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