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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