10     switch.
  11   Q. I am sorry, you do mention it, yes.
  12   A. So that is mentioned here, but others have not been
  13     mentioned because they were not really ...
  14   Q. Future direction: need to review the results, so that is
  15     obviously the next step of any audit process, that once
  16     you have results, particularly with a small unit as you
  17     said, you would need to look back over the previous few
  18     years to see and to check enough data to make the data
  19     meaningful for comparison purposes.
  20   A. Yes.
  21   Q. One would need to review where you got to on the various
  22     measures that were suggested at this meeting.
  23   A. Yes. And also, there are certain things which are not
  24     really documented in the way as you could really find
  25     out from the spirit of the meeting, that now we have

   1     also come to realise that just that yearly figure myself
   2     was not really a type of audit. Audit should be like in
   3     a group of patients: it could be say of a particular
   4     condition and that is what we should be focusing on, so
   5     we really said that in a way, in future audit should be
   6     on a particular problem and that is why, really, we are
   7     saying that we will next time look at the pulmonary
   8     hypertensive crisis, how the patients are being managed,
   9     or in the future look at a particular group like
  10     tetralogy, or a situation like that.
  11   Q. The second paragraph under "Future direction":
  12        "In patients with coarctation with VSD we should
  13     be aiming to perform closure of VSD and pulmonary artery
  14     debanding between 6 and 12 months of age."
  15        Aiming to perform that operation within that
  16     period in that age group suggests you were not presently
  17     doing that operation within that age range, or sometimes
  18     you were missing it?
  19   A. That is correct.
  20   Q. Is that because of the problem with waiting lists that
  21     we looked at a couple of days ago?
  22   A. Yes.
  23   Q. "It was not felt we should be repairing the coarctation
  24     and then going on to closed VSD if necessary as
  25     a primary procedure. With our particular setup it was

   1     felt that this may pose problems."
   2        What was it about the particular setup that would
   3     pose problems in doing that?
   4   A. We are talking of 1989/90, and of course these are the
   5     patients you are really seeing in the neonatal period so
   6     you really would be starting a neonatal operation,
   7     repair the coarctation and then turn the patient back on
   8     and do the VSD closer. I am sure now some centres have
   9     started doing it, quite a few centres may be now doing
  10     it. It was being thought about, but in a way rejected,
  11     as I have mentioned that it would carry very high
  12     mortality and we are not geared up to do too many
  13     neonatal operations because you would be getting a lot
  14     more patients with coarctation and VSD than you get for
  15     other conditions.
  16   Q. When you say "not geared up" to deal with a greater
  17     number of neonates, in what way --
  18   A. Open-heart surgery.
  19   Q. Why was the unit not geared up to that?
  20   A. Because in a way, in 1989/90, we had at that time only
  21     one anaesthetist which I could rely on -- of course
  22     there were one or two others -- and the facility at the
  23     BRI had just been improved, but there was still
  24     a waiting list. It would have created more problems to
  25     our waiting lists. We were already having a problem,

   1     and then there was another new open procedure, and
   2     I felt we should not really be doing it until we have,
   3     in a way, cleared our waiting list and made it more
   4     satisfactory.
   5        At least this way we had tackled the patient,
   6     tackled the immediate problem, and then we can deal with
   7     the VSD as a closed -- as in a routine case -- in a cold
   8     environment. Otherwise it becomes a very urgent
   9     situation.
  10   Q. So what restrained the unit from doing the operation was
  11     first of all waiting lists; secondly, staffing, if I can
  12     say shortages, I think that covers the anaesthetists
  13     point you made; and thirdly, do I get the sense that if
  14     you operate on more neonates, there is less room for the
  15     non-neonates, given the pressures on bed space and
  16     operating theatres caused by the adults?
  17   A. Well, it is an emergency operation. You cannot wait for
  18     the next period to operate, so you have to -- I mean, if
  19     you look in my record of closed cardiac surgery, it was
  20     working at night and various things, so almost I was
  21     doing open-heart surgery every night and then other
  22     surgery next day. So this was adding something new
  23     which I do not think we were geared up to, really.
  24   Q. You say there was only one anaesthetist you could rely
  25     on. There were three who were doing paediatric work,

   1     I think, at that stage -- there may have been more, but
   2     the names that come to my mind are Mrs Masey, Dr Bolsin
   3     and Dr Monk.
   4        Which was the one that you had in mind as the one
   5     you could rely on?
   6   A. Dr Masey.
   7   Q. After this discussion in early 1990, you would have been
   8     waiting, no doubt, to see the 1991 results?
   9   A. Correct.
  10   Q. Those we have got, I think, if we look at UBHT 55/82.
  11     This is 1990, the next year. This shows a considerable
  12     reduction in the mortality rate for the under 1s in the
  13     open age group.
  14   A. That is correct.
  15   Q. Did this come as a relief?
  16   A. Yes. It was also obvious that we were happier in
  17     managing pulmonary hypertensive crisis much later,
  18     because by this time we had introduced a new regime with
  19     the drugs and ventilatory management.
  20   Q. Did it come as a relief not only to you but, so far as
  21     you were aware, to the rest of the unit?
  22   A. I am sure it would have been.
  23   Q. Before I move to the discussion that there was in
  24     respect of these figures, can I just ask that we have
  25     a look at UBHT 55/89? This is under 1s, 30-day

   1     mortality by diagnosis. Scroll down, please. The
   2     figures for the transposition of the great arteries and
   3     the Sennings are in the middle there. Can we highlight
   4     that across? What the figures consist of is no deaths
   5     out of 40 operations from 1984 to 1990 in the under 1s,
   6     which compares very favourably with the United Kingdom
   7     in its mortality rate.
   8   A. Thank you.
   9   Q. So the Senning was one of the success stories, was it,
  10     of the Bristol unit?
  11   A. That was my problem.
  12   Q. It was to your credit, was it not, because you persuaded
  13     Mr Wisheart to begin operating on the Sennings back when
  14     you were Senior Registrar?
  15   A. I think he himself was thinking about it. I would say
  16     instrumental because I had just written from Alabama
  17     where they were doing a lot of Sennings, quite a lot,
  18     with very good results, and here Mr Wisheart has started
  19     seeing a problem with the Mustard which he was doing
  20     before. I mean, he had very good results with the
  21     Mustard, but I thought that we should change and he was
  22     very seriously thinking of changing. Obviously, when
  23     two people talked about the same, then we did change and
  24     we went to make the change, yes.
  25   Q. The figures for 1990 were discussed, were they, on

   1     28th July 1991. You will not remember the date, I am
   2     sure. If we look at UBHT 61/146: Mr Wisheart's house,
   3     8 o'clock in the evening, and can we scroll down?
   4        "By way of introduction to the meeting,
   5     Mr Wisheart provided tables of open and closed cardiac
   6     surgery results for the Bristol paediatric unit.
   7     Comparisons were made in this data for mortality in the
   8     Bristol Cardiac Unit in 1990 and the UK national average
   9     in 1988."
  10        That is the sheet we just looked at.
  11        "Mr Wisheart said that he thought the tables
  12     demonstrated that the problem which had been thought to
  13     have been reaching crisis proportions in the Bristol
  14     unit, when put in context, was actually not as serious
  15     as had been thought."
  16        This is expressing the sense of relief, is it,
  17     that the whole unit had that the figures for 1990 showed
  18     a considerable improvement, for the reasons you have
  19     mentioned?
  20   A. It is shown in the third paragraph, if you read it
  21     further, that we felt that way.
  22   Q. You and he both made the point there had been recent
  23     improvements in operative and post-operative management
  24     to the BRI site which made meetings like this extremely
  25     valuable.

   1        "It was noted that the previous such meeting had
   2     discussed pulmonary hypertension and this had been very
   3     successful."
   4        So the success is attributed to the management of
   5     pulmonary hypertension?
   6   A. Yes, because as we identified before, the two groups
   7     which I was more concerned with, VSD and AVSD, and both
   8     of them had a problem relating to pulmonary hypertension
   9     and hypertensive crisis in post-operative management.
  10     That is the group where -- because we knew Senning was
  11     all right. TAPVD, we had five cases in three years type
  12     of thing, so we were not getting that many, and of
  13     course diagnosis was going to be improved, hopefully,
  14     but the main group I thought was the VSD and AVSD. That
  15     is why we were really saying, it has been minuted like
  16     that, but that is the correct impression.
  17   Q. Going back to the first paragraph under "Introduction",
  18     the feeling that the problem had been thought to be
  19     reaching crisis proportions, focusing on those words --
  20     perhaps you will just highlight them -- is it right
  21     until the 1990 results came out there had been a sense
  22     that there was something of a crisis in the unit because
  23     the outcomes were not as good as they should be?
  24   A. No, I would not say that. I would say concern, but not
  25     "crisis".

   1   Q. So you take issue with the words "crisis proportions"?
   2   A. I think "crisis" is a little bit of an exaggeration,
   3     I would say, but of course there is a concern, and the
   4     concern would be there, if you have the mortality which
   5     appears to be on the high side, even if you put
   6     a statistical range on it.
   7   Q. If we look on, the problem, when put in context, missing
   8     the words "crisis proportions", was not actually as
   9     serious as had been thought.
  10        Is the problem referred to there the problem that
  11     Bristol's results were out of step with the UK's if one
  12     looked at the 1989 data and earlier?
  13   A. I would accept that.
  14   Q. The context is the context provided by the 1990 results?
  15   A. The improvement noticed, yes.
  16   Q. The next paragraph:
  17        "Dr Bolsin said that he thought that the data in
  18     the tables in which the Bristol mortality was higher
  19     than the UK average for two years prior vindicated the
  20     vigilance of the anaesthetic staff in recording their
  21     mortality data and vigorously pursuing requests for
  22     a combined meeting. This point of view was supported by
  23     Dr Burton, Dr Masey and Dr Monk."
  24        What do you recollect being said about the results
  25     of the previous meeting vindicating the approach that

   1     the anaesthetist has been taking?
   2   A. I think this is a personal opinion. I do not think this
   3     was discussed in the meeting or agreed in the meeting.
   4   Q. You appreciate, this is Dr Bolsin's note or minute of
   5     the meeting as he has told us. Subsequently, when in
   6     September he circulated the note, there was objection
   7     taken to it as a minute. But did you see this minute at
   8     the time?
   9   A. Yes. He circulated it. I had it.
  10   Q. If you saw it at the time, did you think at the time
  11     that some of the words used were, as you have told us,
  12     exaggerated, like the words "crisis proportions" and the
  13     private view expressed in the second paragraph?
  14   A. No, I did not look at that critically, as if it was
  15     criticising anything, or the system. I thought this is
  16     a minute of a meeting which is all aimed to improve the
  17     results and performance, and I had no reason to really
  18     question anything and therefore I did not.
  19   Q. So when you read the minute through, did you think that
  20     it was a fairly accurate record of what had been
  21     discussed, or not?
  22   A. I mean, looking back, what I know now and various
  23     things, I am getting into looking very critically about
  24     the use of the word "crisis" and the use of the word
  25     "vigilance" and things like that. But at that time,

   1     I mean, I saw it and I did not really notice any
   2     difference, or --
   3   Q. So it did not strike you at the time as being out of
   4     place?
   5   A. No.
   6   Q. That might suggest that those words or something like
   7     those words may adequately have reflected the meeting?
   8   A. No, but I would not have used the term "crisis".
   9   Q. You would not have used it?
  10   A. And I did not think anybody was really mentioning
  11     "crisis" anywhere.
  12   Q. What those three paragraphs, particularly the first two,
  13     might suggest, is that the anaesthetists, in particular,
  14     had concerns over the mortality figures which had been,
  15     in part at any rate, resolved by the 1990 figures. Was
  16     that the sense of the meeting?
  17   A. I thought that after that meeting everybody was very
  18     pleased that we have managed to achieve something.
  19   Q. Yes. That is not quite what I was asking.
  20   A. No, but I did not get any impression that anaesthetists
  21     as a group had some different feeling or were feeling
  22     differently before.
  23   Q. I am sorry, you misunderstood the question. The point
  24     I am asking about is whether the anaesthetists were in
  25     effect congratulating themselves for having been

   1     particularly concerned?
   2   A. No, I did not get that impression at all.
   3   Q. If we go down to the bottom of the page, there is
   4     a reference to meetings like this being extremely
   5     valuable, and the steps which had been taken over the
   6     last year in respect of operative and postoperative
   7     management.
   8        Those steps came, did they, from the minute that
   9     we looked at a moment or two ago, where each of the
  10     operations was looked at in turn and which was
  11     a meeting, if you recall, of 19th March 1990.
  12   A. That is correct, sir.
  13   Q. Had there been an audit meeting of that type since
  14     March 1990?
  15   A. You mean like the 1 year age group?
  16   Q. In 1990, yes, March 1990. You look at the results of
  17     the 1 year age group, these minutes are of a discussion
  18     the following July, July 1991, and the figures are
  19     reviewed just as the figures had been reviewed in March
  20     1990.
  21   A. That is what I was talking to you, at the end of that
  22     meeting, that we decided from now on we would audit in
  23     a group of patients, the condition or particular
  24     time-frame that would give us a better idea than
  25     presenting a yearly figure. That is why, really, you

   1     see the subsequent audit meetings when, if you have the
   2     record, they would say an arterial switch or something
   3     saying pulmonary valvuloplasty, or balloon atrial
   4     valvuloplasty, that is how it was being audited and
   5     I thought it was more useful.
   6   Q. If we look at UBHT 61/153, this is a letter from
   7     Dr Martin to Dr Jordan, audit of paediatric cardiology.
   8     This is the cardiologists inspired meeting which the
   9     surgeons attended.
  10        "I think it is very important we recommence our
  11     audit sessions in 1992 and after discussion I think we
  12     ought to hold these monthly ..."
  13        The first line, "important that we recommence".
  14     This, to scroll down a bit and remind you of the date,
  15     was 3rd January 1992, so Dr Martin is saying to
  16     Dr Jordan, "Let us start up again, recommence, the audit
  17     sessions"?
  18   A. That is correct.
  19   Q. Had they slipped away or fallen away for some reason?
  20   A. You know the previous audit, when you saw the 1990
  21     figure, and under 1 mortality figures, they were started
  22     by Dr Martin in 1989 and we went on for a year or so,
  23     but then, when the new Trust structure came in and a new
  24     audit setup was established, people were a bit confused
  25     for a year, what would be the audit. I mean, is it

   1     going to be UBHT itself going to organise something
   2     centrally? They were having meetings; we were getting
   3     circulars, but no real structure was coming out. What
   4     we were talking about is the usual audit which we were
   5     getting on Monday, we were talking to, you know,
   6     presenting our data on various things, but not in
   7     a relevant manner, in a format and that is what it is
   8     trying to establish.
   9        So in a way there was an audit going on but not
  10     in a formatted manner and we were waiting for
  11     instruction from UBHT to come out, which did come out,
  12     but not by the time this letter came out.
  13   Q. So if I unpick your last answer, you were saying that
  14     during the time that the Trust began, formalised audit
  15     stopped or diminished for a while and began again in
  16     1992?
  17   A. Yes.
  18   Q. The exception must be the meeting that we have looked at
  19     in March 1990, just before the move towards Trust
  20     status, and the meeting that we looked at in July 1991
  21     reviewing the results, which obviously is formalised in
  22     the sense that it took place and there is a note, albeit
  23     not agreed, of what took place at the meeting?
  24   A. But all this time, monthly audit meetings at both places
  25     were still taking place.

   1   Q. Is it part of the audit cycle that first of all one
   2     should look at how one has been doing; secondly, discuss
   3     how one might improve, the steps that might be taken to
   4     improve; and thirdly, review those steps to see whether
   5     the improvement has been achieved?
   6   A. That is well accepted, but as you know, this all came in
   7     after these things became more formalised; before that
   8     it was not, really. It was an audit in an old-fashioned
   9     manner, sitting in the ward looking at your monthly
  10     figures, coming out with what we were doing, good and
  11     bad and things like that and what we should do. So we
  12     are doing a loop, but not a complete loop, as we come to
  13     know in the mid-1990s in that sense.
  14   Q. The audit loop, as you described it, means, does it,
  15     necessarily that the decision of a meeting should be
  16     written down somewhere so that one can refer back to the
  17     record, so that we have something written to compare
  18     future progress against?
  19   A. That is correct.
  20   Q. Just exploring for a moment the way it was done in the
  21     unit before the audit loop became the accepted idea, you
  22     say just looking at the figures and saying "We have done
  23     well" or "We have done badly", did that, at that stage,
  24     involve discussion, if you felt you had done badly, of,
  25     "Well, how can we improve?"

   1   A. Yes, very much so.
   2   Q. About no particular goals set against which you might
   3     measure that improvement?
   4   A. That is correct, because there was no goal to compare
   5     against.
   6   MR LANGSTAFF: Dr Silove, I think, wanted to contribute?
   7   DR SILOVE: I did not think of anything in particular,
   8     really, except to say that audit in the late 1980s and
   9     early 1990s was a very sporadic affair, and I think it
  10     has only become much more formalised in the last, say,
  11     six or seven years, but it was a very sporadic affair.
  12     I think that the Bristol people were actually conducting
  13     reasonable audit for that time.
  14   MR LANGSTAFF: We have been told, Dr Silove, that one of
  15     the impetuses to formalising audit in the audit loop was
  16     in fact the development of Trust structures across the
  17     country.
  18   DR SILOVE: Yes.
  19   MR LANGSTAFF: This is a national point, because with
  20     the purchaser/provider split, there was a need to
  21     demonstrate performance across a range of indicators,
  22     and it became part of consultants' contracts that they
  23     took part in formal audit?
  24   DR SILOVE: That is correct, but it took a long time for the
  25     process of audit to be developed properly in each of the

   1     Trusts.
   2   MR LANGSTAFF: So the point of drawing that or providing you
   3     with that evidence that we have had is that it might
   4     indicate that ideas as to the way that audit should be
   5     conducted were certainly current prior to 1991, and
   6     sufficiently current for that to be formalised at the
   7     time that Trust status began?
   8   DR SILOVE: Yes, they were certainly current at that time.
   9     I am just saying that it seemed to take a long time for
  10     groups to get together and decide exactly how they were
  11     going to audit things.
  12   MR LANGSTAFF: Would you expect it to happen more in cardiac
  13     surgery, given that the surgeons had collectively
  14     established a national register back in the 1970s?
  15   DR SILOVE: Yes, and I think there always has been audit of
  16     the type Mr Dhasmana has been describing through the
  17     1970s and 1980s. There always was the collection of
  18     surgical data, number of operations done, types of
  19     operations and mortality rates, but that seemed to be
  20     the type of audit that are around.
  21        The rest of audit and closing the loop, so to
  22     speak, had not been formally introduced, I would say,
  23     until the Trusts came into being.
  24   MR LANGSTAFF: Because if any doctor, any clinician,
  25     had a sense that he or she was not doing as well as

   1     others, any self-respecting doctor would want to know
   2     why, how he or she might address it, and at a later
   3     stage, wish reassurance, even if there was no
   4     formal target, that that had been achieved?
   5   DR SILOVE: That is absolutely right, yes.
   6   MR LANGSTAFF: That has always been the position, has it
   7     not?
   8   DR SILOVE: Yes, it has.
   9   MR LANGSTAFF: So audit in that sense had been conducted
  10     throughout the 1980s and what we are seeing is a process
  11     of formalising what has been called the audit "loop".
  12   DR SILOVE: Yes.
  13   MR LANGSTAFF: Which necessarily involves, does it,
  14     recording decisions?
  15   DR SILOVE: Yes, and then following up those decisions at
  16     a later meeting.
  17   MR LANGSTAFF: And developing standards against which
  18     one might actually monitor performance?
  19   DR SILOVE: That is right, yes.
  20   MR LANGSTAFF: So instead of sitting down and looking back
  21     and saying "How well we have done", or "Could we not do
  22     better here", or "My goodness, that is worrying", people
  23     are setting out in advance saying "This is what we want
  24     to achieve and that allows us a year later or 6 months,
  25     whatever the period is, to come back and say this is

   1     what we said we should achieve, have we done it".
   2   DR SILOVE: That is correct.
   3   MR DHASMANA: It is well to bear in mind that cardiac
   4     surgeons had taken a leading role in this. That is what
   5     the UK Cardiac Register is supposed to be doing, to
   6     provide a type of target where an individual surgeon
   7     would look at his or his unit's results and see if he is
   8     falling behind and what steps he has to take to catch up
   9     with it. So cardiac surgeons were really working on
  10     it. It was not as sophisticated as it is now, but we
  11     were doing all of it.
  12   THE CHAIRMAN: May I ask a question? We have heard a lot of
  13     evidence about audit, of course, and the mention of the
  14     notion of the audit loop and closing the loop does not
  15     really take account of the fact of how the loop is
  16     opened, in other words, what the targets are and how you
  17     decide upon those.
  18        Mr Dhasmana has just referred to targets. How
  19     would these targets begin to emerge? Based upon what
  20     data?
  21   DR SILOVE: Essentially, one needs to take a careful look at
  22     all of the cases over a period of a year, which is what
  23     they did, divide them into categories of diagnoses, and
  24     look at results. The difficulty, in the early 1990s,
  25     was the comparators. The UK surgical register was based

   1     on a decision made when it was first set up to collect
   2     diagnoses rather than operations, and I think this was
   3     a fundamental problem. It was very difficult, for
   4     example, comparing transposition operations when the
   5     switch operation started. They were all being lumped
   6     together as transposition.
   7        So I think that each centre, each department in
   8     each centre, needed to establish its own information
   9     base and needed to look at results and try to determine
  10     where there were problems, and then say, "There are
  11     these problems; how can we improve on them"?
  12   THE CHAIRMAN: Is it not a bit more complicated than that?
  13     Not "how we can improve upon them?", but "Can we improve
  14     upon them?" How do you answer that question?
  15   DR SILOVE: That can be difficult, but that is the
  16     fundamental question that has to be asked first, yes.
  17   MR LANGSTAFF: Can I come back from the theoretical to the
  18     historical and go back to the meeting that we were
  19     looking at in July 1991, a different part of the note?
  20     Can we go to UBHT --
  21   THE CHAIRMAN: Mr Langstaff, just interrupting for a moment,
  22     I understand the distinction, but we have to get the
  23     theoretical right as well as the historical.
  24   MR LANGSTAFF: I was not suggesting anything --
  25   THE CHAIRMAN: It is important for all who hear us.

   1   MR LANGSTAFF: Please, in case the wider audience should
   2     misunderstand my comment, it was intended as a link and
   3     not in any sense to --
   4   THE CHAIRMAN: It is very important that it is understood by
   5     all that there has to be some deep thinking about the
   6     questions we are engaged in, and not just reaching
   7     conclusions on what might be bandied about here there
   8     and everywhere as facts and figures. We have to think
   9     deeply of the context in which the figures emerge and
  10     what weight to give to them and so forth. It is for
  11     that reason that we have to press very deeply before we
  12     rise again to reach the sort of answers that people are
  13     looking for.
  14   MR LANGSTAFF: Thank you, sir. Can we go back to UBHT
  15     61/149? You actually looked, in that meeting, as
  16     Dr Silove has suggested one should do, at problem
  17     operations. Here we have the tetralogy of Fallot
  18     patients who were looked at under the heading of
  19     "Problem Operations".
  20        Was it thought at the time that tetralogy of
  21     Fallot patients might be a problem area?
  22   MR DHASMANA: I think I wanted to highlight that the
  23     pulmonary artery anatomy should be better visualised and
  24     that is why, really, I raised the question. I am not
  25     sure whether I had thought that it was a problem area or

   1     not.
   2   Q. But certainly, that is exactly what you are recorded as
   3     saying in the second paragraph there. You are recorded
   4     as saying, or complaining, that the information provided
   5     was just not good enough. That represented your view,
   6     did it?
   7   A. Well, again, the use of words, really. That is what
   8     sometimes -- I would not have said "just not good
   9     enough", I am not that way. I would have said "it could
  10     be better", you know, if I knew, because I was seeing
  11     the film, an angiogram, the two arteries nicely near the
  12     hilum and the main pulmonary artery, but what I was not
  13     seeing was the bifurcation. I had difficulty in
  14     persuading my colleagues, which included radiologists,
  15     to use a supine view, the coronal view, which I had seen
  16     quite a lot in the US and Alabama. So I was trying to
  17     make that point again, and especially as now Dr Martin
  18     has arrived. I was very pleased that he agreed with me,
  19     and assured me that they were trying to do that and
  20     provide me with that information.
  21   Q. Can we scroll down? This is dealing with Mr Wisheart's
  22     comments. About a third of the way down that paragraph:
  23        "He [I think Mr Wisheart] also went on to say that
  24     in his experience deaths had been associated with low
  25     cardiac output, renal failure and pulmonary

   1     insufficiency, probably related to coronary artery
   2     anatomy not being well demonstrated."
   3        Is that again part of the same point?
   4   A. No, again, you know, there was some basis for the
   5     discussions which is missing here. I think
   6     anaesthetists wanted to use a pulmonary artery catheter,
   7     and like any new procedure, you start getting worried
   8     about these things, and especially leaving them in very
   9     small children in ITU. We knew when these things were
  10     being introduced that there were reports of perforation
  11     and various other things, so we were really saying that
  12     if you want to really put in this pulmonary artery
  13     catheter, what information are you looking for? They
  14     said, well, (1) PA; (2) we would get the wedge pressure
  15     and that would give us some indication of how the left
  16     ventricle was coping. I said I can give you a left
  17     atrial line, which can give you an indication of the
  18     left ventricular performance, and you do not have to put
  19     this line in. That was that discussion, really.
  20        I do not think I was literally against the
  21     principle, but expressing my reservation in introducing
  22     a new invasive thing from inside and leaving it in the
  23     pulmonary artery for a long period.
  24   Q. I was not so concerned about the disagreement as about
  25     whether you shared Mr Wisheart's experience, reported in

   1     the paragraph, that some deaths, at any rate, had been
   2     associated with the features which he mentions: "low
   3     cardiac output, renal failure, pulmonary insufficiency
   4     probably related to coronary artery anatomy not being
   5     well demonstrated".
   6        He is stating the problem rather than the
   7     solution. Your answer to me is that we differed about
   8     the solution to it, but is he right on the problem?
   9   A. It comes to the same thing. In tetralogy of Fallot the
  10     other problem is really demonstration of the coronary
  11     artery anatomy. That was sometimes not available, and
  12     it was just because I was told that in small children --
  13     this is at that time; now we know, because they are
  14     doing coronary artery -- it is more risky to demonstrate
  15     coronary artery. That is why, in a way, Mr Wisheart was
  16     saying throughout that he had a problem with coronary
  17     artery anatomy and I had a problem with pulmonary artery
  18     anatomy. So that is what we were saying. But the left
  19     atrial line is also mentioned there, and all the low
  20     cardiac output, renal failure, pulmonary insufficiency,
  21     they also related to left ventricle performance.
  22     So I was really saying that that is another way of
  23     measuring it.
  24   MR LANGSTAFF: Thank you. I am going to move on now, sir,
  25     from mid-1991. Would this be an appropriate moment to

   1     take a break for lunch?
   2   THE CHAIRMAN: Yes. Shall we say until a quarter past 1?
   3     Thank you, Mr Langstaff.
   4   (12.30 pm)
   5            (Adjourned until 1.15 pm)
   6   (1.25 pm)
   7   MR LANGSTAFF: We have just been looking at the mid-1991
   8     position. You recall my asking you about the words
   9     "crisis proportions" and your saying that was something
  10     of an exaggeration as you saw it at the time.
  11        Can I ask you to have a look at a letter
  12     UBHT 61/19? 25th July 1990, it is a letter written to
  13     Dr Roylance and you may have seen as you read the
  14     transcripts of this Inquiry some reference is made to
  15     this letter. Can I take you to the part which I want to
  16     ask you about, it is a letter from Dr Bolsin. Can
  17     I scroll down? The third from last paragraph:
  18        "As a paediatric cardiac anaesthetist, I would
  19     have thought the management directive to improving
  20     quality of patient care should have attempted to address
  21     the unfortunate position of the South West Regional
  22     cardiac centres' mortality for open heart surgery on
  23     patients under 1 year of age. This, as you may not
  24     know, is one of the highest in the country, and the
  25     problem should be addressed."

   1        That is written to the Chief Executive,
   2     Dr Roylance, at the time the District Manager. Plainly
   3     the figures that were available at that time would have
   4     been the 1989 figures that we looked at this morning
   5     which showed an apparent deterioration in the Bristol
   6     results and a comparison over a 5-year period with the
   7     UK which was unfavourable and which you say caused you
   8     yourself some concern and others in the unit, a concern
   9     alleviated by the 1990 results when you got them.
  10        Did you know of this letter at the time?
  11   A. The first time I saw this letter was during the GMC
  12     proceedings.
  13   Q. That is not quite what I asked.
  14   A. No, I did not know about this letter at that time at
  15     all.
  16   Q. What we have been told, amongst other things, is that
  17     there was a meeting of the anaesthetists at some stage
  18     not long after this meeting, probably in 1991, that was
  19     my reference, UBHT 61/49 -- this is Dr Bolsin's own
  20     calendar of events -- where he has told us and Dr Monk
  21     has confirmed that there was a meeting of cardiac
  22     anaesthetists with the Director of Anaesthesia,
  23     Dr Williams and Dr Baskett. The substance that is
  24     recorded there is perhaps not important, save that the
  25     evidence that has been given to us is that the sending

   1     of the letter by Dr Bolsin to Dr Roylance was discussed
   2     at the meeting and was the background to a decision of
   3     that meeting that Dr Bolsin, it is said, should not be
   4     for the future the vehicle for concerns.
   5        Did you have any idea as one of the two
   6     paediatric surgeons that the one of the anaesthetists
   7     has sent a letter to the Chief Executive and the other
   8     anaesthetists were saying "This is not quite the way to
   9     go about it for the future", matters of that sort?
  10   A. I had no idea at all.
  11   Q. The suggestion is made -- I put it that way because
  12     there is a dispute about it, the suggestion is made that
  13     Mr Wisheart himself saw the letter to Dr Roylance. Did
  14     Mr Wisheart ever mention to you having received any
  15     letter from one of the unit critical of the success rate
  16     of the unit at about this time?
  17   A. He did not.
  18   Q. How often did you see Mr Wisheart?
  19   A. At that time we were sharing an office.
  20   Q. How open was he in his discussion with you of matters
  21     which concerned the unit?
  22   A. I thought very open.
  23   Q. If he had had a letter such as the letter that Dr Bolsin
  24     wrote to Dr Roylance, is that the sort of matter that he
  25     would or the sort of matter he might not have discussed

   1     with you?
   2   A. I believe if he had any concern with paediatric cardiac
   3     surgery, expressed to him directly or indirectly, he
   4     would have mentioned it to me.
   5   Q. Plainly he had a concern because you have told us all
   6     the unit were concerned about the 1989 figures. What
   7     I am asking is slightly different: would he, do you
   8     think, have mentioned to you the fact that he had
   9     received a letter, albeit a copy of a letter which an
  10     anaesthetist had sent to the Director of the authority
  11     about the outcome results in paediatric cardiac surgery?
  12   A. No.
  13   THE CHAIRMAN: Mr Langstaff, perhaps you could run that
  14     question past Mr Dhasmana, it does not coincide with the
  15     previous answer, it may be because it was a long
  16     question that "No" came out as "Yes" or "Yes" came out
  17     as "No", perhaps you could ask again.
  18   MR LANGSTAFF: I will put it in a supposed form: suppose
  19     Mr Wisheart got a copy of a letter such as the letter
  20     from Dr Bolsin to Mr Roylance saying "Paediatric cardiac
  21     surgery has poor results"; is that the sort of letter
  22     Mr Wisheart would normally discuss with you?
  23   A. I believe he would have.
  24   Q. Thank you, sir.
  25        In 1991 the cardiac anaesthetists agreed amongst

   1     themselves that they had concerns over the arterial
   2     switch programme and its results. In 1991 you yourself
   3     had gone through the first few operations in the series
   4     and you remember that yesterday or the day before I went
   5     with you and you agreed that of the first 14 cases 6 had
   6     died and the deaths occurred earlier rather than later
   7     within that period?
   8   A. That is correct, sir.
   9   Q. Did you know that anaesthetists were discussing amongst
  10     themselves that they had concern over the results of
  11     that particular operation?
  12   A. No. If I could add, please, I have read the transcript
  13     and I was quite surprised when the doctor made mention
  14     of that in his evidence to you. He had not mentioned
  15     that at all to me.
  16   Q. The decision of the meeting was that Dr Williams
  17     and Dr Monk would take the matter forward and between
  18     them we have been told by Dr Monk it was agreed that
  19     Dr Williams would. Did Dr Williams ever speak to you?
  20   A. No, on that issue, no.
  21   Q. If Dr Williams had spoken to Mr Wisheart, is that
  22     something you would have expected Mr Wisheart to mention
  23     to you?
  24   A. I cannot answer that because I do not know whether he
  25     would have or not.

   1   Q. But it is the same sort of question as I asked you about
   2     the letter.
   3   A. I know, that is why I am -- because I think Dr Williams
   4     was a little bit higher level than I was, so I do not
   5     know whether he would have decided to come to me or --
   6     it is a little bit, I am afraid, hierarchy still goes
   7     on.
   8   Q. That might have been a matter discussed between the
   9     Director of Anaesthesia and a man in Mr Wisheart's
  10     position, at that level and not with someone who was
  11     more junior as you were?
  12   A. That is my feeling but I certainly believe if anything
  13     concerned paediatric cardiac surgery Mr Wisheart would
  14     have talked to me.
  15   Q. When you were discussing -- because you discussed at the
  16     end of 1991, you have told us, the start of the neonatal
  17     switch programme?
  18   A. That is correct.
  19   Q. With whom did you discuss the start of the neonatal
  20     switch programme?
  21   A. It was an ongoing discussion as I mentioned before, but
  22     the paediatric cardiologist, anaesthetist and my
  23     colleague Mr Wisheart.
  24   Q. So you discussed the beginning of that operation with,
  25     amongst other people, anaesthetists?

   1   A. Yes.
   2   Q. When you did that, did you get any sense that the
   3     anaesthetists were particularly concerned about the
   4     results at that stage of the arterial switch?
   5   A. That is why I expressed my surprise because Dr Monk
   6     would have been one of those people really I would have
   7     talked to at that time and, no, it was not mentioned to
   8     me at all.
   9   Q. One of the conclusions the Panel may have to reach, it
  10     is a matter for them, is why it should be that we should
  11     be told by anaesthetists that they had discussions or
  12     concerns which related to surgery you were performing,
  13     the unit was doing and you, another part of the unit,
  14     one of the cardiac surgeons should not be aware or not
  15     have been told of their concerns. Were there as you see
  16     it difficulties in communication between the surgeons
  17     and the anaesthetists?
  18   A. I cannot believe it could be with me really because
  19     I was so openly -- if a man is criticising his own, or
  20     criticising means looking at his own results openly with
  21     everybody concerned with the programme, how could it be
  22     that I was not communicating? I just cannot believe
  23     it.
  24        This is the thing which has puzzled me even during
  25     the GMC, that all these people have been talking about

   1     so-called concern from 1991; they have been working with
   2     me all the time and how could they not mention anything
   3     at that time, or if it is something that after the event
   4     they have all taken high moral ground and at that time
   5     did not like to come out and say anything, which I fail
   6     to understand and I still do not have any answer.
   7   Q. There is possibly a third position which I would welcome
   8     your comments on, it is this: there may have been at
   9     least in some quarters a fear of approaching Mr Wisheart
  10     and a belief because you had been his Senior Registrar
  11     and were junior to him and the hierarchies were as you
  12     just described that to approach you would in effect be
  13     to approach him?
  14   A. If they would have approached me I would have definitely
  15     brought it open anyway and that would have included
  16     talking and being open with everybody and if there was
  17     going to be an inquiry I would have welcomed that
  18     inquiry at that time rather than the Inquiry now and
  19     with what has happened to me since 1995. I would have
  20     liked them to have done this and they should not have
  21     been afraid to get the thing in the open at that time,
  22     if that is what they wanted.
  23   Q. Let me take it in two stages: what was your own view
  24     from your position of the approachability of
  25     Mr Wisheart?

   1   A. I never found him unapproachable, I was always able to
   2     really talk very openly and freely to him at any time.
   3   Q. The second question is this: that is your perception of
   4     the way you might approach him. Did you see anybody
   5     else having difficulties, for whatever reason, with
   6     approaching Mr Wisheart?
   7   A. I think it is very unfair to speak on somebody else's
   8     behalf because I do not know what they are feeling in
   9     their own mind.
  10   Q. That I appreciate. What I am asking you is whether you
  11     think you saw any such difficulty or reluctance.
  12     I appreciate you are not happy to comment but please
  13     help us if you can.
  14   A. Fine, I can only talk of the meetings and various other
  15     discussions when we were together amongst other people.
  16     I then never saw him taking a strong dogmatic view and
  17     giving an impression "You listen to me otherwise I will
  18     not follow your advice" or anything. I thought he was
  19     always open. I looked up to him in a way at times in
  20     the meeting to sort out if I was having a problem
  21     because he had the ability to somehow communicate with
  22     everybody concerned. So I cannot believe that he was
  23     unapproachable.
  24   Q. He has been described I think as occupying something of
  25     an "elder statesman" role at meetings; how accurate

   1     would that description be?
   2   A. I think it is I who had used that term, and yes,
   3     I treated him like that, yes.
   4   Q. Again pressing the point: what I was asking really was
   5     not so much the way that you saw other people reacting
   6     to Mr Wisheart when you were there, but whether in the
   7     several private personal discussions which you have had
   8     -- I am not going to ask you to name anyone -- whether
   9     in the private personal discussions you had with others
  10     when Mr Wisheart was not there, whether anyone mentioned
  11     to you any difficulty that they personally had in
  12     approaching or going to Mr Wisheart about anything?
  13   A. No, on the other hand people told me "Janardan, I wish
  14     you could be as nice as Mr Wisheart" on some occasions.
  15     So it used to be on different -- but I have not heard
  16     any of these people who are now saying what they are
  17     saying mention those words at that time when we were
  18     working together.
  19   Q. Can I embarrass you by asking you what occasions the
  20     people said to you "For goodness sake be as nice as
  21     Mr Wisheart"?
  22   A. It used to be usually theatre really because when I am
  23     operating I am very focused on things and I had
  24     a different -- when I am doing I am concentrating, at
  25     that time I do not want distraction and things like

   1     that. On the other hand Mr Wisheart was very cordial
   2     all the time.
   3   Q. Is that because of focus or because of the pressure
   4     of the situation?
   5   A. Maybe it is personality, people are made in different
   6     ways, I am a little different.
   7   Q. That is why I am asking you, I am passing no judgment,
   8     just asking the question. Do you think the same might
   9     be said of yourself not only in the theatre but when you
  10     were outside the theatre and perhaps under stress or
  11     strain?
  12   A. It is possible, I mean under stress or strain people do
  13     react differently and I cannot really say I have been
  14     marvellous all the time, no, I would not claim that.
  15   Q. We have dealt with events in 1991. Can I now come to
  16     what we see as the 1991 data. We had looked at the 1990
  17     data which was discussed in 1991.
  18   A. Yes, sir.
  19   Q. The 1991 data we find at UBHT 55/108. If we look,
  20     please, for comparative data we find it at UBHT 55/128.
  21     Can we scroll down, please? What we see there, this is
  22     the under 1 results. The UK 1990 mortality is 15.8 and
  23     the Bristol mortality there shown on those particular
  24     diagnoses, 23.2. That is a mixture of conditions.
  25   A. Yes, sir.

   1   Q. Can I look at the overall results which we find at
   2     page 113?
   3   A. Before we move, just to point this out, you know one has
   4     to remember that this is TAPVD, still the group where we
   5     have got still about 50 per cent mortality and I think
   6     that is what really has shown that high figure.
   7   Q. Thank you. If one takes those three deaths out we will
   8     have a different reflection, is the point you are
   9     making?
  10   A. That is correct, sir.
  11   Q. Page 113. If we look across the first line under the
  12     under 1s. What we pick up is 30 per cent.
  13     Unfortunately that --
  14   A. I am not sure we are looking at the same, are we?
  15   Q. UBHT 56/113. This is Bristol for 1991, 30-day
  16     mortality.
  17   A. Because previously we saw number 56 and there was
  18     a different figure.
  19   Q. We can go back to page 128. Under 1s.
  20   A. Yes, here you have 56 and you have a total number of 13
  21     here. I do not know if there is something, also it does
  22     not really, because we have got TGA 11, 5 deaths. I do
  23     not know whether we are looking really at 1990 or 1991
  24     figures or something different, this is the 1992
  25     figures.

   1   Q. That is why, I am sorry, I have been misled by my note.
   2     Can we go back then, I do apologise and begin again at
   3     UBHT 56/113. If we look at that we find the open
   4     results for Bristol under 1, 30 per cent?
   5   A. That is correct.
   6   Q. Was that disappointing to the unit?
   7   A. After 1990, yes, you would say but then we would have to
   8     really look in the categories.
   9   Q. If we go down to page 114 to look in the categories.
  10     This is the under 1s. 1984 to 1991 as a total and as
  11     a percentage. This is including the 1990 where there
  12     has been the good results?
  13   A. Yes. Just the bottom two lines you can really see,
  14     sometimes I am afraid the early figures that is what you
  15     can see, that you may have a cluster of very difficult
  16     problems with multiple problems and that can askew your
  17     figure.
  18   Q. This is the miscellaneous group, is it?
  19   A. Exactly.
  20   Q. Where, as we see, in 1991 6/8, and half, 50 per cent of
  21     the 1984 to 1991, the 8-year total with no comparison of
  22     course for the United Kingdom, the only comparison would
  23     be with the overall figure, no comparison stated.
  24        If we look at the figures, the comparison between
  25     Bristol over that 8-year period and the United Kingdom

   1     in 1990, what is perhaps obvious is that the United
   2     Kingdom in 1990, 15.8 per cent, is very nearly half of
   3     the overall mortality in the under 1s that Bristol was
   4     producing as we saw from the previous slide and Bristol
   5     was getting on for 1 and three quarter times the UK
   6     figure if one takes the range 1984 to 1991. The figures
   7     are not very good for Bristol, are they?
   8   A. I am sorry, I do not understand where you are talking
   9     about? Where did you get 15.5?
  10   Q. If you look down, bottom right-hand corner.
  11   A. 15.8, yes, that is correct.
  12   Q. If you take 28.5 which is the Bristol 1984 to 1991
  13     mortality -- can we highlight that, please -- that is
  14     about 1 and three quarter times the UK figure for 1990.
  15   A. Yes, I mean I would not feel that defensive as to
  16     compare against that big number, 84/91. I can really
  17     just see 1991 in front of me. I do not think I would
  18     really feel that I have to hide between 28.5 or 30,
  19     whatever per cent it really comes to. Yes, it is high
  20     and that is what really we discussed but at the same
  21     time we are now aware that the problem cases which used
  22     to be before say AVSD and VSD, they are still very good
  23     and we have a cluster of these cases grouped into the
  24     miscellaneous which has askewed the figure.
  25        Of course overall mortality is higher but we are

   1     happy that we are still getting a satisfactory result or
   2     good result in VSD and at that time, in 1990, 20 AVSD,
   3     2/9 is about 25 per cent. In the country 23,
   4     25 per cent was the usual mortality.
   5   Q. 1990, if we look across the far right-hand side of that
   6     particular line?
   7   A. That I know is not correct because I attended the Corby
   8     meeting on AV canal, arranged in 1991 where centres from
   9     the country gathered together and Mr Elliott produced
  10     figures and he really said that real figures in the
  11     country was at that time about 25/26 per cent.
  12        Only one centre in 1990 in the country was
  13     producing results under one figure, it was Birmingham,
  14     Mr Brawn, whose figures were 5 or 7 per cent. All other
  15     centres were ranging around 20 to 30 per cent and this
  16     is why really we were very critical of the UK
  17     Cardiological Surgical Register mortality figure.
  18     15.9 is written there, but that is suspect.
  19   Q. Let me understand what you are saying about that: are
  20     you saying the 15.9 figure is wrong in itself or are you
  21     saying that it is misleading because it is a product of
  22     very good results from Birmingham, Mr Brawn, and very
  23     poor results from everywhere else?
  24   A. But I was told --
  25   Q. I just want to be clear what you are saying.

   1   A. I cannot answer you because I do not know the answer
   2     really. I can only give you what I know of the facts at
   3     that time as was told to me in the Corby meeting, that
   4     15.9 is not the correct figure, something is wrong
   5     because a few centres I think, the UK Cardiac Register
   6     has reported that a few centres have not admitted or
   7     entered their data into this Register, so we really do
   8     not know. 15.9 in the UK in 1990 was not an exact
   9     figure in the AV canal.
  10   Q. You thought this at the time?
  11   A. I mean I do not know when this was discussed but this
  12     was a 1991 meeting so these are 1991 figures, so these
  13     would have been discussed in 1992 so I would have known
  14     by that time, yes, because the meeting was arranged in
  15     1991.
  16   Q. On the face of it, whoever compiled this chart must
  17     have thought that was the figure to put in from the
  18     surgical register, whatever the explanation might be?
  19   A. I am sure they had a right reason to enter it, yes.
  20   Q. That would be Mr Wisheart, would it?
  21   A. No, this is the UK Cardiac --
  22   Q. No, Mr Wisheart who prepared the table?
  23   A. I do not know where you got it from. This table looks
  24     like Mr Wisheart's table.
  25   Q. Whoever compiled the table, perhaps Mr Wisheart, quoted

   1     the UK figure as the UK figure?
   2   A. That is correct.
   3   Q. You say this was discussed at the audit meeting in
   4     1992. Indeed it was. Can we perhaps have a look at
   5     that. It is PAR 2/181. 25/3/92, you are present. If
   6     we scroll down. The audit topic, "Paediatric Cardiac
   7     Surgical Mortality for 1991 and comparison to the
   8     previous year". "Findings and observations", we see
   9     what is said there:
  10        "For the last three years mortality for infant
  11     VSD 9 per cent, AVSD 20 per cent, transposition of the
  12     great arteries ...", that would be the Senning
  13     operation, would it?
  14   A. Yes, we were not doing switch at that time.
  15   Q. Or at least not many switches in the under 1s, some but
  16     not many, I think?
  17   A. No, in 1991 there was no switch for this group, simple
  18     TGA.
  19   Q. That is simple TGA, thank you. That is "good results"
  20     is the note. "Poor results in TAPVD and truncus.
  21     Mortality for the closing procedures are low."
  22        Look at the discussion, scroll down so we make
  23     sure we have it all. "Good result for many conditions
  24     in infancy so should aim to increase the infant and
  25     neonatal workload."

   1        Infancy is under 1 year, is it?
   2   A. That is correct, sir.
   3   Q. "High mortality in TAPVD group, problem with the split
   4     site identified as important and miscellaneous group of
   5     patients with high mortality and include infants with
   6     congenitally corrected transposition of the great
   7     arteries and VSD. Query should consider banding."
   8        It picks up at point 4 the point you were making
   9     about the miscellaneous conditions?
  10   A. That is correct, sir.
  11   Q. But there is no comment here on the overall picture,
  12     no comment such as "Well, it is a great disappointment
  13     that last year having achieved just over 12 per cent
  14     mortality in the over 1 group it looks as though we are
  15     now back to 30 per cent where we were in 1989"?
  16   A. I am puzzled you are saying that because in a way
  17     here we have a whole year's work in front of us under
  18     1 year. We have already seen two years before that and
  19     now we are seeing it again in 1991 so following that one
  20     we have looked in and we have got quite a good result
  21     now on VSD and AVSD as I said before. 20 per cent was
  22     quite good at that time and TGA, so we are really saying
  23     that we are doing all right, you know, the problem is
  24     with the miscellaneous group which we have identified
  25     but of course as you saw it is only 8 patients and just

   1     one patient this way or that way could have a difference
   2     of 12 per cent in the mortality really.
   3        One of the cases was corrective transposition of
   4     the great arteries and VSD which Dr Silove would say was
   5     a very difficult problem. I think it is my colleague
   6     tried to correct it and maybe we had a problem there,
   7     I am sure the patient probably did not make it. Some of
   8     the TAPVD, I know one of them was mine and there was
   9     a problem there, the patient was very sick on the
  10     ventilator, we transferred to --
  11   Q. Again can I ask you to pause there for a moment: what
  12     I was asking was whether anyone at the meeting took
  13     a view overall of the results as opposed to looking at
  14     individual series of results?
  15   A. This meeting would have followed in the same way after
  16     that overall result, that when we got the overall result
  17     that this was this, "let us just look in the aggregate,
  18     what has been happening" and as a result of that overall
  19     figure we have this audit meeting.
  20   Q. One of the difficulties perhaps with figures like this
  21     is, is it, if you break down a large figure into its
  22     component parts you have a number of separate small sets
  23     of figures, do you not?
  24   A. You can do the best from the figure what you can
  25     really. I mean you cannot produce a big figure if you

   1     have not got any.
   2   Q. If you break down a large figure into a number of
   3     smaller figures and look at each of the smaller or some
   4     of the smaller figures, it must inevitably be the case
   5     that one death for instance in a small series would make
   6     a very big difference?
   7   A. That is correct.
   8   Q. It must also be the case that it is very difficult to
   9     draw a comparison taking a small group with a national
  10     figure because you simply do not have the numbers
  11     because, as you say, one death might make a very big
  12     difference?
  13   A. When you are looking at the UK Cardiac Register they
  14     have also a big group, miscellaneous in one really, so
  15     you do not know what is their bracketing of different
  16     pathology in that miscellaneous group really, so you
  17     cannot compare that.
  18   Q. Here you do have a number of deaths as you pointed out
  19     in the miscellaneous group, 6 out of 8, which is high
  20     but which obviously carries, or covers a number of
  21     particular conditions and you do not know how
  22     representative they are of national comparisons, do you?
  23   A. That is correct.
  24   Q. Is it, do you think, helpful then -- because you cannot
  25     learn any lessons comparatively with national data very

   1     easily from looking at individual series of operations,
   2     is it not at least helpful to take an overall picture
   3     where you have larger numbers and you can say "Here we
   4     have all the operations, this is what we know Bristol is
   5     doing overall, that gives us at least a valid measure of
   6     comparison against a national figure"?
   7   A. I thought you have already taken the overall picture,
   8     that is what we got from the first table, that overall
   9     our mortality was higher and there is acceptance about
  10     that. Now we are looking at why it is higher and that
  11     is the result of that activity here.
  12   Q. The breakdown here is in order to try to explain, is
  13     it, why the mortality should be higher overall?
  14   A. That is what I have been trying to say.
  15   Q. It is not a question of as it were ignoring the overall
  16     figure but focusing simply on the smaller groups.
  17   A. In the same way as in 1989 we did, this is the same
  18     exercise.
  19   Q. If in 1989 there had been considerable concern about the
  20     figure then, 37.5 per cent if you remember for the under
  21     1s, was there a similar concern as you recollect it
  22     about the 30 per cent for the under 1s here?
  23   A. "Concern" is difficult to put in. If I could go back to
  24     ask that question, what do you really mean by
  25     "concern"? Concern as you define in the Inquiry's own

   1      -- when you asked for a statement, by "concern" you
   2     mean unacceptably poor or "concern" you mean your
   3     attempt to improve? If you take it, you know concerned
   4     with your attempt to improve, yes. But if you say
   5     "concern", unacceptably poor then, no.
   6   Q. Let me use a different word: worried. Was anyone -- as
   7     you recollect it at this meeting -- worried that Bristol
   8     having apparently shown an improvement in 1990 appeared
   9     to have slipped back when one looked at the 1991 figures
  10     to the sort of figures it was producing before?
  11   A. That is why we have done this audit, yes.
  12   Q. So people were worried?
  13   A. We were concerned and wanted to see what has happened
  14     and can we really improve it further, go back to the
  15     same, yes.
  16   Q. If we can scroll down to the bottom. The decision made
  17     by the meeting is that there is a high mortality in the
  18     TAPVD group which needs further detailed study at the
  19     next audit meeting. That I think took place, and I will
  20     come to that in a moment:
  21        "(3) the problem of split site identified as
  22     important in mortality of sick neonates and infants.
  23     Press for full integration of service."
  24        The problems there called the "split site" are the
  25     sorts of problems, are they, that you have been

   1     discussing over the last couple of days with us here?
   2   A. That is correct, because one of the things (that is my
   3     personal belief) was that we needed to have a service in
   4     one place for children and -- in a way I think I was
   5     going to say at that time when you asked me to stop --
   6     and that was really related to my TAPVD and the split
   7     site really because this was a very sick baby on
   8     a ventilator and I said "we would really move the
   9     patient I would operate on" and the patient was moved
  10     with full precautions, you know: anaesthetist,
  11     ventilator, everything, but the patient when he turned
  12     up in our BRI theatre was very sick. We had to massage
  13     to go on bypass. So in a way I have already compromised
  14      -- whatever in our system has compromised the baby
  15     before I could really do a full repair and because of
  16     that it has been mentioned and because I have narrated
  17     it like that.
  18        It is very difficult to come out very openly and
  19     say: "I have definite proof that transfer made the
  20     difference", but I was quite convinced in my mind that
  21     some of the very sick newborn babies could have
  22     deteriorated while in transfer.
  23   Q. The view appears to have been the view of the meeting,
  24     that view?
  25   A. Yes.

   1   Q. So everyone shared the same view?
   2   A. Everybody, and at that time we were also going for
   3     a dedicated paediatric cardiac surgeon. I felt we would
   4     have a good service at one place and we would have
   5     somebody who really would just do the paediatric only.
   6   Q. What advantage do you think there would be in just
   7     having -- at this stage, 1992 -- a dedicated paediatric
   8     cardiac surgeon; what advantage would that have in terms
   9     of outcomes?
  10   A. There was an opening at this time because one of our
  11     colleagues was going to retire. So I saw the opening
  12     that we are going to make an appointment and I was
  13     pushing at that time to have a paediatric cardiac
  14     surgeon which, by that way, he would really be
  15     concentrating on paediatric only he would not be going
  16     through the same struggle which I am having between
  17     adult and paediatric, moving both sides, juggling the
  18     needs of one against the other, he would be solely
  19     concentrating on paediatrics and hopefully work at one
  20     place and that would be good.
  21        Everybody in principle agreed and that is what we
  22     were working. So in a way I thought this meeting also
  23     supported me in my aim to really get a paediatric
  24     cardiac surgeon and this was 1991.
  25   Q. If there had been at this stage a paediatric cardiac

   1     surgeon replacing Mr Keen --
   2   A. Yes.
   3   Q. -- would that mean both you and Mr Wisheart would have
   4     given up doing paediatric cardiac surgery?
   5   A. One of us would have definitely given up and I think
   6     Mr Wisheart was prepared to because he was senior of the
   7     two and felt he was getting more into also the
   8     management side and it was his desire because we were
   9     working to get a Professor, a new Professor as
  10     a paediatric cardiac surgeon.
  11   Q. There were pressures of time upon him which he felt,
  12     were there?
  13   A. I thought it would be better for him that he could now
  14     concentrate more on adult and the management side and we
  15     would have a new person who would be a professor and
  16     because he would be a professor he would only have half
  17     the NHS duties and he could devote that much into the
  18     paediatric and he would need assistance in a way to help
  19     him in one or two rotas and I could provide that rota.
  20     So I was prepared to work in a supporting role to a new
  21     paediatric cardiac surgeon.
  22   Q. It might be thought that if a surgeon dedicated to
  23     paediatric surgery would make a difference to outcomes
  24     that that would be some reflection possibly upon you and
  25     Mr Wisheart who were both providing the service at the

   1     time. The answer you have given so far I think to that
   2     question is: "there were problems juggling adults and
   3     paediatrics and problems with time pressures", do we go
   4     back again to the question of the waiting list that we
   5     looked at two days ago?
   6   A. I have already accepted there was a problem with the
   7     waiting list and the mixed practice was not helping.
   8   Q. Was there also perhaps a question of experience in the
   9     sense that as a paediatric cardiac surgeon sharing the
  10     workload with Mr Wisheart, small numbers, neither of you
  11     were doing enough to become highly proficient at
  12     paediatric cardiac surgery try as you might?
  13   A. Definitely the number did help, there is no doubt about
  14     that, you cannot really say "no" to that question. But
  15     at the same time there are a lot of surgeons in this
  16     country and outside who have got a mixed practice and a
  17     very good practice on both sides.
  18        In a way it is not totally proven that mixed
  19     surgeons are not that good paediatric surgeons, but at
  20     the same time there is a higher probability that the
  21     dedicated paediatric cardiac surgeon would probably
  22     produce better results than a mixed surgeon.
  23   Q. This view as to the probability was the view which you
  24     and Mr Wisheart and others at the meeting shared?
  25   A. Yes.

   1   Q. I want to go to the meeting which discussed TAPVD.
   2     Before I do let us have a quick look at the figures we
   3     find at UBHT 55/118 for the over 1 results. These are
   4     over 1s, "complex surgery". The comparison, very small
   5     numbers between Bristol and the United Kingdom might
   6     suggest that Bristol's performance was getting on for
   7     twice as -- if I use the word 'bad' you know what
   8     I mean, the United Kingdom?
   9   A. I would not call it that at all: 4/18 --
  10   Q. 22.2 per cent?
  11   A. Again I am really saying -- it is 4 out of 18, it is not
  12     really that bad at all.
  13   Q. Because it is small numbers?
  14   A. Yes.
  15   Q. The problem -- I say "problem", the figures are a result
  16     of AVSDs, two out of three and miscellaneous two out of
  17     five?
  18   A. If you look, Fontan we have no mortality, correct TGA,
  19     VSD, PS. It is a very complex group really, no
  20     mortality, but again it is small numbers. You cannot
  21     really pat yourself on one side and then say "you have
  22     done bad" on the other side.
  23   Q. What about the figures if you take into account what is
  24     called "Total" which is the period from 1984 up until
  25     1991? Do we still have a problem with small numbers?

   1     It is the second column, 35 out of 125.
   2   A. I see, that total is for many years, is it?
   3   Q. That is for 1984 to 1991.
   4   A. It includes -- again I am really saying because somehow
   5     I have always felt uncomfortable about grouping
   6     conditions from different year groups because they are
   7     not the same when we talk of -- some years we are good,
   8     some years we are not that good so you cannot really.
   9     I think this has been produced in order to produce
  10     a better figure or number but you cannot make the same
  11     sense because if you look at it now, Fontan, you can see
  12     the problem before, you have about almost -- overall 12
  13     of 28 died. This could now tell you that previously
  14     Fontan results were not that good. Look at last year
  15     "very good", so we have improved there for corrected
  16     transposition, this is the case which you saw previously
  17     and was mentioned -- no, this is over 1 year.
  18        TGA, VSD, PS, again you have two deaths out of
  19     eight. No deaths here.
  20        It gets very difficult because this also includes
  21     the year when we were uncomfortable or we did not have
  22     good results really. That is why really I felt always
  23     that if we are comparing we should compare it with the
  24     latest year we have from the UK Register and then see
  25     why the results are different and where they are

   1     different and how we can improve it. By clumping it
   2     together in 3, 4 years, in my opinion you do not get
   3     a real picture of how things have really gone.
   4   Q. I am interested in that answer because when we began and
   5     I showed you the very first year's results before lunch,
   6     you agreed with me that it was very difficult to make
   7     conclusions from small figures from only one year
   8     because the one year might be out of step and the next
   9     year might be better and so on?
  10   A. Yes.
  11   Q. I thought you had agreed with the proposition I put to
  12     you then that you would need to take a number of years
  13     to look at the situation to see how the comparison was
  14     over a number of years and if you got the same picture,
  15     poor picture each year over a number of years you would
  16     draw a much different conclusion. You would say: "for
  17     some reason, whatever the reason is, we are just not
  18     doing as well as the rest of the UK."
  19        Here when we do have a group pooled over a number
  20     of years, what you are just saying is: "that is not
  21     helpful because it does not show how the trend is, how
  22     we are improving." Which is the proper way do you think
  23     to approach figures such as this?
  24   A. Let me come back: the first one was 84 to 86 and at that
  25     time we hardly had 10 or 11 cases of under 1s in a year

   1     and a total number of 40 or 50 open heart surgeries in
   2     a year for paediatrics.
   3        The situation had changed in the late 1980s, we
   4     were now approaching the 30 or 40 mark in under 1s and
   5     we were now doing 140 or so total cases really. So
   6     I think we have now a reasonable population to come out
   7     with some type of answer.
   8        Also by this time we have already looked into
   9     twice the yearly figure so we should now be really
  10     looking on our progress year by year rather than
  11     clumping them together and, again, getting good and bad
  12     together and then how do you compare where you stand
  13     now. Am I confusing you?
  14   Q. I am not sure you have explained to my satisfaction --
  15     and it may be my fault -- how one reconciles the answer
  16     you gave me in respect of these figures and clumping
  17     which you disapproved of and the answer which you gave
  18     me earlier when you were saying: "one had to clump
  19     figures together in order to get a result"?
  20   A. There was a little difference of opinion between --
  21   THE CHAIRMAN: We are interrupting you, Mr Dhasmana, it may
  22     assist everyone: we feel we have heard enough on this
  23     point. Thank you Mr Langstaff.
  24   MR LANGSTAFF: I am grateful.
  25        If I can move on to the TAPVD meeting. UBHT

   1     61/164, 6th May 1992: "Results of the previous audit,
   2     high mortality in TAPVD group identified in audit
   3     meeting 25th March 1992". That is the one we have just
   4     looked at. Can we scroll down?
   5         "Mortality high. 2 in 2 patients, diagnostic
   6     error and/or surgical approach inappropriate. Three in
   7     some patients, delay in diagnosis prior to referral to
   8     cardiac centre, may be important."
   9        That identifies the reasons that you found on
  10     looking at the results, did it?
  11   A. That is correct, sir.
  12   Q. If we look and see what action to be taken. Point 1 is
  13     to do with the timing of the operation. May we conclude
  14     that coupling that with the third reason for the high
  15     mortality, probably some inference for coming to
  16     operation rather too late?
  17   A. That is correct, sir.
  18   Q. Secondly "echo diagnosis likely to be adequate but need
  19     a good framework of examination."
  20        It is the same point about cardiologists not
  21     giving you the information you needed, is it?
  22   A. There was some problem, yes.
  23   Q. The third I do not think I need trouble you about, save
  24     to say this: "Low age itself is not a contraindication
  25     to successful repair".

   1        Was there a feeling still at this stage that the
   2     very youngest children were a much higher risk to
   3     operate on because of their youth?
   4   A. No, it is interesting. I do not know whether it follows
   5     a few other pages which gives detail of -- the two
   6     patients which survived they were hardly 1 or 2 days old
   7     and those who were unfortunate, they died, they were
   8     more than a few weeks really. So the point was made
   9     that these patients with obstructed pulmonary venous
  10     connection, that they would deteriorate so do not feel
  11     one day we should not operate on, and I think that is
  12     the point it is making really. It is making really that
  13     once a diagnosis is made get on and operate on.
  14        I do not think it was highlighted: again, the
  15     problem with my split site really because, as
  16     I mentioned yesterday, my operating slot was Tuesday,
  17     Thursday and Mr Wisheart's Monday and Thursday if I am
  18     not doing paediatric on that Thursday.
  19        When the TAPVD would come either you operate on
  20     the same night or you wait another 2 days before you
  21     really get a paediatric slot.
  22   Q. And the other two days may cause a problem --
  23   A. Exactly.
  24   Q. -- which is why you would go back to point number 1.
  25        Again we come back to the way the surgery lists

   1     were organised and operating time prepared. The
   2     unfortunate result of that was that some children must
   3     have been put at a higher risk than they would have been
   4     if there had been a dedicated theatre with operations
   5     going on every day?
   6   A. There is a possibility of that, yes, sir.
   7   Q. Sir, on that note, before I move to the next item in the
   8     chronology of audit and concerns, may we perhaps take
   9     a short break?
  10   THE CHAIRMAN: Yes, 15 minutes until 2.37, in other words
  11     2.40. Thank you.
  12   (2.25 pm)
  13               (A short break)
  14   (3.05 pm)
  15   THE CHAIRMAN: Mr Dhasmana, forgive us for making you wait
  16     a while. We had some matters to discuss which were
  17     entirely different from what we have been doing today,
  18     but we have delayed you a bit and I apologise.
  19   MR DHASMANA: Thank you, sir.
  20   MR LANGSTAFF: Mr Dhasmana, we have been looking at
  21     a meeting which took place in May 1992. At that time
  22     did you know that there had been a conversation between
  23     Dr Bolsin and Dr Zorab at the end of 1991 or
  24     thereabouts, expressing concern about the overall
  25     results within the Bristol Royal Infirmary for

   1     paediatric cardiac surgery?
   2   A. No, sir.
   3   Q. In 1992, how often do you recollect that you worked with
   4     Dr Bolsin, roughly?
   5   A. It must be at least once a week in the theatre and then
   6     he would be on call for ITU once a week, and probably
   7     three times in two weeks, so I would have really seen
   8     him at least once or twice in a week, but I would like
   9     to think more than that, because we used to see each
  10     other quite often.
  11   Q. Can I move on, then, to the next meeting, UBHT 61/165?
  12     We have looked at this already. This is the review of
  13     the results of the arterial switch. You remember that
  14     we looked in particular at the words "similar to
  15     reported results, particularly if consider is early
  16     experience."
  17        You were able to tell us that you had in the
  18     course of that meeting, mentioned at the end of the
  19     meeting the results Mr Brawn had been achieving and the
  20     results elsewhere in the world?
  21   A. That is correct.
  22   Q. Can we look at SLD 2/5? Private Eye. It begins with
  23     the bullet point "Gorgeous pouting Virginia Bottomley".
  24     We have seen this before. The bit at the bottom of the
  25     page:

   1        "In America, the mortality rate for arterial
   2     switch, an operation to connect congenitally transposed
   3     arteries from the heart is now 0 per cent. Nearer to
   4     home in Birmingham, it is 3 per cent. In Bristol,
   5     despite the fact that the operation has been performed
   6     since 1988, it is 13 per cent. Sadly, consultant
   7     cardiologists at Bristol Children's Hospital continue to
   8     refer patients to their surgeons to support the local
   9     unit."
  10        Did people, so far as you know from conversation
  11     at the time, read this article?
  12   A. No. I never bought Private Eye.
  13   Q. I am not asking you about you.
  14   A. I am sorry.
  15   Q. Did the other people to whom you spoke speak about this
  16     article?
  17   A. I think somebody passed this on to me. It was given to
  18     my secretary for me to see.
  19   Q. In 1992?
  20   A. Yes. This is 1992, is it not?
  21   Q. This is July, yes.
  22   A. Yes.
  23   Q. Did you recognise the figures which were quoted at the
  24     bottom of the left-hand paragraph and the top of the
  25     middle paragraph?

   1   A. There is no figure. What it quoted was, what surprised
   2     me, what I mentioned at the end of the meeting was
   3     quoted here the wrong way round. So in a way, my
   4     comment was quoted, but no figure, in a way.
   5   Q. So what was quoted you had said?
   6   A. I had mentioned that at the end of the meeting, when we
   7     finished, somebody made a type of remark, "Okay,
   8     Janardan, what is the result nowadays in Birmingham?"
   9     because I did not really know, and the last results
  10     I had known was 5 per cent, but I mentioned -- "I am
  11     sure Birmingham would be now doing 0 per cent", you
  12     know. It was a little light-hearted remark. Then it
  13     got a bit more serious. And America? I said "I do know
  14     Castaneda, they got 3 to 5 per cent".
  15        So in a way, when I saw this thing, I said "It is
  16     my words being quoted here, but it is the other way
  17     round" because I mentioned America 3 per cent and
  18     Birmingham 0 per cent. Here it says Birmingham 3 per
  19     cent and America 0 per cent. So it was my quotation
  20     which has been mentioned here, but of course it is the
  21     wrong way round.
  22   Q. If you saw this, if your secretary left it for you to
  23     see, then other people --
  24   A. No, somebody left with my secretary for me to see.
  25   Q. If your secretary had it and you saw it as a result, did

   1     others working in the department also see it?
   2   A. Well, then I started asking about it and I found out
   3     that quite a few people had seen it.
   4   Q. What was your reaction to it?
   5   A. I was totally appalled.
   6   Q. What were the reactions of others?
   7   A. They almost felt the same way: that where had this come
   8     from, and then I told them that I presented my data --
   9     I mean, I am not sure which date is this one; it could
  10     be the last week or the week before.
  11   Q. Let us scroll up to the top and we will see that
  12     this is the 3rd July. If we go back to the meeting --
  13   A. That was the 3rd June, so I said I presented my data to
  14     the paediatric audit meeting last month, and this
  15     quotation is from there. Until that time I never
  16     thought Private Eye would be a medical journal on
  17     anything like that, I never read it, but I said "Who has
  18     done that?"
  19   Q. Can I stop you there? Were other people as appalled as
  20     you were?
  21   A. No, they said "It is a satirical magazine, you should
  22     not take it seriously". I said "If I am quoted I want
  23     to find out who has done this because I am quoted
  24     wrong".
  25   Q. Can we go back to the minutes of the meeting,

   1     UBHT 61/165, the top of the sheet. We see who is
   2     there. Those particular people who heard what you had
   3     to say?
   4   A. That is correct.
   5   Q. Did you initially, at any rate, think that one of
   6     them must have given the information?
   7   A. I asked to each of them.
   8   Q. You asked each of them?
   9   A. Yes.
  10   Q. What did they say?
  11   A. "Oh, come on, you are joking."
  12   Q. So they all denied it?
  13   A. Yes.
  14   Q. Did you form any view, rightly or wrongly, as to how
  15     the information had got into Private Eye?
  16   A. I extended it further because in a way, all right, we
  17     had a few names there --
  18   Q. Can I take this shortly? Did you actually form a view
  19     as to who had? "Yes" or "No"?
  20   A. I had a suspicion, but --
  21   Q. May I ask you for the name in respect of whom you had
  22     suspicions?
  23   A. Quite a few names, really. I have to exclude them one
  24     by one, if you will let me.
  25   Q. So more than one person?

   1   A. More than one person, yes.
   2   Q. Were they all people who were at the meeting?
   3   A. No.
   4   Q. What effect did the publication in Private Eye of
   5     conversations at a meeting such as this have upon
   6     further audit meetings?
   7   A. I felt that one of the main things about an audit
   8     meeting is that you can frankly air the problem and if
   9     it is going to appear in a satirical magazine, all
  10     right, people were telling me not to take it seriously,
  11     but I was taking it seriously and I thought, you know,
  12     it is a slur on the unit, a slur in the way one is not
  13     correctly reported and that could report anything from
  14     the audit whether it is irrelevant or not, and that
  15     could impair our effort to improve our results or at
  16     least talk about it openly. And I felt that if this is
  17     allowed unchecked, it would affect definitely our audit
  18     meeting and we would not be able to frankly air our
  19     opinion on different subjects.
  20   Q. One of the things which we have noticed is that although
  21     there was a further meeting after this on 1st July,
  22     which would be before the publication of the Private Eye
  23     article -- we will just have a look at that. It is
  24     UBHT 61/166. This is balloon valvoplasty -- we cannot
  25     trace any further document of this sort recording

   1     a medical audit meeting looking at a particular
   2     procedure after 1st July.
   3        Can you help as to why that happened?
   4   A. I think this was produced by Dr Martin, so he may be
   5     able to tell you more about it, why it was not produced
   6     after that.
   7   Q. I do not know that we have had very clear evidence as to
   8     why it is. We have had expressed to us the view that
   9     the Private Eye publication had an impact on audit
  10     meetings which hindered the holding of audit meetings or
  11     the recording of them, or both.
  12        Is that, do you think, right or wrong?
  13   A. I thought there were meetings after that. I have
  14     definitely attended a meeting some time in the winter,
  15     but like you, I am surprised that there are no minutes
  16     after this.
  17   Q. Of this sort. There are a couple of meetings which
  18     I will come to where we will see that there were
  19     discussions, but as again you will appreciate, I am
  20     looking forward in evidence and documents I will show
  21     you. The comment that is going to be made at the end of
  22     the series of documents is that there seem to have been
  23     quite a number of documents up to the middle of 1992,
  24     like this, for instance, and then after July 1992,
  25     a relative -- not complete but a relative scarcity of

   1     any documented audit meeting of this type.
   2        What I therefore have to ask you is: do you think
   3     meetings of this type actually continued to be held?
   4   A. I think meetings of this type did take place but I do
   5     believe that that Private Eye article had an effect on
   6     others in the same way as on me, even though I was told
   7     "Don't worry."
   8   Q. What effect do you think it had on others?
   9   A. I can talk about myself. Before that, I would not mind,
  10     you know, leaving the paper around and just talking
  11     about my results and discussing it openly, and I always
  12     used to start, really, "Well, I have done this, but, you
  13     know, I have put one stitch there, could that have been
  14     the problem?". I was now saying differently. I was
  15     saying, "I had this operation and this, so what do you
  16     think could have happened?", so I have changed a little
  17     bit. Instead of starting with, I do not know why I had
  18     that habit, starting with myself in a way, I thought
  19     that if I am putting myself in front, then others would
  20     have no problem in coming forward if there is some
  21     problem. They would also appreciate that this man would
  22     not mind being attacked, if we have to really say, so
  23     that is why I used to present myself that way.
  24        After that meeting, I became a little more on that
  25     side; instead of presenting myself, I would say here is

   1     the problem, that is what happened; I do not know why it
   2     happened.
   3   Q. So you were more defensive and less open?
   4   A. You could say that, yes.
   5   Q. What about others who would normally participate in an
   6     audit meeting such as this? Were they also more
   7     defensive and less open?
   8   A. I would not think so, but one thing for certain, this
   9     type of paper presentation did not appear that much, it
  10     used to be before.
  11   Q. So one of the points that you agreed with me earlier on
  12     in respect of audit was that it was implicit in the
  13     system that there should be a record against which one
  14     could measure later performance?
  15   A. I quite agree with that.
  16   Q. Without such a record, the system would not operate as
  17     it ought to?
  18   A. I mean, I still do not believe that a record was not
  19     kept. It might not have been circulated, but I know
  20     Dr Martin, he would always have kept a record
  21     somewhere.
  22   Q. So we might have records which we, the Inquiry, have not
  23     had which were kept as it were secretly, privately,
  24     whatever word one wants to use, because of the problems
  25     which people saw as a result of the Private Eye

   1     publication.
   2   A. Yes. I think that after-effect in my mind lasted more
   3     than a few months, really, because the rumblings of that
   4     Private Eye article were there.
   5   Q. We have had Dr Bolsin give his evidence, and as you
   6     know, he denies having been the source of the
   7     information which came to Private Eye in July 1992. We
   8     have had Dr Hammond, who wrote the article, give his
   9     evidence and say to us that he had another high-placed
  10     source within the hospital. You have said you had your
  11     suspicions of a number of people.
  12        May I ask whether you had suspicions of any other
  13     person who attended the audit meeting at which you said
  14     what you said?
  15   A. I think one of the names you have already mentioned
  16     I had suspicion on.
  17   Q. That is Dr Bolsin?
  18   A. That is correct. I mean, I think that was after
  19     exclusion of people who were there, because, you know,
  20     here there are quite a few nurses and physiotherapists,
  21     they were also in the meeting and it is not mentioned
  22     here, people like those in attendance.
  23   Q. Not at this meeting. If we go back to the meeting in
  24     which you said it, let us do that and see the cast list
  25     again. Sister Wakeley, Mrs Vegoda?

   1   A. Yes. But I think that with them came their staff,
   2     really, with Sister Wakeley, the Sister in charge, so
   3     there were staff members with her, a physiotherapist was
   4     there in the Children's Hospital and there were a few
   5     other people. So I asked in a way like I asked
   6     everybody else here, I asked, you know, "I am not really
   7     saying that you were definitely leaked it, but what I am
   8     saying is, did you talk casually in the coffee room and
   9     from there it may have just gone to somebody else?",
  10     obviously, because I did know who the MD was, and I also
  11     knew who his other half is, who was casualty officer at
  12     that time in the BRI. So I said, you know, it is not
  13     unusual, because some of your physiotherapists and
  14     cardiac radiology people who helped the catheter, they
  15     had a common room in the radiology department in the
  16     basement in the BRI.
  17   Q. Again, if I can just stop you there --
  18   THE CHAIRMAN: Mr Dhasmana, just to clarify, I think you
  19     said that you did know who MD was. Is that accurate or
  20     not?
  21   A. That is correct.
  22   MR LANGSTAFF: You mean Dr Hammond, and his other half you
  23     mentioned, that is Dr Gardner?
  24   A. Well, I did not know his name, but I was told his other
  25     half, because they used to appear on television on

   1     various things, Dr Duo, so it was well known, a name
   2     I had forgotten until I saw recently the transcript,
   3     yes, Dr Gardner, the casualty officer in BRI, and
   4     I think at that time, I may be wrong, but Dr Hammond was
   5     in Taunton.
   6   MR LANGSTAFF: Yes, so you wondered whether somebody might
   7     have picked up in the coffee room the conversation from
   8     someone at the meeting and relayed it onwards?
   9   A. Yes, so in a way, once they had told me "No, no, we
  10     don't talk like this", "I am sorry to have asked you".
  11     Then I even asked Dr Bolsin because in a way, I knew his
  12     wife works in the Casualty Department, so I did ask,
  13     saying "I am just asking, I am not really saying that it
  14     has --
  15   Q. Did he say that he did or he did not?
  16   A. No, he totally denied it, he said "No, Janardan, you
  17     should know it better; I was not even present there",
  18     and of course he was right, he was not present there,
  19     and I shut up.
  20   Q. So you remained with your suspicions. Can I ask you
  21     this: there are two reactions possibly to the
  22     publication of data in a magazine such as Private Eye,
  23     or any part of the press, data which says or suggests
  24     that Bristol is not performing well, worries as you have
  25     described to be very cautious about what is said at any

   1     internal meeting, and if there are minutes kept, to keep
   2     them privately and not circulate, maybe to have less
   3     meetings; the other is to seek to answer the criticism
   4     by saying, "Well, actually, these are our results" and
   5     be much more open to the general public about the
   6     results and the reasons for them.
   7        Do I take it that the second approach was not
   8     taken?
   9   A. I do not understand the meaning of "general public" you
  10     are talking about.
  11   Q. Private Eye is bought by a number of readers who are
  12     not medical, but they may have a concern about what is
  13     said in Private Eye. Do you agree?
  14   A. I did not follow that part, really, because I felt the
  15     best thing would be really to explain myself to my
  16     medical colleagues and really take it that way, so I was
  17     continuing with my audit in a similar manner, just you
  18     know except being myself very critical, just less
  19     critical, but it did not stop me from presenting our
  20     data to the department or monthly audit or anything like
  21     that. I would do that.
  22   Q. Where do we find any record you can recall of your
  23     having discussed, after having read Private Eye and
  24     seeing what it said, the data with your colleagues?
  25     I think -- you will correct me if I am wrong -- there is

   1     no record of your having discussed this particular data
   2     again; you had done it once, after all?
   3   A. This article, the switch, was mentioned again when
   4     Mr Wisheart presented January to June 1992 data in
   5     a similar meeting, medical audit, in the month of
   6     August.
   7   Q. Let us look at the next Private Eye article, then, if
   8     we may. That is SLD 2/6, I think. We go down to the
   9     bottom of the page. This is October.
  10        "The sorry state of paediatric cardiac surgery at
  11     the United Bristol Healthcare Trust has been confirmed
  12     by an internal audit of the last two years' operations.
  13     The results of procedures to correct two congenital
  14     heart abnormalities, tetralogy of Fallot and
  15     transposition of the arteries, were especially poor.
  16     James Wisheart, Chairman of the Hospital Medical
  17     Committee, is required to maintain the standards of
  18     medical practice. Curiously he has not felt it
  19     necessary to inform the Trust Board or the trust
  20     purchasers of these findings. Could it be because he is
  21     also Associate Director of Cardiac Surgery ..."
  22        So this information came, did it, from
  23     Mr Wisheart's report to the unit of the half-yearly
  24     results?
  25   A. Yes, but it says here, internal audit of last two

   1     years' operations, and I am not aware which one he is
   2     quoting, really, because what Mr Wisheart presented was
   3     January to June 1992 data.
   4   Q. If we just have a look at what was produced, GMC 8/152,
   5     it is January to June, six months, under 1 year, and
   6     there we have it.
   7   A. Yes.
   8   Q. If we go to GMC 8/153, can we scroll down? If you look
   9     at the Bristol column, the heading of "Bristol" column,
  10     Bristol 1989 to 1991, that is actually three years
  11     because it is 1989, 1990, 1991, but anyone not knowing
  12     that and reading it would read it as two years.
  13   A. You are quite right.
  14   Q. So that is how the two link up, is it not?
  15   A. I can see now, but I had not noticed that before.
  16   Q. If we look there at the particular operations, we have
  17     individual operations recorded. Where would one get
  18     tetralogy of Fallot from, from that?
  19   A. Is it under 1 year? If it is under 1 year, then we were
  20     not doing that many under 1 year.
  21   Q. You would not?
  22   A. No.
  23   Q. Indeed, there is only one mentioned, and it is one out
  24     of one, which tells you, as you pointed out, because it
  25     is small numbers, very little.

   1        Shall we go overleaf to page 154, and find the
   2     over 1 year, and scroll down. Again, we have the
   3     Fallot's results there which appear on the face of it to
   4     be double the United Kingdom results.
   5        The switch operation there is shown, TGA plus VSD
   6     plus PS switch, 20 compared to the UK 1988 mortality
   7     of 17.2.
   8   A. This switch is really to emphasise what we have done
   9     in 1992, and some of this would be switch here, but from
  10     1985 all of these are not switch; there could be some
  11     other means of repairing that.
  12   Q. You would perhaps point out the Bristol figures here are
  13     not just 1989 to 1991, they are 1985 to 1991?
  14   A. That is right.
  15   Q. Can we go back and look at what Private Eye was saying?
  16     It just says:SLD2/6
  17        "The results for procedures to correct two
  18     congenital heart abnormalities, tetralogy of Fallot and
  19     transposition of the arteries were especially poor", so
  20     it does not actually give any figures there.
  21        Did this come to your attention as well?
  22   A. I think the same source provided me another photocopy of
  23     this one.
  24   Q. Was there a discussion about this again?
  25   A. Yes. I gather Mr Wisheart followed this a little bit

   1     more, and he would know more about it. I am not aware
   2     of too much of that.
   3   Q. So the effect of this was to do what, in respect of
   4     audit?
   5   A. I think he did quite well, actually. I may be wrong
   6     here, because Mr Wisheart I am sure will tell you more
   7     about it. I think he collected his own data on
   8     tetralogy of Fallot and other, he probably talked to the
   9     hospital. He may have talked to some other person,
  10     which I am not sure. I felt, you know, the arterial
  11     switch I was already talking about with my colleague,
  12     and I felt I should really not be doing anything more so
  13     far as this article was concerned.
  14   Q. The figures we just looked at were figures -- perhaps
  15     we ought to go back again just to see that we have
  16     covered the period from the very first figures we looked
  17     at this morning. Go back, please, to GMC 8/152. These
  18     are half-yearly figures.
  19   A. Yes.
  20   Q. Can you tell me why it was that 6 months figures were
  21     produced? This appears to be the only occasion when we
  22     have a record of it.
  23   A. As I said before, we decided before, no use putting one
  24     year just like that. Maybe there were too many cases
  25     now coming and we may not be able to discuss that

   1     clearly in the individual case, so why not, especially
   2     now when we are doing more and we are doing more
   3     neonatal surgery, we should review it more often.
   4        So that is why this was the first half year being
   5     seen, because we had just started the neonatal switch
   6     programme.
   7   Q. We do not, as far as I can see, have any figures from
   8     July 1992 to December 1992, as such. The next set of
   9     figures that we have and I need to show you, we have at
  10     UBHT 55/128.  It comes in the annual report for 1992.
  11     Just scroll down a bit, please, this is "Open correction
  12     1992". It is one of the pages in the annual report.
  13        Let me ask you about the annual report first. To
  14     whom was the annual report sent?
  15   A. I do not think this would have been sent anywhere, 1992,
  16     because this is the year when the Society changed from
  17     yearly to financial year, because I had done 1992/93, so
  18     Mr Wisheart -- I mean, this is Mr Wisheart's table. He
  19     may have collected it and he has got it, but this report
  20     may have been presented to either our own audit or
  21     something like that, but this report did not go anywhere
  22     outside, if you understand what I mean.
  23   Q. Just so that you understand where we get this table
  24     from, it is UBHT 55/125, the cover sheet. I am sorry,
  25     that is not the cover sheet I had in mind. Forgive me,

   1     there does not seem to be a cover sheet, you are quite
   2     right.
   3        The annual reports: when there were annual
   4     reports, for whom was the report intended?
   5   A. I think the annual report was mainly produced by the
   6     paediatric cardiology department and the last one I was
   7     aware of was up to 1990. I do not think I am aware of
   8     any annual report thereafter. There was the annual
   9     presentation of data which I did for 1992/93, 1993/94,
  10     and probably 1994/95.
  11   Q. So focusing on the 1990 report and the earlier ones, who
  12     was that report to?
  13   A. I am sorry, which one are you talking about now?
  14   Q. You say the last one you are aware of was 1990.
  15   A. Yes, that is from paediatric cardiology, so they would
  16     have circulated it amongst cardiac surgeons, their own
  17     colleagues and probably the Trust, and I would like to
  18     think to clinics where they were going to in the
  19     periphery.
  20   Q. When you look at these figures after 1990, to whom were
  21     these figures circulated?
  22   A. I really do not know where this paper was from and for
  23     which meeting and I am sure Mr Wisheart would be able to
  24     explain to you more on that.
  25   Q. I think we may find that it was for a meeting in 1993,

   1     looking at the results for 1992. That may be wrong, but
   2     that is what --
   3   A. No, because I presented 1992/93 data to our departmental
   4     audit, the yearly figure and that was in December 1993.
   5   Q. Do you recollect seeing these figures before?
   6   A. During the GMC procedure I have seen a lot of these
   7     figures, but I cannot really say that I really saw that
   8     figure in 1992 or 1993.
   9   Q. If we can scroll down the page, again, if one takes an
  10     overall percentage, the figure produced for the Bristol
  11     unit looks as though it is 23.2 per cent and UK, 1990
  12     mortality is shown as 15.8 per cent?
  13   A. Yes.
  14   Q. So on the face of the figures, Bristol's results are one
  15     and a half times the figure for the rest of the country?
  16   A. But again, one has to look in the problem area, and here
  17     it is TGA, I have lost 5 neonatal switches. That is
  18     what caused this thing. If I was presenting this one,
  19     I explain, and that was how I explained when I presented
  20     1992/93 figure.
  21   Q. If we scroll down, we see the asterisk and the
  22     explanation "without neonatal switch 15.7".
  23   A. Yes.
  24   Q. You were at this stage doing the neonatal switch
  25     operation. What was the point of singling it out, do

   1     you think -- I appreciate that you did not draw up this
   2     table -- singling it out on this table?
   3   A. I do not know. Ask the person who prepared it.
   4   Q. If we have a look at GMC 8/158, we do have a record --
   5     this is why I said there was a sporadic record of audit
   6     meetings.
   7   A. This record is not sporadic. You may not have it, but
   8     this record has always been there, because this is, in
   9     BRI -- I think from there on, it is Mr Bryan.
  10   Q. When he started?
  11   A. Yes.
  12   Q. When he started we began to get the minutes again?
  13   A. Yes.
  14   Q. The gap appears to be from July 1992 until September
  15     1993?
  16   A. Yes.
  17   THE CHAIRMAN: Mr Langstaff, before we move on to
  18     this document, the previous one you said you thought was
  19     prepared for a meeting in January --
  20   MR LANGSTAFF: No, I did not, I said 1993, I did not
  21     say January.
  22   THE CHAIRMAN: I beg your pardon, 1993. Mr Dhasmana
  23     replied that that could not be the case because he
  24     prepared for a meeting in December 1993, the figures for
  25     1992/93.

   1   MR LANGSTAFF: Yes.
   2   THE CHAIRMAN: Is your proposition then that that data
   3     was presented at a meeting other than the one in
   4     December 1993?
   5   MR LANGSTAFF: If it was presented, then that is the
   6     evidence as it must have been. Whether it was presented
   7     or not, we shall have to investigate from other sources.
   8   THE CHAIRMAN: I am grateful, thank you.
   9   MR LANGSTAFF: At the moment, there is no evidence that
  10     it was. That in itself was why I was asking about who
  11     got the report and Mr Dhasmana cannot say that anyone
  12     did, but he cannot say what the purpose then of the
  13     figures was to whom it was circulated; that is right, is
  14     it not.
  15   MR DHASMANA: That is right.
  16   THE CHAIRMAN: Forgive my inability to follow the line
  17     of questioning.
  18   MR LANGSTAFF: Just to tidy that up, if I may,
  19     Mr Dhasmana, the figures I was showing you were figures
  20     which obviously were produced but you cannot say from
  21     recollection whether they were ever shown to anyone,
  22     although plainly they were designed to be?
  23   A. I cannot comment on that.
  24   Q. This meeting, September 1993, and we look at the
  25     wording, the very first wording at the bottom when the

   1     text begins:
   2        "The first audit meeting of the new session was
   3     convened ..."
   4   A. Yes, the first meeting of the new session. The
   5     session which starts after the holiday session, the
   6     holiday period, so September, so that is what he is
   7     talking about. He is not saying it is the first audit.
   8   Q. Thank you, but can you help at all as to why we should
   9     have no copies of any written record of any audit
  10     meeting between July of 1992 and September 1993?
  11   A. As I said before, somehow it is a bit of a mystery.
  12     Monthly, the departmental audit meeting was always being
  13     prepared. The Registrar of the firm would have the
  14     cases, the list, and present it. It would be on an
  15     overhead projector in the department and it would be
  16     presented, discussed, and then these would be given to
  17     the audit co-ordinator, which, at that time, before
  18     Mr Bryan took over, was Mr Hutter.
  19        I always kept my audit papers with me. Quite
  20     a few of those are already, I have seen, on your
  21     Inquiry's computer files. I was trying to look in and
  22     they are all photocopies of my monthly audit
  23     presentation, so they are there. You have them for
  24     1991, you have got 1992, and I have seen it on your
  25     computer sheets.

   1   Q. Mr Dhasmana, to be fair to you, because the point I am
   2     making is the absence of anything that we have in
   3     writing recording the results of a meeting between July
   4     1992 and September 1993, we do have a proposed audit
   5     timetable for 1993. I will just show you that now:
   6     UBHT 61/172 ... addressed to you from Dr Martin, and we
   7     will just have a look at that.
   8        "Proposed timetable and rota ..." it sets it out.
   9        If there is no written record of the meeting on
  10     27th January, 24th February, 24th March and so on that
  11     we now have, is it perhaps the case that any
  12     presentations that occurred on the overhead projector as
  13     you have described were not in fact recorded in
  14     writing?
  15   A. I am very sorry, but they are two different things. If
  16     you look, and this is a paediatric cardiology audit
  17     meeting. The previous presentation with Mr Bryan was
  18     the cardiac surgical audit. They are two different
  19     things and were happening at different places. This was
  20     in the Children's Hospital and Dr Martin was keeping an
  21     eye on this one. The other one was our own departmental
  22     audit, which was Mr Hutter in the beginning and Mr Bryan
  23     from 1990 when he took over. So in a way, they are
  24     different audits.
  25   Q. The surgeons took part in these audits --

   1   A. I said before that, yes, we used to participate in
   2     these.
   3   Q. Again, we have a problem of record. Can I go back to
   4     the September meeting, appreciating, as you pointed out,
   5     that this is the cardiological surgical unit,
   6     GMC 8/158.
   7        If we go to page 159 at the bottom --
   8   A. You can see you got it from my file because that is my
   9     writing which says "File please".
  10   Q. Yes. Paragraph 4, clinical audit, "Mr Wisheart ..." in
  11     fact I will read out the whole paragraph:
  12        "... informed us that as from 31st March 1994 we
  13     would all be expected to conduct multiple disciplinary
  14     clinical audit involving nursing staff perfusion and
  15     other associated medical specialties."
  16        So this is describing the change from medical to
  17     clinical audit?
  18   A. That is correct.
  19   Q. "It was agreed that the department would follow these
  20     guidelines and hopes to introduce within the next few
  21     months, some multiple disciplinary format for some of
  22     the meetings and Mr Bryan agreed ... In addition it is
  23     hoped in the future to have some joint meetings, in
  24     particular with anaesthesia and cardiology."
  25        What that is saying on the face of it is that

   1     there had been no joint meetings with anaesthesia and
   2     with cardiology recently?
   3   A. I do not think there was any joint meeting with
   4     anaesthesia and cardiology at the BRI before that at any
   5     time.
   6   Q. Had there been a meeting with anaesthesia and cardiology
   7     at the Children's Hospital in respect of paediatric --
   8   A. Anaesthetists were invited but they kept saying that it
   9     is an odd time, they cannot really come. So they are
  10     not attending those meetings.
  11   Q. So there was no audit meeting, does it follow, to which
  12     the anaesthetists came, or at least any number of them,
  13     regularly came?
  14   A. Not in the audit meetings that Dr Martin was organising.
  15   Q. So how would the anaesthetists know about the level of
  16     performance of the unit in terms of outcomes?
  17   A. That is a good question. I do not know.
  18   Q. You became Associate Clinical Director in January 1993?
  19   A. That is correct.
  20   Q. What, if any, steps did you take to let the
  21     cardiologists, the anaesthetists, and other members of
  22     the teams that you identified earlier today, know of the
  23     results of the work you were all doing together?
  24   A. I mean, after that, the first meeting I had of my
  25     presentation of 1992/93, I asked Alan Bryan to make sure

   1     that everybody was invited because that would be the
   2     first meeting after this. When I say "first meeting",
   3     the 1992/93 meeting, figures were presented in December
   4     1993 so in a way, they were in writing.
   5   Q. We have been told about a meeting that was intended --
   6     shall we go back to the beginning of this at GMC 8/158?
   7     We see this is on level 7 in the Department of Surgery.
   8   A. That is correct.
   9   Q. We have been told of a meeting which took place on
  10     20th January 1994 at level 7 in the Department of
  11     Surgery?
  12   A. Yes.
  13   Q. At which we are told it had been intended that you would
  14     present the results, the annual results?
  15   A. No, that is wrong. That was an extraordinary meeting,
  16     a paediatric cardiac club meeting, not an audit meeting
  17     of the department, because I had already presented my
  18     yearly audit figure in December 1993, but this was
  19     called because I had stopped my neonatal switch in
  20     October 1993. Dr Alison Hayes was asked to have the
  21     data prepared and all those things, and I was told --
  22   Q. Can I then stop you on that and we will come to the
  23     background to that. You have said enough about it for
  24     the moment.
  25        The surgical results for the whole unit, then,

   1     including adult, presumably, and paediatric, would have
   2     been returned by you to the Cardiothoracic Surgical
   3     Register?
   4   A. That is correct.
   5   Q. And can we have a look at GMC 8/157? 27th September
   6     1993. You are presenting the results to the register?
   7   A. That is correct.
   8   Q. The meeting which you remember as being in December,
   9     can we have GMC 8/163? Go, please, down; and the next
  10     page:
  11        "The next meeting ... held on Friday
  12     3rd December ... at which Alan Kirk will present data
  13     with regard to re-operation ... and Janardan Dhasmana
  14     will present the annual figures as submitted to the
  15     Cardiac Surgical Register."
  16   A. Yes.
  17   Q. So may we take it on 3rd December 1993, you presented
  18     those figures?
  19   A. I did.
  20   Q. And those figures would be both paediatric and adult?
  21   A. Yes.
  22   Q. If anyone within the department had said, "Janardan,
  23     what are the figures?" would you have given them a copy
  24     of the returns to the register?
  25   A. Copies were always sent to my surgical colleagues, so

   1     they all had a copy.
   2   Q. What about cardiological colleagues?
   3   A. Paediatric cardiologists would have had a copy, but it
   4     would not have gone to adult cardiologists and I do not
   5     think, you know, we were sending copies to anaesthetists
   6     in a way, but if somebody would have come and asked,
   7     yes, they would have got a copy.
   8   Q. Why were paediatric cardiologists given the figures but
   9     not anaesthetists?
  10   A. Because we were closely working together; we were
  11     discussing problems, and we had audit meetings called in
  12     paediatric and Children's Hospital and anaesthetists
  13     were called. If they were not coming to the audit
  14     meetings, how would I know they were so much interested
  15     about the figures, unless they kept bringing their
  16     presence into the meeting? They never did that.
  17   Q. When there were any minutes of any meetings such as
  18     meetings of the paediatric cardiology group at the
  19     Children's Hospital, would the minutes be circulated to
  20     anyone who had a right to attend the meeting?
  21   A. I would like to think so.
  22   Q. Not only would you like to think so: did you yourself
  23     ensure that that was done? That the papers would be
  24     sent round?
  25   A. It was not run by me, it was run by Dr Martin at the

   1     Children's Hospital.
   2   Q. So it was Dr Martin's responsibility to send around
   3     the minutes?
   4   A. Yes.
   5   Q. And if results were presented on overhead projector,
   6     they could not, then, be circulated with the minute?
   7   A. No, they were not.
   8   Q. They could only be circulated if there was a written
   9     record?
  10   A. They would be photocopied but Dr Martin did not
  11     circulate -- I do not think any of these papers you saw,
  12     except for the minutes or the summary, the figures
  13     itself, I do not think they were circulated, no.
  14   Q. Why not?
  15   A. I do not know. You ask Dr Martin.
  16   Q. For your part, you did not circulate the results because
  17     you thought the anaesthetists might not have been
  18     interested?
  19   A. No, I did not circulate because it was not my job, but
  20     at the same time, anaesthetists, if they were
  21     conspicuous by their absence, I do not think they could
  22     really complain that they were not getting minutes.
  23     They never attended any of those audit meetings.
  24   Q. Did any anaesthetist ask you about any of the results
  25     during 1993/94?

   1   A. I really did not remember it until I had been asked to
   2     comment on one of the anaesthetists' statements and that
   3     can really just say that these things could be asked
   4     formally or informally, and you may forget it. But if
   5     somebody asked, I would give these figures, yes.
   6   Q. Do you recollect anyone ever asking?
   7   A. Now, having seen this statement, I can say yes, but
   8     before that, I did not recollect.
   9   Q. Following the meeting of 3rd December 1993, you were
  10     about, I think, to tell us how it came about that there
  11     was a meeting on 20th January 1994, a special meeting.
  12     Let me ask you about that now. The meeting at level 7
  13     in January 1994 was a meeting for you to present
  14     results, particularly in relation to switch, you say.
  15   A. It was not just for me, really. It was for Dr Alison
  16     Hayes to present her figures on arterial switches and of
  17     course, I would be there in a way to present whatever
  18     I could really say on my behalf, but I was told "You are
  19     too much involved with this thing, let somebody else do
  20     the audit and you be there to answer whatever questions
  21     are there."
  22        So that is how it was.
  23   Q. Who was going to present the figures?
  24   A. Dr Hayes.
  25   Q. As it happens, you were not able to go because you had

   1     commitments elsewhere?
   2   A. Well, I was operating. I got held up so I started
   3     getting worried and I made enquiries, what is going to
   4     happen? I was quite shocked to find out Dr Alison Hayes
   5     had already presented that data during the first week of
   6     January in the Children's Hospital, one of these Monday
   7     morning meetings, and I was at that time on holiday to
   8     India. I returned only 15th/16th January, and she had
   9     presented just after the Christmas break. So that was
  10     already presented.
  11   Q. That would be to the cardiologists, would it?
  12   A. That would be the cardiologists, the cardiac surgeons,
  13     and I was told Dr Masey and Dr Underwood also had
  14     heard.
  15   Q. So she presented the data; you were not there. The
  16     meeting of 20th January: did you hear anything about it
  17     afterwards?
  18   A. Well, I heard after that that Mr Wisheart presented what
  19     he had on last year's figures, and because he saw me
  20     preparing, I always thought that he knows and by that
  21     time, I would have thought that he also had a copy of my
  22     unit's figures which I had already sent to the
  23     register. So he would have had the data for 1992/93,
  24     but I was quite surprised why he should be doing that,
  25     because I have already presented that, but this was

   1     a different forum.
   2   Q. What we have been told is that he put some figures on
   3     a whiteboard, or possibly a blackboard and discussed and
   4     presented those.
   5   A. I heard that and he also told me that.
   6   Q. So he spoke to you after the meeting?
   7   A. Yes, because I asked him what did they talk about,
   8     arterial switches and various things. Then he said that
   9     "The arterial switches were already discussed before as
  10     you know, but it was mentioned again in the meeting, and
  11     I presented what I could remember from your figure".
  12   Q. Were you worried about the arterial switch?
  13   A. I stopped. That is why I stopped the neonatal switch
  14     programme.
  15   Q. But the non-neonatal?
  16   A. No, at that time I was not worried at all about it,
  17     because I had had no deaths, or only one death since
  18     1990, and I had done about 12 cases by this time.
  19   Q. So why were you asking if they had had the results and
  20     discussion about the switch?
  21   A. The neonatal.
  22   Q. It was the neonatal one you were thinking of?
  23   A. Yes, exactly.
  24   Q. So you had made your decision about that, so that was
  25     it?

   1   A. In a way I was not going to, but Dr Joffe said "Let
   2     Alison Hayes analyse this and find out if we learn
   3     anything more". She came back to almost the same type
   4     of answer which I already knew, that there was a higher
   5     percentage of coronary abnormality in the series and of
   6     course, you know -- I think that is what I remember.
   7     I think she may have mentioned one or two other things,
   8     I am not sure.
   9   Q. But in any event, nothing in that to make you reconsider
  10     your decision?
  11   A. No, no. Neonatal switch, as far as I am concerned, it
  12     was all.
  13   Q. So after that, during 1994, any neonatal switch which
  14     was diagnosed would go off to Birmingham?
  15   A. That is correct.
  16   Q. Did you understand, in early 1994, after this particular
  17     meeting where, as I have described, you had been
  18     surprised to discover the annual results had been
  19     presented, that you were not able to go to the meeting
  20     of the 20th itself, you yourself took no further part to
  21     present data to a meeting because you thought that had
  22     been done. Is that why?
  23   A. Which data?
  24   Q. I am sorry, it was a bad question. After the meeting of
  25     20th January at which you had not been able to come to

   1     present your data --
   2   A. That is correct.
   3   Q. -- knowing that Alison Hayes had presented data to the
   4     cardiologists and surgeons earlier in January, knowing
   5     that Mr Wisheart had presented data to the meeting of
   6     20th January and had told you he had done so, what need
   7     did you see to present any further data to the unit?
   8   A. I did not.
   9   Q. So you did not?
  10   A. No.
  11   Q. Did you have any sense, in early 1994, taking the period
  12     up to June, that anyone with whom you worked had any
  13     concern about either the switch operation which you
  14     continued to do or the results of the unit in general?
  15   A. No.
  16   Q. On probably the 12th, it may have been 5th April 1994,
  17     Mr Wisheart, Dr Monk, Professor Angelini and Dr Bolsin
  18     went out for an evening to a restaurant, Bistro 21 in
  19     Bristol. You know that now.
  20   A. I did not know that until really the GMC proceeding,
  21     that they went to some dinner or something like that.
  22     And the reason, and purpose that I heard, I felt were
  23     quite ...
  24   Q. Part of the reasoning appears to have been a view that
  25     they all four shared that there was a need to discuss

   1     matters of concern, if they were of concern, so as to,
   2     I suppose, create a harmonious way forward. Did you
   3     have any sense, in early 1994, that those with whom you
   4     worked were unhappy with any aspect of the unit's
   5     performance?
   6   A. No.
   7   THE CHAIRMAN: I wonder whether, Mr Dhasmana, you were --
   8     when you were talking about the dinner, you said "and
   9     the reason for it and the purpose, I felt were
  10     quite...", and you did not finish the sentence. I was
  11     intrigued to discover what you felt?
  12   A. I do not know what would have come out in the flow at
  13     that time, but I felt no real -- I mean that, to my
  14     mind, was not the way to discuss the problem in a dinner
  15     meeting at the Bistro club.
  16   MR LANGSTAFF: What would have been the way to discuss
  17     the problem?
  18   A. Well, if the problem is in the paediatric cardiac
  19     surgery, if there is a concern, whether it was relating
  20     to me or not, I would have thought that being 1993 must
  21     have related to my neonatal switch, why did not any of
  22     those gentlemen talk to me and I could have also gone to
  23     same dinner and probably would have raised the question,
  24     or there should have been a meeting of all concerned
  25     parties, and an open airing; it should have been aired

   1     openly.
   2   Q. Did you still share an office with Mr Wisheart?
   3   A. No, I did not. I moved out from the office I think in
   4     1992.
   5   Q. Did you still see him regularly?
   6   A. Yes.
   7   Q. Did you discuss matters of interest to the unit in
   8     1994?
   9   A. I had almost a monthly consultants' meeting arranged
  10     during part of my Associate Director job, or post, or
  11     appointment, and of course Mr Wisheart I would be
  12     meeting quite often in the ITU and other areas, yes.
  13   Q. Mr Wisheart never mentioned, did he, the fact that he
  14     went to a dinner meeting with a view to whatever it was,
  15     ironing out concerns that there might be?
  16   A. Not until after, you know, when it was known to almost
  17     everybody else.
  18   Q. Did you have the sense later on then that you were
  19     almost the last to know?
  20   A. That is a difficult question to answer. I cannot answer
  21     that.
  22   Q. Can we look at UBHT 61/246?
  23   THE CHAIRMAN: If we can just press on that question
  24     a little bit more, you were, after all, doing the
  25     surgery. Did you think it was odd that you were not

   1     there at the meeting?
   2   A. I think that was the word I was really looking for at
   3     that time, "odd" to have gone to that dinner meeting.
   4     So odd, yes.
   5   Q. Not odd that others would go, but odd that you were not
   6     invited, was what my question was?
   7   A. Odd that I was not even told.
   8   MR LANGSTAFF: UBHT 61/246: 12th May 1994, so just about
   9     a month on from the dinner meeting. This is from
  10     Professor Vann Jones to the Chairman of the Trust.
  11         "Dear Peter,
  12         "As you know, Gianni Angelini has been to see me
  13     at your behest to discuss the problems that we have with
  14     paediatric cardiac surgery. I am sure you are well
  15     familiar with the history of this, but it has run along
  16     in a rather half-baked fashion, certainly for all the
  17     time that I have been here. I think we accept the
  18     reality of the position and that it is unlikely that
  19     paediatric cardiac surgery will move to the Children's
  20     Hospital for the foreseeable future, but if the facility
  21     is to be reprovided then we would certainly argue
  22     strongly that space should at least be left for
  23     paediatric cardiac surgery in the new hospital".
  24        Stopping there, we will look at the rest of that
  25     paragraph in a moment.

   1        "I am sure you are well familiar with the history
   2     of the problems that we have with cardiac surgery."
   3        From your looking back to where you were in 1994,
   4     in May 1994, did you think that there had been problems
   5     with paediatric cardiac surgery, problems with something
   6     of a long history?
   7   A. No, it comes to the same definition which I asked
   8     before: what type of problem? Is it a problem to
   9     improve further, or a problem which is unacceptably
  10     poor? Of course, the problem, to improve our
  11     performance, that has always been there. That is what
  12     I was really saying two days ago: that in paediatric
  13     cardiac surgery, I always felt that we had to improve,
  14     more and more and more improve; you have even higher to
  15     go. So that is how I saw it. I was not aware, the
  16     inference with this type of letter really gives, that
  17     there was a problem in the paediatric cardiac surgery.
  18   Q. Because problems in the sense of trying to improve is
  19     what every doctor would do in any department?
  20   A. Exactly.
  21   Q. And the use of the word here must indicate something
  22     special or particularly worrying about paediatric
  23     cardiac surgery.
  24        As you thought about it in 1994, was there
  25     anything that would, in your eyes, then have merited

   1     problems in the sense?
   2   A. I mean, except for my neonatal switches, maybe I was too
   3     focused, too much concerned by my own neonatal switches
   4     that I was not seeing anything, but I was not aware that
   5     there was any other problem.
   6   Q. If we go down to the word "However ...", just highlight
   7     that to pick it up.
   8        "However, our present problem is that we have good
   9     units on our doorstep, namely, in Southampton and in
  10     Cardiff and if paediatric cardiac surgery is to survive
  11     in Bristol, the surgical side certainly needs a very
  12     major shake-up. As you know, at present it is run by
  13     two part-time adult, part-time paediatric surgeons but
  14     it is now such a highly specialised completely different
  15     specialty from adult cardiac surgery that that option is
  16     a very poor second to what is required."
  17        I will go on to what follows in a moment, but this
  18     is a plea for a full-time paediatric cardiac surgeon,
  19     something you supported, you told us earlier?
  20   A. That is correct.
  21   Q. Did you think that the need was so great that it was
  22     appropriate to describe the surgical side as it was as
  23     needing a very major shake-up?
  24   A. I think he was also in a way disappointed, as we were,
  25     that we could not really fill in our professorial post

   1     with the paediatric cardiac surgeon, which we were all
   2     working very hard in 1991 and 1992, and Professor Vann
   3     Jones at that time was very keen for that and very
   4     supportive. So I have a feeling now that what he is
   5     really writing is just to enforce that view again.
   6   Q. He uses fairly strong words, if you read through the
   7     next few lines -- I will let you do that on the screen
   8     to yourself. (Pause). It is the last two lines we come
   9     to in that paragraph:
  10        "If we do not go ahead with it, paediatric cardiac
  11     surgery in Bristol is going to fold and after that,
  12     paediatric cardiology will go with it."
  13   A. I am sorry, I did not realise you were waiting for my
  14     answer. No, I think in a way he is now putting a very
  15     strong pressure on management to accept the
  16     recommendation that they should really be looking for.
  17   Q. So he is arguing a case for paediatric cardiac surgery?
  18   A. That is quite correct.
  19   Q. A case which you yourself would wish to advance?
  20   A. Yes.
  21   Q. You were the Associate Director of Cardiac Surgery?
  22   A. At that time, yes.
  23   Q. Did you know of this letter?
  24   A. No, and he was my Clinical Director at that time, so in
  25     a way, Dr Vann Jones, he was Clinical Director and I was

   1     Associate Clinical Director, so he should have really
   2     told me or talked to me.
   3   Q. He did not tell you that he had written this letter?
   4   A. No.
   5   Q. Did he discuss the contents with you beforehand?
   6   A. No.
   7   Q. Do you know of any reason why you should be out of the
   8     loop?
   9   A. I do not know. I mean, this is a puzzle.
  10   Q. As far as you know, did you have good relations with
  11     Professor Vann Jones?
  12   A. I thought I had good relations with all the gentlemen
  13     who had been here and saying something totally different
  14     than what they said before.
  15   Q. And Professor Angelini?
  16   A. I have changed my mind after the November 1994 meeting.
  17   Q. But at this time?
  18   A. Very good.
  19   Q. Let me just move on. You had no whisper of this letter
  20     having been written?
  21   A. No.
  22   Q. There was no comeback from the Chairman, whether through
  23     Dr Roylance or through Mr Wisheart, which reached your
  24     ears?
  25   A. No.

   1   Q. When did you first know this letter had been written?
   2   A. I saw this letter actually either when the GMC
   3     proceeding was going on, or it is possible when the GMC
   4     files were sent to me. Then I saw this letter. I think
   5     it was in correspondence either with Dr Vann Jones or
   6     Professor Angelini, I do not know, but that is the time
   7     I saw this letter.
   8   Q. Just before we break for the afternoon, may we have
   9     a look at UBHT 61/7? 21st June 1994, a letter addressed
  10     to Dr Monk, if we scroll down. There are five
  11     signatures on this copy. We have seen another copy
  12     which has the additional sixth signature, although some
  13     of the first five are missing.
  14        "Dear Chris,
  15        "We wish to express our concern at the arterial
  16     switch programme currently being undertaken in this
  17     hospital. The mortality is apparently high,
  18     particularly for those operations undertaken in the
  19     neonatal period."
  20        Just stopping there, that was the operation which
  21     you had stopped in October 1993?
  22   A. That is correct.
  23   Q. At least Dr Underwood and Dr Masey were people you
  24     operated with regularly?
  25   A. That is correct.

   1   Q. We mentioned this briefly on Monday. The implication is
   2     that they did not know that that operation had been
   3     stopped. Do you ever recollect telling them in terms,
   4     "Dr Underwood, I am not going to do any more neonatal
   5     arterial switches, we have stopped the programme",
   6     anything like that?
   7   A. I told both of them, and now I remember my last case
   8     anaesthetist was Dr Monk, and it was he himself who told
   9     me, "Janardan, back to the drawing board". And I said
  10     "Well, I am not doing any more".
  11   Q. That was in October 1993?
  12   A. Exactly.
  13   Q. It goes on "The recent death of a 14 month old child
  14     following the arterial switch procedure must now lead to
  15     an open and thorough review of the results so far".
  16   A. I mean, in-between, I have already successfully operated
  17     on another arterial switch patient, and nobody --
  18     I mean, it could be either April or some other time,
  19     March, I have operated on older switch successfully.
  20   Q. The letter is looking for an "open and thorough review
  21     of the results". Can you think of a reason, from your
  22     knowledge -- I am not asking you to speculate from the
  23     minds of others -- as to why some may have had the
  24     feeling that they there had not been an open and
  25     thorough review of the results so far?

   1   A. No, I cannot answer that. I was surprised with this
   2     piece of paper when I saw it for the first time.
   3   Q. Dr Underwood, one of the signatories, anaesthetised for
   4     you some five or six days after the date of this letter,
   5     on 30th June 1994, in a switch operation?
   6   A. That is correct.
   7   Q. Was anything said by her to you at that operation?
   8   A. No.
   9   Q. It is suggested to us that this letter was taken to
  10     Dr Roylance. If it had been, is it the sort of letter
  11     you would have expected to hear of, either directly from
  12     Dr Roylance or through Mr Wisheart as Medical Director
  13     of the Trust?
  14   A. I would think so. I mean, I am equally surprised that
  15     Dr Monk did come and see me in July, and he also did not
  16     mention about this letter.
  17   Q. Because he came to see you in early July, it was I think
  18     after the operation we have just mentioned, was it, the
  19     operation which Dr Underwood anaesthetised for you on an
  20     arterial switch, in which there was an unfortunate
  21     result?
  22   A. No, until that time the patient was in ITU.
  23   Q. So Dr Monk came to you when the patient was still in
  24     ITU?
  25   A. Yes.

   1   Q. And at that time, what was Dr Monk saying to you?
   2   A. That was the first week of July, when he really said --
   3     I mean, I cannot -- I was just going around ITU and
   4     almost finished my ITU round and Dr Monk appears and
   5     I simply said "Hello", and he then said, "Janardan, do
   6     you have a minute?" I said "Yes". He said "Could we go
   7     to your office?" Then we go to the office which is just
   8     outside ITU, and there he tells me that, "Janardan,
   9     I have come to see you because my colleagues feel that
  10     the arterial switches are not doing very well".
  11        I said, well, you know, we have already stopped
  12     the neonatal switch programme and I did not see any
  13     problem with my older switches. Unfortunately, the last
  14     patient died which had very highly abnormal coronary
  15     artery pattern. But before that, the other switches,
  16     you know, I had done by that time I think 13 or 14 with
  17     only one death. This patient, who is now in ITU, I know
  18     he is there but he is virtually inoperable.
  19        I said, you know, "Who are the anaesthetists who
  20     said that they are unhappy?" He said, "Well, you know,
  21     almost all". I said, "Well, just give me the names".
  22     He named and I said "It cannot be Dr Masey and
  23     Dr Underwood because they know all my cases, they have
  24     helped me, so in a way, they have got the figures with
  25     them and they know I stopped neonatal". He said, "Well,

   1     all right, why do you not give me your list of cases
   2     which you have done since you say you have lost only one
   3     patient, and I will talk to my colleagues and then we
   4     will see what we are going to do, but in future, do not
   5     arrange any arterial switch unless you have talked to
   6     us".
   7   Q. And did you agree to do that?
   8   A. Yes, I did. I gave him a list in my hand which was --
   9     it was not typed -- and he said, "Well, that will do, to
  10     make a photocopy", and I kept the -- I mean, the
  11     original was really on the other side of -- I used to
  12     keep a lot of loose papers with me.
  13   Q. So the position is that by the end of the first week in
  14     July, as a result of the discussion with Dr Monk, you
  15     had been told that all or most of the anaesthetists had
  16     concerns about the results in arterial switch
  17     operations; you had tried to explain that the results
  18     were acceptable as you saw them, for the reasons you
  19     have given, because of the particular nature of the
  20     operations, and you had agreed not to list any more
  21     arterial switch operations without first discussing the
  22     matter with the anaesthetists?
  23   A. That is correct. That was July 1994.
  24   Q. That last matter, that you would not list any more
  25     arterial switch operations without discussing the matter

   1     with the anaesthetists, would mean, would it not, that
   2     if a child came to you, referred by a cardiologist, and
   3     thought to be in need of a switch operation, that you
   4     were effectively giving the decision as to whether there
   5     should be an operation or not to the anaesthetists and
   6     not taking it yourself?
   7   A. Well, in a way, I at that time agreed to co-operate with
   8     him, until he comes back with his result of what he has
   9     got from discussion with his colleagues on the basis of
  10     figures which he received from me.
  11   Q. Does it follow -- because I think you have accepted the
  12     conclusion of the last question that I put to you --
  13     that you had a sense at the end of this meeting with
  14     Dr Monk that the anaesthetists took a very serious view
  15     of the situation, so much so that you made the agreement
  16     when you might not otherwise have done so?
  17   A. Yes.
  18   MR LANGSTAFF: Sir, I have a regard to the hour. It would
  19     be unfair, I think, to penalise Mr Dhasmana for our
  20     earlier delays within the Inquiry. Would it now be an
  21     appropriate moment to break?
  22   THE CHAIRMAN: Yes, I think that is right, Mr Langstaff.
  23     Shall we adjourn until 9.30 tomorrow morning? Thank
  24     you. Good afternoon.
  25   (4.30 pm)

   1     (Adjourned until 9.30 am on Thursday, 2nd December 1999)
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   5                I N D E X
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   7     MR JANARDAN DHASMANA (Recalled)
   8        Examined by Mr Langstaff (continued) ........ 1
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001