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Daily transcripts
Hearing summary
2nd 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 continuing to discuss
the annual results of the paediatric cardiac surgical unit in Bristol, comparing the
mortality recorded for Bristol against other centres reporting to the UK Cardiac Surgical
Register. He then spoke about the sources which informed his awareness that concerns were
being raised generally about the unit and said he too was concerned about the arterial
switch programme and had organised a meeting with the cardiac anaesthetists to discuss the
procedure. Mr Dhasmana then spoke about the discussions surrounding the case of Joshua
Loveday, who died following surgery in January 1995. He said that the meeting held the
night before the operation concluded that the procedure should take place and he said he
was reassured by the support of his clinical colleagues. Next he talked about the issue of
informed consent and communications with parents regarding post mortems and retention of
tissue. He concluded by talking about the consequences for his clinical practice following
the review of the paediatric cardiac service in Bristol by Professor Marc de Leval and Mr
Stewart Hunter in February 1995.
Dr Eric Silove, Consultant Paediatric Cardiologist, Birmingham
Children’s Hospital, attended this morning’s hearing in his capacity as a member
of the Inquiry’s Expert Group.
This afternoon the Inquiry heard evidence from two additional
witnesses, Mr Stephen Willis and Mrs Rachel Ferris.
Mr Willis, from Devon, told the Inquiry about his son Daniel who was
born in 1993 with congenital heart defects. Mr Willis explained how he asked questions
about his son’s treatment and queried other options, such as transferring Daniel to
another hospital.
The week’s evidence concluded with Mrs Rachel Ferris, General
Manager for Cardiac Services, UBHT. She described her impression of the attitude within
the hospital towards Dr Stephen Bolsin’s (consultant anaesthetist) expression of
concerns and went on to describe her role in organising the Hunter/deLeval visit. She
commented on the findings of the review and described a meeting she had with Mr Wisheart,
consultant cardiac surgeon and Medical Director to discuss the results of the unit. She
concluded by talking about the arrival of Mr Ashe Pawade, consultant paediatric cardiac
surgeon.
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FULL TRANSCRIPT
1 Day 87, Thursday, 2nd December 1999
2 (9.45 am)
3 THE CHAIRMAN: Good morning, everyone. Good
4 morning, Mr Langstaff. Forgive us for keeping you
5 waiting for 10 minutes, there was just one matter we had
6 to attend to on what I know will be a long day in any
7 event. I apologise for that.
8 MR LANGSTAFF: Sir, if Mr Dhasmana will excuse me
9 for talking across to you while he gets himself ready,
10 conscious that it is going to be a long day today
11 because we have Mr Dhasmana's evidence this morning and
12 in the early afternoon; then not before 1.30, and we
13 expect straight after a lunch break, we will have the
14 evidence of Mr Willis and after he has finished his
15 evidence, we will have the evidence of Rachel Ferris who
16 is recalled to give further evidence to the Inquiry in
17 the light of a statement which we received only very
18 recently.
19 Because of the pressures there will be on time, it
20 is perhaps more convenient if I say what has to be said
21 about morbidity, after the weekend on Monday.
22 THE CHAIRMAN: Thank you for reminding us of that
23 statement, Mr Langstaff. I think, yes, it would be wise
24 perhaps to postpone it until Monday morning on your
25 assurance we will hear it then.
0001
1 MR LANGSTAFF: Yes.
2 MR JANARDAN DHASMANA (RECALLED):
3 EXAMINED BY MR LANGSTAFF (CONTINUED):
4 MR LANGSTAFF: Mr Dhasmana, when I was taking you
5 through the history of each of the year's results,
6 I inadvertently, my fault entirely, did not take you to
7 the actual results of the year 1992/1993 which you were
8 to present at the meeting in 1994.
9 A. No.
10 Q. It is important I think for you that I should show you
11 those results. They are on the screen. If I can look
12 at the top, you see two sets of initials?
13 A. Excuse me, can I just correct: this I had already
14 presented on 3rd December 1993.
15 Q. I am sorry.
16 A. It was not supposed to be presented in January 1994.
17 Q. Again forgive me.
18 A. Thank you.
19 Q. These are the results. Did you prepare them or did
20 Mr Wisheart?
21 A. I prepared it.
22 Q. You have broken them down by surgeon?
23 A. Yes, I did.
24 Q. Why did you do that?
25 A. There had been I think for that year and probably the
0002
1 year before when we started looking into audit figures
2 and audit structure became more formalised, people
3 started asking me that it would be better now if we get
4 the surgeon-specific figures and because this was
5 a whole year's figure and I thought we were doing now,
6 not a big amount but a number good enough really to
7 individually analyse.
8 Q. The point about surgeon-specific figures if you have
9 specific numbers is presumably you can detect if there
10 is perhaps something one surgeon is doing which improves
11 performance or the converse, that he is doing which does
12 not help?
13 A. I felt this would highlight to everybody who is in the
14 room what has been happening and where it is happening.
15 Q. The reference for the transcript is GMC 8/72, if we look
16 at your column, the under 1 and over 1 years, go down
17 the under 1 column to the summary at the bottom, you
18 have 4 deaths in a total of 25 operations?
19 A. That is correct, sir.
20 Q. Which, if we take an annual figure would produce a death
21 rate of 16 per cent?
22 A. That is correct, sir.
23 Q. All of those deaths are in one particular type of
24 operation?
25 A. That is correct, neonatal arterial switch, although
0003
1 4 patients.
2 Q. If we take a look at that line, the TGA with intact
3 septum, where we see there were 7 operations, 4 deaths
4 and we go across to the right-hand side, do you see
5 where the United Kingdom results for 1991 are quoted,
6 the UK 1991 mortality, 12.9 per cent for that?
7 A. Forgive me, I could just still repeat the same thing:
8 you do not know how those patients were treated. That
9 is only the pathology, it does not -- sorry.
10 Q. If you concentrate for a moment, please, Mr Dhasmana, on
11 the question and the point.
12 You explained that by saying this may be
13 a combination of operations?
14 A. That is correct, sir.
15 Q. Indeed, if we look at Mr Wisheart's operations under
16 1 year, it would appear he did 4 with no mortality, but
17 they would all be Sennings, would they?
18 A. Yes, he would have been doing Senning.
19 Q. And the results within your unit for the Sennings had
20 always been very good, had they not?
21 A. Can I add more? If you look here I have also done
22 3 Sennings in the same group, the total number is 7 and
23 I have 4 deaths and I know they were all neonatal
24 switches, so I also had done a few Sennings at that
25 time.
0004
1 Q. Your small series of 7 was a mixture of Sennings and
2 switch?
3 A. That is correct, sir.
4 Q. You do not know what the UK figure was; that would also
5 have been a mixture of Sennings and switch?
6 A. That is correct.
7 Q. We know Mr Wisheart was all Sennings because that was
8 all he was doing?
9 A. Yes.
10 Q. In every other type of operation that you performed
11 under 1 in that year, you had no mortality at all?
12 A. That is correct, and you can see if you let me, sir,
13 that there is a TGA and VSD which is again treated by
14 arterial switch under 1 year. I have operated on 3 with
15 no deaths.
16 Q. If anyone had asked you in 1994 about your figures, with
17 the exception of the arterial switch, how good do you
18 think your figures were?
19 A. I would say excellent. I have no deaths at all in the
20 over 1 year age group and I have operated on 50
21 patients.
22 Q. Yesterday when we were talking about concerns and I was
23 asking you how it was you did not know people were
24 concerned, you obviously could not comment on what other
25 people were thinking, but you did not know. Can I turn
0005
1 the question round and say: mindful of these particular
2 figures for this particular year, did you think you had
3 any particular reason to be worried about your figures
4 apart from the switch?
5 A. It was just my nature, I was so self-analytical that
6 I myself, until I presented these figures and various
7 things, I was questioning myself, but this was mainly on
8 switch -- it is only on switch really and that is what
9 I was saying to Dr Monk when he talked to me.
10 Q. If we look at the bottom of the page, we have looked
11 at your 4 out of 25, 16 per cent. Over 1 year, no
12 mortality in 50 cases. Mr Wisheart, 5 out of 28 under
13 1 year, that is 18 per cent I can tell you, very nearly
14 18 per cent, and 3 out of 44 over 1 year which is just
15 over 6 per cent.
16 What we do not have for the United Kingdom is an
17 overall mortality figure, is it?
18 A. No, because this is a total number and I cannot at the
19 moment tell you whether I have taken it both combined
20 together or it is for under or over 1, I could not say
21 unless I have the chart in front. You can see my
22 problem was I am running out of space really there.
23 Q. Can I have a look at GMC 8/174? This is November 1994,
24 just moving forward a year. You are setting out
25 a number of conditions, a number of operations and the
0006
1 age. Were these all children who during 1994 died or
2 not?
3 A. No, this is for the month of November only.
4 Q. Did they --
5 A. This is what I was talking about monthly audit, this
6 is not a yearly audit, this is the departmental monthly
7 audit at the end of the month so it must have been
8 presented at December or January because in --
9 Q. Can we scroll down. So month by month there was
10 something like this, was there?
11 A. That is right.
12 Q. Month by month no collection of the figures to see how
13 that year was going?
14 A. At the end of the year --
15 Q. But only at the end of the year?
16 A. Yes.
17 Q. I want to ask you about that, come back to that point
18 about the end of the year. For a moment: we have looked
19 at 1992 to 1993 figures that Bristol was producing. Can
20 we have a look, please at JDW 5/254? This should give
21 us the 1993 to 1994 figures, that is the register, this
22 is the return to the register from where the figures
23 come. If we go to page 263, go down to the very bottom
24 of the page, what we have is two groups, as you know.
25 The left hand column shows the number of closed
0007
1 operations and the number of deaths in the over 1 year,
2 that is 10 with no deaths. 1993, open heart operations
3 in the over 1 age group with 4 deaths, just over
4 4 per cent. The under 1s, the 49 closed operations,
5 2 deaths and the open, it is the last two boxes on the
6 bottom right hand corner, 50 operations, 14 deaths?
7 A. That is correct, sir.
8 Q. A total of 28 per cent.
9 A. It looks that way, yes, sir.
10 Q. Here in 1992 to 1993 the mortality had varied, you were
11 showing on overall figures 16 per cent, Mr Wisheart
12 18 per cent. Here for the next year the unit, not
13 broken down by surgeon, 28 per cent --
14 A. It was broken down and presented, you have not got the
15 data in front of me.
16 Q. We cannot find any document where that has been done.
17 A. That is what -- I was also surprised really that you
18 have not got it and I looked around, I talked to
19 hospitals, solicitors, Mrs Julie Austin and I went to
20 her office and, as you know when I was removed from the
21 office my old papers were taken away. So I saw there in
22 the box 13 and it is my file there, it says 1993, 1994
23 and they are surgeon specific in my own hand.
24 Q. Were they ever published?
25 A. I presented that. I presented 1992/1993 in December
0008
1 1993. I presented 1993/1994 some time in September 1994
2 and 1994/1995, again, I think this was even earlier,
3 July or August, I myself presented it. I know it very
4 well.
5 Q. You are telling us you have seen the document?
6 A. Yes.
7 Q. Even though we do not seem to have it?
8 A. I was told that those files, those boxes have been
9 returned from the Inquiry, so the Inquiry has got
10 a copy. That is what I was told.
11 Q. We shall check that because we would need to make sure
12 of that and I give you the undertaking on behalf of
13 those below stairs that that will be done.
14 A. Thank you.
15 Q. In 1994 to 1995, because we have looked now at
16 1992/1993, 1993/1994.
17 1994/1995 we get an overall reflection at
18 GMC 8/185. This time typed. We can see there
19 congenital open heart operations under 1 year, 7 deaths
20 out of 32 operations. 21.9 per cent.
21 The United Kingdom mortality for the year before,
22 1993 to 1994 at 11 per cent. The over 1 year, 6.7
23 compared to 5.4.
24 THE CHAIRMAN: Mr Langstaff, what document is this,
25 just to help me?
0009
1 MR LANGSTAFF: This was presented at the GMC. I am going
2 to ask Mr Dhasmana.
3 This is a document which the GMC had. Do you know
4 where it comes from?
5 A. From me. This is the yearly audit figure of 1994/1995.
6 You have only the summary sheet and it is followed by
7 a number of the papers and they are all in type, I have
8 seen it, it is in our bundle, you know the file you have
9 given me and there is a surgeon-specific figure there on
10 B and D.
11 Q. I was going to take you to that sheet which is
12 page 180. "Paediatric open". We see the various
13 operations. B is who?
14 A. Myself.
15 Q. D is?
16 A. Mr Wisheart.
17 Q. Why use B and D?
18 A. We had five surgeons, I am presenting the whole unit's
19 figure, A, B, C, D, E, it goes up to E really. I think
20 somewhere in the bottom I have written who is A, who is
21 B and who is C, D and E. I know B is me and D
22 Mr Wisheart.
23 Q. If we look down to the bottom of that page there,
24 3 out of 23, it is an annual mortality rate of just over
25 12 per cent. Mr Wisheart, 4 out of 9 is just under
0010
1 50 per cent. The total, 7 out of 32.
2 Again, undoubtedly, as we have seen from the
3 summary, considerably higher than the United Kingdom
4 figure, about twice as high roughly?
5 A. Again, sir, yesterday I was talking about when you
6 have got a smaller number you need to give 70 per cent
7 confidence limit. Here I am giving -- this is in my own
8 hand -- but in brackets it is 70 per cent confidence
9 limit. Also, if you look in the individual pathology
10 you can really see AV canal, 7, 1 death. TGA, VSD and
11 this is the unfortunate case which will be, I am sure it
12 will be discussed, the arterial switch who died. We
13 have TAPVD 1/4. Overall I would say, if you are
14 looking, yes, the overall figure is on the high side --
15 Q. Forgive me, Mr Dhasmana, you were looking at your own
16 results there, I think?
17 A. Yes.
18 Q. It is unfair. It is perhaps favourable to the unit to
19 take 1 death out of 7 in AV canal, that is your series
20 and those are better results than the unit's results
21 which are 2 out of 8.
22 A. I thought I should explain myself first, as I said
23 before I always look at my --
24 Q. What I am trying to concentrate on at the moment is the
25 unit. It is quite obvious from the figures as they
0011
1 stand that your figures are rather better, very much
2 better than Mr Wisheart's on this paper, are they not?
3 A. Yes.
4 Q. So far as the unit is concerned, you were Associate
5 Clinical Director, were you not?
6 A. By this time when this was presented I was not.
7 Q. This is 1994, 1995 you stopped being Clinical Director
8 in about October 1995?
9 A. September/October and that is the time I would have
10 presented it just to finish my term off.
11 Q. Year after year after year with the one exception we
12 have seen of the year where the open heart results were
13 12.5 per cent, year after year after year we have seen,
14 going right back to the 1980s, the apparent results,
15 small numbers, the apparent results produced by the
16 Bristol unit, looking at the unit, not the individual
17 surgeons, were getting on for double the results as
18 presented through the UK surgical register.
19 When you were the Associate Clinical Director you
20 would have naturally a concern for the success of the
21 unit?
22 A. Yes, of course I do.
23 Q. How long would a series such as this go on for year
24 after year after year with perhaps the odd exception
25 being approximately double or thereabouts the reported
0012
1 mortality for the United Kingdom for a year or so
2 previously before you began to think "The audit process
3 we are doing internally, doing our best to work out what
4 is going wrong and how we can improve results... ",
5 because that is what you always wanted to do, how long
6 before you would say to yourself "Well, we are not
7 hitting the right answers, we need some external review,
8 some help from outside to analyse the results, just
9 reassure us that we are actually doing our best"?
10 A. That is what I thought, you know, that probably this
11 Inquiry would come out with. We did not know the time
12 when you really feel that one should be.
13 We were looking every year, we were looking at the
14 figures and you can see there is improvement on and
15 off. You got one year reasonable results, another year
16 down, then up again, down. Obviously when you have
17 a smaller number I think you have to really look at
18 a particular disease group where you are not doing that
19 well. I think when you are doing, say -- for example,
20 if I just take surgeon D here, AV canal, if there is
21 only 1 done in a year, you cannot make a reasonable
22 judgment from that, you have to look at a whole series.
23 That is what really I was getting at, we are looking to
24 that type of experience, what we are really doing in
25 a particular group.
0013
1 We had done that up to 1991/1992 and this is the
2 period, again audit structure is changing, we are now
3 settling into it and I had already looked in my arterial
4 switch experience, talked to them and I was expecting
5 others would do the same and obviously this was part of
6 that process.
7 Q. You have seen, I imagine, the results which this
8 Inquiry has produced from the statistical surveys which
9 have been done and the statistical synthesis presented
10 to us by Dr Spiegelhalter.
11 If one takes that at face value then the results
12 reported suggest that the Bristol unit for the under 1s
13 had as near as makes no difference to twice the average
14 mortality of the United Kingdom across the entire
15 period, 1984 to 1995, so far as one can measure it.
16 A couple of questions: do you accept that is
17 probably the case?
18 A. I would say that looking at the UK Cardiac Register
19 year by year, not twice every year, it is definitely
20 higher under 1 year of age. That I accepted a long time
21 ago. But every year I would find some reason for it and
22 that was my problem. For example, in my case I found
23 arterial switch.
24 To be honest I did not realise there was a major
25 problem on the other side with another group really
0014
1 until things were analysed again in the disease basis
2 because when you were presenting a yearly figure like
3 that and you see 1 out of 1 you say "Well, it is only
4 one, I am sure it is not" and you need to really look.
5 Of course I knew about arterial switches, I knew
6 about my results all the time and I knew they were
7 improving and had improved. So I had no question about
8 my own self. Of course I was not particularly certain
9 about a few operations in the unit if you understand
10 what I mean.
11 I have some opinion on statistical reports, if you
12 want me to say now or wait until --
13 Q. I think now is your opportunity to say what you would
14 like to say unless you prefer to put it in writing, it
15 is a matter for you.
16 A. I have put it in writing and probably you have not
17 received that yet, but I am not a great statistician and
18 I cannot claim to understand everything that has been
19 said in a few sections of those but I certainly would
20 like to challenge their interpretation of my surgeon's
21 log. I am quite certain about my surgeon's logs as they
22 have been put in there but I am not sure who has
23 classified patients from my surgeon's log according to
24 disease group as it appears in that table really.
25 Just to give you one example, I do not know
0015
1 whether it can be flashed here on the screen but I do
2 remember, I will give an example which is: personally
3 I feel it very degrading for any cardiac surgeon to
4 realise from the notice that he has more than
5 17/18 per cent mortality in ASD which is the simplest
6 form of cardiac surgery. In my surgeon's log I have
7 done under 15 years of age a total number of 95
8 patients, only 1 death, a very seriously ill child,
9 about 9 or 10 months old. There is no other death.
10 If you look at my interpretation of that figure
11 there, it puts the total number 136 with 17 deaths.
12 I do not know where they have got that number from. My
13 guess is, they have taken my "miscellaneous" which is
14 about 36 or 37 with 14 deaths there and combined them
15 together, but I may be wrong.
16 Q. I do not want to enter into a debate here.
17 A. No.
18 Q. Because this is not perhaps the right occasion to do
19 it. I think it is important you have the opportunity to
20 express your views as you have done in public so they
21 are there and can be addressed. The answer I think you
22 may find is the way in which, for the purposes of making
23 an overall comparison, the various databases have had
24 the operations classified and codified. Inevitably in
25 any such process there is, as the statisticians were the
0016
1 first I think to admit, a degree of judgment and
2 uncertainty. That I think is best perhaps expressed in
3 answer to a point you have made by our statisticians
4 rather than by me on my feet here. That will be more
5 helpful to the Inquiry. The point you have made plainly
6 deserves respect and deserves to be looked at by the
7 statisticians.
8 THE CHAIRMAN: Yes, I think that is right. I think it
9 would be important for it to constitute what in our
10 procedure we call a "full written comment" on the
11 evidence and therefore going to the public domain and
12 a response to it encouraged from statisticians. After
13 all we have said from the outset that this process of
14 analysis is still going on and clearly it needs to be
15 have been formed by evidence from all quarters?
16 A. Can I make another comment, sir?
17 MR LANGSTAFF: Please.
18 A. I feel quite bad about my neonatal arterial switch
19 results, like I lost 9 out of 13. According to
20 a statistical report I have lost 90 per cent of my
21 patients. In a way that is again for something which is
22 so open, GMC has gone through, gone into the public
23 domain and it still appears in the statistics a year and
24 a half later, in such an auspicious and august body, as
25 90 per cent mortality of my neonatal switches.
0017
1 MR LANGSTAFF: Again I think that is a similar point
2 which will be taken up and responded to by the experts
3 who advise the Inquiry. If needs be they will enter
4 into an appropriate and public discussion on paper with
5 you about those figures. That is the only way
6 transparency can be achieved so you can be satisfied
7 that the result is a fair one, and they can and we can
8 and the public can.
9 THE CHAIRMAN: Again I interject merely to say that our
10 task is, as I said right at the very outset, to get to
11 the bottom of things and that is all the interest we
12 have. But it is very important for Mr Dhasmana and
13 everyone else to realise that the Inquiry still has
14 a number of months to go, it is by no means finishing,
15 we are ending one phase of it on 16th December, namely
16 oral hearings, but it is a process which will be going
17 on for some months thereafter and it is this process of
18 refining our understanding of information which will be
19 an important element as we proceed?
20 A. I am grateful to you, sir.
21 MR LANGSTAFF: Suppose then that we concentrate upon the
22 data which the unit itself produced by the return to the
23 Cardiothoracic Register. The data which you had back
24 from the register showing what the UK mortality was for
25 a year or so beforehand, I am returning to the point
0018
1 I was on before I asked you about the Inquiry's
2 statistics, throughout the period for which we have
3 looked at the returns Bristol's mortality rate was
4 getting on for twice that of the UK in the under 1 age
5 group.
6 So far as the responsibility of the Associate
7 Director of Cardiac Services is concerned, what would
8 you expect such a manager, such a director to do?
9 A. When I took over in 1993, there were no clear-cut
10 guidelines, I was not given any job description nor what
11 I should be doing or what I should not be doing.
12 I talked to various people, that is the retiring
13 Associate Director in my own speciality, I talked to the
14 Clinical Director of Surgery at that time who was the
15 overall boss and I talked to the General Manager of
16 Surgery and Associate General Manager of Cardiac Surgery
17 at that time. The impression I was given was that the
18 Associate Clinical Director's job is really to help the
19 Clinical Director to run the department in order to
20 perform the contract and the associated problems with
21 it.
22 Q. Did that not involve responding to figures, ensuring
23 that they were analysed, perhaps having some degree of
24 control over consultants?
25 A. I did not think you had any control over your fellow
0019
1 consultant in the NHS.
2 Q. You had no job description, no degree of control over
3 your fellow consultants; part of the role was to chair
4 meetings, was it?
5 A. Yes.
6 Q. Did you find chairing meetings easy, you personally?
7 A. Until I had co-operation of people, yes. I am not
8 a medical politician and I like in a way a frank, open
9 discussion and people really airing things out in front
10 rather than saying something behind, that is what
11 I believed in. I had not taken any managerial
12 responsibility for that and I could see it coming and
13 that is why I was anxious and I took a course before
14 taking over this Associate Clinical Director's
15 responsibility and the course in a way went on the same
16 line, that it is much more discussion, which I had
17 believed in the same way and I was following that and in
18 the first year I had no problems as far as the meetings
19 and those things were concerned.
20 But I also felt that my predecessor was doing too
21 much on his own. So I in a way, you could say allotted
22 part of my job to different people. Like audit --
23 John Hutter was continuing, I had left it with
24 John Hutter and when Mr Bryan took over I thought "He is
25 the youngest man and probably knows more about this
0020
1 information technology thing, computers", I asked him to
2 take over, so he was in charge for audit.
3 Similarly I made somebody else responsible for
4 infection and this type -- so I had delegated a lot of
5 my responsibility to other people as I thought was the
6 proper, relevant structure and it carried on very well
7 for the first year and I did not have much problem until
8 -- which I now realise -- the politics started
9 appearing and there was probably some type of struggle
10 for some type of power which I did not realise. I was
11 never power hungry, I never asked for any and I thought
12 I was a reluctant entrant to this management structure
13 and I was more interested in the clinical management of
14 patients really. I did not give them that much time in
15 management as some other doctors were doing.
16 In a way you could say there was a little failing
17 on my part as a manager, but then I did not claim to be
18 a manager and when I found I could not really get on
19 with these people with so many arguments and discussions
20 in the later part, that I said "No, I am stepping down".
21 Q. If you were interested in the clinical side and not in
22 management, if you felt unsure as you indicated about
23 your skills in management so that you had to look for
24 some training, if as it happens you had no guidance from
25 anyone else as to how to do the job, if you were
0021
1 reluctant to take that on and if you found dealing with
2 other people, particularly given the "politics", as you
3 call it, at least in 1994 and therefore always might
4 have had that problem, why did you take the post in the
5 first place?
6 A. In the first place there was no politics. I thought we
7 had a very happy unit really, everybody was talking to
8 each other in 1993.
9 Also at that time Mr Keen had retired, Mr Wisheart
10 was now going to be either HMC Chairman or Medical
11 Director, I am not sure at that time, and Mr Hutter was
12 a comparatively new person and Professor Angelini was
13 just appointed. So we did not have anybody else to be
14 the Associate Clinical Director so somehow you could say
15 it was thrust on me and I felt I could tackle it if
16 everybody cooperated with me, and that is how I took
17 over in the beginning.
18 Q. If I come back to the way we started this, part of the
19 management role perhaps to look at figures. You say you
20 approached it by looking at the figures for individual
21 operations. One of the matters we have noticed -- you
22 say there are documents in your handwriting, you
23 produced figures for the particular year. We do not
24 have, apart from what I have shown you on the screen,
25 any typed copies of results after 1992 to 1993; were any
0022
1 typed results produced and circulated?
2 A. Sir, I have said yesterday and I am saying it again, it
3 was being produced, yes.
4 Q. As part of your role as manager you might have been
5 expected, or as director you might have been expected,
6 were you, to call a meeting to deal with particular
7 issues; was that part of your job or not?
8 A. I thought that was the Audit Coordinator, he was doing
9 it, that was the Audit Coordinator's job.
10 Q. You had no role in asking for a meeting and saying "This
11 is a matter of concern, let us discuss it"?
12 A. If the Audit Coordinator had asked me "Let us do that"
13 then, yes, I would call it.
14 Q. We dealt yesterday with some of the concerns that
15 came to your notice when Dr Monk spoke to you about the
16 switch operation in early July 1994. You had not heard
17 any of the other matters which we have had some evidence
18 of and which you know of from your involvement in the
19 GMC and having read the transcript here.
20 Kay Armstrong has told the Inquiry that she had
21 concerns and worries which she did not express to you;
22 did you have any inkling of that?
23 A. I think she has already told you; I cannot really guess
24 what is in somebody else's mind really.
25 Q. We are told that eventually there were only two nurses,
0023
1 Onyx Brewin and Alison Reed, who were prepared to scrub
2 for a switch operation; did you know that?
3 A. I was very pleased for that because in a way it would
4 be better, in the same way as a surgeon we have
5 concentrated on one person, as anaesthetists they are
6 considering two persons, so it would be better if the
7 expertise is limited to two people really so they would
8 know what I was needing at a particular time, I was very
9 pleased with that.
10 Q. Did you know anything of the contact there had been
11 with Dr Doyle of the Department of Health through
12 Professor Angelini or Dr Bolsin until November 1994?
13 A. No, I did not.
14 Q. In October 1994 you went to a meeting outside Bristol
15 and you tell us in your statement that is where you
16 heard for the first time of the degree of concern that
17 there was being expressed within Bristol about
18 paediatric cardiac surgery?
19 A. This was a congenital heart disease course at Great
20 Ormond Street Hospital, London, which I and Mr Wisheart
21 were due to take turns to attend and in 1994 it was my
22 turn so I went there, yes.
23 Q. How did you find out?
24 A. My colleague -- because after all paediatric cardiac
25 surgeons in the country know each other, they used to
0024
1 come and, in a way when they are talking they are also
2 saying "I gather you are having a problem with arterial
3 switches".
4 Q. Which you had had problems with?
5 A. That is correct.
6 Q. So there is nothing surprising in that, was there?
7 A. No, it was not surprising.
8 Q. Was anything else said which was surprising to you?
9 A. The way it was said, you know, I mean when I said "Tell
10 me if you did not have any, or somebody else". Then
11 this followed on "You know why we are saying because you
12 know your anaesthetists and your Professor has been
13 talking about bad results in paediatric cardiac surgery
14 in Bristol. So in a way it started from arterial switch
15 directly to me and when I asked for more or asked for
16 a further explanation, it ended up bad results in
17 paediatric cardiac surgery at Bristol and that is being
18 communicated to these people by the anaesthetists and
19 the Professor.
20 Q. And your reaction to that?
21 A. I asked the Professor -- of course we have only one --
22 about the anaesthetists, I said "who is the
23 anaesthetist?", "well, our anaesthetists told us". Then
24 we had an evening -- they had a reception in the evening
25 and when it was a bit more informal, people had a drink
0025
1 and so there a name appeared.
2 Q. Did you get a name?
3 A. Yes, I did.
4 Q. Was the name Dr Bolsin?
5 A. It is.
6 Q. You came back in October to Bristol, feeling what?
7 A. I felt if there was such unhappiness that my Professor,
8 especially when for 6 months before that I was very
9 closely working with Professor Angelini for this
10 appointment of paediatric cardiac surgeon, between May
11 and September when we appointed this person, and we were
12 working together because both of us were focused on
13 a single person in a way.
14 I was quite surprised that we were meeting, we
15 were talking in his office, my office, in the department
16 and he never mentioned those things to me. Dr Bolsin
17 working together and even we had cases at a private
18 hospital and things and I have been to his house, he has
19 been to my house, he never mentioned those things to
20 me.
21 So I came back and I said "I am going to ask them
22 directly", and that is what I did.
23 Q. Was that at a meeting?
24 A. This was -- I think I was in London GOS in October and
25 next our monthly audit meeting, because I thought -- as
0026
1 I said before, I like to talk in the open, going and
2 talking to a person and again we do not know what he
3 said, what I said, it would be better if I talked in the
4 group really in front of my other colleagues so that we
5 really know what we are talking about and our next
6 monthly audit meeting was in November and when the audit
7 meeting finished then people started going and I said
8 "could I please consult my colleagues, could we just
9 sit for a while and I need to talk to you".
10 Q. Was the meeting a friendly and pleasant one?
11 A. It started friendly.
12 Q. Did it break out into an argument?
13 A. It became -- I think somebody had described
14 "acrimonious", at that time I did not understand what
15 acrimonious meant but it probably explains it. It was
16 not more an argument in the end, it became almost
17 a one-sided, a Latin burst.
18 Q. Not being the Latin, were you for your part angry and
19 cross?
20 A. I was angry but I am not very good with my words so
21 I became dumb when I heard somebody really saying "kiss
22 my feet".
23 Q. Why was it that Professor Angelini -- that is the man
24 you have in mind, is it not?
25 A. Yes.
0027
1 Q. How was it in the conversation that occurred that
2 Professor Angelini, you remember, was saying "kiss my
3 feet"?
4 A. After that I became totally dumb because I thought "if
5 I respond now I am angry I may say something and I will
6 regret it". Obviously he himself felt a bit bad having
7 uttered those words so he was trying to explain and it
8 became, as I mentioned, one-sided. He really said
9 "well, I tried to save your bacon, the Department of
10 Health was going to close the unit and I really fought
11 your corner, I really told them your results are very
12 good, we do not need to stop the unit, it is just we
13 really need to look at a few things." But I am sorry at
14 that time I was in no mood to reciprocate or communicate
15 any further and I just kept listening, but some of this
16 has gone out of my head also, so what I remember is what
17 I have told you.
18 Q. The point he was making was, was it, that there had been
19 concern expressed to the Department of Health about the
20 results in paediatric cardiac surgery and that he, in
21 letters to Dr Doyle, had suggested that the unit was
22 solving the problems by appointing a new cardiac surgeon
23 so that the work would go on taking place; is that more
24 or less what he was saying?
25 A. At that time I did not understand that that is what he
0028
1 was saying, but when I read further information on that
2 I think it became more clear. I do not think it was
3 that clearly mentioned at that time.
4 What upset me, all right, I mean we were meeting
5 almost every other day or every week in the unit, we
6 were working on a common purpose, to get a paediatric
7 cardiac surgeon and he never mentioned that there was
8 this talk with Dr Doyle or the Department of Health
9 because now we are working -- this is the time I was
10 feeling so happy that almost my dream was being
11 completed, we were moving to a site where paediatric
12 cardiac surgery would be carried out, we were getting
13 a dedicated paediatric cardiac surgeon for which we were
14 working since 1990.
15 So I was very pleased and I was very pleased that
16 he was with me on this one to get the man from the Royal
17 Melbourne Children's Hospital. Then I hear that on the
18 same line he talked to Dr Doyle and there was a concern
19 of closing the unit. He talked to other people, why
20 could not he really just tell me at the same time?
21 Q. When you were told it might be said by him you got
22 cross?
23 A. If you are told by somebody "kiss my feet", would you
24 take any further part in the conversation?
25 THE CHAIRMAN: Mr Dhasmana, what did you understand was
0029
1 meant by that?
2 A. I think the way it was said was quite bad really.
3 THE CHAIRMAN: It is just I wondered what you thought was
4 meant by that?
5 A. Very humiliating.
6 MR LANGSTAFF: After that meeting did you ever enjoy
7 friendly relations with Professor Angelini again?
8 A. I would say I had a working relationship, we were
9 working together.
10 Q. Is the answer "no"?
11 A. No.
12 Q. Did you ever see the letter at about this time which had
13 been written to the Department of Health about
14 paediatric cardiac surgical results?
15 A. No.
16 Q. Did you ask what had been said to the Department of
17 Health?
18 A. Not to him, but I asked Mr Wisheart later.
19 Q. Did you think that it related to the switch operation?
20 A. No, not in that letter.
21 Q. You thought it was more general than the switch?
22 A. Yes.
23 Q. If you thought that concerns had been expressed to the
24 Department of Health and it was not simply a question of
25 the switch operation, would it not do you think have
0030
1 been an appropriate step to say (if you did not) to
2 Mr Wisheart or Dr Roylance or to the unit as a whole:
3 "these results are being queried, we need to have
4 a full and proper comprehensive review of the results"?
5 A. I did talk to Mr Wisheart and Mr Wisheart then told me
6 that he is in the process of doing it and he has now had
7 a meeting with a few other people and he did mention the
8 name of Professor Farndon at this time and he said he is
9 going to arrange a meeting between ourselves and the
10 anaesthetists and it is going to be either in the coming
11 December -- because now we are talking of almost the end
12 of November so it would be either just before Christmas
13 or after Christmas.
14 Q. A meeting did take place at Dr Joffe's house on
15 8th December, did not it?
16 A. That was a different -- the purpose was different and
17 I called for that meeting.
18 Q. That was just to do with the switch?
19 A. Yes. Can I go to the background for that?
20 I had a patient on my list -- which I am sure you
21 are going to discuss some time today, Joshua Loveday --
22 who was referred to me in May or June that year, 1994,
23 and was on my waiting list and so-called priority
24 waiting list when I had promised this patient an
25 operation between 4 to 6 months time.
0031
1 Q. Let me interrupt you and pick up the Joshua Loveday
2 case, if we may. You have I think the medical records
3 there?
4 A. Yes, sir, I have.
5 Q. You have looked at them. Can I take this fairly
6 quickly, we will come to the points we may want to
7 discuss in greater detail? Joshua was born on 22nd June
8 1993. You may not recollect the exact day, but that is
9 his date of birth.
10 He was suffering, was he, from a double outlet
11 right ventricle with a subpulmonary VSD?
12 A. Yes.
13 Q. Which is sometimes known as the Taussig-Bing --
14 A. Taussig-Bing anomaly.
15 Q. There was an early operation which you performed in
16 order to repair a coarctation?
17 A. It was quite serious. Yes, interrupted aortic arch. So
18 I repaired the interrupted aortic arch and banded the
19 pulmonary artery when he was hardly a few days old.
20 Q. That was in 1993 shortly after he was born?
21 A. Yes, sir.
22 Q. He was kept under review in 1993 and was seen in
23 a clinic in Gloucester by Dr Martin?
24 A. Yes.
25 Q. On 22nd May 1994, so very nearly 11 months old, he came
0032
1 into the Children's Hospital for a cardiac
2 catheterisation?
3 A. That is correct.
4 Q. That showed -- do you want to pick this up in the notes
5 -- there was no evidence of the coarctation?
6 A. What it means, repaired.
7 Q. That the aortic oxygen saturation was 61 per cent which
8 is low, is it not?
9 A. Very low, sir.
10 Q. So he would be mildly to moderately cyanosed, would he?
11 A. He would be moderately cyanosed.
12 Q. One of the problems I think with this particular
13 condition that Joshua was suffering from is the aorta
14 and the pulmonary artery which were lying side by side?
15 A. You usually see -- in Taussig-Bing anomaly there is
16 a rotation of the aorta from its place but it is not
17 completely rotated. So though it is anteriorly
18 malposed, it is not exactly anterior and you do see it
19 from time to time, unless Dr Silove has something to
20 say.
21 DR SILOVE: I agree with that. The aorta is generally
22 slightly -- in this case was generally slightly anterior
23 whereas in transposition you usually find the aorta well
24 anterior and we in general terms refer to the problem
25 that Joshua had as side by side great arteries with the
0033
1 aorta perhaps very slightly anterior to the pulmonary
2 artery.
3 MR LANGSTAFF: So an operation on such a condition to
4 correct the Taussig-Bing syndrome is made more
5 complicated, is it, by the side to side anatomy?
6 DR SILOVE: The surgeons tell me it is. I am not a surgeon
7 as you know, but they are very concerned when there is
8 side to side anatomy of the great arteries and I believe
9 the main reasons for that (and perhaps Mr Dhasmana can
10 correct me if I am wrong) the main reasons are that
11 firstly there is a greater distance that one needs to
12 use to transfer the coronary arteries. So the coronary
13 artery transfer is probably slightly more difficult and
14 the other problem is that there can be difficulty in
15 performing the usual so-called Lecompte manoeuvre which
16 is used when the great arteries are truly
17 anteroposterior in which the pulmonary artery is
18 actually moved forward from where it lay originally on
19 to the right ventricular outflow tract. I believe there
20 is difficulty in doing that in side by side great
21 arteries, but Mr Dhasmana I am sure has some experience
22 of this.
23 MR LANGSTAFF: Is that basically right?
24 MR DHASMANA: Yes.
25 Q. It is an operation which is more complex, more difficult
0034
1 than (if there is one) a straightforward transposition
2 with VSD?
3 A. Yes, but I had fortunately a very good result in this
4 series, double outlet right ventricle, if you remember
5 from yesterday's presentation on that May/June meeting
6 1992, that by that time I had operated on 3 or 4 double
7 outlet right ventricle with that type of artery and they
8 all survived.
9 Until this time, until Joshua Loveday, I had
10 operated on six such patients and there was only one
11 death so I had quite good results really in particular
12 on this type of condition, which I am not claiming
13 a great thing, but I was pleased with it.
14 DR SILOVE: Could I add that there was the additional
15 problem in Joshua of having some narrowing of the right
16 ventricular outflow tract leading to the aorta. This
17 was particularly well seen on the echocardiogram that
18 I saw. I have not actually seen the angiocardiograms
19 but I was quite convinced on the echo that I saw that
20 there was quite definite subaortic narrowing.
21 MR DHASMANA: Yes, the first case I did, double outlet right
22 ventricle -- and at that time the Bristol unit was being
23 visited by Dr Sommerville, and this was my first case
24 really -- I had to open almost both outflow tracts
25 really to remove the obstruction and she told me that
0035
1 most often they see it on both sides, it is not just one
2 side, you can see it on both sides also.
3 So it is a known problem made worse you could
4 really say by adding banding.
5 MR LANGSTAFF: Could we have a look at UBHT 217/135 because
6 you have raised your own history in this operation?
7 THE CHAIRMAN: I am looking at it for a moment,
8 Mr Langstaff.
9 MR LANGSTAFF: It has been redacted. We see that certainly
10 at the start with the non-neonatal switches you operated
11 on what we see as the Taussig-Bing, it is the "DORV with
12 subpulmonary VSD", is it not?
13 A. That is correct.
14 Q. On that page we have four such cases?
15 A. That is right, and they survived.
16 Q. Let us go overleaf. Before we get down to the bottom of
17 this page, the last was in 1991. Go overleaf again.
18 After Joshua Loveday had already been put on your
19 operating list, the most recent operation before you
20 came to operate on him in which you had had
21 a Taussig-Bing syndrome had been a child who died?
22 A. Yes, this patient had a problem with a coronary artery
23 abnormality. It was also a very peculiar situation,
24 that they were both coming out from the same sinus in
25 the back. So when you are transferring that it goes
0036
1 almost on the front of what is now the new aorta. So
2 the pulmonary artery was compressing on it and that was
3 the problem here.
4 Q. Before Joshua Loveday you had not operated successfully
5 on a Taussig-Bing syndrome since 1991, you had done one
6 operation and sadly that child (for the reasons you have
7 given) did not survive?
8 A. I am afraid in paediatric cardiac surgery there are
9 conditions which you do not see almost every day, but
10 that does not really mean that you should not be
11 operating the next time when you see it. Even in big
12 centres I do not think double outlet right ventricle is
13 seen that often, I do not know what Dr Silove would say.
14 DR SILOVE: Yes, I will confirm that the Taussig-Bing
15 arrangement is really a fairly rare form of
16 transposition with VSD; you do not see many of those
17 cases.
18 MR LANGSTAFF: It is frequently the case in such a syndrome
19 that one suspects that the coronary artery pattern may
20 be abnormal, is it not?
21 MR DHASMANA: That is for all these malposition cases where
22 there is part of double outlet right ventricle or
23 transposition of the great arteries because coronary
24 artery, the sinus has to move as the aortic lie is
25 moving. So the coronary sinus which would be normally
0037
1 like this becomes like this (indicating) and it depends
2 on what is the rotation is the part of the coronary
3 abnormality.
4 Q. You presented what I think we have here in typescript in
5 handwriting, did you, to the meeting on 8th December at
6 Dr Joffe's house?
7 A. Yes, sir.
8 Q. Without I think Mr Wisheart's additional operations,
9 that has been added on this typescript since I think.
10 Who was at the meeting?
11 A. Sorry, which meeting?
12 Q. Dr Joffe's house.
13 A. I had called every anaesthetist who was working in the
14 paediatric cardiac surgery, so that included Dr Bolsin
15 and he was the only one who did not turn up.
16 Q. You had at that stage voluntarily agreed with the
17 anaesthetist, you told us yesterday, not to do any more
18 switch operations unless they agreed?
19 A. That is why I said if I could give the background to
20 that meeting, please.
21 Q. Please.
22 A. You know the way time flies, it is all right when we are
23 looking back but between June and December it is quite
24 a big time, but here in a busy unit, July when Dr Monk
25 told me that that is what the anaesthetists have decided
0038
1 that in a way if you are really arranging any more
2 switch operations, you must discuss with us.
3 I gave him a list. He did not come back to me and
4 at that time he also does not tell me that they had
5 really signed a letter, as you were showing yesterday.
6 We were going through the appointment of a new
7 paediatric surgeon, moving cardiac surgery to the
8 Children's Hospital so obviously I am too busy with
9 other things and somehow this just slipped out of my
10 mind to follow this patient's operation until Dr Martin
11 saw this patient in his clinic in November, I think it
12 could be either 21st or 22nd November at Gloucester.
13 He then sent me a note or talked to me on the
14 telephone saying "Janardan, what are you doing about
15 this patient, you promised an operation in 4 to 6
16 months, and he has not been called?" Then I told him,
17 you could say I had remembered what had happened. He
18 said "well, then call a meeting".
19 Q. Pausing there, the best thing for this child would
20 probably to have been operated on soon after the
21 catheter in May 1994?
22 A. That is correct, sir.
23 THE CHAIRMAN: Would you forgive me if I interrupt, it is
24 quite important. You put it to Mr Dhasmana that "you
25 had at that stage voluntarily agreed with the
0039
1 anaesthetists, you told us yesterday, not to do any more
2 switch operations".
3 MR LANGSTAFF: Without their consent.
4 THE CHAIRMAN: I think it needs to be added that as regards
5 the neonatal switches he had agreed, as I understand it,
6 and had also agreed not to do any without further
7 discussion; is that not the case?
8 MR LANGSTAFF: Yes.
9 THE CHAIRMAN: Just to make that clear on that question,
10 perhaps.
11 MR LANGSTAFF: I am sorry, that I had thought was
12 comprehended by the question. Obviously it was not,
13 I am grateful.
14 THE CHAIRMAN: It may well be my not reading it or listening
15 too attentively but it is clear now.
16 MR LANGSTAFF: It is absolutely important to get it right.
17 I am sorry, Mr Dhasmana?
18 A. That is quite correct, the neonatal switch was stopped
19 and for older switches I agreed with them that if
20 I arranged any I would talk to them.
21 Q. You were going to go on to tell us that Dr Martin had
22 seen Joshua in his clinic in November in Gloucester and
23 written you a letter?
24 A. I am not exactly certain whether he wrote me a letter or
25 sent me a memo or telephoned to say: "Janardan, what is
0040
1 happening with this patient, you have promised an
2 operation in 4 to 6 months and it is more than 6 months,
3 I saw him, he is getting quite blue?"
4 Then I told him about my conversation with Dr Monk
5 and what I have agreed with him. He said "what has
6 happened since?", then it came to me "I have not really
7 followed that and Dr Monk has not really come back to
8 me". He said "why do you not arrange a meeting" and
9 I looked in my diary, the next paediatric cardiac club
10 was going to meet at Dr Joffe's place in December.
11 He said "arrange for everybody to come there and
12 then we will talk about arterial switches in older
13 children and what we are going to do." I said "all
14 right."
15 So I talked to Dr Joffe, he was quite agreeable
16 and I took it on myself really to call everybody
17 concerned with the paediatric cardiac surgery and I made
18 personal telephone calls and communicated to everybody
19 that I would be grateful if they attended this meeting,
20 all of them.
21 Dr Bolsin, when I talked to him he looked in his
22 diary, he said "sorry, I am busy at that time somewhere
23 else but I will see what I can do". In the end he did
24 not turn up. All the other anaesthetists were there:
25 Dr Masey was there, Dr Underwood was there.
0041
1 Q. So the meeting then took place. What discussion was
2 there about the Joshua Loveday operation? Was it about
3 the operation or was it about the switch programme
4 itself?
5 A. It was about the older switch programme. It is just
6 I intimated to them that: "I have got a patient on my
7 list to be operated on".
8 Q. So no specific conversation about that particular
9 patient, just about the switch programme?
10 A. Yes.
11 Q. Were there any figures discussed at that meeting?
12 A. I took my hand notes because I was not going to that
13 meeting without any information with me. So in my hand
14 I had written down all the switches which I had done
15 right from number 1 in 1988 -- I am talking of all older
16 switches -- until the last one.
17 Q. That is what we see copied out in typewriting at least
18 at the top of the document we have here. This is
19 a typed version of that handwritten document, is it not?
20 A. After the 24 all these have been added later really.
21 Q. Yes, but 24 and above is a typed version of your
22 handwritten document?
23 A. That is correct, sir.
24 Q. That was the material before the meeting?
25 A. That is right.
0042
1 Q. I think I can probably pick up the substance of the
2 discussion when I come to deal with the presurgical
3 meeting in respect of Joshua Loveday. I am conscious,
4 sir, of the time, it is now just before 11.00; may we
5 have a short break?
6 THE CHAIRMAN: Let us break until 11.10. Thank you,
7 Mr Langstaff.
8 (11.00 am)
9 (A short break)
10 (11.10 am)
11 MR LANGSTAFF: Mr Dhasmana, if you had had any idea before
12 the 11th January 1995 that Mr Wisheart and Dr Roylance
13 might have been considering a review of the paediatric
14 cardiac surgical results, would you have gone ahead with
15 the operation?
16 A. No, sir. Also, if I could add, if I had known about the
17 letter signed by the anaesthetists, even on that day
18 when they met in Dr Joffe's place, if they would have
19 mentioned that there was a letter, I would have been the
20 first one to say, "Why do you not establish the review
21 first, who is going to do that, and then we really
22 proceed with the operation?" But I did not know about
23 it.
24 Q. If the child then needed an operation in the meantime,
25 pending the review --
0043
1 A. Well, it is the cardiologists, I would have referred
2 back to Dr Martin, "Please do what you feel necessary
3 now".
4 Q. And the result might very well have been that the child
5 would have been referred to Birmingham or wherever?
6 A. That is his decision.
7 Q. So before the meeting of 11th January, did Dr Monk
8 speak to you about his view that he thought at that
9 time, before the meeting, that it was not advisable to
10 do the operation?
11 A. I was quite surprised to see that in the transcripts.
12 No, sir.
13 Q. He told us he spoke to you and he thought you had agreed
14 with him -- that was the impression he said he got --
15 that you would not probably go ahead with the operation?
16 A. If I would have agreed, I would not have proceeded with
17 the operation.
18 Q. Did anyone else speak to you before the meeting on
19 11th January 1995?
20 A. Once Mr Wisheart told me, I think probably it was either
21 the Monday or the Tuesday, that there is a meeting
22 arranged for the Wednesday, there is now common
23 knowledge in the unit, so of course when I am going up
24 and down, looking after other patients or operating --
25 because on Tuesday I operated on two patients in the
0044
1 usual manner -- people would have definitely asked me
2 and talked to me and asked me, yes.
3 Q. Do you recollect whether they were expressing views as
4 to whether the operation should or should not go ahead?
5 A. I did not see it that way. I thought, while I gather
6 there is a meeting, what is it? So I thought that was
7 more like an inquiry rather than expressing their
8 concern or wish this way or that way.
9 Q. Just pausing there, before the meeting starts, had you
10 ever, in your experience as a surgeon, had the director
11 of anaesthesia or the director of any other part of the
12 teams that helped towards cardiac surgery come to you
13 and say, "Janardan, we are unhappy about you doing this
14 operation or that operation without talking to us
15 further", except in the case of the switch?
16 A. No.
17 Q. The techniques involved in the arterial switch in
18 non-neonates are to an extent similar to the techniques
19 involved in neonates, are they not?
20 A. Here, a little difficult pathology, but the technique of
21 coronary transfer is the same, not the rest.
22 Q. And it was the same of coronary transfer, that you are
23 concerned you might not have got right in the neonates?
24 A. Yes.
25 Q. Had there ever been, in your past, a series of
0045
1 operations which you discontinued because you were
2 unhappy at your ability to do it right -- apart from the
3 switch?
4 A. I did not discontinue it. I changed certain steps in
5 the operation, like, you know --
6 Q. I am talking about the neonatal switch operation here;
7 you discontinued that?
8 A. Yes.
9 Q. And the techniques are not very different, at least when
10 you come to coronary artery transfer, to the techniques
11 in the non-neonatal switch?
12 A. That is correct.
13 Q. Had you ever discontinued any particular series of
14 operations because of your concern about your own
15 ability to do it successfully before?
16 A. I did not have any concern in the rest of the other
17 groups of patients, no.
18 Q. When you looked back, even in 1995, early 1995, on
19 the neonatal switch, the operation you discontinued, did
20 you say to yourself, "Well, I wish perhaps I had stopped
21 it earlier"?
22 A. The retrospectoscope is such a good thing. I wish, even
23 now, the number of times when I look back, I sometimes
24 doubt my sanity, I really do, why did I go on doing it,
25 why did I follow it? I wish I did not had, but at the
0046
1 same time I wish I had a crystal ball, if I know that
2 this patient I am going to operate tomorrow is not going
3 to make it, I would be the first one to say, "No, I am
4 not doing it". But at that time you are thinking that
5 you are really going to use your ability to improve this
6 patient. That is how I really took it.
7 Q. The retrospectoscope you are applying from today. What
8 I would like to know is whether, in the beginning of
9 1995, you had a similar view of "Well, because
10 I eventually gave up the neonatal switch because I felt
11 I could not do it, I rather wish that I had stopped
12 earlier"? Did you have that view then?
13 A. I thought I did stop on two occasions earlier, but
14 somehow I really started again. I stopped after the
15 first operation; then the visit to Birmingham spurred me
16 back on. I stopped after the next about when two
17 patients died, and then took patients back to Birmingham
18 again, having talked to Mr Brawn and seen what it is,
19 and then successfully operated on an older patient with
20 a very complex problem, got my confidence back again,
21 but I think I have always questioned myself, looking
22 back. I wish I could have done that.
23 Q. While we are on this point, you have always been
24 someone who, as I understand some of the evidence we
25 have heard, was deeply upset by the death of any child.
0047
1 A. Any patient, yes.
2 Q. And expressed that openly to parents from time to time,
3 where there had been the death of a child?
4 A. I would express openly. I have written in my letter to
5 GPs, I always started "With the deepest regret I am
6 sending you the summary..."
7 Q. Because whether it was or it was not your fault, you
8 were sorry, but it had happened?
9 A. It was as a human being, and being certain....
10 Q. I am sorry, let me move on. Do you want to take
11 a moment?
12 THE CHAIRMAN: If ever you need to take a break,
13 Mr Dhasmana, you just tell me.
14 MR DHASMANA: I am sorry, I am all right.
15 MR LANGSTAFF: This line of questioning -- I am sorry
16 it has been distressing to you -- came about because
17 I was asking you what was in your mind at the start of
18 the Loveday meeting.
19 Had you ever had a series of results questioned by
20 your colleagues as, for instance, the results have been
21 questioned on 8th December at Dr Joffe's house?
22 A. I think Dr Joffe's house was a little different, because
23 here I called the meeting so I was expecting myself to
24 be questioned, so I was in a way prepared. I did not
25 feel that there was any hostility when they were asking
0048
1 any questions.
2 Q. All right, but the meeting that was held the night
3 before the Joshua Loveday operation was, was it,
4 unusual?
5 A. It surprised me, because I thought that is what I did
6 with the meeting at Dr Joffe's house, and in my mind,
7 I have already explained the reason and why I am
8 proceeding, but Mr Wisheart called the meeting and he
9 said that "I am afraid you have to really repeat
10 yourself again to this meeting", so I said "Fine, then
11 I will do that".
12 Q. Again, as part of the background to the meeting, you
13 knew that Professor Angelini had been saying things
14 about the surgical results which you thought at the time
15 related to all the surgical results, but involved the
16 switch.
17 A. That is correct, sir.
18 Q. So who was it who chaired the meeting?
19 A. Mr Wisheart.
20 Q. Why did he chair the meeting when you were the Associate
21 Director of Cardiac Surgery?
22 A. I am sorry, we are talking of --
23 Q. The pre-operation meeting on Joshua Loveday.
24 A. Because I thought as the Medical Director he called the
25 meeting, and I think he did tell me that the meeting was
0049
1 called because of Professor Angelini and Dr Bolsin's
2 approach either to him or Dr Roylance, I could not be
3 very clear at this time, but I thought, you know, it
4 came from high up in the management, so it was quite
5 acceptable for a Medical Director to chair.
6 Q. At the meeting -- let us look at a note of the meeting.
7 We have it at UBHT 54/11. You see the people there, and
8 then the process is this, is it: that first of all the
9 meeting decides whether or not there should be
10 a continuing switch programme in a particular age group,
11 and then decides whether or not the operation on Joshua
12 Loveday should go ahead. Was that the pattern that it
13 took?
14 A. I think that is correct, yes.
15 Q. Can we then look at the figures that were presented,
16 UBHT 126/51? What you are looking at here is a revised
17 version because there was initially a difficulty with
18 the figures which related to Mr Wisheart, if you
19 recall. This data was produced by Dr Pryn, was it?
20 A. Can I see the bottom, please?
21 Q. Yes, certainly.
22 A. Yes, it is. That is what really impressed me: that
23 Dr Pryn had included the figures from the UK Cardiac
24 Register.
25 Q. If we were to take the overall picture -- can we
0050
1 scroll up a little bit -- looking at your patients only,
2 because you were the surgeon who was going to do the
3 operation, if one took an overall view from 1988 to
4 1994, 46 per cent mortality, if that was a true
5 reflection of the operation you were going to do the
6 next day, you would not do it, I take it?
7 A. If that were the true reflection of the age group we
8 were talking about, and if that is what -- I mean, here
9 I take myself as somebody who is really facing, you
10 could say, the jury, and they were going to decide and
11 tell me whether I should do it or not.
12 Q. So you had a choice as a surgeon whether to do it or
13 not, did you not?
14 A. But that choice was already made once I put the patient
15 on the list, really, so as far as I am concerned, the
16 patient was on the list after I talked to the
17 anaesthetists in December, and they agreed for me to
18 proceed with my older switches.
19 Q. Suppose you had learned of some strange complication
20 affecting the patient because, let us suppose, further
21 cardiological investigation had shown it, and suppose
22 you recognised an anomaly which you know that someone
23 somewhere else has treated successfully, you have not
24 come across, you have no particular experience,
25 something new has cropped up since he has gone on your
0051
1 list. Would you still go on and operate just because he
2 is on your list?
3 A. No, no. I would expect the cardiologist to tell me if
4 there was any change, yes.
5 Q. So once it is on your list, did you leave the decision
6 as to whether to go ahead or not to the cardiologist?
7 A. All paediatric cardiac surgical patients, when they are
8 put on the list, they are usually followed by the
9 cardiologist, they are not really discharged from the
10 clinic. They still attend the cardiologist from time to
11 time until the operation is carried out, just for that
12 reason.
13 Q. I am not sure that has actually answered the question
14 I was asking. I am looking at your role in this.
15 Plainly the cardiologist may still want you to do the
16 operation. Do you have, do you think, continuing
17 responsibility once somebody is on your list, if
18 circumstances change or your view of the circumstances
19 changes, to say "No, I will not"?
20 A. That is correct, yes, I will do that.
21 Q. So it is not just a question of somebody being on your
22 list and therefore you are performing the operation?
23 A. That is correct.
24 Q. So far as the switch programme as a whole is concerned,
25 if we look at the figures that we have on the screen,
0052
1 the relevant line is the non-neonates, is it?
2 A. That is right.
3 Q. If we took that line again, the total from 1988 to
4 1994, the figure there would be 33 per cent?
5 A. That is correct, sir.
6 Q. The figures which the meeting considered as not being
7 very different from the UK experience were, were they,
8 influenced by the bottom line that we see there, the
9 over a year, 1990 to 1994, 1 death out of 8, 13 per
10 cent?
11 A. That is correct, sir.
12 Q. That involves, does it not, breaking down the overall
13 figure first of all into neonates and non-neonates,
14 secondly looking at non-neonates, breaking that down
15 into two smaller groups, over and under 1 year, and then
16 breaking that down further into 1990 to 1994, and
17 excluding the two earlier years?
18 A. If you read a lot of papers on the subject, that is how
19 they are usually presented. I thought Dr Pryn -- that
20 is what impressed me, that he had put it in a very
21 scientific manner.
22 Q. If you had taken the cases of Taussig-Bing and broken
23 it down yet further, that you had performed between 1990
24 and 1994, the figure would have been higher than 13 per
25 cent, would it not?
0053
1 A. No. Taussig-Bing, I mean, I would have 1 out of 6, but
2 for Taussig-Bing, then you compare the pathology and the
3 mortality is 25 to 30 per cent, so my figure at that
4 time was better.
5 Q. The comparison we get at 13 per cent between 1994 and
6 that line there, if we look down to the UK Cardiac
7 Surgical Register data at the bottom, the line we have
8 to focus on is in TGA plus VSD, the bottom line across
9 there?
10 A. That is correct, sir.
11 Q. Where it appears that the overall mortality rate has
12 been dropping?
13 A. Yes.
14 Q. The last available data recorded there was 1992. Might
15 one have expected that it would have dropped further
16 during the 1990s?
17 A. Well, in the same way, if you look at my figure, you
18 cannot compare one year from his to one year from mine.
19 If you look in 1994, I may have operated on 3 or 4 with
20 no deaths, so I had zero mortality. My one death out of
21 8 or 9, whatever cases were there under the series was
22 in 1991. There have been no deaths since -- I am sorry,
23 another death -- no, that was a smaller child.
24 Q. Did you tell the meeting that the last operation which
25 you had conducted upon a Taussig-Bing syndrome, the
0054
1 child had been lost?
2 A. Yes, I did.
3 Q. So the meeting concludes, as we have heard -- we have
4 been through this with others, so I will take it fairly
5 quickly. The meeting concludes, as we have heard, that
6 there is no reason, from those figures, analysed in that
7 way, breaking it down in that way, not to go ahead and
8 do the operation.
9 That does not, however, does it, answer the
10 question whether one should go ahead and do the
11 operation?
12 A. Well, I thought that was a clinical meeting. If the
13 decision was made on the basis of clinical grounds or on
14 the surgeon's previous result, then that decision is
15 acceptable to me. That means he should go ahead.
16 Q. I do not know that you necessarily followed the question
17 which I was asking. Looking at the figures on their
18 own, leaving aside for the moment the question of this
19 particular child and clinical judgments that may have to
20 be made, but the meeting as I understand it came to the
21 conclusion that there was no reason from the figures
22 analysed in this way not to go ahead with the
23 operation. There was no negative. That still left the
24 decision whether you should go ahead.
25 A. Well, then I thought the meeting's decision was that it
0055
1 should go ahead.
2 Q. And that is the second part of the meeting?
3 A. Yes -- I am sorry, the second part? I do not understand
4 the "second" part.
5 Q. The meeting went in two stages: looked at the statistics
6 first and then decided what to do, whether the operation
7 should go ahead or not?
8 A. All right, thank you.
9 Q. Whose decision was it that the operation should go
10 ahead? The meeting's, or was it your decision together
11 with Dr Martin?
12 A. No, this was initially the meeting's, but there was just
13 one exception at that time.
14 Q. What clinical basis would an anaesthetist have for
15 saying this operation should or should not go ahead?
16 A. No, you are talking on a political basis, and which he
17 mentioned.
18 Q. So the political objection was made by Dr Bolsin, was
19 it?
20 A. That is correct.
21 Q. Did you understand from what he said that the Department
22 of Health had been contacted about the operation?
23 A. Well, you know, I would have asked, but my other
24 colleagues asked him that question and what does he mean
25 by "political consequences", or political -- I am not
0056
1 sure what exact words were used, but "politics" itself
2 was used, and then he really came in by saying that as
3 you all know, he is already in touch with the Department
4 of Health in connection with the audit in the UK Cardiac
5 Surgical Anaesthetic Association, and because he is
6 involved, he has already been in touch with the
7 Department of Health and has told them that this
8 operation is going on, and we are meeting, and he feels
9 that we should not really be doing it.
10 Q. So you did know from what he had said that the
11 Department of Health had been contacted about the
12 operation?
13 A. That is what he said, yes.
14 Q. And did he suggest anything as to what the view of the
15 official in the Department of Health to whom he spoke
16 was?
17 A. No.
18 Q. Did he give you any reason to think that the view
19 was, "Yes, the operation should go ahead", or "No, it
20 should not"?
21 A. No. What he really said was that he was going to
22 ring them, what was the decision of this meeting.
23 Q. Let us go back to the note at 54/11 and scroll down,
24 please. In the third paragraph:
25 "CRM and JDW having had frank discussion on this
0057
1 point earlier in the afternoon with [Dr Monk] (believing
2 that the risks exceeded the possible benefit)". That is
3 in brackets; was anything to that effect said at the
4 meeting?
5 A. CRM did not even mention anything in the meeting that
6 he had discussion with Mr Wisheart earlier, and he felt
7 that it should not be in the benefit (sic).
8 Q. Can we go overleaf, please? The way this is written
9 suggests that the decision to actually proceed with the
10 operation, the clinical decision, was taken between
11 yourself, Mr Wisheart and Dr Martin.
12 A. No, it is not like that. I mean, looking back, when
13 you analyse it one can get that impression but it was
14 not like that. Once the decision was made and I thought
15 that was the end of it, then Mr Wisheart called me and
16 Dr Martin out of the room to an adjoining room and said,
17 you know, "Do you think this operation could be
18 delayed?"
19 Q. So Mr Wisheart was wanting to delay the operation, was
20 he, as far as you could tell?
21 A. I think the word used was -- I mean, I still recollect
22 it very well, that "We have a loose cannon here", and it
23 could have some repercussion. I felt, you know -- and
24 also Dr Martin at that time -- that this was a clinical
25 meeting to decide on the clinical course of the patient,
0058
1 and I do not think we should be guided by political
2 repercussion. If the meeting called agreed for me to
3 proceed with the operation, then he did ask me, "Are you
4 happy to proceed with it?" I felt I did answer him,
5 "Yes, I am".
6 Q. Did Dr Martin say anything to the meeting about the
7 need for the operation?
8 A. Yes. Dr Martin did really emphasise, which I supported,
9 that this operation, this patient, cannot wait too long;
10 he is getting bluer and he has -- and I added to that
11 that we know from the past catheter that the aortic
12 saturation is 61 per cent and he has PA banding and we
13 know with PA banding the known problem of subaortic and
14 subpulmonary stenosis could get worse. I do not think
15 we should wait too long.
16 Q. Was that the way he put it?
17 A. He did, and I supported him.
18 Q. Did he tell the meeting when he had last examined
19 Joshua Loveday by means of catheter?
20 A. When he last examined the patient by means of catheter?
21 Q. Or echo?
22 A. Catheter was the obvious, there were the notes in front
23 so everybody knew when that was.
24 Q. So that was May?
25 A. Yes. Echo, I do not think it was discussed there at
0059
1 all. I do not remember echo being discussed.
2 Q. Did he indicate when it was that he had last examined
3 Joshua Loveday?
4 A. I do not remember it was discussed there, no.
5 Q. Did he give the impression of any urgency beyond what
6 you have already said?
7 A. No.
8 Q. Was there, as you think back on it, any reason, from
9 what he said, why the child could not have been
10 transferred, referred, to another centre?
11 A. I do not think there was any discussion of transferring
12 the child or referring the child to another centre. The
13 discussion was whether the child could wait another two
14 or three months and that was discussed. But the
15 question was in a way, if you are waiting for a new
16 surgeon to come here, it will not be before April or May
17 and we are talking of January, and no new surgeon, just
18 returning to a new centre, would do such a complex
19 operation, so that could be another few months, and I do
20 not think -- I mean, that is what he really said, the
21 child cannot really wait that long.
22 Q. The only need to consider whether a new surgeon might do
23 the operation would be some sense or feeling that that
24 surgeon might be able to do the operation better.
25 A. But that surgeon, even on arrival in May, did not do any
0060
1 arterial switch until the next November or December.
2 The surgeon by that time was not really very much
3 experienced by his own, really. He was working in
4 a very good centre and I know, when he came at the time
5 for interview, he had not done any arterial switches on
6 his own, except for one or two. I talked to him after
7 the interview --
8 Q. Can I stop you there for a moment, because the point
9 that I am examining is what, if anything, was said about
10 the urgency and the consequences of what that might have
11 been. Can we look at UBHT 54/4? This is a statement
12 made by Mr Wisheart on 3rd June 1996.
13 Can we go to page 7? He deals, in the second full
14 paragraph, just above the block at the bottom, you see
15 "after the meeting was over ..."
16 Do you see that paragraph?
17 A. That is correct.
18 Q. He says "I proposed that the operation should be
19 postponed as it was not appropriate to carry it out at
20 a time of such pressure and such anxiety."
21 Just pausing there, there was, was there, pressure
22 and anxiety?
23 A. I think it is his interpretation.
24 Q. Did you think there was pressure and anxiety?
25 A. I thought calling that meeting by itself was pressure
0061
1 and anxiety, yes.
2 Q. "Dr Martin", he goes on, "advised that the operation
3 should not be postponed for longer than one week on
4 account of the patient's severe cyanosis. When pressed,
5 he adamantly insisted that one week was the absolute
6 maximum."
7 This is talking about the meeting you had with
8 Dr Martin and Mr Wisheart. How accurate an account do
9 you think that is that we are looking at at UBHT 54/7?
10 A. I am not sure that I can recall a term like "adamant"
11 and "one week".
12 Q. The picture Mr Wisheart is painting is that as
13 a Medical Director, he had no choice, effectively, but
14 to allow the operation to go ahead, because the
15 cardiologist was saying, "This is urgent, we cannot
16 postpone it for any more than a week, we have to do it".
17 How accurate would that be as a description of the
18 meeting you had with Mr Wisheart and Dr Martin?
19 A. I think "urgent" was mentioned by Dr Martin, but I do
20 not think, you know -- I mean, I do not remember exactly
21 that the terms were used like, "within a week", or ...
22 Q. Mr Wisheart uses the words "When pressed, he [Dr Martin]
23 adamantly insisted ..."
24 In other words, the picture that is painted there
25 is that Mr Wisheart saying to Dr Martin, "Look are you
0062
1 sure it has to be done within a week?", something along
2 those lines. "Does it really have to be done? Can it
3 not wait for longer", that sort of thing?
4 A. I think if I ... I cannot be certain that a week was
5 mentioned, but I could be wrong.
6 Q. So can you help as to how hard Mr Wisheart tried to find
7 out if there was any alternative to what Dr Martin was
8 saying about the possible time to do something else?
9 A. I think Mr Wisheart was quite sincere when he talked to
10 us, you know, whether we really cannot postpone it. And
11 equally, Dr Martin was -- and I think I also supported
12 him, that the operation was now urgent, having said 4 to
13 6 months prior, waiting, but I do not think it would
14 have really come out like, you know, a week or days, or
15 this type of thing.
16 Q. So the sense is that there is Mr Wisheart sincerely
17 saying, "Let us put this off". And Dr Martin saying,
18 "Well, no, we cannot really", and you supporting him?
19 Is that a reflection?
20 A. In a way, yes.
21 Q. This was a child whose oxygen saturations had not
22 actually altered.
23 A. Well, is that right? I mean, I do not know. You will
24 have to really look in the notes.
25 Q. Let us look back at the notes.
0063
1 A. The major oxygen saturation next time would be in the
2 operating theatre. By that time the patient would have
3 had some oxygen.
4 Q. I was going to ask you about that. If we look at your
5 note, it is MR 164/4. Scroll down to the bottom. It is
6 on the screen.
7 A. I have it both ways, yes.
8 Q. Do you have it?
9 A. Yes, I have.
10 Q. "Previous repair of the type 1 interruption using the
11 lesser subclavian arterial flap and PA band", and you
12 give the date, "now moderately cyanosed, aortic
13 saturation 62 per cent"?
14 A. I think I am still quoting what was in the catheter,
15 really, because I do not think we would have known in
16 the ward what was the oxygen saturation.
17 Q. So is this right: that you had no idea before the
18 operation, because there was no measurement, as to
19 whether the arterial saturations had got worse than they
20 had been at the time of the catheter in May?
21 A. Not every child is with an oxygen monitor. He is not
22 working there, so it was not a monitored.
23 Q. The only way to find out would be some further test?
24 A. But there is no need for that test. You already have
25 a quite low known oxygen saturation.
0064
1 Q. When Joshua Loveday was placed on your list, that was
2 what, in November, was it?
3 A. That is correct.
4 Q. And the operation was scheduled for January 1994?
5 A. Yes.
6 Q. Tell me: was there, as you recollect, a postponement
7 during December at the parents' request?
8 A. Yes.
9 Q. But in any event, the surgery was elective; there was no
10 emergency about the surgery itself?
11 A. No. The patient was on the priority list; it was not
12 elective in that sense, no.
13 Q. When the discussion took place between Dr Martin,
14 Mr Wisheart and yourself, Mr Wisheart was suggesting
15 that the operation might be delayed, postponed,
16 Dr Martin saying, "Well, no, it needs to be done"; if,
17 let us suppose, Dr Martin had said, "Well, it needs to
18 be done sooner rather than later, but we can always do
19 it within three or four weeks", if that had been the
20 position, would you then have said, "Well, let us put it
21 off?"
22 A. Yes.
23 MR LANGSTAFF: Dr Silove, you have been through the notes in
24 some detail. Was this a child who, so far as one can
25 tell from the notes, urgently required operation rather
0065
1 than soon required operation?
2 DR SILOVE: As far as one can tell from the notes, I do
3 not see any evidence of a significant change in the
4 child compared with the time that he had the cardiac
5 catheter in May. If they were very concerned about him
6 being more cyanosed, one would have expected, it was
7 very simple in 1995, to put a pulse oximeter on the
8 finger. It does not hurt, it is not invasive and you
9 can measure the oxygen saturation in a matter of
10 seconds, and they could have measured the oxygen
11 saturation and checked whether it was less than 61 or
12 62 per cent, which might have been an indication that
13 the child was deteriorating but I must say from what
14 I have said in the notes, I could not see any strong
15 evidence for any real deterioration that made the
16 operation urgent within a week. He had waited seven
17 months. I would be very surprised if there had been any
18 significant change over the next few weeks.
19 Q. Is there anything in the notes which contradicts that?
20 MR DHASMANA: That is what I was just looking at.
21 Sometimes nurses do put that pulse oximeter. I was
22 looking to see if they have done that.
23 DR SILOVE: The only recording I have of the oxygen
24 saturation pre-operatively was actually in the
25 anaesthetic room, the anaesthetic chart, where the
0066
1 saturation was around 60 per cent, 60/61 per cent, but
2 the child was already presumably anaesthetised at that
3 stage.
4 MR LANGSTAFF: So it may not be reliable?
5 DR SILOVE: It would not be very different from 60 per cent
6 when the child is awake. It might not be absolutely
7 reliable, no.
8 MR LANGSTAFF: So there is some indication from the notes
9 that there was no deterioration, in fact, but that is
10 the furthest the notes can help us.
11 DR SILOVE: Yes, but there is a limit to how much I am able
12 to find in the notes. Medical records are not written
13 for an Inquiry, they are written for the management of
14 the patient at the time.
15 MR LANGSTAFF: Can we look at UBHT 54/13? Go down to the
16 bottom of the page. It is the second last sentence:
17 "Based on the results that we have discussed",
18 this is Dr Martin's own note, "we did not feel it was
19 appropriate for referral to another centre. The
20 decision, therefore, was made to proceed with the
21 planned arterial switch operation the following day."
22 You could not recall a moment or two ago there
23 being any discussion about referral to another centre.
24 Does that help?
25 MR DHASMANA: Yes. I mean, I have seen in the transcripts
0067
1 those things being mentioned. I do not think there was
2 any discussion on referral to another centre.
3 Q. So do we have this as the position: that at the end of
4 the meeting between Mr Wisheart, yourself and Dr Martin,
5 you and Dr Martin agreed that the operation not only
6 could but should go ahead the next day.
7 A. Following the whole meeting's agreement for us to
8 proceed, yes, but I do not think we should really be
9 just isolating it, particularly in this case when
10 a meeting has been called to discuss this child's
11 operation for the next day. If the meeting has agreed,
12 I do not think that two persons should just be isolated
13 like that.
14 Q. The reason I put it like that is that first of all you
15 were physically in a side room. Why was it that
16 Mr Wisheart spoke to you and Dr Martin on one side?
17 A. I do not know. I mean, I was myself quite surprised,
18 really. Maybe Mr Wisheart would have another answer,
19 but I was surprised that if this has been discussed in
20 there, then why call outside? But that is what he
21 really asked, and that is the answer we gave him. We
22 came back again and he conveyed that message to the
23 people who were there.
24 Q. Is it not perhaps because the clinical information about
25 this particular child has to come from the cardiologist
0068
1 whose patient the child is and you were the surgeon who
2 had to be satisfied that on the basis of the information
3 given to you, the decision to operate was appropriate?
4 A. But these were already discussed in the meeting before,
5 so there was nothing new which we mentioned there to
6 Mr Wisheart.
7 Q. We have had a view, you see, from Dr Monk, and I think
8 Dr Bolsin -- I may be wrong on that, but certainly from
9 Dr Monk -- that at this meeting, there was clinical
10 information given by the cardiologist which he, as an
11 anaesthetist, felt he could not contribute to. It was
12 the cardiologist's role to decide and refer the
13 treatment and advise on the condition of the patient, so
14 he accepted, of course, what Dr Martin said.
15 Is that a fair point?
16 A. No, I thought if people are called to a meeting and it
17 was going to be decided at the end of the meeting, then
18 everybody has to express their point whether they are
19 anaesthetists or cardiologists or surgeons, if they are
20 dealing with the same age group and the same paediatric
21 problem.
22 Q. If the cardiologist says, "Look, I have seen this child
23 six weeks ago, or seen the child recently. The child is
24 getting very blue, in other words an operation pretty
25 urgently, that is my view", if that is what the
0069
1 cardiologist says, the anaesthetist is not going to
2 query that, is he?
3 A. Well, I do not know. Ask them. I mean, as far as
4 I am concerned, nobody queried him.
5 Q. The second matter which was raised I think by
6 Mr Wisheart with you was, was it, whether you felt under
7 pressure?
8 A. That is correct.
9 Q. The meeting itself was pressure, you have said?
10 A. Yes.
11 Q. We have been into the background, the unusual
12 features in the background, when you knew that your own
13 performance of the switch series in non-neonates was
14 queried by some of your colleagues.
15 A. Non-neonates, yes.
16 Q. There must have been great pressure on you?
17 A. Going into the meeting, but coming out, I felt very
18 good, because people supported, I thought, you know,
19 people supported me. People expressed their trust and
20 belief in me, so I was feeling very much better.
21 Q. When you came out of the meeting, you knew what you
22 had not known when you went in, that the Department of
23 Health had been contacted; that Mr Wisheart's view was
24 that the operation should be postponed if at all
25 possible?
0070
1 A. It was not his view like that. He was asking the
2 question, whether it can be postponed. I mean, that was
3 the question and he said, you know, "Here we have in
4 a way a loose cannon, and if the patient dies, which is
5 possible with any cardiac patient, this could happen".
6 And we felt that this was a clinical meeting and we
7 should not really be deciding on the basis of political
8 repercussion.
9 Q. The operation on a child, as we have heard, who not only
10 had a difficult anatomy, because of the side by side
11 positioning of the two great vessels, but also had had
12 previous surgery, which complicates the transfer of
13 coronary arteries, does it not?
14 A. All of these patients had previous surgery. All of
15 these patients, if you look at the double right
16 ventricle, they all had pulmonary banding and something
17 else was done, so this was nothing new.
18 Q. Can we look at the operation note itself, which is back
19 to MR 164/4? The typed version is at page 5. If we go
20 down to "procedure" --
21 THE CHAIRMAN: Thank you. I was just taking some
22 addresses off.
23 MR LANGSTAFF: The description is given here, Mr Dhasmana,
24 of the way in which you went ahead with the operation,
25 and you describe transecting the pulmonary artery, just
0071
1 below the band, two coronary arteries implanted in their
2 new position using a trap-door method. You say as the
3 arteries were side by side, the right coronary artery --
4 those are the words there -- appeared "rather taut",
5 even although it was anastomosed on the right anterior
6 sinus.
7 So the problem you and Dr Silove were mentioning
8 earlier of the right coronary artery in this sort of
9 anatomy being taut, had been demonstrated in the event?
10 A. Yes.
11 Q. That is what happened?
12 A. That is correct.
13 Q. Can we go overleaf? As the arteries were side by side,
14 the Lecompte manoeuvre was not used."
15 Then I think we can read down to just above the
16 black dot, where we have "Once the heart was beating and
17 it was full, it was realised that the right coronary
18 artery was very taut."
19 This time it is "very taut".
20 "Therefore, an attempt to mobilise the right
21 coronary was made, but this caused injury to the right
22 main artery itself."
23 So can I understand what was happening here?
24 Because the right coronary artery was very taut, you had
25 a feeling, did you, that this might affect the
0072
1 anastomosis and compromise the circulation to the heart
2 after the operation, unless you did something about it?
3 A. To understand that, you have to go back to the findings
4 section, because unless you know what the problem was,
5 we cannot really explain that.
6 Q. Let us go back to page 5.
7 A. If you look in here, I am really saying, because this is
8 something in a way I had not envisaged before, that the
9 right coronary artery had multiple orifices. Normally,
10 the right coronary artery comes out with one orifice and
11 then starts branching outside the aorta. Here, there
12 were multiple branches coming out from the aortic sinus
13 itself, so in a way, what would have been a normal-sized
14 right coronary artery was now comparatively smaller
15 multiple branches. In most of these patients there is
16 a side-by-side location, so when you move the right
17 coronary artery on to the side, though it is taut, but
18 because it is a reasonable size, it will still manage.
19 Here, because there are multiple orifices, now
20 they have got taut and the right main coronary artery
21 was now not taking the same amount of blood which it
22 would normally have done. That is what I am really now
23 meaning, because when you are doing this operation, at
24 that time the heart is empty and it is not realised how
25 taut it could be until the heart is filled and starts
0073
1 beating. It was at the end of the operation that
2 I really realised how taut it had become now, so I am
3 trying to mobilise it, because one of the things
4 I learned from Birmingham was that you do not mobilise
5 the coronary artery too much, because you could damage
6 it or it could cause kinking. So it was not mobilised
7 too much before. Now when I see that, the SD segment
8 starts changing, which is noted and that really tells me
9 that the coronary artery is not supplying enough blood,
10 so I start mobilising.
11 This is a very thin-walled artery, and of course,
12 the next thing I know, it is damaged.
13 Q. So what you are describing is this: that you did not
14 know, before you began the operation, that there were
15 multiple orifices at the origin of the right coronary
16 artery?
17 A. That is correct.
18 Q. Is that something which you would have expected to know?
19 A. It is a known abnormality, but it is rare, so in a way,
20 yes, you can find it, but fortunately, not in that many
21 patients. I do not know what would be the incidence?
22 DR SILOVE: I do not know what the incidence would be,
23 but it would also be virtually impossible to demonstrate
24 either by echocardiography or angiography. You would
25 not be able to tell the surgeon in advance that there
0074
1 are multiple orifices.
2 MR LANGSTAFF: So this is something you have to deal
3 with on the table, is it?
4 DR SILOVE: Yes.
5 MR LANGSTAFF: Going back to the second page, page 6,
6 the tautness and the need, possibly, to mobilise the
7 right coronary artery would have been appreciated before
8 you began the operation, because you knew of the side by
9 side anatomy which might involve such a procedure. Am
10 I right?
11 A. Well, that is almost understood that there will be some
12 more distance here to go than normally you do in other
13 cases, yes.
14 Q. And it was the act of mobilising the artery in order to
15 try to relieve the tautness that injured the coronary
16 artery as you have described?
17 A. That is correct.
18 Q. And once the coronary artery was injured, it being as
19 small as it was, there had to be an attempt made to
20 supply the blood to the heart from another source, which
21 was why you went to the mammary artery?
22 A. That is correct.
23 Q. But at that stage you are fighting a difficult battle,
24 are you not?
25 A. The very tiny right intramammary artery, so in a way you
0075
1 are hoping that the right side of the heart does not
2 need too much blood and hopefully it should provide
3 enough blood supply, but it was not enough. And about
4 that mobilisation and the injury, Mr Brawn was asked
5 that question at the GMC and he really said it could
6 happen with any surgeon anywhere.
7 Q. Yes, it could happen.
8 A. Yes.
9 Q. Sometimes it does not, sometimes it does.
10 DR SILOVE: I discussed this with Mr Stark before he
11 left and he said it is the sort of thing that can
12 happen. It is particularly difficult in a patient who
13 has had a previous operation where there are presumably
14 adhesions and that is where the pericardium is adherent
15 to the surface of the heart and it presumably makes
16 mobilisation of the coronary artery more difficult.
17 MR LANGSTAFF: So it is recognised that it may well, in
18 the best of hands, happen. Equally, it may not happen.
19 You would have been aware, I take it, in general terms,
20 of the risk of inadvertently damaging the artery in the
21 course of the operation?
22 MR DHASMANA: We all know if the coronary artery is
23 damaged, you have a problem.
24 Q. Do you think that perhaps the distractions, the
25 tensions, the pressures, caused by the circumstances in
0076
1 which the Loveday operation came to be performed, could
2 not have made your concentration, your focusing upon the
3 surgery, any easier?
4 A. I can talk of myself, that when I am in the operating
5 theatre, I am very focused. At that time, I do not
6 remember what is happening to anybody else; I just have
7 that one in front of me, and I would have forgotten what
8 we talked about the night before. I am very focused.
9 I do not think there is any conversation.
10 I mean, this happens in a surgeon's life, I think,
11 almost quite often. To give you an example, I operated
12 on a very sick baby just born one or two days on the
13 night when the Dispatches programme was flashed all over
14 the country, on 6th April 1995. As soon as the
15 programme was finished, the phone rang. I was the
16 surgeon on call. I could not say that I would not
17 operate, having seen and heard what was being told about
18 me. I went back, operated in the middle of the night,
19 and successfully operated on that child.
20 Q. But did it make the operation any easier? The answer to
21 that must be "No". Are you saying that although it
22 could not have made the operation any easier knowing
23 that, any degree of tension or perhaps tiredness or
24 stress makes no difference?
25 A. Not to me. I can tell you that, as far as I am
0077
1 concerned in the operating theatre, I am a different
2 person.
3 Q. That view, that it was best avoided, was a view put
4 forward to us by Mr Bryan, and you may have read what he
5 said about the operation when he suggested that any
6 surgeon in circumstances such as this would be bound to
7 have at the back of his mind the problems, the
8 difficulties, the stresses. You are saying you did not?
9 A. No.
10 Q. Let me come back to the question which I asked pretty
11 much towards the beginning of our investigation into the
12 operation on Joshua Loveday, when you say if you had
13 known that Dr Roylance and Mr Wisheart may well have
14 agreed that there should be a detailed review of the
15 surgical results, you would not have operated?
16 Why would you not have operated?
17 A. Because when management is really saying "We are going
18 to review the paediatric experience" and I am told it is
19 because of arterial switch, I would say "It is better
20 you review it before I really operate next", because it
21 is like you have an official notice of something, better
22 I do not do any, because now it is a review.
23 Q. In such a case, you are saying "If the case had been in
24 my list and I had known there was going to be a review,
25 I would not have done it."
0078
1 A. That is correct.
2 Q. What is it then about the fact that the review is
3 proposed by management rather than there being concern
4 amongst your colleagues, that makes the difference?
5 A. But that is what I am really saying. At the end of the
6 meeting, I did not feel there was a concern amongst
7 colleagues. Colleagues actually felt very supportive.
8 I have been told who is going to anaesthetise. I have
9 been told now that the cardiologist wants me to proceed,
10 and the meeting there had no objection to this operation
11 proceeding, except the "political" word used by
12 Dr Bolsin. Dr Monk did not say anything there than what
13 has been written in the notes.
14 Q. And your Medical Director suggesting or pressing or
15 gently suggesting, whichever it might have been, that
16 the operation was better postponed?
17 A. I do not think the word was used, "better postponed".
18 I thought he was asking if it could be postponed.
19 Q. Did you discuss with the parents of Joshua Loveday what
20 had happened the night before?
21 A. That is my deepest regret, really. With what happened
22 at the end, I regret that I did not really tell them
23 everything when I met them. I wish I had. But at that
24 time, I just had come out from a long tiring meeting,
25 having heard the supporting ways, and I felt quite
0079
1 confident that there would be no problem and this child
2 would be moving about tomorrow or the day after, and
3 I do believe that I felt, you know, that I would be
4 causing more anxiety by telling them what had happened,
5 which, in retrospect, I accept is not right. I do
6 regret that very sincerely and I wish I could really
7 have told them what had happened before.
8 Q. You quoted a risk, we are told by Amanda Evans, the
9 mother of Joshua Loveday, a risk of 80 to 85 per cent
10 success.
11 A. No, it is all written very clearly here, 20 per cent,
12 which I told you, and this was just because I am coming
13 out from the meeting where 20 per cent was so much
14 flashed like that, that was at the back of my mind.
15 Actually, Mrs Evans, in her statement to the GMC, quoted
16 that first time when I spoke to her again, 40 per cent
17 mortality, so, in a way, you can really see what I was
18 thinking about, this condition before, but having come
19 out from this meeting, I gave the risk that was really
20 in a way mentioned by Dr Pryn and my colleagues.
21 Q. You made no adjustment for that risk because this was
22 the Taussig-Bing syndrome and that made it more
23 difficult?
24 A. I mean, I think when I talked to them the first time,
25 I was thinking of Taussig-Bing, and that is why I gave
0080
1 that higher figure. But sometimes you can see how
2 a meeting can change your mind, really. I do not think
3 that 20 per cent would exactly fit in my description of
4 Taussig-Bing, but I really came out from the meeting,
5 20 per cent I put in for a non-neonate of his size for
6 the arterial switch, because Taussig-Bing by itself was
7 not discussed in any of the pathology which is
8 mentioned. Dr Pryn, in the end.
9 Q. Just examining why it should be 20 per cent, because
10 if you thought about it in greater detail, perhaps you
11 would have said to yourself, "20 per cent is for the
12 operation of transposition with a VSD. This has the
13 greater difficulties because we have the Taussig-Bing
14 syndrome; we have a previous operation, the banding
15 operation"; and indeed, your most recent experience of
16 it was a fatality. So if you had thought about it, you
17 would have put the risks higher, would you not?
18 A. No, I do not think you change your mind because
19 something happened with the case which just proceeded.
20 You have to really still look at your own experience
21 over a period of time, what you have done. I still now,
22 just before that, 6 patients with one death, so that is
23 still 15 or 16 per cent, really. I mean, I did not have
24 20 per cent experience, I had only 16 per cent, so
25 20 per cent --
0081
1 Q. When you first quoted the 40 per cent risk, you had
2 had a number of patients with this condition with no
3 fatalities.
4 A. Yes. I mean, that is why really I was surprised,
5 I was just quoting she had mentioned 30 to 40 per cent.
6 I have not put any figure on it, I am really saying how
7 her mind at that time registered 30 to 40 per cent and
8 later, 15 to 20 per cent. So one of those is wrong.
9 I am quoting her own words, and it is possible I may
10 have mentioned that it is a higher risk, but I am not
11 sure I would have mentioned 30 to 40 per cent.
12 Q. Is it right or not, then, that as a result of this
13 meeting on 11th January 1995, you reduced the level of
14 risk that you had originally quoted, do you think?
15 A. No. I gave the result which came out from this meeting,
16 which, if you look back, is higher than my own result in
17 that pathology.
18 Q. Since I mentioned the question of information to the
19 parents, may I ask you just some questions about that
20 before I return to the chronology?
21 Do you believe that the parents and the families
22 should be allowed, indeed helped, to make a decision to
23 agree to an operation in an informed way?
24 A. Well, that is what has changed over the years, really,
25 because a few years ago, we did not know what was
0082
1 "informed consent". I think informed consent has only
2 come in in the last two or three years, in a way, so at
3 that time, I could really say I did not know what was
4 informed consent.
5 Q. So now you take the view that all the risks and relevant
6 facts need to be explained?
7 A. I do, yes.
8 Q. But you did not necessarily from that view in 1995?
9 A. No, because there was no such knowledge, or
10 information.
11 Q. Does it follow that because you were adopting the
12 practice at the time, the parents and patients to whom
13 you quoted risks -- because you quoted a percentage,
14 that was your practice, was it not?
15 A. Mortality I used to quote, but when I am now responding
16 to parents' statements, they are quoting the other way
17 round: they remember the success, really. I tended to
18 always mention, percentage-wise, the mortality.
19 Q. So back to the question: looking back on it, is it the
20 case that the percentage you quoted to parents did not
21 go as far as you would now think is proper and
22 advisable?
23 A. I mean, I thought it was quite proper at that time,
24 really, but what is advisable, I am still not sure in my
25 mind what you are really getting at.
0083
1 Q. When you came to talk to parents about the operations,
2 did you tell them anything about the current record in
3 the unit?
4 A. I used to tell them, in a way, that we were not doing
5 this type of thing before; now we have started doing
6 it. But I do not think I have really mentioned, except
7 for the first few cases in the beginning, that this is
8 what has happened in the past and I am not -- you know,
9 this is my results, no, not that way.
10 Q. We have Mrs Collier who tells us that although her
11 daughter was one of the first, if not the first,
12 neonatal switch operations that you performed --
13 A. She was the first neonatal switch operation.
14 Q. She thinks you did not tell her that she was the first.
15 A. I am quite surprised, because at that time there was
16 a child recovering from a switch operation, who was
17 older. I told her that that is the type of operation
18 I was doing before in the older child; now I am doing it
19 in a new-born.
20 Q. Do you believe, now, that informed consent should
21 include a discussion about whether other units or other
22 surgeons might offer a lower risk to the patient?
23 A. Well, there is now guidance coming out from the College
24 and things, whether you believe it or not, that is what
25 you have to follow.
0084
1 Q. But you did not, do I take it, do that then?
2 A. There was no guidance at that time, and I did not know
3 we were supposed to be saying that, because I had worked
4 in a number of places and I heard nobody saying those
5 things.
6 Q. You were saying yesterday the good results in the
7 Senning operation were your problem. I think that may
8 have been in the context of the decision to begin or not
9 to begin the neonatal switch series?
10 A. I think what I am really saying, because, you know, what
11 we were trying to do in Bristol, or I was trying to
12 bring the unit up to the level that we could really deal
13 with these cases, was delayed because of such a good
14 success we had with Senning. If Senning had a mortality
15 higher than you have seen, then probably reluctance on
16 cardiologists to accept my advice in 1985/86 to move on
17 to switch would have been accepted better, and we would
18 have gone on the same pace as most of the centres in the
19 country were doing, because by the time they became
20 proficient, we were starting. We do not know what was
21 their earlier mortality and we could have been just in
22 the same category. I am sure that our earlier mortality
23 is no different than two years ago these people had.
24 Unfortunately, they are not before you; I am before
25 you. That is what I said was my problem.
0085
1 Q. Did you tell parents -- because we have a number of
2 parents who have told us that you did say something
3 about the Senning operation; you did say something about
4 the switch operation, and the flavour of those
5 statements, as you will have seen, is that you were
6 encouraging the patient, the parent, to agree to the
7 switch operation rather than the Sennings.
8 Did you quote the different percentage risks of
9 mortality for each operation?
10 A. Whenever I have mentioned, I think if I was seeing
11 a child, then talking to the parents, I would in a way
12 draw diagrams and I would really say what was wrong, and
13 of course, then I would mention that there are two ways
14 of dealing with it: one is if I am seeing the child at
15 7 or 8 months of age, and no VSD, then there is no use
16 talking about the switch there; that is
17 a straightforward Senning.
18 But of course in a child where both operations
19 could be advised, there, especially a neonate, I would
20 be talking of two ways of dealing: one is Senning, but
21 that means waiting for 6 to 8 months from now, when this
22 would be carried out. Unfortunately, the long-term
23 outlook of Senning is not certain. Secondly, the
24 arterial switch which I can repair right now, of course,
25 it carries a high mortality, as compared to Senning, but
0086
1 with Senning, low mortality and long-term uncertainty,
2 I think higher mortality at this time is quite
3 acceptable, and I would strongly recommend that arterial
4 switch is the better operation. That is how I put it.
5 Q. So the reflection that the parents give us is right: you
6 were making a strong recommendation, but your
7 recollection is that you explained the different risks?
8 A. Yes, sir.
9 Q. Before I leave the neonatal switch and risks, two more
10 matters I want to explore with you. The first is that
11 at round about lunchtime on the first day of your
12 evidence it has been suggested to me that we passed over
13 a question and answer which was given about the
14 non-neonatal switch, the original switch operation, when
15 you were making a comparison of the mortality in that
16 operation with the previous operative way of dealing
17 with transposition of the great arteries and AVSD?
18 A. That is correct.
19 Q. Just so that there is no -- I did not think there was
20 any uncertainty about what you were saying, but if there
21 is, can you tell us, before you began the first switch
22 operation in 1988, roughly what mortality were you
23 getting for patients presenting with that condition in
24 the operation which was then performed?
25 A. You mean what I said on that day, that until that time,
0087
1 or until 1990, really, I had done four operations:
2 Senning plus VSD closure, with one death. So that was
3 my own result of the 25 per cent mortality. But the
4 literature on this condition, the transposition with VSD
5 or similar type of problem, I said from Kirklin's book,
6 which was a 1986 publication, so in 1988 was the most
7 recent information, was ranging between 20 to 40 per
8 cent mortality in this condition, with the Senning
9 operation. Because it carries that mortality, people
10 were now getting with arterial switch similar mortality,
11 so why not move to arterial switch in this age group, in
12 this pathology.
13 Q. Can I move from that to go back to the question of your
14 getting consent from parents and quoting them the
15 risks. The very first time you ever did an arterial
16 switch operation, either on a non-neonate or a neonate,
17 upon what did you base your assessment of risk?
18 A. I very well remember this patient's parents, because
19 I told them, this is the first time I am doing it, and
20 I told them that I had until now assisted and that was
21 five years ago. I told them that although mortality is
22 like this, the figures I have already explained to you,
23 but of course this being a first child, it could be this
24 way or that way, meaning 50:50. And they were very
25 clear. This patient I had already operated on in the
0088
1 past and they happened to come from north of Gloucester,
2 and I said, "If you want, I can refer you to
3 Birmingham". They did not want to. This has all
4 been -- they have even mentioned that to the GMC meeting
5 and I have quoted that in my statement.
6 Q. When you got some experience, for instance in the
7 neonatal switch -- let us look at one of your later
8 cases. Take for example the case of Daniel Willis,
9 whose case we will look at this afternoon: on what did
10 you base your assessment of risk there?
11 A. I have a huge problem with the neonatal switch in a way
12 to know, really, how can I quote my own statistics,
13 because I have not got any running series of success.
14 So there, I was going mostly on the basis of published
15 literature and the American paper which I quoted before,
16 which was going on the medium sized centre, what they
17 would expect, and knowing about the term which is not
18 really accepted, earlier experience, I am using the term
19 here.
20 Q. So the position would be for someone like the Willises
21 that they were getting a perception of the risks in the
22 literature but not the risks in your particular unit?
23 A. That is correct.
24 Q. Was that not effectively misleading, do you think?
25 A. I did not think at that time -- we are talking of
0089
1 1992/93, there was no guideline, and almost all surgeons
2 were quoting, whenever they were starting a new
3 operation, what they were expecting from published
4 literature.
5 Q. When you come to something like truncus arteriosus,
6 where the unit's record was not one of the happiest, did
7 you quote risks on the basis of the literature or on the
8 basis of what the unit was doing?
9 A. The first few patients I always quoted 50:50 may or may
10 not make it. I even quoted 60 per cent, but my record
11 is very good in truncus after 1989; I had done 6, 7 or 8
12 without any deaths. I think in 1993/94 when I was
13 talking to a parent about truncus, I would be giving
14 a risk of about 30 per cent.
15 Q. From that last answer, it appears you modify your
16 assessment of risk given your own personal experience?
17 A. That is right. If you have a series you will quote with
18 confidence, you can quote. If you have no series, you
19 have nothing else to fall back on except published
20 literature, which you believe in.
21 Q. I want to contrast the fact that your good experience
22 causes you to reduce an estimate of risk made to
23 a parent, as in, you say, your truncus arteriosus after
24 1989, but your bad experience, as in the neonatal
25 switch, did not cause you to increase your risk estimate
0090
1 to a parent, rather it made you go back to published
2 literature and rely on the general medical risk in any
3 particular centre.
4 Why take a different approach depending on whether
5 your results were good or bad?
6 A. It was not a different approach. I find it difficult to
7 explain nowadays with whatever information we have in
8 the post-1995 era, what we should be talking to parents
9 and what we should not be. I do believe that one has to
10 put, especially as a surgeon, in the era you were
11 talking to parents, and what was happening. I did not
12 think I was doing anything different than what was being
13 done elsewhere. If any of those parents would really
14 have asked me what was happening before, I would
15 definitely have told them that had happened.
16 Q. That relies on them asking you. You are the expert?
17 A. Well, I am afraid at that time, that is what the
18 practice was, and I was just following the practice.
19 Q. You did not have to follow anyone else's practice; you
20 had your own relationships with parents, did you not?
21 A. Well, you do not develop a relationship on the first day
22 you are seeing them, really, do you?
23 Q. What, if anything, prevented you from saying, for
24 instance, "Well, the risk in this operation is 25 per
25 cent but what you ought to know is that the last five
0091
1 such cases that I have dealt with have been entirely
2 successful". That is one way of putting it, if that has
3 been the case. One would have no problem with that, if
4 25 per cent reflected a general risk.
5 The converse: "The risk is 25 per cent but what
6 you need to know is that sadly, for I think particular
7 reasons, but sadly the last five I have operated on have
8 all died". Did you ever think of putting it that way?
9 A. Not at that time, no. I did not tell them my
10 successes or failures, unless I was asked about it.
11 Q. Do you think you ought to have told them, rather than
12 wait to be asked?
13 A. Now, I think what has happened after 1995, I think, yes,
14 we should be now doing that, but thinking always changes
15 with the passage of time. We have become wiser now.
16 Q. I am going to turn from this particular issue and away
17 from the case that we have on the screen, which is that
18 of Joshua Loveday, but can I just ask you,
19 Mr Dhasmana -- I am not going to ask you in detail about
20 some of the cases that we have heard evidence about, in
21 which you are the surgeon concerned.
22 What I am going to ask you to do, if you would not
23 mind, is to have a look, at your leisure, when you can
24 have a look at the notes, and look at the transcript in
25 respect of Melissa Clarke and Verity Curnow, and let us
0092
1 have any comments that you wish to make, to respond to
2 what has been said on the transcript. I asked you one
3 question, I think, about Melissa Clarke's case in the
4 course of the questioning that there has been so far.
5 There is one other general matter I want to ask you
6 about?
7 A. Can I respond? I have already sent my statement on
8 both these cases, really. I have already responded to
9 their statement.
10 Q. It is not simply the statement, we have dealt with both
11 of those cases in evidence in transcript and we have
12 expert input, and you have a right to respond to what
13 has been said. You may wish to do so. If you do not,
14 it is entirely up to you. If you do, we would be very
15 glad to receive any comments that you have to make. We
16 shall make sure that before you leave here, if there is
17 any doubt about it, we can point you to the passages in
18 the transcript that deal with those cases.
19 A. Okay, I will read the transcripts again, but I thought
20 my response to those two statements probably has covered
21 it, but I thought you were going to ask me something
22 from the transcript to clarify any further?
23 Q. The only thing I want to ask you is about a practice
24 which it is suggested in relation to -- it came up in
25 the Melissa Clarke case but it is of course of general
0093
1 application. It is suggested that the decision whether
2 or not to use a urinary catheter at operation so that
3 there might be easy drainage thereafter in intensive
4 care was one which would be made by the surgeon.
5 A. No. I am very pleased you actually asked me that,
6 because I have seen in the transcript, and it worried
7 me. Urinary catheter: I think that Melissa Clarke is
8 not the patient really, this is on some other patient
9 where the urinary catheter is a problem, not with
10 Melissa Clarke, if I remember it correctly. But yes,
11 the urinary catheter has been mentioned here.
12 There is a history about this relating to
13 Bristol. There was initially, I think in the early
14 1980s, a lot of catheter-related problems, especially
15 with the male children and they were in the form of
16 ureter stricture, and of course at that time there was
17 a different type of catheter being used. It was changed
18 to a feeding tube type catheter, and still the problem
19 was persisting, so a paediatric urologist really felt
20 that this practice should be changed and probably
21 Mr Wisheart can fill you in a bit more, because he was
22 the consultant at that time. It was decided in
23 consultation with the paediatric urologist to insert
24 suprapubic catheter in the children. When I came back
25 from the GOS and by that time Dr Masey had also arrived
0094
1 as a consultant, we felt it is a little too drastic
2 a measure to really prevent development of ureter
3 stricture, so we came out and by this time I had
4 experience of visiting American centres where a lot of
5 infants and new-born did not have a catheter; they
6 simply had a urine bag; a nurse would press on the
7 bladder. You get the urine, and of course, if you are
8 concerned, you can always catheterise in the
9 post-operative period. So we said, "Why not follow
10 this: that you still catheterise patients who are past
11 infant age, but new-born and infant, especially small
12 ones, let us just carry on with the urine bag and
13 measure this way. If we have a concern, we will pass
14 the catheter". So that is what was going on. This was
15 not uniform policy; this was not just the surgeon's
16 policy. I think this was surgeons and anaesthetists,
17 they were all involved, but of course, it went on like
18 that.
19 If I remember it correctly, when I visited
20 Birmingham for the neonatal switch operation, those
21 new-born, they did not have a catheter; they also had
22 a urine bag. But Dr Silove can correct me if I am
23 wrong.
24 DR SILOVE: I think it varies a great deal in
25 Birmingham what is done, but it is not really an area
0095
1 that I personally get involved with.
2 MR DHASMANA: But in a child who is approaching a year
3 or something like that, we certainly had catheter. One
4 of the patients, I do not remember the name, who has
5 been criticised quite heavily about a lack of catheter,
6 if the pages of the medical notes would have been turned
7 a few pages this way or that way, you would have noted
8 that the patient had a phimosis and there was
9 a difficulty to pass the catheter. That is why, in that
10 patient, the catheter was not inserted or could not be
11 inserted.
12 Q. You will appreciate why I do not ask you publicly to
13 identify the patient.
14 A. I did not name him.
15 Q. I know that is why you have done it, so that the wider
16 audience understand, but if you can perhaps, through
17 your legal representatives or directly afterwards,
18 identify that particular case to us, because as the
19 Chairman has indicated, the conclusions the Panel would
20 wish to reach, we want to make sure they are as right as
21 possible.
22 A. All right, I will do that, sir.
23 Q. Since we have just been taking about the operations and
24 the way in which you would relate to parents, can I ask
25 a further couple of questions? First of all, when you
0096
1 got consent for an operation, was it your practice to
2 have the consent form witnessed by yourself or by one of
3 your junior staff?
4 A. I am not sure on that. I do not think at that time any
5 witness was needed.
6 Q. But normally the consent form is taken -- it says it is
7 taken by a particular doctor?
8 A. Yes, if I have taken the consent, I would write my name
9 and I would sign it that I have talked and taken
10 consent, and then the parents would sign on the bottom
11 part, but my signature does not need to be witnessed by
12 anybody else.
13 Q. When you came to deal with the question of death after
14 an operation which had not gone right, or after an
15 operation which you may have thought, as an operation,
16 was successful, but the child deteriorated in the
17 Intensive Care Unit afterwards, and you had to talk to
18 the parents about what had happened, what do you
19 recollect you said to them about postmortems?
20 A. This used to be a most difficult period, in a way, the
21 time, that one really had to come out and talk to
22 parents and give the bad news. So in a way, somehow
23 I was always emotional during this meeting and the only
24 way I could really just, you know, express it was just
25 quickly get to the point. Which may have sounded, you
0097
1 know, a little bit blunt, but I could not really say
2 anything different because somehow I felt as soon as
3 I entered the room and they saw me, they knew what I was
4 going to say. So I would really just say, "I am very
5 sorry, he did not make it", or "did not come out", or
6 "this has happened". And because it had happened in
7 theatre or whatever, like that, I would then say that
8 "A Coroner's postmortem will be carried out and I am
9 sorry, I cannot really say anything more on that because
10 it is a legal matter". That is how I put it.
11 Q. If some parents may have found that a bit matter-of-fact
12 and brutal, is that because you had difficulty yourself
13 in dealing with the subject with the parents?
14 A. I think I myself used to get upset with the loss of
15 a child or a patient in theatre, or even in ITU, really,
16 yes. I would say that was a little -- it used to be
17 very difficult for me to communicate very well at that
18 time.
19 Q. Do you think you said anything about the possibility
20 that organs might be retained?
21 A. No, I do not think I said anything like that.
22 Q. Can we have a look at UBHT 308/18 it is dated August
23 6th 1992. This is to you from Professor Berry.
24 "I know that we have discussed this issue before,
25 but increasing pressure from the Coroner's office and
0098
1 the Department of Health as well as the Royal College of
2 Pathologists means that we must put our house in order.
3 "When we last discussed this matter, it was left
4 that you would ask your patient's permission for us to
5 retain cardiac tissue from Coroner's postmortems. You
6 will recall that the pathologist is only allowed to
7 retain tissue for the purposes of establishing the cause
8 of death and that for the Coroner's purposes the cause
9 of death can be general.
10 "There is no difficulty with hospital
11 postmortems ..." he explains why.
12 In the next paragraph:
13 "In future we will not be able to retain the heart
14 unless there is a signed statement from the notes from
15 one of the doctors looking after the child that they
16 have satisfied themselves that the parents of the child
17 do not object to the retention of tissue ..."
18 It deals with what might be said to the parent by
19 way of explanation, and emphasising the purposes for
20 which retention might be suggested.
21 What you are saying is that you personally did not
22 find it easy to raise any such matter with the parent.
23 A. No, no, not in the way you are putting it. I used to
24 find it difficult to talk to parents after the child's
25 death. Of course, you know, when the question of
0099
1 postmortem would come, I would really say the postmortem
2 examination will be carried out, but of course until
3 this time, I did not know that I had to really tell them
4 that their organ would be retained. That is why I did
5 not tell them.
6 Q. If we just look at your reply, page 70, the second line:
7 "Lately there has been some oversight on my part
8 to discuss the matter with parents and relatives and
9 therefore consent was not taken by my junior staff."
10 That, taken at face value, suggests you did know,
11 but had not been doing it?
12 A. I did know his previous letter. I think I have
13 responded in my statement on this section, if you want
14 to really see, I have already given, I thought,
15 a reasonable explanation. If you turn to that, it will
16 save repeating all these things.
17 Q. It is WIT 84/106. If we go down, Issue J4, you say the
18 first time you became aware was in 1988 or 1989?
19 A. Yes. I mean, Dr Berry's letter at that time came in.
20 At the same time, I saw Dr Joffe's and also Dr Jordan's
21 response, and what they were really saying was that
22 instead of clinicians really saying, it should be from
23 the hospital and we should devise a form which should
24 include, by itself, so that you do not have to spell it
25 out; it is written there, the parents will read and
0100
1 sign.
2 Q. On the basis that it would be easier for the parent to
3 cope with the information in writing rather than in the
4 emotion of the moment, to try and take in what you are
5 saying?
6 A. That is what I am saying, yes.
7 Q. Why is it that, having been told in 1988 or 1989 that
8 separate consent might be needed, you appear to have
9 been a bit lax about it until the letter we were just
10 looking at?
11 A. No, I was not lax, I was leaving it for management to
12 come out with the form and nothing came out.
13 Q. Mr Dhasmana, I think I am going to be probably another
14 I would think 20 minutes, at the risk of being wrong, in
15 the questions that I have to ask you.
16 Sir, it is perhaps better a matter for Mr Dhasmana
17 whether he would wish -- I do not know whether the Panel
18 would wish to consider Mr Dhasmana's feelings in the
19 matter, or simply take a break?
20 THE CHAIRMAN: We would of course wish to consider
21 Mr Dhasmana's feelings, as everyone else's. I think in
22 the circumstances, why do we not press on and complete
23 the evidence of Mr Dhasmana? Subject to your --
24 MR DHASMANA: I am totally guided by you, sir.
25 MR LANGSTAFF: Going back to the story, as it were,
0101
1 because I have taken you through a number of years for
2 a number of different purposes, and shown you figures
3 and dealt with the question of concerns, after the
4 question of Joshua Loveday, in the early part of 1995,
5 was there a considerable publicity about the Bristol
6 unit and the way in which paediatric cardiac surgery had
7 been performed?
8 A. In April? Yes.
9 Q. And that has been described as "whistle-blowing". Do
10 you think, from your perspective having been through it,
11 that there is a proper function for whistle-blowers to
12 perform?
13 A. I really feel, it is unfortunate that it has really come
14 to the extent of saying "whistle-blowing".
15 Whistle-blowing is, if you are somehow not talking to
16 the person, it relates to my operation or is seen as my
17 operation, and I have been seeing this person day in,
18 day out, at home, his home, my home, other hospitals.
19 How could he not communicate to me directly?
20 I am sure at the same time I am equally now not
21 just one person, because it is obvious now that a lot of
22 people have really come out here saying that there were
23 a lot of problems, and I am afraid they are all taking
24 a high moral ground after the event. I wish they would
25 have done it right at that time. If they had that much
0102
1 of a conviction, why could they not have come out in the
2 open and talked to me? We would have had an open
3 meeting, an inquiry or whatever; we would not have been
4 in this position now.
5 There was no need for whistle-blowing, as I really
6 see it, and it is unfortunate that somebody has to
7 really do that. I do not know why it happened.
8 Q. You have obviously puzzled in your mind why it might be
9 that people did not come to speak to you.
10 At WIT 213/26 you respond to a statement we have
11 had from Julia Thomas. If we scroll down to
12 paragraph 4, you say you do know that in the mid-1990s
13 you were under a lot of pressure and a bit more
14 outspoken in your remarks during the ward rounds:
15 "I could be seen as being abrupt without myself
16 being aware of it. Miss Thomas would remind me, and
17 I would go back and apologise to the nurse concerned if
18 I had hurt her feelings."
19 So there were occasions, were there, that you
20 had -- because Miss Thomas said something to you -- to
21 go to a nurse and say, "I am sorry, I did not mean it",
22 or something like that?
23 A. Of course, once this thing became public and I have come
24 to known that people have gone out and were talking
25 without talking to me, and whom I thought were seeing me
0103
1 every day and I was treating them like a friend, so of
2 course I was a little bit, you know -- I would say at
3 times quite a bit upset and unhappy about the working
4 position. Sometimes, in the round, I could have reacted
5 that way and that is why I have admitted it and said
6 that, and I have no hesitation going back and
7 apologising to the person concerned.
8 Q. Perhaps it is the same point, but I ought to give you
9 the chance to comment on it. If we look at UBHT 228/1,
10 this is a letter of October 1995, so after the events
11 surrounding the operation on Joshua Loveday. It is from
12 Fiona Thomas, and she is complaining to you that you
13 were verbally aggressive to the identified person on
14 Ward 5A. She says, "Why didn't you come and speak to
15 me? It is totally inappropriate to speak in that way",
16 and so on. She says:
17 "I have discussed the issue with the senior staff
18 nurse on Ward 5A who has informed me that 9 out of 10
19 nurses will not do a ward round with you as they are
20 frightened of what you will say to them. The theatre
21 staff are also standing up for themselves and some are
22 refusing to scrub for you in theatre.
23 "I am sure this may be a shock to you, to hear
24 that the nurses have a negative attitude towards
25 you...", and saying it must improve.
0104
1 A. That letter is not true. I talked to Fiona after that
2 and she knows the background. Do you want me to narrate
3 the background to this letter? I think, you know,
4 I cannot explain this letter unless I tell you why it
5 happened.
6 Q. Then tell us?
7 A. I go into the operating theatre. This is an adult
8 patient who has been anaesthetised and who is about to
9 be operated on, and then I see the patient has not been
10 shaved. This is not the first time; it had happened
11 before. I had talked to the nurse in charge of the ward
12 and of course there is always some explanation. So
13 I had talked to her before and I said, "Why can't
14 somebody really keep an eye on this thing? When the
15 patient is going down to theatre, somebody should shave
16 him."
17 Having done that, I see it again when the patient
18 is in theatre. I tell my junior staff and somebody,
19 "Please, if you do not mind, could somebody just shave
20 the patient"? They are doing that, and this is not
21 right. We are in the cardiac theatre and are ready to
22 do the operation, and the patient is being shaved
23 there.
24 So I pick up my phone and I want to talk to the
25 Sister in charge of the ward. The SCA picks up the
0105
1 phone and she is a very bubbly girl, and of course we
2 used to say "Hello", "Good morning, sir", various
3 things, and talk. I said, "Who is there?", so she
4 says. I know this girl very well, so there is no real
5 problem, but I said, "Sarah, I need to talk to [whoever
6 is Sarah's boss]." She does not understand the
7 seriousness of the problem. She says no, they are
8 having what they call the 11 o'clock change-over duty,
9 and they are having that meeting. I said, "Well, can
10 somebody come and talk to me on the phone?" She comes
11 back, "I will take a message". I said, "Sarah, it is
12 not related to you, it is not your job, what I am really
13 going to talk about". She said, "No, tell me and I will
14 convey it to them". I said, "Well, if you want to
15 hear..."
16 Now, you see, I am a surgeon. The patient is on
17 the table, has not been shaved. Of course I am
18 annoyed. So I really tell her, "Please tell Sister that
19 I will not be a very happy person when I come up and see
20 her" because this is what had happened.
21 Now, that is all I really told her. If she
22 thinks, you know, that I was verbally aggressive, I do
23 not know who else in my position would say anything
24 different, having tried to talk to the nurse in charge.
25 This was the situation.
0106
1 I talked to Fiona. Fiona said, "I have a problem
2 with the nurses, a shortage and various things. You
3 still should not be rude." I said, "This is not
4 rudeness. You have to consider the patient on the table
5 and infection. If a person tomorrow gets an infection
6 and various other problems, it is I who have to answer
7 the patient".
8 So in a way, that is what it is she was really
9 saying. And the nurse in charge -- that is not quite
10 correct. I think I have responded again in my statement
11 to Fiona Thomas and I have explained that that letter is
12 not true; it does not reflect the truth in it. It is in
13 my statement, if you want to read that, if you like.
14 But I think I have explained the reason.
15 Q. I need not ask you more about that letter. You had to
16 be given a chance to say what the background was to it.
17 During 1995 the idea had been, had it, that when
18 Mr Pawade came you would assist him on a part-time
19 basis, so that he had some cover, and Mr Wisheart would
20 stop operating on children?
21 A. That is correct.
22 Q. After the report from Messrs Hunter and de Leval,
23 I think you had personal letters from Mr de Leval to
24 which you responded, thanking him for his kindness and
25 support.
0107
1 A. Thank you.
2 Q. In June 1995, did Dr Roylance have discussions with you
3 seeking to persuade you to take up adult work only?
4 A. Yes, he did.
5 Q. You were reluctant?
6 A. Yes, I was.
7 Q. Were cardiologists continuing to refer cases to you?
8 A. Well, I did notice, when I returned from holiday in
9 August, that the referrals had now minimised -- they had
10 not completely stopped but they had minimised, but
11 I expected that, because if you have one full-time
12 dedicated paediatric cardiac surgeon who has no waiting
13 list, he has just started, I expected that. But I did
14 not realise that there was some other motive behind it.
15 Q. What other motive do you see?
16 A. Later I was told that I should not be doing any more
17 paediatric work.
18 Q. We have a letter at UBHT 61/350, which is a letter from
19 Mr de Leval to Dr Roylance of 13th September. Can we
20 scroll down?
21 "I have just heard that Mr Dhasmana has been asked
22 to relinquish his functions of paediatric cardiac
23 surgeon."
24 He says what a surprise it is. In the third
25 paragraph he says:
0108
1 "I am led to believe that the quality of
2 Mr Dhasmana's work is not disputed ..."
3 The question I am asking about this letter is not
4 its contents but whether you were ever shown it at the
5 time?
6 A. No, I came to know about this letter -- I think it is
7 too close to the GMC. Whether it was at the GMC --
8 Q. This is September 1995.
9 A. I am sorry. I mean, I knew about it a few weeks after.
10 Whether it is possible that before Dr Roylance was
11 leaving --
12 Q. So someone did tell you about this letter?
13 A. Yes.
14 Q. I do not want to trouble you with any of the rest of the
15 history which continues from then. There are one or two
16 points I have to pick up with you, if I may. You were
17 upset to lose the paediatric work?
18 A. Very much so, yes.
19 Q. Given the opportunity, would you feel able to operate on
20 children again?
21 A. Not now, because now four years have gone, really, since
22 I have done the last paediatric operation, but at that
23 time I was really very upset because here I have shown
24 in my record that I was improving, and the last five
25 years of my work, I would say, except for the arterial
0109
1 switch, was better than average in the country. The
2 de Leval and Hunter committee also in a way supported
3 that. It was their recommendation that I should
4 continue. Mr de Leval and Hunter, they also said that
5 if I wanted to do full-time paediatric work, which I did
6 tell them because paediatric cardiac surgery I loved
7 more than the other side, then I should really leave
8 adult cardiac surgery. They advised the Trust that if
9 I wished that, then my adult duties should be shifted to
10 the other side, but in the present situation, it should
11 just be that I should help and assist Mr Pawade to
12 develop the unit.
13 I had no problem with that, so I thought I had
14 already proven in my record that I was an above average
15 paediatric cardiac surgeon. I could not say "very good"
16 because my neonatal switches were not that good, but the
17 Hunter/de Leval report also supported me and here I am
18 being asked to leave paediatric cardiac surgery mainly
19 in response to media pressure which has come up since
20 April 1995. That is what upset and distressed me.
21 But one could really see that, in spite of that
22 media pressure, when I moved out from paediatric to
23 adult, my adult work did not suffer; it was reviewed by
24 further inquiry and found to be good. In the subsequent
25 two years, the UBHT's own audit showed me I was the
0110
1 number 1 and number 2 surgeon out of four in adult
2 work. So my work was, I think, quite good. That is the
3 reason I was very upset, the way it was taken away from
4 me. I felt it was taken away from me; I did not stop
5 doing it.
6 Q. Did you feel that the team spirit was affected after the
7 Joshua Loveday operation?
8 A. I think morale was very low.
9 Q. Had people who had previously been supportive of you now
10 become hostile to you?
11 A. Yes.
12 Q. You have spoken about Mr Brawn and how you went to see
13 him in Birmingham. When you went to see him in
14 Birmingham to talk to him about the neonatal switch,
15 which you were then reviewing, in December 1992, you
16 told him why it was you were going, because you had
17 a run of failures?
18 A. Yes.
19 Q. Did he say anything to you about whether you should stop
20 or continue?
21 A. No. That is why I was making the point the day before
22 yesterday that he gave me a video: "The next time you
23 operate, have a good look at it, so this will be a type
24 of refresher for you". He gave me no indication that
25 I should not be doing it. I was quite surprised when
0111
1 I heard, at the GMC, he said -- he also meant as if he
2 did not know me.
3 Q. He suggested, I think, that you should have stopped
4 before you did.
5 A. Well, he said that he could not be certain when to stop,
6 but if it was him, he would have stopped sooner than
7 I had stopped. That is how he put it. But I was quite
8 surprised that Mr Brawn, after going to see him twice,
9 watching his operation on three occasions, meeting him
10 at Paris and in the same room looking at the same film
11 and talking about it, at the GMC he expressed some
12 distance from me, which I did not realise before.
13 I wish he could have been a bit more honest, if what he
14 said at the GMC or in his report was really how he felt
15 at that time.
16 Q. Did you speak to him at all before or immediately after
17 the operation on Joshua Loveday?
18 A. No. I mean, again, when I came to know that people had
19 been in touch with him, before Joshua Loveday operation,
20 he knew that I had been to him twice; he knew that we
21 had talked about the problem. He could have just talked
22 at the same time to me, saying, "Janardan, you are going
23 to do this operation tomorrow. I think it would be
24 better if you don't". Certainly I would have respected
25 his opinion more than anybody else at that time.
0112
1 Q. I have asked you whether you had ever heard from various
2 other people about their concerns. I have not asked
3 whether you ever heard anything from Dr Doyle prior to
4 the Joshua Loveday operation?
5 A. I think you asked me yesterday whether I had anything
6 from Dr Doyle. No, Dr Doyle has never been in touch
7 with me at any time.
8 Q. I have not asked you about Sister Herborn.
9 A. Sister Herborn I remember, because she has made that
10 statement to the GMC also. I think it was just like
11 that, you know, that day, on Tuesday or Wednesday, when
12 I am either in-between cases and she is asking, "What is
13 this meeting tomorrow?", and then I just simply said,
14 you know, this is about the switch. Her next question
15 was, "I thought the switches were stopped". I said,
16 "No, neonatal switches were stopped, not the other
17 switches".
18 That is what this meeting is about. That is where
19 it stopped.
20 Q. Finally, you say you went to quite a number of meetings
21 at which there were other people in the same field. It
22 was one of those in October 1994 when you heard that
23 concerns had been expressed by Professor Angelini and
24 Dr Bolsin.
25 Did you, through that source or any other, become
0113
1 aware of the circumstances surrounding the
2 de-designation of paediatric infant and neonatal cardiac
3 services nationally?
4 A. I myself attended a meeting, a BPCA meeting, in the
5 British Cardiac Society office in 1992 or 1993 -- I do
6 not know whether Dr Silove would have been there -- but
7 Dr Hunter was chairing the meeting. At that time, the
8 recent report was being discussed and it was suggested
9 that although we are discussing it, from what we hear,
10 the Department of Health is going to completely finish
11 it off anyway.
12 Q. Was there a financial motive behind the unit retaining
13 supra-regional status which meant that paediatric
14 cardiac surgery would be done in Bristol when otherwise
15 it might not have been?
16 A. I do not think I understand the gist of your question,
17 really, because I do not know much about finance myself.
18 Q. Suppose that some children had not come to Bristol; they
19 had been referred elsewhere?
20 A. I see. That decision was taken in 1983/84 and I was not
21 in any position to make that decision at that time.
22 Q. What about the decision to develop operations such as
23 the neonatal arterial switch, to look to increased work
24 load in paediatric cardiac surgery? Was there
25 a financial reason why that was desirable, so far as you
0114
1 know?
2 A. No. I was trying to develop the arterial switch for
3 clinical needs; I had nothing financial in my mind.
4 Q. Finally, do you know whether any of your surgical or
5 cardiological colleagues are or were Masons?
6 A. No. I still do not know. I am not; that, I can tell
7 you.
8 MR LANGSTAFF: I did not think you would be, somehow.
9 Sir, those are all the questions that I have, save
10 for the very last one, which we ask all witnesses, which
11 is this: whether you, Mr Dhasmana, having been asked
12 lots of questions over the last three and a half days,
13 feel that there is something that you ought to have put
14 better, that you wanted to add or you have noted about
15 what you have been asked, or something you would wish to
16 say?
17 MR DHASMANA: I am very grateful for that opportunity,
18 because I felt that a lot of things have been said about
19 me in the media and in various other corners, and
20 probably this is the first opportunity I really have to
21 put something from my side. I would like to take that,
22 if that is all right. I am grateful for that.
23 First of all, I would like to express my regret to
24 parents of all children who have unfortunately died
25 following surgery, and I wish I could turn the clock
0115
1 back, but it is not possible and except for expressing
2 my regret, I feel I cannot do anything more.
3 One thing I do want to reassure everybody, I was
4 not and I am not a cavalier surgeon. I did not, and
5 I do not, risk any patient's life until I believe fully
6 that I can benefit that patient with my intervention.
7 Unfortunately, it did not work on many occasions
8 and I wish I had not operated on those children. Very
9 recently, the media have even used the term "guinea
10 pig", that I used patients as a "guinea pig". I have
11 never done that, and I would never believe in using
12 a patient as a guinea pig. I followed the practice at
13 that time, as I saw my elders and my seniors doing it,
14 and my trainers doing it, and when I went to another
15 centre, other doctors doing it.
16 I am sure this Inquiry will find some guideline to
17 prevent again what has happened before. I have already
18 had a lot of distress, but it has distressed me even
19 more to see the headline that a disgraced surgeon "used
20 children as guinea pigs". I have seen, in the
21 transcript, terms used, that dedicated doctors do not
22 make competent doctors, which I think is wrong. It is
23 dedication which really makes you see where you are
24 going wrong, improve on, and hopefully achieve the
25 results which you want to. As far as my dedication is
0116
1 concerned, I think people know about it. I do not
2 consider myself an incompetent doctor and I hope the
3 Inquiry finds that out.
4 My results, barring arterial switch, should speak
5 of myself as a surgeon, and I hope the Inquiry looks
6 more carefully to make a meaningful judgment on that.
7 I am a surgeon. I have been trained as
8 a surgeon. I do not know the politics and
9 unfortunately, nowadays, for any clinician to work
10 successfully you have to be a politician, and that is
11 a sad state of affairs. People I have worked with for
12 20 years in the same hospital, and this distresses me
13 now, to find that I am not considered as one of them.
14 I do not know why these letters have been flying around
15 about me without me being in the picture. If these
16 things would have been brought to my attention, I would
17 have been the first to stop and say, "Come on, have
18 a look at this". Some of them have really said that if
19 they had really come to me, they would have told me, it
20 would have come out in the open, but if you felt that
21 strongly, why were you afraid of letting this thing come
22 out in the open?
23 A lot of people, my colleagues, who now really say
24 that they are seeing a problem, especially the
25 anaesthetists, they were not even on the scene. Two of
0117
1 them were appointed after June and July 1993. By that
2 time, as I said, the worst of the problem had already
3 gone over. A lot of things have come on at the time
4 when we were already working to improve the situation.
5 I have been working hard in my way. It was not
6 dramatic: it was slow, tedious. Unfortunately, you
7 could say, I was going through the process.
8 I saw the problem as I saw it in Bristol, and
9 I was trying to improve in my work, working for a split
10 site right from the very beginning. You have letters in
11 1987 I was pushing to get open-heart surgery moved to
12 the Children's Hospital. We worked to have a dedicated
13 paediatric cardiac surgeon in 1990 and these things were
14 coming in fruition in 1994/95, which I thought was the
15 best time of my life, when I really was dropped like
16 a bullet from a very high place. I was asking for help
17 all the time. The arterial switch, I was not the one
18 who was really just, you know, doing it and not telling
19 anybody. I was doing it and then asking people, "What
20 has gone wrong?" I was asking for help. I did not get
21 it locally. I go to outside, ask for help. I thought
22 I was getting very good help. That is why I stuck with
23 him. Now I am very pained that he thought that was not
24 a good training. I wish he would have told me at that
25 time. Things could have been a little different.
0118
1 All these things, what have they done to me? They
2 have ruined me professionally, financially, my family
3 life has gone and I have lost confidence in myself.
4 This is the first time in the last two years that I have
5 been able to speak to any audience for three days.
6 I was not sure on Monday whether I would be able to
7 really stand up to these questions. Thank God Almighty
8 for giving me the courage. All this courage has really
9 come from support which I had from my close relatives,
10 and there are still patients and parents who have
11 continued to support me, making me feel that I am still
12 trusted in some corners.
13 Again, I emphasise, whatever suffering I have gone
14 through, and I am going through, is no match to the
15 suffering which you had with the loss of your child, and
16 I wish I could turn the clock back. I cannot say any
17 more. Thank you very much.
18 THE CHAIRMAN: Mr Partridge?
19 MR PARTRIDGE: I have no questions, thank you.
20 THE CHAIRMAN: Mr Dhasmana, thank you. We are much assisted
21 by your evidence. I think we will take lunch until
22 5 past 2.
23 (1.35 pm)
24 (Adjourned until 2.05 pm)
25 (2.15 pm)
0119
1 MR LANGSTAFF: Mr Willis, if you would stand, please to take
2 the oath?
3 MR STEPHEN WILLIS, (SWORN):
4 Examined by MR LANGSTAFF:
5 MR LANGSTAFF: Mr Willis, your full name is Stephen John
6 Willis?
7 A. It is.
8 Q. You would like to be addressed as Steve?
9 A. That is fine, yes, thank you.
10 Q. Your wife is Michaela Willis who has given evidence to
11 us already but in her case limited to one particular
12 issue, that of the retention of tissue?
13 A. Yes.
14 Q. You want to tell us about events surrounding the brief
15 life of your son, Daniel, who was born on 18th May 1993
16 and who died 7 days later at the Bristol Royal
17 Infirmary?
18 A. Yes, that is correct, yes.
19 Q. You were first told that something might be wrong,
20 were you, when very shortly after Daniel was born you
21 received a telephone call from your wife to say that he
22 had been taken down to the Special Care Baby Unit
23 because he was a little blue?
24 A. Yes, that is correct.
25 Q. That was in North Devon. Dr Richardson who was
0120
1 a paediatric consultant looked after you and told you
2 fairly quickly that Daniel would have to be transferred
3 in the Bristol Children's Hospital?
4 A. Yes.
5 Q. I think, do you have pretty well nothing but praise for
6 the way in which Dr Richardson dealt with you and your
7 family?
8 A. Yes, that is right, yes. Dr Richardson was very
9 helpful, very open, very honest and very supportive.
10 Q. Some things I think in your statement -- we ought to
11 have your statement on the screen, WIT 285/1, it
12 finishes at page 15. That is your signature at the
13 bottom?
14 A. It is.
15 Q. Some of the matters we are going to go on to discuss
16 I think are very clear in your mind?
17 A. Yes.
18 Q. Are some not?
19 A. Quite possibly. Some of the events I remember
20 particularly well because they were particularly
21 important to me at the time and some were particularly
22 important to me afterwards, so they tend to sort of
23 stick in the memory more so. Especially as there was
24 a couple of years in between Daniel's death and the
25 revelation of the problems at Bristol.
0121
1 Q. One of the matters which you give evidence about in the
2 statement, page 8, paragraph 20, if we turn over the
3 page we see how it comes, is about a visit you had at
4 Daniel's bedside from a doctor who described herself as
5 an anaesthetist for an operation the following day.
6 When she was describing what would happen she burst into
7 tears?
8 A. Yes.
9 Q. You identify that person as Dr Susan Underwood?
10 A. Yes.
11 Q. Is that something which on reflection you would wish to
12 change?
13 A. Yes, it is. That statement was made following research
14 because we were not sure exactly who the person was and
15 we did some research and we actually found out from
16 Dr Stephen Bolsin a name of who he thought it was and we
17 were pretty certain we had got the right person, but it
18 since transpires that it was not Dr Susan Underwood, it
19 was Pippa Swayne, as later research sort of indicates to
20 us that she was the anaesthetist who actually came to
21 speak to myself and my wife the night before the
22 operation rather than Dr Susan Underwood. It was
23 a genuine mistake which was, it was researched but
24 unfortunately we were given, with the best intentions in
25 the world we were given the wrong name.
0122
1 Q. In some of the details you set out in your statement the
2 product of research like that?
3 A. That, so far as I can recall is the only one we really
4 needed to find out. Everything else really I think is
5 from memory or from prompting sort of to remember things
6 when I was making the statement.
7 Q. With that correction, is the statement do you think,
8 full complete and accurate?
9 A. I have read it this morning, yes, so far as I am aware
10 and to the best of my recollection, yes, it is.
11 Q. You want to highlight I think a number of specific
12 matters. We will come to those as we go through the
13 story.
14 A. Certainly.
15 Q. For that reason, because the Inquiry will take your
16 statement as read, if I miss anything, please, either
17 remind us of it at the end if you think it is important
18 but otherwise assume -- and you would be right -- that
19 it will have been taken as read. I shall try and focus
20 upon the matters which you have indicated to me are of
21 particular importance to you or are particularly clear
22 in your memory.
23 A. Okay, fine.
24 Q. We had left Daniel's story with him being transferred to
25 the Children's Hospital, you I think not having any idea
0123
1 about which centre was good, which centre was not and so
2 on?
3 A. Yes.
4 Q. When you got to the Children's Hospital, you had been
5 following on behind Daniel in your car. Did you speak
6 to anyone about his condition?
7 A. Well, there was lots going on in the hospital at the
8 time. Can you be more specific, sort of ...
9 Q. You recall going down to see Dr Joffe?
10 A. Yes, that was a little later, sort of after we had
11 arrived.
12 Q. What in particular do you have as a memory of your
13 discussion with Dr Joffe?
14 A. I am a little bit squeamish personally and the sight of
15 blood makes me sort of feel a little uneasy so when we
16 were taken into -- there was no blood involved in this
17 particular case, but I am using that in order to
18 highlight how I feel about things. When the monitor was
19 put on to Daniel to show how his blood was flowing and
20 so forth, the blue and the red, the oxygenated blood and
21 the blood returning, I felt odd about looking at that.
22 Although I was in the room I just turned round to sort
23 of try and sort of distract my vision of what was going
24 on, although I could hear it because it was only
25 a couple of metres away.
0124
1 I turned to one wall in particular which was on
2 the left as you went into Dr Joffe's consulting room and
3 I looked at the charts or graphs on the wall and then
4 I was torn between looking at what was going on and
5 looking at the charts because the charts were referring
6 to mortality -- again I cannot remember exactly what was
7 the operation they were referring to but it seemed that
8 in that office or that consulting room somebody had been
9 keeping a chart, tracking all the deaths of children who
10 had come through there on particular operations.
11 I think it was broken down into several different
12 operations but I cannot really remember the detail other
13 than sort of once I saw "mortality", as I put in my
14 statement I thought this was a little bit bizarre. You
15 were coming in here with a child of your own who is very
16 poorly and you turn to one of the walls and all it talks
17 about is the death of children.
18 Q. Is "bizarre" the right word to describe the way you
19 found it, do you think?
20 A. There were probably many other words to describe it, but
21 unusual and upsetting and strange and, I suppose it does
22 describe it quite well in one respect, in that I did
23 think these people obviously just look at a piece of
24 meat rather than a human being, to them it is just
25 a number on the graph and so, I do not know what words
0125
1 other people might use to describe it, "bizarre" is sort
2 of one that sprang to my mind.
3 Q. Can you help me with the nature of the graph you saw.
4 First of all, how large was it or they?
5 A. I would say it was something in the region of flipchart
6 size which I think is -- would that be A2 or A1.
7 Q. Maybe A1, I do not know. You tell me because you saw
8 it.
9 A. Yes, sort of about that wide and that sort of tall, if
10 that is any --
11 THE CHAIRMAN: That may not show up on the transcript!
12 A. About a metre square, around that size.
13 THE CHAIRMAN: We will get it right later, perhaps.
14 MR LANGSTAFF: A metre square is very helpful. Was there
15 one on the wall or was there more than one?
16 A. There were several, there was approximately around four,
17 there may have been slightly more. I did not exactly
18 sort of stand there counting them, I was ...
19 Q. Hand drawn like a flipchart?
20 A. Yes, yes, definitely hand drawn. I do recall there was
21 some done in black ink and some in red ink, although
22 what that indicated I could not help you with.
23 Q. It was a graph?
24 A. Yes.
25 Q. A line graph, one of the ones that has mountains and
0126
1 valleys, or was it a bar graph?
2 A. It was a line graph -- a bar graph, is that the same
3 thing?
4 Q. A bar graph is the one with the columns of different
5 heights. A line graph is the one which goes from point
6 to point and therefore is a continuous line but it tends
7 to have sharp peaks and sometimes troughs.
8 A. Yes, yes, that is what it was on mine.
9 Q. The writing on it that let you know it was mortality or
10 death?
11 A. Yes.
12 Q. Where was that? Was it in print, was it in handwriting?
13 A. No, it was handwritten. As I am recalling it now,
14 I think it was in black ink either at the top of the
15 paper or at the bottom of it but I can remember it being
16 handwritten in black.
17 Q. Apart from the fact that it was black and red which you
18 tell us in your statement that it was on a piece of
19 paper about a metre square with this identification: do
20 you remember anything about the years to which it
21 related?
22 A. It was current to the time, I cannot remember how far
23 back but I can remember sort of wondering if Daniel
24 might be the next little mark on one of these graphs, so
25 that is how I can recall it was current to the time.
0127
1 Q. Do you know whether it related to any particular
2 operation or procedure or category of patient?
3 A. The only category as regards children or babies, that
4 sort of -- I am pretty clear in my own mind, it did not
5 relate to adults but then you would not expect it to
6 anyway in a Children's Hospital, would you.
7 Q. Did it give you the impression perhaps of something that
8 may have been put there having been used at a lecture or
9 presentation?
10 A. No, it struck me as having been put there for
11 information purposes for people using that particular
12 room or office.
13 Q. The room or office was one where there was an
14 echocardiogram?
15 A. It is.
16 Q. Did you understand that it was Dr Joffe's own room or
17 was it a room in general use, amongst others, by
18 Dr Joffe?
19 A. I have always believed it was Dr Joffe's room. Yes,
20 I have always believed it was Dr Joffe's room, I did not
21 sort of have an opinion of the people that used that
22 room but I always felt it was his room, full stop.
23 Q. Exploring that for a moment: what is your feeling based
24 on?
25 A. The time really. It is not a question I have ever asked
0128
1 myself. I am trying to relate back to that time. All
2 I can ever remember is we were going to Dr Joffe's room
3 to have an echocardiogram of Daniel's heart and it was
4 that simple. It was just relating back to the time,
5 that I think it was his room.
6 Q. Plainly you were upset by seeing a chart which
7 indicated, as you have said, that perhaps to the
8 hospital children were numbers rather than people.
9 A. Yes.
10 Q. Looking back on that and trying to draw lessons for the
11 future, what do you think ought to have taken place that
12 did not?
13 A. Do you mean as regarding the charts on the wall?
14 Q. Yes.
15 A. Because if I was to advise the medical profession,
16 I would advise them not to have such things because they
17 are very, very upsetting to parents and information of
18 that nature should be probably made available to parents
19 if -- it is not something you just want to look at
20 without having it interpreted.
21 Q. One of the problems the Inquiry has to grapple with
22 perhaps is how information is best presented.
23 A. Yes.
24 Q. On one level no information is given about mortality at
25 all in that way, no parent may ever have the idea that
0129
1 there is mortality. The moment that a unit produces
2 records of mortality, then inevitably it is going to
3 seem it is looking at children as though they are
4 numbers rather than people. How does one avoid giving
5 offence by giving information?
6 A. I think it is the appropriate time and the appropriate
7 place. I do not know what more I can say about that.
8 I think the appropriate time and place was not just as
9 we had arrived in the hospital and just as we were
10 having preliminary investigations without really
11 speaking to -- we did speak to medical people prior to
12 that obviously, but we had no idea what to expect and it
13 was just, interpreting raw data or raw statements on
14 a wall about deaths of children was not the appropriate
15 time or the appropriate place for me as a parent to see
16 those figures.
17 Q. Seeing that chart I think is your firm impression, your
18 lasting impression of the meeting with Dr Joffe?
19 A. It is.
20 Q. You cannot now recollect any of the details of that
21 particular conversation?
22 A. Other than around that time as I put in my statement we
23 were told that Daniel would need a shunt the following
24 morning. I think that was Dr Joffe who told us.
25 Q. That was a catheter procedure I think which happened and
0130
1 you met Mr Dhasmana, did you, after that or before that?
2 A. I think it was after that, yes, I am pretty sure it was
3 after.
4 Q. He was able to tell you, as you tell us in your
5 statement, that the catheterisation had gone well, it
6 would I think have been what they call a septostomy?
7 A. Yes.
8 Q. You describe -- paragraph 13 of your statement, it is
9 page 5, the foot of the page -- the way in which
10 Mr Dhasmana explained to you the success of the catheter
11 operation, the septostomy, discusses two operations and
12 your recollection that he "Could say nothing good about
13 the Senning but was extremely positive about the
14 switch"?
15 A. Yes.
16 Q. You may have missed yourself his description this
17 morning of what he would say to parents about the
18 procedures. Because there will be plenty of time to
19 write in to the Inquiry, perhaps when you have had an
20 opportunity to look at what he said about his
21 explanation in general terms to parents, if you can just
22 confirm that is probably what he said to you or if you
23 feel it was not, let us know what he said to you that
24 was different.
25 A. Okay.
0131
1 Q. You were obviously very concerned about what the future
2 held for Daniel. Here he was, he had had one operation
3 already successfully. He needed another within a matter
4 of days. Did you understand that his life was seriously
5 at risk?
6 A. Yes.
7 Q. Did you talk to Mr Dhasmana about the chances of success
8 in the operation?
9 A. Yes, this is something that I recall very clearly, in
10 that we specifically or I specifically asked when he was
11 in the room with us what the success rate, the survival
12 rate, the death rate was for this operation and
13 specifically again went to the corridor outside the room
14 in the ward in the Children's Hospital to confirm his
15 answer with him again because I was continually
16 worrying, "Did I hear him correctly? Is it an 85 to
17 90 per cent success rate? Is that correct? That is
18 really good" and I wanted to reassure myself so
19 I followed him shortly after he had left the room to ask
20 him to confirm that this was the best place for him to
21 have the operation and what the success rates were.
22 Q. Suppose he had said "Well, this is a reasonable place
23 but there are better places. However, Daniel's
24 operation needs to be done as a matter of an emergency
25 and we can do it here, we have already started", what
0132
1 would your reaction, do you think, have been?
2 A. I would have inquired further as to what the other
3 options would have been. He may well have started it,
4 "Does that mean it is not possible to transfer him
5 somewhere that has actually got a higher success rate?",
6 that is what my reaction would have been.
7 Q. If he had said "Somewhere else may have a higher success
8 rate, but there is a risk in transferring a sick, young
9 baby like Daniel anywhere, any distance"; how would that
10 have affected the equation do you think?
11 A. I think more information would have been needed as to
12 what the additional risk was in transferring him and
13 where it may have been to and what the chances were of
14 a more successful outcome staying in Bristol or being
15 transferred elsewhere. I think sort of more information
16 would have been asked for and then obviously we could
17 have made the decision based on options that we may have
18 had.
19 Q. To what extent do you think looking back on it and
20 accepting hindsight can play tricks?
21 A. Sure.
22 Q. To what extent do you think the balance of advantage
23 would have come into it in any scientific way so that
24 you would have said to yourself "Well, there may be an
25 80 to 85, or 85 to 90 per cent chance of success here,
0133
1 that is what I have been told, it may be 95 per cent in
2 Boston, in the United States but the risk of transfer
3 are very great, therefore ..." To what extent do you
4 think looking back on it you would have weighed those on
5 any scientific as opposed to any emotional level?
6 A. Yes, scientific as in if we had known the statistics for
7 that particular surgeon or that particular hospital as
8 compared to the national average or international
9 average. But I think we would probably be only sensibly
10 talking about nationally rather than internationally.
11 Q. Again, I apologise if it complicates it and makes you
12 think back: suppose the surgeon had said to you "Well,
13 every case is different because every human being is
14 different, and even although one can classify this
15 condition under one head, there are differences between
16 one baby and another, and it is very difficult to give
17 you an accurate prospect of success here or there
18 because no baby is the average to which the national
19 average relates, so I cannot really give you the
20 greatest of assistance but I can tell you that here you
21 can expect something in the region of ..." and gone on
22 like that. Would the degree of uncertainty do you think
23 have persuaded you to stay where you were or go on
24 elsewhere?
25 A. I think I would need to know if Daniel's case was a more
0134
1 complicated or more straightforward operation, because
2 whilst there is not an average there is certainly sort
3 of, from the information I have sort of been made aware
4 of, it can be seen if an operation is going to be on the
5 face of it more difficult or more straightforward.
6 Q. You say that you asked him anyway for the success rate.
7 What rate did he quote you?
8 A. He quoted me 85 to 90 per cent success rate.
9 Q. Can you look at page 6 of your statement, paragraph 15?
10 What is said there is when you specifically asked for
11 the success rate you were told unequivocally 80 to 85?
12 A. Yes.
13 Q. Are you confident that it was 85 to 90?
14 A. Sorry, no, it was 80 to 85, sorry, my mistake.
15 Q. You were confident twice in evidence. Again you will
16 appreciate why I push you on this --
17 A. The first mistake was through research, as I said, the
18 second one is actually sat here sort of under pressure
19 from this particular forum, trying to get everything
20 precisely right, you know.
21 Q. Mr Dhasmana recollects that he would have said 20 to
22 30 per cent risk of mortality which is I suppose
23 80 per cent success down to 70 per cent. You do not
24 agree with that?
25 A. I made this statement when I was not under the pressure
0135
1 I am under now, with a clear head, so I would stick with
2 -- I would say that the statement was correct.
3 Q. Did you ask him anything more than simply statistics,
4 simply "What is the chance for Daniel in this
5 operation?" You say in paragraph 17 that you
6 specifically asked him whether this was the best place
7 or whether there was somewhere else that the operation
8 should be performed.
9 A. I did say that a few minutes ago, yes.
10 Q. What was his reply to that?
11 A. As I have put here, really, he told me everything would
12 be fine, everything will be fine here. You know the
13 exact words are difficult, but that was what was said.
14 I made this statement earlier this year which is sort of
15 6 years later. To remember the exact words somebody
16 said to you 6 years ago is not --
17 THE CHAIRMAN: Mr Willis, do not worry about the
18 precise differences here, it is your general
19 recollection to the best of your ability we are
20 interested in. Certainly no-one is anxious to point out
21 that you used this word there and that word there
22 because we are dealing with what we can recollect from
23 some time ago.
24 A. Thank you.
25 MR LANGSTAFF: Can I move on from there? I think we
0136
1 have probably covered that enough.
2 The one thing I should ask you: if somewhere else
3 had been suggested, Mr Dhasmana had not said "you are
4 fine here" or words to that effect, would you have been
5 able at that time to go somewhere else?
6 A. We would have been financially able if it is sort of, if
7 by your question you mean if we would have been able to
8 go somewhere else we had to pay for, we probably would
9 have been financially able at that period but also
10 I would have investigated further whether it was
11 possible to be transferred within the NHS at that time.
12 Q. We then go through to the night before the operation.
13 You have discussed previously what you would do during
14 the operation and you described how it was suggested you
15 should go out to Bristol while Daniel's operation was
16 being conducted.
17 Did you meet at some stage someone called Helen
18 Stratton?
19 A. Yes, we did, yes.
20 Q. Was that before or after the operation?
21 A. That was before the operation.
22 Q. When you came back from Bristol having wandered around,
23 waiting, and I imagine worrying, did you see her again?
24 A. Yes.
25 Q. Is there a very clear recollection that you have about
0137
1 something that happened then that you will never forget?
2 A. Is this the first time we came back?
3 Q. The first time you come back.
4 A. As I have said in the statement really, that is the
5 recollection that I have, that we came back and we were
6 told everything was, as far as she was aware, going to
7 plan but there was no real news yet and we should
8 disappear and telephone again later or call back later.
9 Q. There were no problems with that?
10 A. No, we were quite -- we then sort of -- our spirits were
11 lifted in the afternoon part of the day.
12 Q. When you came back again after that?
13 A. When we came back after that, as I have put in
14 paragraph 23, we were eventually taken -- Helen Stratton
15 took us to her room and the first thing she did was
16 introduce us to the intensive care nurse who will be
17 looking after Daniel. That was her first words to us
18 and we thought "Absolutely wonderful, this is great".
19 Q. Because it meant?
20 A. Because to us, if it happened to anybody, if you were
21 told "This is somebody who is going to be looking after
22 this person" you think "This is good, he has come
23 through it, he is going to be coming into there very
24 shortly". After a short pause which would not have been
25 more than seconds, she said "But we do not think he is
0138
1 actually going to make it though". That one incident
2 sticks in my mind and I do not know why somebody who
3 must have had the training that Helen Stratton probably
4 had to have been in such a position would have possibly
5 not realised how insensitive that was.
6 Q. You are lifted up only to be dashed?
7 A. Yes, yes.
8 Q. What message for the organisation of care and for the
9 future, for other parents who might be in a similar
10 position, would you wish to gain from that?
11 A. I do not suppose there was any easy way of telling
12 parents what she had to tell us, but obviously it would
13 have been better that the intensive care nurse had not
14 been there and we had not even been introduced to her if
15 the prognosis was -- as it was relayed to us immediately
16 sort of after the introduction.
17 Q. Do you think that in general terms honesty, even if you
18 are giving disappointing news, is a better policy than,
19 in colloquial terms, trying to break it gently?
20 A. It is for me. It is probably different for different
21 people but certainly there was no -- what happened to us
22 in Helen Stratton's office was not trying to break it
23 gently, I do not know what it was about, it was very
24 baffling to have been told that "This is the nurse who
25 is going to look after Daniel" when really what she
0139
1 wanted to tell us was "The operation has gone very badly
2 and he is probably not going to come through it".
3 Q. Was there any sense that you had that she might have
4 found it difficult to tell you bad news and that
5 therefore she began in what certainly is a falsely
6 reassuring and, as you describe it, very cack-handed way
7 at least?
8 A. I cannot really remember that sort of, I just remember
9 the words she used and how she told us rather than sort
10 of her demeanour and how she looked or sat or whatever
11 else.
12 Q. You shortly after that did get bad news from Mr Dhasmana
13 himself?
14 A. Yes.
15 Q. Did he come out of the operating theatre to speak to
16 you?
17 A. He did, yes. It was not actually shortly after that, it
18 was quite a while after that, it was probably a couple
19 of hours if I remember correctly because I think it was
20 between 5 and 6 o'clock when this was happening, I think
21 it was about 7.30 or around 7.30, quarter to 8 when
22 Mr Dhasmana came out to tell us that Daniel had died.
23 Q. You describe his distress and your reactions.
24 A. Yes. As he describes himself -- I did hear part of his
25 evidence this morning, as he described himself, he was
0140
1 emotional and he was to the point. He did not mess
2 about, he told us exactly what happened or that Daniel
3 had died and we did feel -- obviously we felt loss of
4 things but we did feel also sorry for him and felt that
5 he really did not know, he indicated he did not know
6 what had gone wrong, he did not know why he could not
7 save him.
8 Q. What I think you next wanted to focus on is your next
9 contact with Helen Stratton following the death?
10 A. Yes. She was with Mr Dhasmana when he came to tell us
11 about the death.
12 Q. Was there something that happened after that which you
13 feel was unfortunate?
14 A. Yes. I think there was certainly then a mentality that
15 -- it was as if there was some sort of unwritten or
16 written procedure then where parents must do X and then
17 they must do Y. Really we were very quickly ushered --
18 I would not say bullied, but getting very close to being
19 pressured into going down to see Daniel's body in
20 a Moses basket, around the operating theatre area.
21 I took him down to the operating theatre earlier in the
22 day, I carried him down to the operating theatre. And
23 we were given very little real choice in that situation,
24 we felt we were not really asked properly or were not
25 asked at all if we actually wanted to go and see him, we
0141
1 were told that that is what must happen.
2 Q. What was wrong about that as you now see it?
3 A. For anybody who has lost anybody near to them, they will
4 know people react in quite polarised ways when a close
5 relative has died. Some of us, like myself, actually in
6 the correct time, will maybe want to go and see the body
7 and say their farewells that way. Others, as in my
8 wife's case, would not actually want to go and see the
9 dead person or the dead body. That is what is wrong
10 with it, that you were not given the option.
11 Q. You were not asked?
12 A. Yes, precisely.
13 Q. The point you would like to make really is that a number
14 of efforts may be well meaning, such as taking a lock of
15 hair and a footprint and photograph?
16 A. Yes.
17 Q. But the parents should be asked?
18 A. Yes.
19 Q. Rather than it being assumed that the parent will always
20 or any parent will find that beneficial?
21 A. Yes, that is my view because also, following on from
22 that, I do not know if you are going to ask me the
23 question, if I can go on to the photograph situation,
24 now, is that okay?
25 Q. Yes, please.
0142
1 A. They also took a photograph of Daniel dead in his Moses
2 basket and sent that to us, which, again we did not ask
3 for that. It automatically happened and we, given
4 a choice would not have had that. It is strange because
5 once you have got the photograph of your dead child you
6 cannot really throw it away. So it was sealed in an
7 envelope and hidden away because it is quite a sort of
8 strange situation and unfortunately a year or so ago
9 I opened it and it is quite distressing to actually have
10 that in the house, it is difficult to know what to do
11 with it and we would not have had it if we had been
12 given a choice.
13 Again it comes down to not being -- all parents,
14 all parents in this room are probably different on how
15 they would approach it and probably many of them would
16 be glad of that photograph and probably some like myself
17 would not be.
18 Q. The point you are making is the need for consideration
19 of the views of the individual?
20 A. Yes.
21 Q. Accepting people are individuals and that they will
22 differ, but you, the administrator, the hospital, the
23 nurse need to know; that is the point you are making?
24 A. Yes.
25 Q. Is there something of a similar point you want to make
0143
1 about the retention of organs?
2 A. Only in so much as, again as I have said in my
3 statement, if we had been asked about retention of
4 organs for medical research purposes then we probably
5 would have said "Yes". But the way things have been
6 handled, to actually find out that parts of your child
7 were kept without your knowledge and the way it was
8 revealed to you years later is obviously again of
9 a similar nature, very distressing.
10 Q. Perhaps it is obvious what should be done about it, but
11 perhaps you would tell us in your own words how you
12 would put it, the way that matters like this should be
13 dealt with?
14 A. Yes, as you say it probably is obvious. I think, and
15 I have not investigated this further, but I think it was
16 said that it does say on some form somewhere that organs
17 may be retained. I do not know if that is true or that
18 is not true. Even if it does it is not obvious to you
19 when you have just gone through the death, you do not --
20 it is rather like the agreements we all sign when we buy
21 a new car or whatever. If we spent some time reading
22 all the small print on the back, we would be there for
23 the whole day. We might read it later on when we get
24 home, but in this case if it is in small print we should
25 be told orally that is what might happen and we should
0144
1 also be told if anything has been retained.
2 Q. You tell us about how the events of April 1995 were
3 handled when the story broke about paediatric cardiac
4 surgery at Bristol. There was publicity and you have
5 described your own reactions of shock and so on.
6 A. Yes.
7 Q. Until then, would I be right in thinking that you had
8 assumed that everything had been done that could be done
9 for the best?
10 A. Definitely, yes, yes. We felt, as you say, everything
11 had been done that could have been done and we felt
12 Daniel was just one of the unlucky 15 or 20 per cent who
13 did not survive and that there was no particular reason
14 why he was in that group as opposed to being in the
15 other group who had survived or should survive.
16 Q. What can you say about the way that that news to
17 a number of parents was dealt with by the institution as
18 a whole?
19 A. The news was on the -- I saw it first of all on the BBC
20 6.00 news on BBC 1. I think it was flashed up, as they
21 do flash up when they are going to bring on something in
22 the next few minutes and I called my wife in to watch it
23 because I had realised it was relating to Bristol but
24 I did not realise it would be relating to us.
25 We watched the article and there was a claim made
0145
1 on there that the BRI had set up a help line. So
2 I telephoned them, although there was not as I recall
3 a special number flashed up or anything. So I called
4 the main switchboard at the BRI only to be told that
5 they did not really know anything about this. They put
6 me through to the cardiac ward to be told there that
7 they did not know anything about this and they would go
8 and ask the Sister -- they asked somebody else anyway
9 and eventually an answer came back "No, we do not really
10 know anything about this, telephone back tomorrow during
11 office hours" or whatever.
12 My wife then sort of took over the telephoning of
13 Bristol and I think it was about 9 days later we made
14 a several calls, the exact number I cannot say. We were
15 contacted by either Mr Joffe or his secretary. Again,
16 for clarification of that you would have to ask my wife
17 because I was not involved at that time.
18 Q. So here you were, a help line set up because it was
19 anticipated people might be in distress?
20 A. Yes.
21 Q. Yet when you try and use the service there is no service
22 to be accessed very easily?
23 A. Definitely not on the day that the news was announced
24 that there was an inquiry, albeit sort of internally.
25 Q. I am asked to ask you to confirm that when you say
0146
1 "Daniel was just one of the unlucky 15 or 20 per cent
2 who did not survive" that that is a reference back to
3 the success ratio that you were given by Mr Dhasmana?
4 A. The 80 to 85 that we have now established, yes.
5 Q. It is the other side of the coin?
6 A. Correct.
7 Q. You make the point towards the conclusion of your
8 statement about how good and helpful you found the care
9 generally speaking at the Children's Hospital.
10 A. Yes.
11 Q. You make really the same comment there as you do in
12 respect of Dr Richardson, the paediatrician who first
13 referred you to Bristol?
14 A. Yes.
15 Q. The points which you have been making which stick out in
16 your mind are really points about giving the parents
17 information and choice and dealing with parents in
18 a manner which is sensitive to their feelings?
19 A. Yes.
20 Q. I have asked you a lot of questions. I have not as you
21 know taken you through every detail of Daniel's life and
22 treatment; is there any other point which you want to
23 make which you think I have not covered or anything you
24 would like to tell us which we have not yet dealt with?
25 A. No, I think anything I felt that I would like to bring
0147
1 to the attention of the Inquiry has been brought to
2 their attention.
3 MR LANGSTAFF: Thank you, Steve. There may be questions
4 from the Panel and possibly from Mr Lissack.
5 THE CHAIRMAN: There are no questions from us. Mr Lissack?
6 MR LISSACK: Nor me, thank you.
7 THE CHAIRMAN: Mr Willis, I am very grateful to you
8 for coming and talking to us this afternoon, we are much
9 in your debt. Thank you very much indeed.
10 (The witness withdrew)
11 MR MACLEAN: Sir, the next and final witness for today is
12 Mrs Rachel Ferris. Mrs Ferris, would you stand, please
13 to take the oath?
14 MRS RACHEL FERRIS (SWORN):
15 Examined by MR MACLEAN:
16 MR MACLEAN: You are still I think Rachel Corrie Ferris?
17 A. Yes.
18 Q. You have given evidence to us before arising out of the
19 first of three statements that you have now made to the
20 Inquiry.
21 A. Yes.
22 Q. I am sure the Panel will remember that you were
23 appointed General Manager of Cardiac Services at the
24 UBHT from November 1994?
25 A. Yes, that is right.
0148
1 Q. You had previously worked in the Directorate of Surgery
2 from May 1993?
3 A. Yes.
4 Q. Before that in various other aspects of health care
5 within Bristol?
6 A. Yes.
7 Q. Since you were with us last time, Mrs Ferris, there has
8 been quite a lot of paper generated in relation to your
9 evidence: first of all WIT 89/60, please? This is
10 a supplementary statement you made to the Inquiry
11 following on from your oral evidence last time having
12 had a chance to read the transcript; is that right?
13 A. Yes, it is.
14 Q. That ends, does it, at page 64?
15 A. Yes.
16 Q. That is right?
17 A. Yes, that is right.
18 Q. I think Mrs Maisey also put in some written comments
19 following your attendance last time and I think, if we
20 have a look at page 65, you have seen those?
21 A. I have not seen that, no.
22 Q. We will make sure you have the chance to see that,
23 Mrs Ferris. More materially for today's purposes, you
24 yourself have supplied a statement dealing with audit,
25 have you not, page 71?
0149
1 A. Yes, I have.
2 Q. That is the audit statement, is it not?
3 A. Yes, it is.
4 Q. If we go to page 82, that is the last page of that?
5 A. Yes, that is right.
6 Q. If we go to page 94, this is the first page of your
7 final statement dealing with Issue A and the concerns?
8 A. Yes.
9 Q. That runs to page 108, that is the last page of that
10 one?
11 A. Yes, that is right.
12 Q. I am not going to show you them, Mrs Ferris, because
13 I know you have had a chance to see these. In respect
14 of your Issue N statement we have had comments from
15 Margaret Maisey, from Hugh Ross and from James Wisheart?
16 A. Yes.
17 Q. We may want to refer to some or more of those as we go
18 along. It is right, is it not, when you became the
19 General Manager of Cardiac Services, we touched on this
20 last time when you were here, that your initial focus
21 was on adult work in the adult cardiac service?
22 A. Yes, that is right.
23 Q. Your interest in paediatric work in terms of being
24 a manager of it was going to be relatively fleeting?
25 A. Yes, the decision had already been made that the
0150
1 children were transferred and I understood my role to be
2 merely administrative to tie up those loose ends for the
3 transfer of that service.
4 Q. Can you speak up a little, please, Mrs Ferris? The
5 decision had been taken to end the split site and
6 Mr Pawade had been appointed but had not yet taken up
7 his post?
8 A. Yes, that is right.
9 Q. If we go to page 99, please, of your statement. I want
10 to go to page 95 please, paragraph 5:
11 "Prior to meeting Dr Bolsin, I had formed an
12 impression of him. I had been given the impression that
13 Dr Bolsin was a young, intense consultant who was
14 'rocking the boat'. He was portrayed as someone making
15 unfounded accusations, criticising Mr James Wisheart.
16 I had known Mr Wisheart prior to joining the Directorate
17 as a widely respected senior figure. At the time, I was
18 worried that he was being unnecessarily criticised.
19 I was therefore suspicious of Dr Bolsin before I met
20 him. I expected to find him implausible and, frankly,
21 odd. Some of my colleagues were clear in their distrust
22 of Dr Bolsin and I , perhaps naively, adopted a similar
23 view."
24 In fact prior to meeting Dr Bolsin you had not,
25 because you had not met him, had any opportunity
0151
1 yourself independently of forming any judgment about
2 him?
3 A. No, I had not had that opportunity, no.
4 Q. Who was it or from where was it that you got the
5 impression that he was "young, intense and 'rocking the
6 boat'"?
7 A. That impression had been formed really by a discussion
8 with my previous manager who was the General Manager of
9 the Directorate of surgery.
10 Q. Who was that?
11 A. Which was Janet Maher and we continued to meet and get
12 together following my appointment to the Cardiac
13 Services Directorate.
14 Q. Was she the source of the suggestion that allegations
15 against Mr Wisheart were being made, which allegations
16 were unfounded?
17 A. Yes, she was. She was the first person really that
18 I spoke to about Dr Bolsin, so the very first impression
19 I got of him was from those conversations.
20 Q. You told us last time -- the reference is page 99 of
21 your transcript last time, which is where I got the 99 a
22 moment ago from -- that you were told that "a witch hunt
23 was taking place to try and undermine the credibility of
24 Mr Wisheart", and the people who were doing it were
25 doing it "simply for their own motives and for their own
0152
1 agendas" and should not be believed, in fact should be
2 ignored; do you remember saying that?
3 A. Yes, I do remember that, yes.
4 Q. Who used the expression "witch hunt", if anyone?
5 A. I am not sure I can tell you that. That impression was
6 given to me by a discussion with Janet and also later,
7 sort of, within the Directorate so that -- I do not know
8 anybody actually did give me that particular label, but
9 that was the impression that I gained very shortly after
10 joining the Directorate.
11 Q. You seem to be making the point in this paragraph that
12 the accusations that were being levelled were not being
13 levelled at paediatric cardiac services generally or
14 paediatric cardiac surgery even, but were being levelled
15 at Mr Wisheart personally; is that what you understood?
16 A. Yes, we are talking about the period almost immediately
17 after I took up cardiac services, so the end of
18 November/beginning of December 1995 --
19 Q. 1990?
20 A. Sorry, the end of November 1994/December 1994. Yes,
21 that was the impression that I gained, that this was
22 something personal and related to Mr Wisheart. I did
23 not have an impression at that stage that this was
24 specifically related to paediatric cardiac surgery.
25 Q. So you did not even understand that the allegations
0153
1 against Mr Wisheart were about his paediatric work as
2 opposed to his adult work?
3 A. No, not at the first stages, no. It was presented as
4 a clash really between Mr Wisheart and Dr Bolsin.
5 Q. I was going to ask you about that: if Mr Wisheart was
6 the object of this talk or concern the initiator of it
7 as you understood it was whom?
8 A. Well it was Dr Bolsin. What, initiating the criticism
9 of Mr Wisheart?
10 Q. Making the allegations, yes?
11 A. Yes, that it was Dr Bolsin.
12 Q. How was it explained to you that the accusations against
13 Mr Wisheart were unfounded?
14 A. Because I think -- I do not remember the exact words --
15 but I think I tried to ask what exactly was going on,
16 what was behind it and sort of given the impression that
17 there was really nothing behind it. There was not
18 a sort of view that there were figures or evidence or
19 statistics to suggest that there was a problem. Just
20 that this is a personality sort of issue.
21 Q. You took up your post in November 1994, did you know
22 Mr Wisheart had a meeting with Professor Farndon at
23 about that time?
24 A. No, I did not know that.
25 Q. Which discussed adult and paediatric cardiac surgery?
0154
1 A. No, I was not aware of that meeting, no.
2 Q. You would not have attended the audit meetings that the
3 clinicians would have held?
4 A. I attended audit meetings with the clinicians at a later
5 stage. I cannot be precise about the date that
6 I started to go to the routine audit meetings, but
7 I certainly was not attending any audit meetings in
8 November or December 1994.
9 Q. In December 1994 there was a meeting in Dr Joffe's house
10 to discuss either the non-neonatal switch programme
11 generally, or Joshua Loveday in particular or some
12 combination; did you know about that meeting at that
13 time?
14 A. No, I had no knowledge of that at all.
15 Q. There is no mention here of any accusations of concerns
16 being levelled by Dr Bolsin or anyone else against
17 Mr Dhasmana?
18 A. No, although I became aware later that it was the
19 practice of both paediatric cardiac surgeons that was
20 being looked at. When I first joined the Directorate
21 and was trying to find out what was going on it was
22 really presented as an issue around James Wisheart and
23 Dr Bolsin.
24 Q. You say "later", I think we will see in your statement
25 shortly that you did not become aware of concerns about
0155
1 operations performed by Mr Dhasmana on children until
2 about a month after the Joshua Loveday operation; is
3 that right?
4 A. Yes, that is right.
5 Q. When Mr de Leval (as he then was) and Dr Hunter came to
6 Bristol?
7 A. Yes, I was not really aware that there was any specific
8 issue surrounding paediatric cardiac surgery until the
9 time of the Marc de Leval and Stewart Hunter visit.
10 Q. If we look at this paragraph again: why should you have
11 been worried that Mr Wisheart was being unnecessarily
12 criticised?
13 A. I think that was just my first reaction. I had known
14 Mr Wisheart and that he was a widely respected figure,
15 a senior figure and I just felt that if he was being
16 attacked unnecessarily and I had just been given the
17 impression that it was unnecessary, then I was worried
18 about that, it did not seem fair to me.
19 Q. Who were the colleagues, plural, who were clear in their
20 distrust of Dr Bolsin?
21 A. I think initially, as I have said, my main impression
22 was formed by a discussion with Janet Maher. But as
23 events unfolded really the sort of relationship with
24 Dr Roylance and with Margaret Maisey gave me that
25 impression, that they were not taking Dr Bolsin
0156
1 seriously.
2 Q. All three of those people you have mentioned were
3 managers --
4 A. Yes.
5 Q. -- to some extent or rather: Janet Maher,
6 Margaret Maisey and Dr Roylance?
7 A. Yes.
8 Q. What about the attitude of other clinicians who worked
9 in the cardiac services unit so far as you were able to
10 discern?
11 A. It depends what timing you are looking at. Obviously as
12 I had been there longer it became clear that there was
13 a very clear divide between clinicians in respect of who
14 supported or did not support Dr Bolsin.
15 I suppose if you are going to ask me who those
16 clinicians are, the clinicians that were in support of
17 Dr Bolsin were Professor Angelini and Mr Bryan. Those
18 who seemed to me to be suspicious of Dr Bolsin were
19 Mr Hutter, Mr Wisheart and Mr Dhasmana. So there was
20 a divide in that sense between those five cardiac
21 surgeons.
22 Q. The surgeons were split 3/2?
23 A. Yes.
24 Q. What about the anaesthetists?
25 A. I did not have such, in the early stages, a close
0157
1 relationship with the anaesthetists. Obviously as time
2 went on I became aware that Dr Davies and Dr Pryn were
3 on the Dr Bolsin side and Dr Underwood and Dr Masey were
4 on the Mr Wisheart/Dhasmana side, if you want to break
5 it down into specific sides. But, as I say, I did not
6 have such a close relationship with the anaesthetists so
7 I talked to them less and it was only at the later stage
8 that I started to talk to them more.
9 Q. Before you became aware of the difficulties which had
10 preceded the operation on Joshua Loveday, and you did
11 not become aware of that until February 1995?
12 A. No.
13 Q. Did you know that the anaesthetists had all written
14 a letter sent to Dr Monk in June 1994 expressing their
15 concern about a series of operations that Mr Dhasmana
16 did?
17 A. No, I knew nothing about the anaesthetists' letter until
18 -- I did not really know anything until after the
19 Marc de Leval visit.
20 Q. You have mentioned the lineup if you like of the
21 surgeons insofar as their attitude to Dr Bolsin with
22 Professor Angelini and Mr Bryan being more sympathetic
23 than the other three, if you like.
24 What about the relations between the surgeons
25 themselves? How, for example, did Mr Hutter and
0158
1 Professor Angelini get on?
2 A. I think it is fair to say that they had a professional
3 relationship but they did not get on particularly well.
4 Q. I think we have heard that expression once already today
5 from Mr Dhasmana: "professional relationship"; is that
6 a euphemism for not getting on?
7 A. I think it means that they did not like each
8 particularly much but they conducted their affairs as
9 professionally as they could. So they were not
10 unpleasant to each other in public areas or they did not
11 have major rows or slanging matches, they just got on
12 and did their jobs and spoke to each other when they
13 needed to, but they were not proactive about seeking
14 each other out to try and work together in any sort of
15 closer way.
16 Q. Were their offices, those two, Mr Hutter and
17 Professor Angelini, were they close by one another?
18 A. Professor Angelini's office was on a floor above, so he
19 was on level 7 and Mr Hutter was on level 6, so there
20 was a floor between them.
21 Q. They were never on the same floor in your time?
22 A. No.
23 Q. You said last time in the transcript that you were told
24 about the "witch hunt" as you put it. You said the
25 notion you had was that "people were doing it", in other
0159
1 words witch hunting "simply for their own motives and
2 for their own agendas and should not be believed, in
3 fact, should be ignored". Did anyone ever tell you to
4 ignore Dr Bolsin or what he said?
5 A. I was -- and this is really only one person -- but I was
6 advised to steer clear of both Dr Bolsin and
7 Professor Angelini and that it would be sensible to do
8 so, it would be sensible for me to become involved in
9 that particular issue.
10 Q. Advised by whom?
11 A. Again by Janet Maher. Could I say, sir, you asked me
12 about the split and the impressions of Dr Bolsin and
13 Professor Angelini within the Directorate and I have
14 answered that.
15 I think also, because I had a managerial role and
16 therefore had a much wider role within the Trust, I did
17 pick up -- perhaps at a later stage, but there was
18 certainly a feeling through the senior managers'
19 meetings which are the meetings of all the general
20 managers -- that it was very unfair the witch hunt and
21 I think it was probably at those meetings that the
22 expression "witch hunt" against Mr Wisheart was used
23 more commonly.
24 So I was experiencing a divided opinion both
25 within the Directorate but also within the wider Trust
0160
1 context.
2 Q. When were you first aware of this witch hunt, before or
3 after you became General Manager of Cardiac Services?
4 A. After, it was after. I was actually -- I was on
5 maternity leave before I came to work in cardiac
6 services, I had not been working in the Trust so it was
7 after I had started. The issues or the response of
8 people in the rest of the Trust, I think it would be
9 fair to say, came later, you know as things unfolded
10 people made their minds up about what was going on and
11 expressed them through forums like the senior managers'
12 group but perhaps that was later.
13 Q. There came a time when you met Dr Bolsin?
14 A. Yes.
15 Q. You say this took place probably in early January 1995?
16 A. Yes, it was not long after I had been appointed.
17 Q. Do you now know if it was before or after the
18 Joshua Loveday operation?
19 A. I am sorry I cannot say. I think it was before, it was
20 certainly before the Marc de Leval visit but whether it
21 was before Joshua Loveday's operation I really do not
22 know, it is very hard to pinpoint the actual dates. It
23 was not long after I had started and that is the best
24 I can do really pinpointing the time.
25 Q. Having as it were had your expectations of Dr Bolsin
0161
1 lowered by what you had heard about him beforehand --
2 A. Yes.
3 Q. -- what impression did you form having met him?
4 A. I think I felt he was actually fairly normal depending
5 on how normal it is for people working within the Health
6 Service. He did not strike me as being particularly
7 old, or ... he was very keen on audit and really I found
8 that he talked at me a little, he was you know quite
9 forceful and quite instructive in the discussion but
10 I took that to be enthusiasm and nothing more than
11 enthusiasm and I actually did form a relatively positive
12 impression of him after meeting him.
13 Q. Were you able to interact with him or was he as it were
14 all transmit and no receive?
15 A. I think initially he did most of the talking and I did
16 most of the listening and I think it amused me slightly
17 because he was very quick to start to point out to me
18 the financial benefits of being involved with audit
19 which is always something that clinicians feel they need
20 to do to get a manager's interest. So I thought it was
21 interesting he went straight for that tactic.
22 We had a dialogue. I was particularly interested
23 in what he was telling me about audit in New York and
24 what had happened there. I asked him questions about
25 that and so he did most of the talking, but it was not
0162
1 entirely him talking at me.
2 Q. You did not know, as we have mentioned already, about
3 Joshua Loveday's operation until some time after it had
4 taken place?
5 A. Yes, that is right.
6 Q. So you knew nothing about the meeting that took place
7 the night before that operation?
8 A. I knew absolutely nothing at all about any of the events
9 that led up to the Joshua Loveday operation until after,
10 well after it had taken place.
11 Q. Did you know anything about a letter that
12 Professor Angelini had written to Mr Wisheart before the
13 operation?
14 A. I think I became aware of things afterwards, but
15 certainly not prior to the operation or at the time of
16 the operation, no.
17 Q. You said this last time -- and in his evidence he
18 confirmed it -- you had met Mr McKinlay once or possibly
19 twice since he had become Chairman of the Trust on
20 1st July 1994?
21 A. Yes, that is right.
22 Q. Were those meetings with him after you became General
23 Manager of Cardiac Services?
24 A. Yes, they were.
25 Q. They must have been November or later, 1994?
0163
1 A. Yes.
2 Q. What did you discuss with him?
3 A. It is very difficult to remember the meetings, but
4 I know I discussed with him issues about the development
5 of the Directorate and the development of adult services
6 and the need for the development of a strategy. My
7 concerns -- that I have expressed to you when I gave
8 evidence in June -- that the Trust did not seem to know
9 what it was doing or where it was going and I wanted to
10 develop the Cardiac Services Directorate.
11 I think we may have talked about relationships and
12 the difficulties between clinicians, but I do not recall
13 that we had very -- or that we had any detailed
14 discussion specifically about paediatric cardiac
15 surgery.
16 Q. To the extent that you discussed your goals for the
17 Cardiac Services Directorate, those goals were all adult
18 focused because the children were leaving?
19 A. Yes, absolutely.
20 Q. There has been a suggestion from one or two quarters
21 that there was a decision made -- certainly something
22 Mr McKinlay mentioned -- by about Christmas 1994 or
23 thereabouts, that there should be a review of paediatric
24 cardiac surgery or paediatric cardiac services at the
25 UBHT which was going to be set in train at the beginning
0164
1 of 1995 or thereabouts; do you remember any word of that
2 reaching you before the Hunter/de Leval visit?
3 A. Not at all. The first review that I was aware of for
4 paediatric cardiac surgery was to facilitate the
5 Hunter/de Leval visit. The decision may have been made
6 that this review was going to take place but I was not
7 asked if I could, or informed that I would need to be
8 involved in that.
9 Q. Joshua Loveday would have been in the unit at the BRI
10 shortly before his operation and the operation took
11 place on 12th January. There was then some further
12 correspondence involving the Department of Health and
13 Dr Roylance, again contemporaneously; did you have any
14 knowledge or involvement in that?
15 A. No, I had no knowledge of Joshua Loveday's operation
16 until the Marc de Leval visit.
17 Q. Mrs Ferris, I do not have very many more questions to
18 ask you but we have been going for some time without
19 a break. I am going to turn to the Hunter/de Leval
20 report shortly. Perhaps before I do we should have
21 a short break for the comfort of those who have been
22 going now for some time?
23 THE CHAIRMAN: Shall we say 3.40?
24 (3.40 pm)
25 (A short break)
0165
1 (3.40 pm)
2 THE CHAIRMAN: Mr Miller, Mrs Ferris had some papers which
3 may be in another room, so we were just going to go and
4 get them.
5 MR MACLEAN: Is it the comments on your statement? Perhaps
6 while those are being brought, could I show you
7 something else, UBHT 61/354. A memorandum from you. We
8 see to whom it is sent. 17th February 1995. If we can
9 scan down a little, you are sending round the programme
10 for the visit from Dr Hunter and Mr de Leval three days
11 hence on 10th February 1995?
12 A. Yes, that is right.
13 Q. What was your role apart from sending around that
14 programme, in the visit by those two doctors on
15 10th February?
16 A. I had a very minor role to play in the arrangements for
17 this visit. I believe I was responsible for sending the
18 correspondence such as this out, booking rooms,
19 arranging catering and trying to ensure that the people
20 who would be required to attend were available, and that
21 I could slot them into the relevant slots during the
22 day, so it was really an extremely minor role.
23 Q. How and when did you first learn the visit was going to
24 take place?
25 A. I do not remember the date, but it was all arranged in
0166
1 a rush. I have said in my statement I believed that
2 both John Roylance and Margaret Maisey advised me that
3 the meeting would have to take place, possibly I am
4 wrong, that it was both of them and perhaps it was just
5 John Roylance, but I was told this meeting would need to
6 take place and asked to make those arrangements.
7 Q. I think the passage you are referring to is WIT 89/98,
8 at the bottom of the page, paragraph 20.
9 Is that the passage?
10 A. Yes, that is right.
11 Q. "I was advised by Dr Roylance and Mrs Maisey of the need
12 for this visit. I did not know anything about Joshua
13 Loveday at this stage. I was told the visit by de Leval
14 and Hunter was taking place because there had been some
15 'trouble making'."
16 A. Yes, that was the word that was used.
17 Q. You have seen Mrs Maisey's comments, have you?
18 A. Yes, I have seen her comments.
19 Q. She says it is not correct she advised you of the need
20 for the visit and she does not recall any conversation
21 and it is unlikely there would have been such
22 a conversation because she had no involvement in the
23 Hunter/de Leval visit?
24 A. I think she may be right. I cannot remember whether she
25 was involved. When I wrote the statement, I thought
0167
1 I had been informed by both of them at the same time.
2 I am sorry if I was wrong and created a false
3 impression. I must have been advised by Dr Roylance,
4 unless somebody else can tell me who actually asked to
5 make this arrangement. I know it was not Professor Vann
6 Jones.
7 Q. Mrs Maisey says:
8 "I had no involvement in the Hunter/de Leval visit
9 or in the issues surrounding it which were regarded as
10 being medical matters dealt with by Dr Roylance."
11 Would that accord with your view of how
12 Dr Roylance would see it, that Hunter/de Leval was
13 a medical matter and therefore not a matter for
14 Mrs Maisey?
15 A. I think she is probably right. Certainly it would
16 be John Roylance's style that this was specifically
17 a medical issue, and as I said, I was not encouraged to
18 play anything other than a purely administrative role in
19 setting up this meeting.
20 Q. If you might be wrong that you were advised by
21 Dr Roylance and Mrs Maisey of the need for the visit,
22 indeed, I think you accept Mrs Maisey's word for it?
23 A. Yes, I do.
24 Q. So the second sentence of that paragraph cannot be
25 entirely accurate, why should we place any reliance on
0168
1 the reference to "trouble making"?
2 A. I am sure I can understand how you might draw that
3 conclusion, but I remember that it is the sort of thing
4 that sticks in your mind. You have a long passage of
5 time between these events -- actually I have noticed an
6 error on the statement. It says "1999", I am sorry, it
7 has put me off.
8 Q. Yes, it should be 1995?
9 A. It has been a long passage of time. It is difficult to
10 remember whom you saw, when you saw them and it is
11 a reference to dates -- I think it is hard to remember
12 when you saw people and the dates, but I think the
13 specific words will stick in your head. That is quite
14 a firm description and I remember being struck by that.
15 Q. So you remember those words basically used quite
16 clearly?
17 A. Yes. The only thing I would agree is that I cannot be
18 completely clear about who used them, but, yes, whoever
19 told me that the visit was needed said that there had
20 been some trouble making.
21 Q. Although you did not have any direct involvement in
22 Mr de Leval and Dr Hunter's visit in the sense that they
23 were interviewing you, you did nonetheless have
24 a conversation with Marc de Leval?
25 A. Yes, I did.
0169
1 Q. He asked you if you thought there were any problems with
2 paediatric cardiac surgery?
3 A. Yes, he did. He asked in a very, very direct way.
4 I think I said "Hello, I am here to show you to the
5 venue for this meeting" and as we walked over, he said
6 "Do you think there are any problems with paediatric
7 cardiac surgery?"
8 Q. And you said?
9 A. I did not say anything immediately, because I was
10 shocked that he would have asked me. I then I think
11 probably mumbled that, "No, I do not think so. I do not
12 think there is a problem. I do not really know",
13 I said.
14 Q. Why on earth should you be shocked that somebody coming
15 to conduct an investigation in paediatric cardiac
16 surgery should ask such a question of the General
17 Manager of the unit?
18 A. Because I had had the impression it was not anything
19 I would be involved with, I did not know very much about
20 it, other than the snippets that I had heard, and I had
21 also been concerned about the visit being presented to
22 me as a result of trouble making, so I was shocked that
23 he should ask me to make a comment -- I was not shocked
24 that he was asking me as a manager to comment, I was
25 shocked that he was asking me to make that comment
0170
1 following the presentation of this as being as a result
2 of trouble making. I felt put on the spot. I felt
3 "This is a difficult issue, there is obviously
4 something going on here, there is this trouble making
5 going on, I have heard other things, I am not really
6 sure what is going on", and it took me by surprise that
7 he should ask me in that direct fashion.
8 Q. What was the true answer to the question; did you think
9 there were any problems with paediatric cardiac surgery
10 as at 10th February 1995?
11 A. I think my answer at that stage would be, "I do not
12 really know, but perhaps possibly I think there may be
13 something to this". That was the view I was starting to
14 form, and really around that visit, so when I said "No,
15 I do not think so", I was not being absolutely straight
16 with him.
17 Q. If in fact you thought that the true answer was, "I do
18 not really know but there might be", to say "I do not
19 think so" gave a false impression to Mr de Leval of your
20 true feeling?
21 A. Yes, it did, and I obviously regret having given him the
22 false impression. I was very worried that this had been
23 presented to me as something that came about as a result
24 of trouble making and I think at the same sort of time,
25 when I was advised about this, although we were having
0171
1 external advisers coming in, there was this sense that
2 I had that this was something we did not want to be
3 dealt with outside of the Trust.
4 Q. Where did that --
5 A. But this is whoever -- if it is not Margaret Maisey,
6 then I am sure it must be John Roylance. The person who
7 told me we needed the visit gave me that impression.
8 Q. Did you talk to Dr Hunter?
9 A. I may have said "Hello" and shown him around, but I did
10 not have a conversation with him, no.
11 Q. Can we go to page 99, please? Paragraph 23. At the end
12 of the programme, that means at the end of the day's
13 visit?
14 A. Yes, I think it was the last session on the programme.
15 Q. It was still on the 10th?
16 A. Yes.
17 Q. It was an open meeting which you were at along with
18 others, amongst them Dr Bolsin and Mr Wisheart?
19 A. Yes.
20 Q. How many other people were at that?
21 A. There was a roomful. It was in the Eye Hospital
22 boardroom, I think, and it was around the boardroom
23 table, so there were probably 10, maybe less, but
24 I recall a number of people. I could not tell you who
25 they all were, and I cannot really tell you how many,
0172
1 because the thing that has really stuck in my mind was
2 the body language and interrelationships between
3 Dr Bolsin and Mr Wisheart.
4 Q. Dr Roylance was not at that meeting?
5 A. No, he was not at that meeting, no.
6 Q. He was not at any of the meetings with Hunter/de Leval?
7 A. No, I believe he met with them, if I remember rightly,
8 he started off at the beginning of the programme, and
9 I think that is how possibly I was then asked to collect
10 them from Trust Headquarters and take them to the Eye
11 Hospital. But no, he was not actually at any of the
12 meetings at that venue.
13 Q. If we look at the first sentence of the next paragraph:
14 "At the end of the meeting I walked over to Trust
15 Headquarters with Dr Roylance."
16 A. Yes, I do say that.
17 Q. If he was not at the meeting, how could you be walking
18 back with him?
19 A. He may have come to the Eye Hospital at some point in
20 the day. I was not involved in all the meeting, so
21 I was out of the venue, chasing up people, finding out
22 where people were, and so forth, really servicing that
23 meeting. I obviously cannot be precise about the time
24 that Dr Roylance and I walked back to Trust
25 Headquarters, but I know that at some stage during the
0173
1 day, that is exactly what we did do.
2 Q. Can we look at WIT 89/112? This is Mr Wisheart's
3 comment on your statement. Mr Wisheart says:
4 "Dr Roylance did not attend that meeting".
5 A. Yes.
6 Q. That is the point dealt with.
7 A. Yes, that is correct. I think I just dealt with that.
8 Certainly on that day and from that venue, because
9 I distinctly remember the way we walked to Trust
10 Headquarters, I mean, the route we took. It is rather
11 sad, but I do actually remember where we walked.
12 Q. So Mr Wisheart may well be right about that?
13 A. In terms of that comment, "Dr Roylance did not attend
14 that meeting", Mr Wisheart is absolutely correct, yes.
15 Q. If we go back to page 99, paragraph 23, where we were,
16 the atmosphere you describe as being "tense" and the
17 body language you say was "most striking"?
18 A. Yes, that is right.
19 Q. You then go on to define, if you like, Mr Wisheart's
20 body language. What about Dr Bolsin?
21 A. Dr Bolsin was also very red in the face; he was very
22 flushed. He also looked down. There was very little
23 actual direct eye contact between the two consultants.
24 I believe there was somebody sitting between the two,
25 and I was sat at the end of the table, so they were both
0174
1 sat with their heads down, talking to each other but
2 with only occasionally looking at each other.
3 Q. Were Professor de Leval and Dr Hunter still present?
4 A. I think they must have been, but I cannot actually
5 remember. I am sorry, it was so striking for me, the
6 relationship between Dr Bolsin and Mr Wisheart, that
7 I really paid little attention to anybody else.
8 Q. In this discussion you had with Dr Roylance, walking
9 towards Trust Headquarters, you say he made some comment
10 that he, Dr Roylance, "should not really have let James
11 organise the day"?
12 A. That is right, yes.
13 Q. Is it right that James organised the day?
14 A. It depends what you mean by "organising" the day. If
15 you are talking about administrative arrangements, then
16 I organised the day. If you are talking about
17 contacting the person, asking them to come, I know that
18 he was in touch with Marc de Leval before the meeting
19 and he was also talking to Marc de Leval and to
20 Stewart Hunter about things like accommodation and
21 hotels and things, but I understand that he made the
22 first contact with Marc de Leval and I thought that is
23 what Dr Roylance was referring to, that he had allowed
24 James to perhaps decide on how best that day should be
25 structured and who should be there. He did give me the
0175
1 impression -- he smiled as he said that, and gave me the
2 impression of treating the day very casually.
3 Q. How did you expect him to treat it?
4 A. It put the wind up me and I thought he might well be
5 just as concerned and worried about it. It could just
6 be the tension after a long day, after a long day you
7 want to relax and try and, you know, let yourself feel
8 better about it, but he just struck me as being very
9 casual.
10 Q. As we have discussed once or twice, up until this time,
11 you were not aware of the events surrounding Joshua
12 Loveday; is that right?
13 A. Yes.
14 Q. If we scan down to the bottom of the page, you recall
15 your personal response and the circumstances of the
16 Joshua Loveday operation.
17 "I was amazed it had taken place at all. I felt
18 that the clinical factors which were used to justify the
19 operation proceeding were only one part of the picture."
20 Then you go on to say that the operation, if it
21 actually happened, should the patient not survive, would
22 have a devastating effect on the surgeons and the unit,
23 as well as Joshua Loveday's parents and family?
24 A. Yes.
25 Q. But in fact the unit had carried on operating, working,
0176
1 for nearly a month after that operation had taken place
2 and without you having learned about it?
3 A. Yes, but I think that everybody will agree that that
4 operation did have a devastating effect on the unit. It
5 may have been carrying on going through the motions for
6 a month between the operation and the visit of de Leval
7 and Hunter, but it did have exactly the sort of impact
8 on the unit and on the people working within it that
9 I felt it would have. I have to say, I am obviously
10 looking at that with the hindsight at that time; I was
11 not involved with the discussions about Joshua Loveday's
12 operation prior to it taking place, but this response
13 that I am describing here is not the response I have
14 thought of now; it is something that I very vividly
15 recall from the time.
16 Yes, it did have a devastating effect, and as you
17 saw, the surgeons' views became polarised, the
18 confidence in the unit was very much damaged. So, yes,
19 they may have continued for a month, but I think it did
20 have a devastating effect. And I think the point I am
21 trying to make here is that I was astounded, absolutely
22 astounded, that anyone would make any decision based
23 purely on the clinical factors without taking any notice
24 whatsoever of the wider context.
25 Q. You yourself would not be in a position to judge the
0177
1 clinical factors which may or may not have pointed
2 towards Joshua Loveday needing any operation, or that
3 operation, or as to the urgency of the operation?
4 A. Absolutely not, and I would never put myself in
5 a position to try and influence or make any decisions
6 based on clinical information that I cannot possibly
7 make a decision about.
8 Q. And you would not be in a position to judge whether or
9 not any particular surgeon, any particular anaesthetist
10 or any other clinician, was or was not good at their
11 job, as a clinician?
12 A. I would be in a position to take advice about whether
13 individual clinicians were good at their job, but
14 I would not be able to make that judgment myself, no.
15 I do not have that experience.
16 Q. You will no doubt by now have heard of the events that
17 took place at the meeting on 11th January 1995?
18 A. Yes.
19 Q. Are you aware of the views that have been attributed to
20 Dr Bolsin at that meeting?
21 A. I am not sure of the specific ...
22 Q. He is saying that essentially whatever the statistics
23 show for Mr Dhasmana's success rate for the particular
24 operation, there might be political repercussions if the
25 operation were to take place?
0178
1 A. Yes, I am aware of that now. I do not know when
2 I became aware of that initially, but that is absolutely
3 the comment I suppose I am trying to make here. I think
4 it is absolutely right.
5 Q. It is the same point, is it not?
6 A. It is exactly the same point, yes.
7 Q. Did you see the first version of the Hunter/de Leval
8 report when it came into the Trust?
9 A. No, I did not, no.
10 Q. Did you ever see, if we go to UBHT 52/263, this is the
11 report of the visit of 10th February 1985. If we go to
12 the bottom of the page, the last sentence:
13 "The overall post-operative management of the
14 Royal Infirmary appears to be highly disorganised with
15 conflicting decisions between the ... surgeons and the
16 Registrar and the SHO who do rounds at 8.00 am."
17 Do you remember seeing that?
18 A. I remember knowing about it. I do not think I was ever
19 officially informed of the report and that that was one
20 of the conclusions they had drawn. It filtered down to
21 me at some stage afterwards, possibly in discussion with
22 Professor Vann Jones.
23 Q. This is a comment on the BRI, not the Children's
24 Hospital, of which you were the General Manager?
25 A. Yes, it is.
0179
1 Q. This reference to ward rounds would apply as much to
2 paediatric patients as to the adult patients?
3 A. It is a comment of the patients in intensive care.
4 Q. It is a highly critical comment?
5 A. Yes, it is.
6 Q. Did you think it was a fair albeit critical comment?
7 A. Yes, I thought it was a fair comment. It was one that
8 the whole management of the Intensive Care Unit was
9 something we were trying to improve and clarify
10 different roles and it was a huge source of stress for
11 the nurses, so it was a particular issue.
12 Q. You would not quarrel with the description "highly
13 disorganised"?
14 A. It is quite a strong description, but, yes, it was
15 disorganised. I think the roles of different
16 individuals and the roles they played in providing that
17 service were confused. I think that led to
18 disorganisation. As I say, this comment was not made
19 clear to me through any official mechanism following the
20 Hunter/de Leval report being produced.
21 Q. Let us look at 268, please? Still in the same
22 document. Paragraph 7. This is essentially one of the
23 recommendations of the report:
24 "An atmosphere of co-operation and understanding
25 between the various departments is essential so as to
0180
1 alleviate the tension, the distrust and the present
2 untenable atmosphere which without any doubt jeopardises
3 the outcome of the patients."
4 A. Yes.
5 Q. Did that strike you as being fair comment, that the unit
6 was tense, with an atmosphere of distrust which was
7 untenable?
8 A. Yes, I think that is a very good description.
9 Q. You may or may not know now, and may not have known at
10 the time, but some changes were made to this report.
11 Did you know that at the time?
12 A. Yes. I think around the time, because obviously there
13 were a lot of angry people talking about the change to
14 the report. But I heard that through corridor
15 discussions and ...
16 Q. What was your understanding of how it came about that
17 changes were made to the report?
18 A. The way it was presented to me was that the report had
19 been too hard-hitting initially and not acceptable to
20 the Trust and toned down. That was the way it was
21 presented to me, but obviously I rely on discussions
22 with people in corridors.
23 Q. What do you mean when you say it was unacceptable to the
24 Trust?
25 A. I am sorry, can you say that again?
0181
1 Q. What would you say was unacceptable to the Trust so it
2 was toned down? Did you understand that meant the
3 Board, Mr McKinlay, Dr Roylance, who?
4 A. Well, I thought Dr Roylance, but I know that Dr Roylance
5 was not actually there at the time that the report was
6 first produced, so maybe this is hearsay, following the
7 publication of the report a couple of weeks later. But
8 that it was seen to be too damaging to the Trust in its
9 current format.
10 Q. You say it was corridor discussions that gave you this
11 impression. Do you remember with whom?
12 A. I think with Professor Angelini and perhaps Mr Bryan.
13 It is very hard to remember. You have to appreciate in
14 a unit like this Directorate, there are lots of
15 interactions from very many staff and you have many
16 discussions in corridors with many people, but I would
17 say that when you asked me about the two "sides", the
18 people who were on Dr Bolsin's side, if you want to use
19 that label, were, I think, the people that suggested
20 this report had been toned down.
21 Q. Was there any talk of that nature from anyone who was
22 not on Dr Bolsin's side?
23 A. No, I do not think so. I do not recall having
24 discussions with the Chairman or with Dr Roylance or
25 with Mr Wisheart or Mr Dhasmana about the report, no.
0182
1 Q. There was a reference in the initial version of the
2 report to one surgeon being higher risk. Do you
3 remember that?
4 A. Yes, I do.
5 Q. That judgment that Hunter/de Leval made would fall
6 into the category of matters that you yourself would not
7 be equipped to deal with?
8 A. No, I would not be able to make that judgment, no.
9 I think also after discussion with Professor Vann Jones,
10 there was -- I do not know if it was really with the
11 report, but concern about the quality of the data and
12 whether it was valid and whether actually those aspects
13 of the report were robust enough. I cannot remember
14 anything specific, though, to the report.
15 Q. WIT 89/100, paragraph 27, you refer to a meeting between
16 yourself and Mr Wisheart.
17 A. It was not a formal meeting, it was "Come to my office,
18 I would like to talk to you".
19 Q. So it was at Mr Wisheart's behest?
20 A. Yes, it was, yes.
21 Q. Before we go any further in this paragraph, you have
22 seen what Mr Wisheart says about this, have you not?
23 A. I am sorry, I have forgotten. Can I look again,
24 please?
25 Q. WIT 89/112, the bottom of the page. The comment is
0183
1 actually over the page. He does not recall, but your
2 perception of the meeting is incorrect?
3 A. Yes, he does say that.
4 Q. Let us go back to page 100.
5 A. Can I say, I am not sure it was a perception.
6 I remember very clearly the discussion.
7 Q. That is what we are coming to. This meeting was at
8 Mr Wisheart's behest?
9 A. It was, yes.
10 Q. What was it about? What did you think you were about to
11 have a meeting about, when you walked into the room?
12 A. I felt I had been summoned. It was very much, I do not
13 think I was grabbed physically but asked "Would you come
14 into my office, I would like to talk to you".
15 Q. Had you had such a meeting that you learned of in that
16 way before?
17 A. No, I had not, no.
18 Q. This was the first time you had been called into
19 Mr Wisheart's room?
20 A. The first time in that sense. We obviously had met at
21 times when they were not formal meetings, but it was the
22 first time I had been asked to specifically come into
23 his office, and actually have one-to-one meetings.
24 Mr Wisheart tended to prefer they would be arranged so
25 there would be a preset time and I would come at
0184
1 a particular time. This was not like that, this was
2 very much "I would like you to come to my office, I want
3 to talk to you about these figures".
4 Q. You say you could tell Mr Wisheart was angry?
5 A. Yes, I could tell. Mr Wisheart was not the sort of
6 person who would show anger in a very overt or blustery
7 or loud way. When he became angry, he became much
8 quieter, he was very controlled and he spoke very
9 slowly, and that is exactly what he did on this
10 occasion.
11 Q. Had he ever been angry with you in this way before?
12 A. That is difficult to say. I mean, I know, I certainly
13 gave evidence in June that he had not been very happy
14 with me on previous occasions, but I think I must have
15 referenced this in my mind as being one of those first
16 occasions and possibly at Associate Clinical Director
17 meetings earlier. I cannot remember when we had all the
18 discussions about the intensivists, but he was certainly
19 very unhappy about that. This sticks in my mind as
20 perhaps a very early indication of him not being pleased
21 with what I was doing within the directorate.
22 Q. Is it right that you had been asking questions?
23 A. Yes. I think so. I think everybody was asking
24 questions at that stage. I think it was a topic of
25 every conversation in every corridor before, during and
0185
1 after most meetings.
2 So, yes, I had been listening to discussions and
3 I really -- I think you have to realise that I felt very
4 responsible for having come into this situation and
5 making a very quick judgment that the criticisms against
6 Mr Wisheart were unfair and having been advised this was
7 not the case, I wanted to try and find out what the true
8 situation was, and I felt it was important to ask lots
9 of questions, and that is what I was doing.
10 Q. Which particular questions was Mr Wisheart seeking to
11 put you right about?
12 A. The meeting went on to look at results. I paraphrase,
13 I do not remember his exact words, but he said "I know
14 you are asking about results; let me show you mine".
15 Which he did. Can I stress here, I said in the
16 statement, I am not sure if it was paediatric or adult
17 results; I am quite certain now we actually did look at
18 adult results.
19 Q. Why are you certain about that?
20 A. Because I think it is just that there is a figure in my
21 mind, all the surgeons' results were there, so it was
22 results for all surgeons, and obviously the others were
23 not doing paediatric work. It was the sorts of
24 figures -- I will not go into it. It was the sort of
25 figure that would be associated with adult operations
0186
1 rather than paediatric ones.
2 Q. If we scan down the page a little to 28, there is
3 a reference to "risk stratification". Do you see that,
4 in the last line?
5 A. Yes, I can see that.
6 Q. Was there a risk stratification system in place in
7 Bristol at that time for adult cases?
8 A. Yes, there was, yes.
9 Q. Was there such a system for paediatrics?
10 A. No, not as far as I know.
11 Q. Mr Bryan told us on Day 63, page 31, there was no risk
12 stratification system for paediatric work.
13 A. So, then, obviously we are talking about adults here.
14 Q. Mr Langstaff tells me that may be a slight
15 over-paraphrase, but anyone who is interested will find
16 what Mr Bryan actually said at Day 63, page 31.
17 We can see what you say in paragraph 28, that you
18 picked up a particular figure and you say that
19 Mr Wisheart became angry. He was already angry, was he
20 not, from the beginning?
21 A. I think at the beginning he was not -- he was angry, but
22 I think he was -- he had a task which I think he
23 expected to be told that this was the situation, and
24 I think he was more angry because I then responded and
25 actually questioned what it was that he was showing me.
0187
1 I do not think he actually expected me to question the
2 information he was showing me. I think he was both
3 surprised and annoyed about it.
4 Q. He explained his figures were fine in the context of the
5 risk stratification, and has taken on more difficult
6 cases?
7 A. Yes, but the information was not risk stratification, it
8 was total numbers. I cannot remember where that
9 information came from.
10 Q. You would not yourself be able to tell, would you,
11 whether or not he was doing more or less difficult
12 cases?
13 A. No, I would not. If he was telling me that the reason
14 his figure was higher than anybody else's, it was
15 because he was doing more complex cases and higher risk
16 cases, I would not be able to absolutely determine
17 whether that was correct. But then I would have an
18 opportunity to look back and actually look at the
19 mortality for the cases once they were risk stratified
20 to see how his cases compared with everybody else's.
21 Q. If we go over the page, to 101, the top of the page, you
22 turned to Mr Dhasmana?
23 A. Yes.
24 Q. You say that you did not think it appropriate in
25 February or March to air your developing concerns with
0188
1 Mr Dhasmana. He was too involved, and you did not feel
2 comfortable discussing results with him?
3 A. Yes, that is right.
4 Q. So it may be there is not much to add, but do I take it
5 from that that you would have challenged Mr Wisheart for
6 his results more readily than you would Mr Dhasmana
7 about his?
8 A. I do not think that, had Janardan done the same thing,
9 shown me results, then I would have asked questions
10 about it, so I would have been in the same position with
11 Mr Dhasmana saying "Please come to my office and discuss
12 the figures", I would have done exactly the same thing,
13 but I did not feel comfortable to specifically seek out
14 Mr Dhasmana to discuss that issue with him, because he
15 was very upset and emotional about those sorts of
16 issues. You have to remember, we have not particularly
17 developed a particularly good relationship, and he saw
18 that as being "got at".
19 Q. You told us last time about his lack of abilities as
20 Associate Clinical Director.
21 A. Yes, I think I was very clear about my views about his
22 abilities as an Associate Director.
23 Q. You said you went away from the meeting with Mr Wisheart
24 feeling worried and not being convinced by his
25 explanation.
0189
1 A. Yes. When I left that meeting, I felt that up until
2 that point I had been seen as peripheral to what was
3 going on, maybe asking a few questions, but I felt,
4 after the meeting, that Mr Wisheart had sort of put me
5 in the category of those people that were against him,
6 so I thought, "Well, I have nailed my colours to the
7 mast now and this is going to be difficult".
8 Q. But you did feel left out; you felt as if you were cut
9 out of the loop?
10 A. I felt I had a role to play and it was being handled
11 initially as a clinical matter, although you have to
12 remember that also I had a very close relationship with
13 Professor Vann Jones and we were working together to
14 manage the directorate. So I may have been directly
15 left out, but vicariously, I was involved through the
16 relationship with Professor Vann Jones.
17 Q. Why should it be, if Mr Wisheart had presented you with
18 his data and said "This is fine, will you take out the
19 risk stratification and the fact that I am doing the
20 higher risk cases", why should you be satisfied by that?
21 A. Because I only had his word for it. I had not seen
22 anything that really indicated that that was true. The
23 way he was presenting it to me was not that that was
24 definitely an explanation, but that that was his
25 impression, you know, he was not saying, "I can give you
0190
1 chapter and verse on how this demonstrates that I am
2 taking higher risk cases than anybody else", so I did
3 not think it was a very robust approach and I wanted to
4 find out more and to check that out a bit more. It is
5 not that I particularly picked on Mr Wisheart. I think
6 with all surgeons, you do not take at face value
7 absolutely everything that they say to you.
8 Q. You said that you worked closely with Professor Vann
9 Jones?
10 A. Yes.
11 Q. You had a good working relationship with him?
12 A. Yes, I did.
13 Q. He was the Clinical Director. Your working relationship
14 with Margaret Maisey was poor?
15 A. Yes, it was.
16 Q. Very poor?
17 A. It had been poor. I think when I started in cardiac
18 services it improved greatly, and she had been involved
19 with my appointment to that post. It then -- so it went
20 along for about a year as actually being a relatively
21 good relationship. It was really only towards
22 Margaret's retirement that it got difficult again.
23 Q. Your relationship with Dr Roylance was poor?
24 A. I would not describe it as poor, I would describe it as
25 very limited. I did not really have a relationship with
0191
1 Dr Roylance. I had very little to do with him and on
2 the very few occasions that I had sought his advice or
3 spoken to him, it had not been particularly favourable.
4 I would not describe it as poor in the same way as the
5 relationship with Margaret Maisey was poor.
6 Q. You had a perception that Dr Roylance related better to
7 managers who were clinicians than managers who were not?
8 A. I did have that perception, and I think it was shared by
9 many others. I do not think I was alone in that
10 perception.
11 Q. You have had a chance I think to see the statement we
12 have had from Tessa Beacham, who worked as the Assistant
13 Director of Personnel at the Trust between April 1991
14 and December 1997?
15 A. Yes, I have seen that.
16 Q. She refers to something called the Management
17 Development Group, which she ran on behalf of
18 Dr Roylance?
19 A. Yes.
20 Q. If we can turn, please, to WIT 481/3, if we go to
21 paragraph 13, she says:
22 "The members of the Management Development Group
23 knew that Dr Roylance's executive colleagues operated an
24 open-door policy and would happily speak to any members
25 of staff about things which were of concern to them,
0192
1 away from the MDG."
2 Then paragraph 14:
3 "There were initially about 30 people who attended
4 the MDG."
5 Is that right?
6 A. Yes.
7 Q. Then it was expanded to be a rather larger body.
8 A. Yes.
9 Q. "The MDG was considered by the non-attenders as a club
10 to which it was necessary to belong in order to succeed
11 in UBHT."
12 A. Yes. I am pretty sure I was one of the original
13 30 people involved in that. But yes, that was the
14 perception of the Management Development Group.
15 Q. That was the "in-crowd" --
16 A. Yes.
17 Q. -- with Dr Roylance?
18 A. Well, Dr Roylance and with Margaret Maisey. But yes.
19 Q. She says:
20 "The MDG provided the nucleus of people from which
21 aspiring managers were recruited."
22 She then goes on to say that it was eventually
23 decided to extend the membership down to Associate
24 General Managers and Assistant Managers and other
25 specialists, bringing the total number of members to
0193
1 around 100?
2 A. Yes, at the time of my first involvement with the
3 Management Development Group I was General Manager of
4 the Ophthalmic Unit so I had been involved in the
5 narrower membership you have just described.
6 Q. Then you went to work in the Directorate of Surgery?
7 A. Yes.
8 Q. Janet Maher was the General Manager there?
9 A. I am sorry, when I left Dr Roylance I went to work in
10 the Directorate of Medicine and Janet Maher was the
11 Manager there.
12 Q. You were what, at that stage?
13 A. I was Associate General Manager at that stage.
14 Q. I think you told us last time that the Eye Hospital was
15 a smaller organisation?
16 A. That is right, a small and less complex organisation.
17 Q. So when was the first time, having left the Eye
18 Hospital, that you again had dealings with the MDG?
19 A. I think I always went to the MDG. I do not recall not
20 going following the move from the Eye Hospital. I do
21 not think I ever stopped going to the Management
22 Development Group.
23 Q. If we go over the page to page 4:
24 "Membership of this group caused concern for some
25 people, especially the more junior manager and those who
0194
1 were less familiar with the way the executive team
2 worked. They may well have felt intimidated by the ease
3 with which the original MDG members conducted themselves
4 at the Tuesday evening meetings. There was also
5 disgruntlement at the way people were grouped: this was
6 known as the 'cadres'. The idea of stratifying the MDG
7 into cadres originated from work done by Sir Bob Horton
8 in Shell."
9 Then you see there is a criticism of Mr Stone.
10 "This was never satisfactorily overcome and caused
11 lingering resentment amongst the junior members, one of
12 whom was Rachel Ferris".
13 A. Yes, I see that.
14 Q. Was that a fair comment?
15 A. No, I think there are two issues. That
16 paragraph contains two issues that I think need to be
17 addressed. I think the first was the issue of the
18 actual development of the management cadres itself,
19 which I would like to comment on, and I think the second
20 is the whole issue of "lingering resentment". The first
21 issue I think I was very vocal. Ian Stone is with me
22 today and will attest to this, but I was very vocal
23 about the way the cadre groups were developed. I found
24 the idea itself was a good one but I thought it was
25 badly handled. I thought there had been a lack of
0195
1 objectivity in deciding who belonged to which group.
2 I think I did write to Ian to say I thought it was not
3 handled properly.
4 You will also point out I was not in the group
5 I expected to be in, so I can understand Tessa
6 suggesting there is something of sour grapes here.
7 I have to say, to provide a balance to that, more
8 recently the Trust has also reorganised or re-evaluated
9 senior managers' pay and grades, and I did materially
10 benefit from that, but I also felt that that had been
11 badly handled and had not been dealt with in a proper
12 and objective fashion. I also wrote to Ian Stone about
13 that. I do not want to give the impression that
14 I complain about every new policy idea within the Trust,
15 but trying to give some balance. I was not materially
16 disadvantaged the second time, but I still felt this had
17 not been properly handled.
18 Q. What were the groupings?
19 A. There were four groups, with 1 being the top group and
20 4 being the bottom group, and I was in group 2, if
21 I recall.
22 Q. What did "top" and "bottom" mean?
23 A. I think it was looking at the most experienced managers
24 with the most complex directorates and who, you know --
25 the Trust then had a process of moving people around to
0196
1 manage the service, so picking people according to their
2 skill and experience to go and work in particular areas,
3 so if you were in number 1, then you were seen to be
4 more experienced and more able to take up, maybe,
5 a complex role elsewhere within the Trust.
6 Q. So managers were seen as premier league managers and
7 some as lower division managers?
8 A. Yes. I was in the second division.
9 Q. I think it is probably now called the first division?
10 A. Can I say, I really would like to focus on this issue of
11 lingering resentment. I have already explained, tried
12 to give some balance in terms of my responses to how
13 this thing was developed, but the "lingering resentment"
14 comment I feel strongly gives some impression that my
15 motives indeed for giving evidence to this Inquiry are
16 somehow dubious, implies this resentment that has never
17 gone away, is actually motivating the sort of criticisms
18 that I am making of the previous Trust management.
19 If I could quickly respond to that, I think there
20 are four points I need to stress: firstly, I was not
21 materially disadvantaged by the clashes I had with
22 Mrs Maisey, and in fact, even before Hugh Ross started,
23 I had achieved a position within the Trust that was
24 relatively secure, and I was relatively -- in fact I was
25 very well thought of by Margaret Maisey at that stage,
0197
1 and considered to be experienced.
2 I think secondly, any attempt really to use an
3 Inquiry like this to make some sort of -- you know, have
4 a go at people, shows a staggering lack of judgment.
5 I think everybody would agree.
6 Q. I do not think Tessa Beacham suggested that. She is
7 simply saying she detected some lingering resentment
8 amongst the junior members, one of whom was you, about
9 the league tabling of the MDG.
10 A. I think this, and many of the other comments on my
11 statement have given that impression. "Lingering
12 resentment" gives the impression to me that is very much
13 clouding judgment, and creating a situation where these
14 criticisms of the Trust are born simply from lingering
15 resentment.
16 I actually have no recollection of the management
17 cadres until I saw this yesterday, and in a way, I am
18 glad it has come back up again, because it illustrates
19 to me the thing that I said in June that the
20 decision-making within the Trust was not based on
21 rational decision-making and objective criteria, but was
22 based on whim and on whose face fitted and who the
23 executives within the Trust wished to promote.
24 Q. So the choice of those who were in the premier league,
25 as you saw it, was based on whose face fitted?
0198
1 A. Absolutely. I did not want to be in division 2, but
2 I did object to some people being in division 1 who had
3 very little experience and were not doing a complex
4 job. I was merely trying to find out what was the
5 criteria that was used and what was the selection
6 process for that, I would not want to focus on my
7 objection. If I had been in division 4, I am sure
8 I would have been very unhappy, but division 2 was
9 okay.
10 I really wanted to focus on, as I have just said,
11 what was the criteria for this, what was the selection
12 process, how was it handled, was it a fair and effective
13 way of dealing with management development within the
14 Trust, and I did not see anything that made me think it
15 was a fair and effective way. It just illustrated that
16 the Trust did very little certainly at senior management
17 level that was acceptable in terms of selection
18 processes. I think I have said the same about the
19 selection processes adopted for the Clinical Directors.
20 Q. You have said that your evidence to the Inquiry is not
21 born simply through lingering resentment as Tessa
22 Beacham puts it. To what extent is it born through
23 lingering resentment? It was not simply lingering
24 resentment?
25 A. I do not believe it was born through resentment at all.
0199
1 I suppose our experiences colour our judgments, but no,
2 I would not -- I have asked myself many times why I am
3 here. It is not something that I felt I really wanted
4 to push myself forward for. I genuinely do not believe
5 that this evidence is based at all on lingering
6 resentment. What I had hoped to do, and particularly
7 hoped to do in June, was to show that this was an
8 organisation where, when a problem of the gravity of
9 paediatric cardiac surgery arose, it was very, very
10 difficult to find the right mechanisms to deal with it.
11 Whilst they may have existed in theory, with
12 disciplinary procedures, grievance procedures and
13 discussions with managers, the whole culture of the
14 organisation did not lend itself to dealing with this
15 problem. I feel that all of the staff working at the
16 BRI -- and I think I am in a slightly more fortunate
17 position, because I have worked both within the
18 directorate and can comment on what happened there, but
19 have that wider managerial view of how the Trust
20 performed. I actually felt that far from wanting to
21 give evidence to this Inquiry, I felt it was my
22 obligation to do so, and to be as honest and as open as
23 possible, even if, as we have seen today, that then
24 means that my own managerial shortcomings are
25 illustrated in public.
0200
1 So I feel very strongly that my evidence is not
2 born out of lingering resentment but out of a need to
3 really be honest and open and direct about what
4 happened, so I do have a unique insight into both the
5 directorate and the Trust management.
6 Q. Let us move to something else. I think there are three
7 topics that I still have to deal with. I hope to take
8 each of them shortly.
9 WIT 89/103, paragraph 44 of your statement of
10 concerns, deals with discussion you have had with Hugh
11 Ross. This is October 1995, the managers' away-day at
12 Barrow Hospital. Hugh Ross spoke to you to say he was
13 worried about the way in which your actions were being
14 perceived by Mr Wisheart?
15 A. Yes, he did. He sought me out to make this comment to
16 me. It was the first tea-break. I think it may have
17 been early 1996, actually. Either the end of 1995 or
18 early 1996.
19 Q. "He indicated that Mr Wisheart was angry with me and
20 that Mr Wisheart gave the impression that if I continued
21 to involve myself in paediatric cardiac surgery, my
22 career in the NHS would be severely compromised."
23 A. Yes, he did say that.
24 Q. "I felt faint and physically sick."
25 A. Yes. I know that looks pathetic, but that was the
0201
1 impact that that announcement had on me.
2 Q. You have seen what Mr Ross says about this, page 111.
3 About halfway through the paragraph, the end of the
4 line, we see the word "I do not recall ..."
5 A. Yes, I do see that. I saw that yesterday as well.
6 Q. "I do not recall indicating to her [you] that
7 Mr Wisheart had made any comments about her future
8 career prospects. Indeed, I would not have thought then
9 or subsequently that he could have any significant
10 influence on such a matter. I think it is likely
11 I would have shared with her any irritation Mr Wisheart
12 had expressed about her role in the matter, although
13 I cannot recall for sure if he had done so, or whether,
14 if so, I had mentioned it. Hence my reassurance to her
15 that this was now my responsibility ..."
16 A. Yes, I have seen that. I remember this distinctly,
17 because it had such a big impact on me, it was a very
18 frightening thing to happen. It made me reflect
19 immediately on whether I had done something wrong and
20 I needed reassurance that I had not been doing things
21 I should not be. I am absolutely certain that the word
22 "career" was used, and obviously it is disappointing
23 that Hugh's version and recollection of events is not
24 the same as mine, although it is four years ago and
25 I can understand that something that was very, very
0202
1 significant to me may not have that significance to
2 other people. But no, I would stand by all of the
3 comments made in my statement.
4 Q. You do that notwithstanding the comment Mr Wisheart has
5 made about this. You have seen that, have you?
6 A. Yes, I still stand by that. That is what was said.
7 I must perhaps add that immediately after this away-day,
8 I went to see my Personnel Manager within the Trust,
9 because I wanted to find out from the personnel point of
10 view what could actually happen to my career and what
11 could this mean and what should I do about it, and she
12 recalls -- she obviously cannot comment on Hugh's
13 discussion with me, but she recalls I did come to see
14 her immediately and what I have said to the Inquiry is
15 exactly as I said to her.
16 Q. Two more points, Mrs Ferris. First of all, WIT 89/103,
17 paragraph 40: a discussion about Mr Dhasmana and whether
18 or not he was going to or ought to stop operating on
19 children. You say, towards the end of that paragraph:
20 "It was apparent to me that even if Mr Dhasmana
21 had acceptable results, Mr Pawade's were so
22 exceptionally good that it created a distinct contrast
23 which further fuelled the concerns of staff and placed
24 Mr Dhasmana under even greater pressure."
25 What time-scale are we talking about here? This
0203
1 must be the summer of 1995, must it not, because
2 Mr Pawade only started on 1st May?
3 A. Yes, and it was obvious from the first operation
4 Mr Pawade did that there was a great deal of difference
5 between the way children were doing following surgery
6 and then Mr Dhasmana. Obviously that is more looking at
7 the children, it was not based on an understanding of
8 what those operations were and what the complexities of
9 those operations were or any of those sorts of things.
10 It is just an impression that I, and all of the staff
11 working in theatre and in intensive care and the ward,
12 had of how children of Mr Pawade's were doing in
13 contrast to Mr Dhasmana's.
14 Q. But you are not able to tell us whether or not Mr Pawade
15 was doing a similar type of case as the cases that had
16 previously been done?
17 A. No, I cannot give you clear information about the
18 comparison, although I do know when I first spoke to
19 Mr Pawade on May 1st, I think that his very first cases
20 were relatively simple cases, he did not want to come in
21 and operate on very complex children straightaway, so
22 I know at least for the first couple of weeks he was
23 operating on easier cases. But no, I have no idea about
24 that.
25 Q. Then I think finally, if we go to UBHT 58/65 I hope this
0204
1 is the minutes of an Executive Committee of the Board on
2 17th March 1995. Do you see that?
3 A. Yes.
4 Q. If we go to page 66, we see paragraph 3. Mr Wisheart
5 was to continue to operate on children over 1 for all
6 conditions apart from AV canal, and so on. Then
7 paragraph 8:
8 "An away-day would be organised to debrief those
9 who had travelled to Melbourne to visit Mr Pawade so
10 that they could pass on the information they have
11 gleaned."
12 I think it is right, is it not, that Dr Maisey,
13 Dr Underwood, amongst others, had been to Melbourne?
14 A. Yes.
15 Q. The plan was that they were going to be working with
16 Mr Pawade when he took up his post; is that right?
17 A. Yes, that is right.
18 Q. I think it is right that by the end of 1995, or the
19 beginning of 1996, neither of those two consultant
20 anaesthetists was any longer working with Mr Pawade on
21 paediatric cardiac work?
22 A. Yes. I do not remember the times, but yes, at some
23 stage they stopped working with Mr Pawade.
24 Q. Can you help us with why the original plan, obviously
25 the purpose of sending people to Melbourne was so that
0205
1 they would work with Mr Pawade when he arrived, was not
2 carried through?
3 A. No, I cannot really help with that. I was under the
4 impression that Mr Pawade preferred to have his own team
5 around him, but I was not really party to those
6 discussions.
7 Q. When you say "his own team", who do you embrace within
8 that?
9 A. I think he wanted his own team of anaesthetists and
10 perfusionists. There was also an issue around
11 perfusion. He was very clear whom he wanted to perfuse
12 these cases, so those are the sort of professionals I am
13 thinking of.
14 Q. He had the same cardiologist?
15 A. Yes, the paediatric cardiologists were the same.
16 MR MACLEAN: Mrs Ferris, you have been patient with us today
17 in waiting to give evidence. You have heard this
18 before. Having finished the questions that I have for
19 you, is there anything else you want to say to the
20 Inquiry now?
21 A. Just one very small point, really, picking up on
22 Mr Ross's comments on the issue about my career, he says
23 that even if there had been threats, it could not
24 possibly have happened, and I would just like to say to
25 the Inquiry, I think that is rather an irrelevant
0206
1 comment, because what struck me was that my career was
2 threatened and that you can say with hindsight, okay, my
3 career has survived, but who knew at that time what
4 might happen?
5 I was very, very worried and it did not matter
6 that it was perceived as being not a real threat. It
7 actually caused me to change my behaviour; it caused me
8 to want to withdraw and not be involved in paediatric
9 cardiac surgery, although I must stress it also
10 reassured me that here at last was a Chief Executive
11 willing to support me and to allow me not to be
12 embroiled in this sort of terrible situation. But
13 I really would like to point out, it is quite irrelevant
14 whether the threat was real or perceived, it had a big
15 impact on me. If that was the sort of impact it had on
16 other people, obviously that is very important.
17 MR MACLEAN: I am told, sir, there is no re-examination.
18 Are there any questions from the Panel?
19 THE CHAIRMAN: No, there are no questions from the Panel, so
20 thank you, Mr Miller. It suffices for me to say, thank
21 you again for coming and giving evidence. Once again,
22 we are very grateful to you and you have helped us. We
23 shall be leaving on December 16th so we shall not see
24 you again, but if there is anything you would like to
25 write by way of evidence, of course that opportunity
0207
1 exists for some time yet. Thank you very much.
2 MR MACLEAN: Sir, could we prevail upon Mrs Ferris for just
3 a moment while Mr Langstaff indicates who is coming next
4 week?
5 MR LANGSTAFF RE NEXT WEEK'S TIMETABLE:
6 MR LANGSTAFF: Sir, next week we begin at 10.30 on Monday
7 morning. There will, I anticipate, be a statement as to
8 the Inquiry's approach to morbidity.
9 We will have the evidence next week of Dr Roylance
10 returning; of Dr Halliday returning; and Dr Joffe giving
11 his evidence for the first time.
12 THE CHAIRMAN: Thank you very much, Mr Langstaff, as ever.
13 Good afternoon, everyone. Until Monday, at 10.30.
14 (4.45 pm)
15 (Adjourned until 10.30 am on Monday, 6th December 1999)
16
17
18
19
20
21
22
23
24
25
0208
1
2 I N D E X
3
4
5 MR JANARDAN DHASMANA (recalled):
6 Examined by Mr Langstaff (continued) ........ 2
7
8 MR STEPHEN WILLIS (sworn):
9 Examined by MR LANGSTAFF .................... 120
10
11 MRS RACHEL FERRIS (sworn):
12 Examined by MR MACLEAN ...................... 148
13
14 MR LANGSTAFF re Next Week's Timetable ............. 208
15
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001