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Daily transcripts
Hearing summary
6th December 1999
The Bristol Royal Infirmary Inquiry oral hearings this week continue to
hear evidence covering concerns raised about paediatric cardiac surgery at the Bristol
Royal Infirmary (BRI) between 1984 and 1995 and any failure to take action promptly.
Today, Dr John Roylance, former Chief Executive, United Bristol
Healthcare NHS Trust (UBHT), gave oral evidence to the Inquiry. He began by discussing
when he first became aware of concerns relating to paediatric cardiac surgical outcomes
and commented on general demands from clinicians for funding to improve services and the
management responsibility to prioritise finite resources. He discussed the level of
referrals to Bristol and discussed the attempts to recruit a paediatric cardiac surgeon in
the early 1990s. He described the discussions amongst UBHT, Bristol University, Regional
Health Authority and Department of Health staff about the paediatric service in Bristol
and commented on the Trust reaction to articles in the magazine Private Eye, claiming that
high mortality rates were being recorded in Bristol for paediatric cardiac surgery. Dr
Roylance then described his options for acting upon concerns including seeking advice from
the medical royal colleges. The Inquiry then heard about the working party report for the
Supra Regional Services Advisory Group carried out by the Royal College of Surgeons in
1986, which recommended that referrals to Bristol needed to increase in order to improve
outcomes. Dr Roylance stated that he had not seen this report. He then spoke about
referrals from South Wales to Bristol and concerns raised about the quality of the service
and the response from the Bristol paediatric cardiologists and surgeons. Next he told the
Inquiry about correspondence he received from Dr Stephen Bolsin, Consultant Anaesthetist,
at the time of application for Trust status, which referred to high mortality rates for
paediatric cardiac surgery. He then focussed on waiting times for the Bristol cardiac unit
and commented on results of regional reviews, which showed dissatisfaction with the
Bristol service. He noted the request from the Regional Health Authority for a proposal
which would increase capacity in the unit, unification of the service and steps to improve
quality. Dr Roylance concluded the day’s evidence by talking about observations from
Martin Elliott, Consultant Paediatric Surgeon, who highlighted the ‘split site’
as a potential risk.
|
FULL TRANSCRIPT
1 Day 88, 6th December 1999
2 (10.35 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Mr Langstaff.
5 MR LANGSTAFF: Good morning, sir. Sir, today we have the
6 evidence for the second time of Dr Roylance, addressing
7 largely different issues from those which he addressed
8 when he first came before us getting on for some six
9 months ago, but before he comes -- and my apologies for
10 delaying the beginning of his evidence -- may I deliver
11 what was promised last week, which is a statement on the
12 Inquiry's approach to morbidity.
13 MR LANGSTAFF:
14 RE INQUIRY'S APPROACH TO MORBIDITY:
15 MR LANGSTAFF: On Day 75, which was last month,
16 11th November, I gave a report on morbidity and
17 suggested that I would set out in more detail the work
18 programme on post-operative morbidity which is now under
19 way. I am happy to do so. It is important, I think, to
20 begin with familiar although important starting points.
21 The Inquiry is required by its terms of reference
22 to make findings as to the adequacy of care at Bristol.
23 I made clear in my opening statement on 16th March that
24 we would look at all paediatric cardiac surgery and at
25 all outcomes, not only death but also morbidity, such as
0001
1 brain damage.
2 Evidence has thus far been put before you from
3 a wide variety of sources, including more than 200
4 statements from parents, and on a wide variety of
5 indicators, the statistical analysis and the Clinical
6 Case Note Review being but two of those indicators.
7 It is not within the Inquiry's terms of reference,
8 and this was made clear at the outset, to examine and
9 seek to explain what happened in the case of each
10 individual child who died or suffered damage while being
11 cared for at the Bristol Royal Infirmary or the
12 Children's Hospital during the relevant period. It is
13 the Inquiry's responsibility, however, to reach
14 conclusions as to the adequacy of care overall and in
15 this regard every single case will be taken into
16 account.
17 To the extent that it throws light on the adequacy
18 of care, the issue of morbidity associated with
19 paediatric cardiac surgery is of central interest to the
20 Inquiry, yet the analysis of morbidity is, as has been
21 said on a number of occasions, extremely complex.
22 It is much more complex than mortality, yet, as
23 the evidence itself has indicated, the analysis of
24 mortality is far from straightforward.
25 The task of collecting and piecing together
0002
1 evidence on morbidity is fraught with problems of
2 definition and problems of degree. Further problems
3 arise with the interpretation of such evidence as can be
4 gathered, by which I mean ensuring that the Bristol
5 evidence is set in a fair and proper context, not only
6 of the time, but also relative to other centres.
7 It is important that I should lay bare these
8 difficulties so that those who have an interest in this
9 Inquiry, including the wider audience, may have insight
10 into how we propose to proceed further.
11 We take the term "post-operative morbidity" to
12 mean problems with a child's health which were not
13 apparently present before the surgery and which manifest
14 themselves as functional impairments or disabilities,
15 and which would not have been present, or present to
16 such an extent, in the absence of surgery.
17 Different types of problems can follow paediatric
18 cardiac surgery, including neurological complications
19 ranging from severe brain damage to longer term learning
20 disabilities, breathing and kidney complications,
21 problems with the liver and bowel. The most serious
22 types of post-operative morbidity, we are advised, tend
23 to become evident first within 36 hours of an operation;
24 other problems, such as learning difficulties, may not
25 become apparent for a very considerable time. Thus the
0003
1 first challenge for the Inquiry is in establishing
2 a presence, and the second challenge the extent, of
3 post-operative morbidity, when some children's problems
4 may not have become apparent during the period of their
5 stay at the Royal Infirmary or the Children's Hospital.
6 The next challenge is to examine and identify the
7 causes of any such problem as emerges. That is not
8 straightforward. For example, it cannot be said that
9 because surgery was followed by a post-operative
10 complication, that the surgical procedure necessarily
11 caused that complication. Post-operative complications
12 may, we are told, be caused by many factors: they may be
13 a consequence of the child's initial state of health.
14 Sometimes even the facts of a child's initial state of
15 health are not fully apparent at the time of surgery.
16 I have in mind the case of very young babies who have
17 heart surgery, where there is always a possibility that
18 neurological damage occurred during or shortly after
19 birth, yet this damage will not have become manifest in
20 those who have heart surgery at such a very young age.
21 Complications can also possibly be related to the
22 care of the child pre-operatively, for instance, to any
23 delays in surgery, to the surgery itself, to
24 post-operative care or indeed, to a combination of some
25 or all of these. Of course, when one is looking at
0004
1 post-operative care, it may be that those disabilities
2 which take a longer period to arise may not necessarily
3 be attributable to care here in Bristol but may be
4 attributable to follow-up care, or its absence,
5 elsewhere.
6 Disentangling the causes of post-operative
7 morbidity -- and I stress that in the plural, causes,
8 because post-operative morbidity can very often be
9 multi-causal -- is an extremely complex task which most
10 branches of medicine have yet to achieve today.
11 Notwithstanding those complexities, the Inquiry
12 has adopted a number of strategies to allow morbidity to
13 be examined. We are, I hope, right to regard the
14 complexities as challenges to be overcome rather than
15 a brick wall in our path which means we simply turn
16 aside.
17 The further strategies, then: we have, through the
18 Clinical Case Note Review, received evidence from our
19 expert panel in relation to a number of children who,
20 although they survived surgery, nonetheless did not make
21 a full recovery. We have had evidence, to which I shall
22 make further reference later, arising from the review
23 which was done of the Hospital Episode Statistics as to
24 how the apparent picture of post-operative morbidity in
25 Bristol may compare to that in other centres for
0005
1 children of very much the same age elsewhere in the
2 United Kingdom at the relevant time.
3 In addition, the Inquiry is both engaged in and
4 actively exploring further work to identify and separate
5 illness and damage which resulted from receiving
6 paediatric cardiac surgical services from that which did
7 not. The further work comprises, first, seeking expert
8 clinical advice on the issues involved in assessment of
9 post-operative complications; second, further analysis
10 of data on post-operative morbidity at Bristol, using
11 the following sources: the UBHT coded clinical records
12 dataset; the UBHT Patient Administration System, known
13 as PAS; the UBHT surgeon's logs dataset; and the
14 Hospital Episode Statistics (HES) dataset, together with
15 a sample of 80 cases which was studied in detail during
16 the Clinical Case Note Review; third, a systematic
17 review of existing published research evidence on the
18 outcomes, including morbidity, of paediatric cardiac
19 surgery with specific reference to the period 1984 to
20 1995, which we hope will contribute to the Inquiry's
21 understanding of wider research evidence on the outcome
22 standards of paediatric cardiac surgery, against which
23 the expression of concerns in Bristol need to be set.
24 In addition, the Inquiry is assessing the
25 feasibility of other research to investigate the impact
0006
1 of risk factors on outcomes in paediatric cardiac
2 surgery, including post-operative morbidity.
3 We have signals from the statistical evidence thus
4 far given to the Inquiry. For instance, it will not
5 have escaped your notice that in the material that was
6 put before the Panel earlier this year, there was, on
7 the face of it, an apparent statistically significant
8 difference between Bristol as a centre and other centres
9 in so far as some aspects of post-operative morbidity
10 were concerned. Indeed, in other aspects, the
11 difference tended towards significance.
12 But it would be unduly simplistic, and therefore
13 wrong for any Inquiry charged with looking at matters in
14 detail, for one simply to pick from the statistical
15 report, as it were as conclusive evidence, a statistic
16 showing that there is, for instance, a much greater
17 incidence of neurological damage following operation in
18 Bristol as compared to other centres, as indicating that
19 that is in fact the case once all has been examined.
20 It is right that I should remind you that when
21 that statistical evidence was given, there were a number
22 of caveats which are important. The first was that,
23 although the statistics appeared as it were to the
24 casual reader to relate to post-operative morbidity,
25 that only related to the time at which the morbidity was
0007
1 assessed. It might have been at any stage during the
2 stay in hospital. One could not say, on the face of the
3 statistics, because of the way in which the dataset was
4 compiled, whether the morbidity was apparent before or
5 after an operation. It may be, for instance, that
6 a number of children coming to surgery in Bristol, for
7 whatever reason, had a greater number of complications
8 pre-operatively than did children coming to operation
9 elsewhere in the country; if you like, case mix may be
10 an explanation, or at least in part an explanation.
11 Secondly, we heard from the statisticians that it
12 was their view that the data compiled in respect of
13 Bristol through HES, which is the measure of comparison,
14 was, so far as morbidity was concerned, very full.
15 There was some hint, from what they said, that they
16 thought this was unusually complete, and it may simply
17 be that an apparent difference is no more than the fact
18 that in Bristol records were made, and made with care,
19 made with completeness, which were not made with such
20 care and completeness elsewhere, so the apparent
21 difference may be no more than an artefact of data
22 collection.
23 It is considerations such as these which plainly
24 require the fullest investigation. They in themselves
25 represent the challenge of which I spoke and the
0008
1 challenge has to be addressed if, indeed, at the end of
2 the day, the Inquiry is going to be in a position to say
3 something meaningful about morbidity as well as
4 mortality.
5 In taking forward the further work, one must make
6 further caveats:
7 (1) available data on post-operative morbidity are
8 severely limited across the board, and not just at
9 Bristol;
10 (2) post-operative diagnoses, where they are
11 recorded, are only an approximate indicator of
12 post-operative morbidity;
13 (3) attributing morbidity to identifiable
14 components and quality of care is not a straightforward
15 matter;
16 (4) there is, even today, no commonly accepted
17 method of assessing post-surgical morbidity in
18 paediatric cardiac surgery;
19 (5) morbidity data needed to be set in the
20 contexts of the strengths, weaknesses and limitations of
21 the relevant data sources;
22 (6) morbidity data for Bristol need to be set in
23 the context of comparable morbidity data for other
24 specialist centres;
25 (7) such data as does exist was not, we know,
0009
1 recorded uniformly at all centres, thus variation in the
2 quality and extent of data collection must be taken into
3 account in any interpretations.
4 The Inquiry is working actively on the issue, and
5 will continue to do so into the Year 2000. Anyone who
6 imagines that the work of the Inquiry ceases when
7 16th December has come and gone would be entirely
8 misled; it continues, and continues with the same energy
9 that I hope and believe has characterised it thus far.
10 The results of the work would inform the Inquiry's
11 final assessment of the adequacy of care. All relevant
12 work will of course be published and comments invited.
13 As always, any material that goes before the Panel will
14 go before the public too.
15 The final output will be incorporated into the
16 Inquiry report.
17 Sir, I hope that that description of the Inquiry's
18 past, current and future work in tackling what I have
19 described as "the challenge" of morbidity will be
20 helpful.
21 THE CHAIRMAN: Thank you very much, Mr Langstaff.
22 MR LANGSTAFF: Sir, I wonder if Dr Roylance may now join
23 us? Dr Roylance, would you kindly stand to affirm?
24 DR JOHN ROYLANCE (AFFIRMED):
25 Examined by MR LANGSTAFF:
0010
1 Q. Dr Roylance, I am sorry for keeping you waiting a little
2 this morning. You have been with us before and
3 therefore you will appreciate that I shall begin by
4 showing you the statements which you have given us since
5 the last time you were here.
6 Last time, you will recall, I was asking you about
7 your statement on Issue B, which took us, at WIT 108,
8 from pages 41 to 42.
9 You have since then -- can we have on the screen
10 please -- given us a statement, WIT 108/43, where you
11 tell us in a statement about the issue of audit and that
12 goes through to page 48, does it? At the bottom it is
13 signed and you have enclosed appendices from pages 49 to
14 page 117.
15 A. Yes.
16 Q. I asked you a number of questions the last time you were
17 here about audit and you expressed the desire to
18 formalise what you wished to say, and this, I think, is
19 that statement, having considered the matter at greater
20 length and with access to the documents to which you
21 wish to refer?
22 A. Yes.
23 Q. Do we also have, at the beginning of page 118, your
24 statement in relation to the expression of concerns,
25 which takes us through, does it, to page 131, where it
0011
1 is signed last week on 1st December, and again,
2 enclosing an appendix which takes us through from
3 page 132 to 138?
4 A. Yes.
5 Q. Are the contents of those statements true and accurate
6 so far as you are aware?
7 A. Yes.
8 Q. As before, Dr Roylance, I do not propose to take you
9 through those statements in detail, paragraph by
10 paragraph; they should be taken as read by the Panel.
11 The questions that I have to ask you will be addressed
12 to them, and will take matters from them, and ask you
13 more about those particular issues.
14 Can I begin by asking you a number of general
15 questions, essentially to see if I can establish with
16 you some dates or approximate dates which will inform
17 the rest of the questions which I have to ask you.
18 When was it, as you recall, that you were first
19 aware that paediatric cardiac surgery at the Bristol
20 hospitals was not achieving its full potential?
21 A. I was aware at the time I became District General
22 Manager, which would have been April 1985, that there
23 was a desire by the staff within the service for
24 improvements.
25 Q. That must be true of any service, because one would
0012
1 always expect clinicians --
2 A. Yes.
3 Q. You say in your statement you have been aware for some
4 time that paediatric cardiac surgery had not been
5 achieving -- these are your words -- its full potential.
6 A. Yes.
7 Q. When do you think you were aware of it in those terms?
8 A. I do not think I can give a date, because this was, you
9 will understand, an evolving sense within the service,
10 beginning very early on with the paediatric
11 cardiologists, who, like all other paediatric
12 specialists, wanted all children's services to be within
13 the Children's Hospital.
14 It gradually gained more and more support within
15 the district, although never consensus, never a view
16 held by everybody, and I therefore cannot give a day
17 when I suddenly became aware that there was a desire to
18 improve the facilities of paediatric cardiac surgery.
19 Q. When was it, do you think, that you first became aware
20 that paediatric cardiac surgery performed at Bristol was
21 not one of the best units?
22 A. That was the sort of argument that was pressed as
23 a support for the philosophy of the improvements that
24 were required, that we were not the "gold standard", if
25 I can put it that way.
0013
1 Q. So those two go together: an awareness that paediatric
2 cardiac surgery was not achieving its full potential,
3 together with the awareness that it was not one of the
4 best units?
5 A. Well, I have to say, when people press a district
6 General Manager or Chief Executive for substantial
7 additional resources within their particular service,
8 they do not ally that with the statement that "we are
9 already leading the field and the best in the country",
10 so the two sentiments go together.
11 I am being slightly careful because it did not
12 distinguish that particular service from virtually any
13 other service in the Trust. Everybody wishes to be
14 better and real comparative data did not exist.
15 Q. Can I press you a little, because what I am exploring is
16 your own perception. If I can, if it is possible, put
17 a date upon your perception that paediatric cardiac
18 services were first of all not achieving their full
19 potential, and secondly, were not one of the best units,
20 that would be helpful. It may be that there is
21 a difference between that view and a view expressed to
22 you by, let us say, any service that was the "gold
23 standard", but also seeking to improve, as it would
24 inevitably be?
25 A. No, I do not think that is a fair reflection of the
0014
1 Health Service as I knew it. Nobody ever came to me and
2 said, "We are the best unit in the country, we are
3 setting the gold standard and please we want
4 substantially increased resources more to do better".
5 Q. So you have to look at the bid made to you as District
6 General Manager or Chief Executive; you have to decide
7 whether or not what is told to you is told to you from
8 a position of real comparative weakness, or whether it
9 is just the clinicians fighting their corner for more
10 resources?
11 A. You are implying that comparative data was available to
12 me, which of course it was not.
13 Q. No, comparative view, rather than comparative data.
14 A. It is always a difficult judgment to make in terms of
15 which was the highest priority, as expressed within the
16 district. I am trying to be helpful and you are asking
17 me for a specific time when I felt this service needs
18 improving, and I do not think I can answer that question
19 because that is not the way it evolved.
20 Q. Given, taking that last answer, that you see it as an
21 evolution, when, tracing it back, do you think the
22 evolution began?
23 A. With the very first paediatric cardiac operation, if
24 I understand your question.
25 Q. So far as you are concerned, from the moment you became
0015
1 District General Manager you were aware that there was
2 a pressure for improvement which, can I put it this way,
3 had some proper basis for it, as opposed to simply being
4 a unit wishing to bend your ear for more resources in
5 order to improve what was already quite good?
6 A. I would like to say yes, but I would not like to add to
7 that that I thought that anybody who wished to improve
8 the quality of the service was making an improper
9 request. I respected all the requests of people.
10 Within the hospital, everyone is pressing for
11 excellence, everybody is pressing for improvement on
12 excellence, and I do not think any of those requests
13 were improper. The difficulty the District Health
14 Authority had, and subsequently the Trust, was to find
15 a way of putting into a priority order the requests that
16 were made.
17 Q. When did you first become aware of the changes necessary
18 to improve the unit and to realise the potential
19 paediatric cardiac surgical service?
20 A. Well, I think in the late 1980s and early 1990s there
21 was an evolving, increasing pressure for the
22 improvements that I think I knew were desired even when
23 I became a District General Manager.
24 Q. It is one thing, is it, to be aware that this is what
25 others might like on the one hand, and to have
0016
1 a personal awareness yourself that a particular step is
2 necessary to secure the improvement?
3 A. I think you flatter me if you feel that I have
4 a personal judgment about these things. It was a matter
5 of a wide discussion, and a view taken, initially by the
6 District Health Authority, and then subsequently by
7 purchasing health authorities.
8 Q. Were you ever aware that the throughput of cases in
9 paediatric cardiac surgery, and in particular, in the
10 neonatal and infant group, was low, and that the
11 Department of Health and the Regional Health Authority
12 were concerned to increase it?
13 A. Not until very late on. Not until somewhere in 1995,
14 I suspect. That was not an issue that was discussed
15 with me or the District.
16 Q. If that view had been expressed to the director, the
17 Clinical Director when Clinical Directors were
18 introduced, or the Chairmen of the division before that,
19 by the Department of Health, would you have expected to
20 have heard of it?
21 A. Only if it was a logical next step that something
22 I could do for them existed. I do not think that simply
23 the Department of Health and in this case I imagine you
24 are talking about the supra-regional designation group,
25 talking with the local clinicians, they would not
0017
1 normally have included -- well, they did not include me
2 in their conversation.
3 Q. You make reference in your statement to what you
4 describe as the "long history" of attempts to recruit
5 what you describe as an "appropriate surgeon". When do
6 you see that long history as having begun?
7 A. I cannot be sure that efforts were not made before
8 I became District General Manager, but certainly, soon
9 after 1985. When you say there were "efforts to
10 recruit", that is rather the end. There were efforts to
11 identify the resources to enable us to create a post.
12 Q. I am taking the words, I hope not inaccurately, from
13 your own statement, page 125, paragraph 31 at the foot.
14 You are talking here about events in 1994, and reference
15 to a conversation with Professor Angelini. What you say
16 is:
17 "He did not seem to appreciate the long history of
18 our attempts to recruit an appropriate surgeon ..."
19 That is where the words come from.
20 A. Yes, and I accept that. What I was trying to elaborate
21 on is that the first two-thirds or more of that long
22 history were an attempt to identify the resources. By
23 the time I spoke to Professor Angelini, we had already
24 endeavoured to solve the problem by recruiting
25 a Professor who was an expert in paediatric cardiac
0018
1 surgery. So by that time, we were in the recruitment
2 phase of the long history.
3 Q. I follow that. What I was hoping to do was to see if
4 one could put a date on when the long history began.
5 A. No. I do not think there is a start date in that
6 situation. Certainly I suspect that in what, 1987, the
7 Health Authority at that time approved the intention.
8 I am looking for an event that I can use to answer your
9 question. I think somewhere around 1987 or thereabouts,
10 the Health Authority approved the intention of
11 endeavouring to achieve the two events.
12 Q. And the "two events", one is the --
13 A. They were both interlinked. I hope everybody
14 understands that. One was to unite the service on one
15 site and the other was to recruit a paediatric cardiac
16 surgeon who was not also an adult cardiac surgeon to
17 work in that unified service.
18 THE CHAIRMAN: Dr Roylance, do you need a little time to
19 organise your papers?
20 DR ROYLANCE: Thank you very much indeed. I just thought it
21 would be helpful if they were by my elbow, I am sorry.
22 MR LANGSTAFF: You say at another stage in your statement
23 that you repeatedly made it clear to the whole Trust --
24 so this is obviously referring to a time when the Trust
25 was in existence -- that whistle-blowers would not be
0019
1 victimised.
2 When did you first, as you recollect it, so make
3 it clear?
4 A. I think at the same time as the term "whistle-blower"
5 became common parlance. I cannot actually quite
6 remember when that was, but I think it was fairly early
7 in the Trust's existence. I was only Chief Executive
8 for four years, and I suspect it was in the first two
9 rather than the last two. A "whistle-blower" was a new
10 description to us, and we had to make clear that --
11 I think some Trusts at the time were endeavouring to
12 include in consultants' contracts a silence clause or
13 confidentiality clause. We made it clear that there was
14 no way the Trust would or could prevent them expressing
15 their views in public.
16 Q. Again, along the lines of trying to establish as best
17 I can dates for a number of matters, when did you first
18 know that anaesthetists had concerns about paediatric
19 cardiac surgery?
20 A. I think at the end of 1994, the beginning of 1995.
21 Q. When did you first realise that anaesthetists on the one
22 hand and surgeons, possibly cardiologists on the other,
23 were in disagreement?
24 A. The first time I was aware of disagreement, as
25 I understand the question, was immediately prior to the
0020
1 proposal for the operation on Joshua Loveday.
2 Q. So that would be January 1995?
3 A. Yes.
4 Q. When was it that you first decided to have an
5 independent review of paediatric cardiac surgery?
6 A. It was certainly after the case conference, because
7 until that reported, there was no sustained clinical
8 agreement. I am not absolutely certain whether that
9 decision was made the night before the operation or
10 immediately after the operation. I had been persuaded
11 that it was probably the night before, but on
12 reflection, I do not remember that and I really do not
13 think in the excitement of the time and the issue of
14 Joshua Loveday, I would have been quite so statesmanlike
15 and mature and reflected in the middle of the night or
16 late in the evening to deal with the total problem.
17 I find it much more likely that I slept on it and
18 agreed the inquiry the following day, but I am sorry,
19 I cannot be certain of the precise time, whether it was
20 the night before or the following morning. If you want
21 me to say what my belief is, it is that it was the
22 following morning.
23 Q. Two things may help and I mention them now, although the
24 likelihood is that we will come back to them. The first
25 is that when you gave evidence to the General Medical
0021
1 Council, you thought it had been between the case
2 conference and the operation. That was the best of your
3 recollection at the time.
4 A. Yes.
5 Q. The second is that we have had evidence from Dr Doyle
6 who in the course of his evidence, suggests rather that
7 he had to push in conversation -- he is not entirely
8 clear -- to persuade you to have an inquiry, which you
9 then readily agreed to, let it be said, but that might
10 suggest your mind had not been made up at the time you
11 spoke to him, or at least, not fully made up. I do not
12 know if either of those helps you?
13 A. There are two conflicting pieces of evidence. At the
14 time of the GMC Inquiry I had listened in detail to
15 James Wisheart being absolutely certain he spoke to me
16 on the evening after the case conference about an
17 inquiry. I find it difficult to gainsay him. I think
18 if you read the transcripts, you will see that
19 I expressed uncertainty, but accepted it could well have
20 been the night before.
21 As I say, on reflection I do not find that a very
22 plausible explanation, but I have told you, I have no
23 precise memory and cannot help you as to whether it was
24 the night before or the following morning. I believe it
25 was the following morning.
0022
1 Q. The third piece of evidence, which at the end may help,
2 I do not know, is that we have heard from Mr McKinlay
3 that he went home for Christmas in 1994, having believed
4 from conversation with you that you and he had decided,
5 prior to Christmas, to have just such an inquiry?
6 A. Well, I am sorry, but I am obliged to say that he is
7 mistaken in his memory. There is no question that
8 I agreed to an inquiry, or even contemplated an inquiry
9 before Christmas.
10 Q. Again, looking at the chronology of certain events,
11 certain knowledge that you may have had, or awareness,
12 when was it that you first knew that neonatal arterial
13 switch operations had been discontinued?
14 A. Some time in the lead-up to the recruitment of
15 a consultant in paediatric cardiac surgery, in the
16 work-up to the recruitment of Ash Pawade, because that
17 became part of, if you like, the requirement, the job
18 description of the applicant.
19 Q. The interview there was 20th September 1994?
20 A. Yes. It would have been early in that year that we were
21 discussing the mechanics and the processes of
22 recruiting. It is a long process of getting approval
23 from a wide variety of sources, including the
24 appropriate Royal College, and so on, and then putting
25 in an advertisement and then having time for
0023
1 shortlisting, taking up references. So it would have
2 been a minimum of three months, and probably five months
3 before the interview.
4 Q. So that would put it some time between April, May, June,
5 that rough sort of period?
6 A. Yes.
7 Q. When did you first become aware that Dr Bolsin had been
8 collecting, let us call it "figures", or "data"?
9 A. After the visit of Marc de Leval and Stewart Hunter.
10 Q. Not before?
11 A. No.
12 Q. Can I turn to something a little different, again by way
13 of introductory questions? You, as District General
14 Manager first, as Chief Executive second, had an
15 overview of a number of very different surgical and
16 other medical services?
17 A. Yes.
18 Q. When issues arose in respect of a particular service,
19 was it your habit to seek information from those who
20 might know more about the issues, such as those
21 intimately connected with delivering the service, for
22 instance, the Clinical Director?
23 A. I think the answer is "Yes". I am not sure what you
24 mean by "issue", but I was in constant contact with the
25 Clinical Directors and saw it as my personal
0024
1 responsibility to underwrite their success.
2 Q. If I can take an example and just -- I think you have it
3 right. If we look at JDW 3/134, it is a letter to you
4 from Mrs Binding of the NHS Executive dated 22nd June
5 1992.
6 "The attached correspondence has been received ...
7 matters which can best be dealt with by your Trust.
8 I would be grateful if you could look into the matter
9 and reply directly to Mrs Hooper."
10 If we go back a page to 133, you say to
11 Mr Wisheart in the memo:
12 "Please find attached the letter received from the
13 NHS ME. Please could you let me have a draft letter so
14 that I may reply back to them."
15 You had a draft letter and replied back?
16 A. Yes.
17 Q. That is a particular example of a letter being raised.
18 There was a flash on the screen of a handwritten
19 letter.
20 A. Yes.
21 Q. And that flash on the screen was the letter obviously
22 enclosed by Mrs Binding from the NHS Executive?
23 A. Yes.
24 Q. And you are asking Mr Wisheart effectively to draft your
25 response?
0025
1 A. Yes, I would be adopting the same procedure as the
2 author of the letter to me. She had had a problem
3 presented to her and she thought I would be able to
4 produce the answer, so she sent it to me. I had
5 a problem presented to me, I know Mr Wisheart produced
6 the answer, so you will see I asked him to produce
7 a draft letter. As a courtesy, I would always sign the
8 letter back. If the enquiry was made to me, I would
9 always sign the letter back, but clearly I could not
10 answer it from my own knowledge, I would have to obtain
11 the necessary information from those who would have the
12 necessary knowledge.
13 Q. Can we look at UBHT 61/273? It is a letter from
14 Professor Angelini to Dr Doyle, 19th August 1994.
15 A. Yes.
16 Q. Shall we go to the end of it, which I think is on the
17 next page? It is copied or purports to be copied to
18 you. If we go back to page 273, it is a letter -- again
19 we will come to it in greater detail later on --
20 expressing some frankness and concern about paediatric
21 cardiac surgery, or dealing with that issue.
22 A. Yes.
23 Q. You write on it -- that is your writing, is it not?
24 A. Yes, that is my writing.
25 Q. So "James" is James Wisheart?
0026
1 A. Yes.
2 Q. And you are John Roylance?
3 A. Yes.
4 Q. "Could I have your comments".
5 A. Yes.
6 Q. You have the letter in, it relates to your service, you
7 address that in each of the examples that we have seen
8 to Mr Wisheart.
9 A. Yes.
10 Q. In general over the period 1984 to 1995, if a concern
11 were expressed to you about cardiac surgery, would you
12 have addressed it to Mr Wisheart, or referred it on to
13 Mr Wisheart for information?
14 A. Well, it would depend precisely at the time, because
15 James Wisheart had occupied different positions, but if
16 it were appropriate, yes.
17 Q. When, as we have already mentioned, the operation took
18 place on Joshua Loveday, at about that time and just
19 before or just after, as you recollect it, you decided
20 to have an inquiry, an investigation into paediatric
21 cardiac surgery, that was your decision, was it?
22 A. Well, I am sure that I would have to accept
23 responsibility for the decision being made, but
24 I believe it was jointly reached by James and I, but
25 I have no hesitation in saying as Chief Executive, that
0027
1 I would have to take final responsibility for the
2 decision.
3 Q. What, if any responsibility, did the Trust Board have
4 for it?
5 A. That would depend on whether this was seen to be an
6 executive matter working within the policies of the
7 Trust Board, or was a new issue on which the Trust Board
8 had to express a policy view. I suspect at the time the
9 urgency made me act on it anyway and expect the Health
10 Authority to support my action when we next met.
11 Q. So this would be executive action taken between
12 a meeting of the Board?
13 A. Yes.
14 Q. To which you would expect the Board's endorsement
15 subsequently?
16 A. Yes.
17 Q. Can we look at letter ? You recall a moment
18 or two ago I showed you the letter which Professor
19 Angelini had sent to Dr Doyle and copied to you.
20 A. Yes.
21 Q. And upon which you had invited Mr Wisheart's comments.
22 A. Yes.
23 Q. Your letter back, 12th September 1994, if we go down to
24 the third paragraph, or second and third:
25 "I felt I should write to confirm the Trust
0028
1 Board's awareness of this problem".
2 Leaving aside what that means, we will come back
3 to this again in some detail.
4 You speak of the awareness of the Trust Board in
5 paragraph 2. Paragraph 3:
6 "The decision has already been taken by the Trust
7 Board ..."
8 So your letter to Dr Doyle appears to be written
9 as Chief Executive on behalf of the Board. Is that
10 a fair understanding of the position or not?
11 A. Yes. I think many people would view that my every
12 action was on behalf of the Board.
13 Q. You are taking some responsibility on paper, are you,
14 for the need to deal with the problem, as it is called
15 and the way in which the problem has been dealt with?
16 A. Yes. We may have to define what we mean by "the
17 problem", but, yes, I am actually informing Dr Doyle of
18 the true status of the situation, because the copy of
19 the letter I had from Gianni Angelini did not reflect
20 the true position.
21 Q. The reply, which again, going back over some of the
22 letters I have shown you, to understand the general
23 system that if you had something in writing from an
24 important source relating to paediatric cardiac surgery,
25 you would, depending upon the year in which it happened,
0029
1 go to Mr Wisheart?
2 A. Yes.
3 Q. Or others, for input?
4 A. Yes.
5 Q. But you would respond, and you asked him, if you recall,
6 to draft a response to the letter from Mrs Binding?
7 A. Yes.
8 Q. Can we look at JDW 3/158, and scroll down? This is the
9 second page of your response, and again, I will come
10 back to the full response later. You say here in the
11 last full paragraph:
12 "Turning to the more general consideration of this
13 matter, we have had made a firm decision to enter into
14 absolutely no discussion or debate with Private Eye, but
15 on the suggestion of the Chairman of the Trust, it is
16 likely that we should circulate to the paediatricians
17 whose children we serve a regular report on the results
18 of our work."
19 So again, you are responding to a letter. You
20 were, after all, the addressee of the original letter?
21 A. Yes.
22 Q. And you are responding as Chief Executive and on behalf
23 of the Trust, here referring to a discussion you have
24 had with the Chairman of the Trust Board.
25 A. Yes. It may not have been my discussion with the
0030
1 Chairman of the Trust Board. Could I see the reference
2 at the top? It might be helpful.
3 Q. Of course, can we go back to the page before, please?
4 A. I cannot swear to you now, but it may well be that this
5 is a letter dictated and typed on behalf of James
6 Wisheart which I signed. When I asked him for
7 a letter, at that stage I think, I did normally expect
8 to have a letter which I was able, properly, to sign.
9 Q. I thought that might be the case. As it happens with
10 this particular correspondence, and again, I will come
11 back to this so you have every chance to look at it in
12 some detail, there were three drafts of a response?
13 A. To this one?
14 Q. I am sorry, I beg your pardon, not that one, that was
15 Mrs Hawkins, I am sorry. So you think he drafted this
16 and you happily signed it?
17 A. Yes. I cannot swear that I did not edit it. I would
18 have no record of so doing, but I suspect it is a letter
19 written by him, dictated by him, which I signed.
20 Q. All these three letters, the events we have looked at,
21 the commissioning of the report, the response to the
22 letter or the correspondence between Dr Doyle and
23 Professor Angelini, the reply here to Ms Binding, in
24 each of those you are taking action as Chief Executive,
25 or saying that you are taking action as Chief Executive,
0031
1 in respect of the service which was provided by the
2 paediatric cardiac clinicians.
3 A. Yes.
4 Q. So you had, and accepted, where appropriate,
5 a responsibility to act?
6 A. Yes I think ...
7 Q. If you had seen the letter from the anaesthetists which
8 you say you did not see in the middle of 1994, asking
9 for a detailed and comprehensive review of paediatric
10 cardiac surgery -- I will come to the exact terms of the
11 letter in due course -- what do you think you would have
12 done upon receipt of that letter?
13 A. I hope I would have acted maturely and responsibly and
14 correctly, in which case my first response I think would
15 have been to take advice from James Wisheart, who was
16 the medical adviser to the Trust Board. This was
17 a medical matter.
18 At that time he was Chairman of the Medical
19 Committee at the same time, I think. But I would have
20 discussed it with the Clinical Director of Anaesthetics
21 as well.
22 I did not understand the letter. I still do not
23 understand the letter. I would have been very anxious
24 to know the background. It was, at the same time,
25 a professional issue and I would have taken it upon
0032
1 myself to ensure that the appropriate professionals
2 resolved what was clearly a dispute. I could not make
3 a judgment about it. There was no way I could have an
4 independent opinion, but I do hope that I would have had
5 a meeting.
6 I am trying to be honest and say I do not know now
7 in which order I would have had the discussions, but
8 I certainly would have included the Director of
9 Anaesthetics in it; I would have included James.
10 I probably would have included Hyam Joffe as well, as
11 representing the group of staff who were actually
12 referring patients for surgery to Bristol. I would just
13 like to give a general view that I would have had the
14 right people in my office very shortly after I had seen
15 the letter to have a preliminary discussion about
16 a situation which I would have found quite
17 extraordinary.
18 Q. Suppose that you had a letter or a document from
19 a reputable and respectable source which suggested that
20 the way in which paediatric cardiac surgical services
21 were being delivered was dangerous, potentially
22 dangerous, to the children. Would you have taken some
23 action, as Chief Executive?
24 A. Absolutely. I would have activated the proper
25 professional pathways to deal with that situation.
0033
1 Q. What would they have been?
2 A. They would have been with the local people to start
3 with, I would not have gone behind anybody's back, but
4 in the sense that I think I understand your question,
5 I would have referred it to the appropriate Royal
6 College or Royal Colleges, to get their professional
7 advice, to ask them to advise me, because that, in my
8 view, at that time, was their responsibility.
9 Q. So if there was any suggestion of danger, or potential
10 danger to a patient, you would have gone outside the
11 hospital and the clinicians within it, but had it been
12 the anaesthetist's letter, I think you would at least in
13 the first place have conducted your discussions within?
14 A. Yes. I mean, I answered the question I hope honestly,
15 because I did not see that as a letter to me saying the
16 situation was dangerous. I believe that was about,
17 now -- and I think I would have found out very quickly,
18 about a particular series that by that time had already
19 been stopped.
20 Q. The question was necessarily a hypothetical one at this
21 stage, and it was very much asking, well, if, from
22 a respectable and reputable source, you had a suggestion
23 of potential danger to a patient, what did you as Chief
24 Executive think you would have done about it, and you
25 say, "I would have gone to the Royal Colleges for
0034
1 advice"?
2 A. I was prefacing that by saying I would have to establish
3 that your first presumption was proper, and in this
4 case, the way I would have found out was talking to the
5 anaesthetists. If I found that there was a genuine
6 conflict of opinion about the quality of service, and
7 particularly if anybody had implied in any way at all
8 that the situation was dangerous, if they could not
9 resolve it to the total satisfaction of the people who
10 ought to have been talking to each other, if there was
11 an issue whether the service was dangerous or not,
12 I would have had to activate the professional hierarchy.
13 This would start with a professional view from the Royal
14 Colleges and then a managerial view through the Regional
15 Medical Officer and the District Medical Officer, who at
16 that time had responsibilities for medical performance.
17 The one thing I could not do was take a personal
18 decision, make a personal judgment and deal with it.
19 I could only have done that on proper professional
20 advice.
21 Q. Turning, again, to something of an introductory topic,
22 and the last that I shall deal with before I turn to
23 some of the events in chronological order: you say that
24 at no stage, until at least 1995, was it suggested to
25 you that the service provided by paediatric cardiac
0035
1 surgery was unacceptably poor?
2 A. Yes. Not at all.
3 Q. Something may turn upon the force one gives to the word
4 "unacceptably". How poor does a service have to be
5 before it is unacceptable? Can you give us some
6 indication of the way in which you would have looked at
7 it?
8 A. When, in the opinion of this responsible and
9 authoritative person, it is unacceptable. I could not
10 make a judgment for that. It would not be possible for
11 me to say that a mortality rate of X was acceptable and
12 a mortality rate of Y was unacceptable. There was no
13 way I could make that judgment, or would not make that
14 judgment. Having responsible professional advice that
15 it was unacceptable would be the basis for my action.
16 Q. There has to be, has there not, a watershed below which
17 you would not think it necessary or appropriate to seek
18 the advice of which you have just spoken, and beyond
19 which, you would regard it as irresponsible not to.
20 First of all, is that right?
21 A. I could not possibly, even today, draw a line above
22 which I would ignore the advice that a service was
23 unacceptable and below which I would accept advice that
24 the service was unacceptable. If somebody said, in
25 a serious way, that the service was unacceptable, then
0036
1 I would have to activate the proper professional
2 processes to determine the propriety of that remark.
3 I could not determine it and it would be quite wrong to
4 suggest that I could make a judgment between an
5 acceptable or unacceptable service in terms of mortality
6 rates. In terms of non-clinical processes, then
7 I could.
8 Q. I hope that you have not misunderstood the question
9 I was asking, which was not whether you personally would
10 be in a position to judge the acceptability or
11 unacceptability, but on what occasions you might think
12 it appropriate to seek the outside advice which would
13 inform you as to the acceptability or unacceptability of
14 the service?
15 A. Whenever I was told, in anything other than a frivolous
16 way, that a genuine opinion was held that a service was
17 unacceptable. I cannot think of a circumstance where
18 I could be given that information and make a personal
19 judgment that I did not believe them.
20 Q. What if you were presented with statistics, figures,
21 outcome results, showing that in a particular year, let
22 us suppose, the outcome in terms of mortality for
23 paediatric cardiac surgical services was one and a half
24 times that of the average of the United Kingdom, for
25 that particular year? Would you regard that, on its
0037
1 own, as indicating any need for further investigation or
2 explanation?
3 A. I would ask whoever showed me the figures what they
4 meant. I mean, what one would need to do is to ensure
5 that whoever was offering these figures understood the
6 spread of results about the country and where the local
7 results sat in that spread. If you are saying to me, if
8 anybody shows that our Trust was below the average,
9 I would have been concerned. We were a teaching
10 hospital and strove to be above the average in
11 everything. But I do not think I could have had
12 a personal judgment at all at being shown figures.
13 I would have invited professional advice on those
14 figures. Where I would go would depend on what the
15 figures were, who gave them to me, what advice I got
16 locally, but I could not personally make a judgment.
17 Q. The judgment you would make is whether to take further
18 advice, and from whom?
19 A. No, I do not actually think that is a judgment issue.
20 That is a clarification issue and not a judgment issue.
21 We are back to your original question, which
22 I understand, that if I was told by a responsible and
23 authoritative source that there was a problem, then
24 I would have to act on that advice. I could not form
25 a judgment.
0038
1 Q. I think I was taking it further, and just asking in
2 general terms, before we look at any specifics, that if
3 you were considering the outcomes in terms of mortality
4 of a particular service and you saw that those outcomes
5 were one and a half times or twice as high as the United
6 Kingdom for a whole in any one year, you would, would
7 you, seek an explanation from those involved in the
8 service in Bristol to ensure that they understood what
9 the figures showed and give you an appreciation of what
10 they meant?
11 A. Yes. We have been pursuing this, and the answer is yes,
12 I would. We have been pursuing this as if somebody
13 would come to me and show me figures from which I would
14 have to make a judgment. That is not what would have
15 happened. They would have come and given me an opinion
16 and supported it with figures, I believe. If they had
17 not given me an opinion, I would have sought one.
18 I would not have formed any judgment on the basis of
19 numbers. I could not, and it would have been quite
20 improper.
21 Now you are saying, would I make a judgment as to
22 whether to activate the professional mechanisms for
23 looking into issues of that nature? That would be not
24 on my judgment of the figures at all but on the
25 professional advice I was given as to whether this was
0039
1 an issue that required resolution.
2 Q. So if your secretary, let us suppose, happened to put
3 before you, on the desk, the figures for a particular
4 service for the last five, six years, indicating that
5 the performance in each of those years was well below,
6 let us suppose, that to be expected from the average
7 institution in the UK, your reaction would be: well,
8 no-one has come to speak to me about these figures?
9 A. No, no.
10 Q. Would it be to ask any questions? What would it be?
11 A. I cannot imagine the circumstance that you relate, that
12 my secretary suddenly got some figures and gave them to
13 me. For reasons we will come to, that would not have
14 happened at all; that was not a possible scenario.
15 But if somebody sent me figures, unless they sent
16 them anonymously, I would ask the person why they had
17 sent them, what that particular person thought they
18 meant and what their advice was. Depending on who the
19 person was, I may well have taken professional advice
20 within the Trust and then, if necessary, professional
21 advice outside the Trust.
22 But there was no way that somebody would send me
23 some figures for me to form a judgment about them; they
24 would have had more sense than that.
25 MR LANGSTAFF: Sir, I am about to turn now to some of what
0040
1 I have described as the "chronological episodes".
2 I notice the time. We have not been going for long with
3 Dr Roylance because of the statement made at the
4 beginning, but it is now just gone a quarter to 12.
5 Sir, I have just been handed a note which proposes
6 times, and I see that you proposed to continue until
7 12.30.
8 THE CHAIRMAN: If that is not too oppressive on the witness
9 and others, I thought that might be appropriate, under
10 the circumstances, and then have a lunch break at
11 12.30.
12 DR ROYLANCE: I cannot speak for others, but it is not
13 oppressive on me, sir.
14 MR LANGSTAFF: Sir, there are views from behind me, from
15 those who represent Dr Roylance, that that would
16 probably be too long.
17 THE CHAIRMAN: Whom am I to rely upon: Dr Roylance or those
18 who advise him?
19 MR LANGSTAFF: Sir, safety first, I think would be the --
20 THE CHAIRMAN: I am grateful. Why do we not just say, we
21 will take 10 minutes now and reconvene at noon, and then
22 press on thereafter. Thank you.
23 (11.50 am)
24 (A short break)
25 (12.10 pm)
0041
1 MR LANGSTAFF: Dr Roylance, can I take you back to
2 1986? Can we have a look, please at RCSE 2/8. Go
3 overleaf to 9. What I am about to show you is a passage
4 from a report of the joint working party of the Royal
5 College of Physicians and the Royal College of Surgeons
6 in 1986. It is dated 1st September. It relates to the
7 supra-regional services as it says at the top of the
8 page.
9 First of all, did you know there had been
10 a working party shortly after designation as a neonatal
11 and infant cardiac centre was granted to Bristol to
12 review the services generally?
13 A. If you mean a meeting of it, no, I did not.
14 Q. Did you know there had been a report?
15 A. No.
16 Q. Did you ever see this report?
17 A. No.
18 Q. Can we have a look at page 13? If we look on page 13
19 at letter D:
20 "The working party noted that three units, namely
21 Bristol, Newcastle and Guy's were doing fewer operations
22 per year than desirable for a supra-regional centre.
23 Bristol and Newcastle have legitimate claims for
24 development on geographical grounds and should be
25 encouraged."
0042
1 The last sentence in the paragraph:
2 "The workload of these three centres and
3 Harefield should be reviewed in two years' time."
4 Because you never saw the report you never saw
5 that paragraph?
6 A. That is true.
7 Q. Was the information that that paragraph contains as to
8 the working party's view ever given to you?
9 A. No.
10 Q. Would you expect as District General Manager to be told
11 of such a view affecting the development of the service
12 in Bristol?
13 A. No.
14 Q. This was something which would remain with the
15 clinicians providing the service rather than coming to
16 you as District General Manager?
17 A. Yes, yes.
18 Q. Looking at the possibilities, if you had been asked for
19 your advice and assistance as District General Manager
20 as to what Bristol might have done to develop the
21 service, would you have had, do you think at that stage
22 any suggestions to make?
23 A. As a District General Manager, no, none at all.
24 Q. Was it, as you saw it at the time, part of your function
25 as District General Manager to take part in the planning
0043
1 of the different services into the future?
2 A. Yes.
3 Q. Would part of planning involve an appreciation of the
4 numbers that one might expect in terms of throughput of
5 patients of a particular description?
6 A. That would be part of the professional advice that would
7 be summarised and put into the planning process, yes.
8 If it is paediatric cardiac surgery, that was a low
9 volume service in which those referred were met in
10 full. So there was in principle no planning issue for
11 what was then the District Health Authority.
12 Q. Did you have any appreciation of the throughput in
13 Bristol compared to that in other units?
14 A. No.
15 Q. You knew it was a low volume service but you had no
16 idea, do I take it, how low volume compared to anywhere
17 else?
18 A. No, not at all. When I say "low volume service",
19 congenital heart disease is in terms of the major
20 pressures on the Health Service a very small element.
21 Q. At the time, had you been asked, do you think you would
22 have had any view as to a relationship between the
23 numbers of operations of a particular type that
24 a surgeon or others in the team might perform and their
25 experience and hence expertise in that particular
0044
1 operation?
2 A. Only in the most general terms. Only in the most
3 general terms.
4 Q. And the general would be "the more you do the better you
5 are likely to be", along those lines?
6 A. I was aware over those years, again I cannot tell you
7 the date I became aware, I became aware that the
8 profession as a whole and certainly the Royal Colleges
9 came up with more and more suggestions to concentrate
10 expertise in fewer and fewer places and there was always
11 a discussion about the competing requirements of what
12 I can summarise as access and quality. The judgment as
13 to where along that spectrum any particular service
14 should be was a professional issue and the professional
15 advice over the years I knew about it changed.
16 Q. Can we move away, then, from the working party and move
17 on to what we have at WO 1/4? This is a letter from
18 Professor Henderson to Dr Gareth Crompton in Wales.
19 I do not expect you ever saw it; confirm that for me?
20 A. No, I did not see it, no.
21 Q. At page 6 in that letter, towards the bottom of the
22 page:
23 "Bristol. It has been suggested [says Professor
24 Henderson and the other signatories] elsewhere that
25 Bristol provide a supra-regional neonatal cardiac
0045
1 surgical service for Wales. The overriding objections
2 to this have been stated. Moreover it is no secret that
3 their surgical service is regarded as being at the
4 bottom of the UK league for quality, and it is difficult
5 to see how this problem could be resolved in the
6 foreseeable future."
7 In 1986 -- I will come to 1987 in a moment when
8 the Heart Circle in Wales were involved in a media
9 presentation about Bristol about which you may have some
10 recollection. In 1986 did you have any sense that such
11 views were being expressed by other clinical
12 professionals about the Bristol surgical service in this
13 field?
14 A. No.
15 Q. In 1986 would you have had any sense from what you then
16 knew or were told by others as to the accuracy or
17 otherwise of that statement, the statement that is in
18 the letter?
19 A. I knew of no rumours, chat anywhere that Bristol was, as
20 it says here at the bottom, in any "league", I did not
21 even know of the existence of a league.
22 Q. You knew I think -- perhaps you did not -- there were
23 proposals that may have involved a greater number of
24 Welsh children coming to Bristol?
25 A. What I did know was that there was an issue with South
0046
1 Wales which at the time was being led by Ian Baker, the
2 District Medical Officer in that it was a professional
3 issue and not by me as a District General Manager
4 because I was a manager, that South Wales wished to opt
5 out of the supra-regional designation system and have
6 their own service and I think this was precipitated when
7 the cardiologist who was an adult and paediatric
8 cardiologist in Cardiff retired --
9 Q. Dr Davies?
10 A. -- I do not know his name, I am sorry. I do not think
11 I did. Then the problem facing Cardiff I think it was
12 that they were able to appoint a single man to do both
13 services and they were not able to appoint a paediatric
14 cardiologist so there was no paediatric cardiac surgical
15 unit.
16 So this was an argument between some people in
17 Wales (particularly around Cardiff) the Welsh Office and
18 the Department of Health and to an extent Bristol.
19 I was not involved in it, it was a matter of
20 professional opinion.
21 I was aware peripherally that some people (whether
22 they came from the Department of Health or the Welsh
23 Office I cannot tell you today) came and looked at the
24 department and were satisfied --
25 Q. I can help you on that. Can we have a look at
0047
1 WO 1/263? This is a situation report. It is from
2 a Dr Jennifer Lloyd from the Welsh Office. It is dated,
3 I can tell you, 21st November 1986. You can see it
4 begins:
5 "The working party set up under the aegis of the
6 Welsh Medical Committee reported...", and so on.
7 The very bottom of the page deals with the Joint
8 Working Party Report, which you have seen?
9 A. Yes.
10 Q. If we go over to page 265,266, she describes a visit to
11 Bristol.
12 A. Yes, thank you.
13 Q. You can see there was -- it is about five lines down:
14 "The facilities were inspected in the company of
15 one of the two consultant paediatric cardiac surgeons
16 and a specialist paediatric consultant anaesthetist and
17 the Sister in charge."
18 It deals with the plans to improve or to develop
19 her own cardiac surgical unit.
20 About a third of the way up from the bottom, there
21 is a sentence beginning:
22 "In frank discussions with the clinicians, there
23 was a positive wish to increase throughput and continue
24 the trend of improving outcome with the ensuing
25 maintenance and developing of skills. That view
0048
1 coincided with that of the Joint Colleges' report ..."
2 et cetera.
3 What clinicians -- they would be a surgeon,
4 anaesthetist, sister in charge -- were saying was "We
5 want to increase our numbers and therefore because
6 numbers are associated with outcomes, improve our
7 outcomes". That I think is the effect of it.
8 Did you know that the clinicians had that view?
9 A. No, no, I was trying to explain only in general terms
10 that I was aware, I was not involved in the issue. My
11 understanding at the time was simply that there were
12 difficulties in a conflict of the wishes of South Wales
13 and the advice of the supra-regional designation unit.
14 Because South Wales is not under the Department of
15 Health but under the Welsh Office you can understand
16 that there were problems there as to what was the way
17 forward.
18 Q. If you go down to the bottom of the page:
19 "We were unable to obtain from the DHSS who do
20 not hold figures broken down by units any figures on
21 outcome by centre. We did however raise the question of
22 outcome with Bristol staff. They put to us the accepted
23 point that outcome is influenced greatly by case mix.
24 They were quite open in quoting outcomes for some of the
25 commoner procedures", and they talk about a gradual
0049
1 improvement.
2 Again, does it follow from your earlier answers
3 you did not know what the clinicians in particular
4 thought about their outcomes, their procedures?
5 A. No, I knew none of the details of this at all. I did
6 know -- I was aware because Ian Baker would have kept me
7 informed, that there was an issue between whether we
8 were to provide services for South Wales or they were
9 going to develop their own unit. There was an issue.
10 I only understood the issue in the most general terms
11 and was not involved in its resolution.
12 Q. That is the end of 1986. In June 1987, if we have
13 a look at UBHT 133/29, this is a letter (as we will see
14 in a moment) from Dr Joffe, Mr Wisheart, Dr Jordan and
15 Mr Dhasmana. It is in relation to Wales. If we go over
16 to page 30, the top of the page:
17 "Thirdly, and apparently related to the above
18 recommendation, the Bristol paediatric unit has been
19 subjected to a campaign of vilification, and the word is
20 chosen advisedly, which we find quite extraordinary and
21 very sad."
22 It illustrates that by quoting a chunk from Heart
23 Surgery, the Second Class Service, which was apparently
24 screened on 16th June, the BBC Wales series "Week In
25 Week Out".
0050
1 There one can see a degree of concern expressed
2 by, it is said, "independent, well-informed sources
3 about the standard of operations carried out at the
4 receiving centre at Bristol". It suggests that this is
5 a concern widely held.
6 You will see it goes on to talk about parents
7 asking their children not to be referred to Bristol for
8 surgery, preferring to travel to London.
9 Did you become aware in 1987 that there had been
10 a campaign of vilification?
11 A. I have no memory of the contents of this letter at all
12 or of the events that it relates to.
13 Q. It was really the events that I expected you might have
14 some knowledge of?
15 A. No, no memory at all.
16 Q. If something were in the media, on the TV expressing
17 concern about a particular operation which Bristol did,
18 whatever the field, is that something you would have
19 expected to know about?
20 A. Yes, I think so, but not if it was on Welsh TV.
21 Q. Even although it might have affected some of the
22 catchment area for some of the patients at Bristol?
23 A. I would not have used the word "expected to know".
24 I might have been told but I do not know that we
25 monitored all television output and anybody would have
0051
1 told me. I think if anybody needed my assistance or
2 help they would have discussed it with me. I believed
3 they did not. It is very difficult to prove
4 a negative. I have to say I think if this had been
5 brought to my attention at that time I would remember it
6 now and I have no memory of it at all.
7 Q. There was a letter, going on to see if it may jog your
8 memory, if you have one. Page 194/22. The four
9 doctors, two surgeons, two cardiologists, whose
10 signatures are there write a letter to the editor about
11 the TV programme and say that the allegations are
12 unfounded.
13 If we move on, having shown you that, to 209/12.
14 It is a letter to Mr John Grey, Legal Services,
15 22nd December. Can we scroll down?
16 "Thank you for letting me see a copy of the
17 letter from [a Welsh firm of solicitors I think]. In
18 commenting on us I shall refer to Mr Robert Johnson's
19 letter of 16th June, addressed to Mrs Bennett of the
20 Children's Heart Circle, Wales. The tenor of that
21 letter is while proceedings against the Heart Circle are
22 possible it is not our wish, and in order to enable us
23 not to take proceedings against them, we require the
24 following...", the papers amended, to be told to whom
25 the paper was circulated and so on.
0052
1 A few lines further down:
2 "One must add to that that Mr Hall, either in his
3 personal capacity or on behalf of the Children's Heart
4 Circle in Wales, used some of that defamatory material
5 in the BBC programme screened on 16th June, 1987 ..."
6 What appears to be happening is that the
7 possibility of legal proceedings for defamation in
8 respect of the quality of paediatric cardiac services
9 was investigated at the time by, if we scroll down
10 a little bit further -- Mr Wisheart and he, Dr Jordan,
11 Dr Joffe, Mr Dhasmana plainly knew about the issues.
12 Do you have any recollection of knowing that legal
13 advice was being sought as to whether or not there might
14 be defamation claims in relation to material that had
15 been screened about the cardiac services at Bristol?
16 A. No, and I am quite certain I did not know.
17 Q. Again, is this the sort of matter you might have
18 expected as District General Manager to know about?
19 A. I am quite calm in not knowing about it. Saying whether
20 I expected to know about it, no, I think the legal
21 department worked closely with doctors on professional
22 matters and I would only be invited to involve myself if
23 it became a managerial issue.
24 Q. It follows, does it, if concerns were being expressed
25 publicly, which might very well be defamatory, in
0053
1 respect of a service which the hospital was providing as
2 opposed to targeted at individuals within the service,
3 that that would not necessarily be a matter you would be
4 upset if you did not know about it?
5 A. I certainly would not be upset if I did not know about
6 it, no.
7 Q. It would not, you think, be a managerial issue?
8 A. It is not a managerial issue, it is a professional
9 issue.
10 Q. So a decision whether the Trust's resources might be
11 used in suing the BBC for defamation, if that is what
12 was in mind, or individuals for defamation was
13 a professional issue and not a managerial one?
14 A. I think at any stage when resources were being committed
15 I think I would have been told. As I read this letter
16 no resources are being committed.
17 Q. But the possibility they might be in legal action you
18 would not know about unless and until the proposal was
19 put "Let us do it"?
20 A. No, I certainly would not. I mean whether they would
21 have gone directly to the Director of Finance or me
22 I cannot tell you today. As I recall I do not think
23 that John Grey had in a sense a budget for legal actions
24 with a freedom to spend it as he wished. But
25 I certainly do not think I was told of, what shall
0054
1 I say, early skirmishing in all circumstances.
2 Q. Here one might think that the hospital is being
3 represented by John Grey on behalf no doubt of the
4 clinicians involved, but the hospital is being
5 represented to others as a potential litigant, it is
6 looking for apologies and so on. The hospital's name
7 might be taken or used in that way without necessarily
8 your knowing of it?
9 A. I do not read this as involving at that time the
10 hospital, but the signatories, I mean the four people as
11 a professional issue, and at that time professional
12 integrity or the defence of doctors was separate from
13 the defence of the hospital and John Grey used to give
14 a very good service to doctors in the rare event for an
15 individual doctor that he was faced with possible
16 litigation.
17 Q. You appreciate that what the earlier documents I have
18 shown you seem to suggest is that the screening in Wales
19 was not in relation to individual doctors as such but in
20 relation to the service as a whole. If that is so, then
21 is it the case that litigation might be taken in respect
22 of a service which the hospital provided as opposed to
23 professional activities of an individual clinician
24 without you as the District General Manager necessarily
25 knowing about it?
0055
1 A. No, I do not think so, and I do not think this in fact
2 is a letter about the hospital taking umbrage but about
3 clinicians taking umbrage about what is said about
4 them. I certainly was not advised to address the view
5 that the hospital was being improperly maligned.
6 Q. What Catherine Hawkins has told us is that at some
7 stage, and she thinks around 1987, which would be round
8 about the time this was happening, she spoke to you and
9 asked you to investigate some concerns including
10 concerns in respect of outcomes.
11 What she told us -- and I will take you to the
12 transcript -- I am afraid I shall have to read it to you
13 and ask you for your response. She says that she had
14 regular reviews and she says she would have been asking
15 for the District General Manager to investigate why
16 there were problems in cardiac surgery, she was firm in
17 attributing anything that she had to say about concerns
18 to cardiac surgery as opposed to --
19 A. Adult cardiac surgery?
20 Q. She said cardiac surgery and she did tie it to adults.
21 A. Can I tie it to adults to simplify the conversation?
22 Q. Certainly.
23 A. Because what she was talking about at that time, and
24 I remember the issue, was adult cardiac surgery.
25 Q. In 1987 there was a conversation that you recollect
0056
1 between yourself -- thereabouts -- and Mrs Hawkins?
2 A. Yes, sir.
3 Q. Her recollection was that you told her that the
4 authority had identified an individual they thought
5 might be the problem and they were going to change the
6 situation in the unit, another consultant was being
7 appointed and things might get better; that is her
8 recollection?
9 A. Well, her recollection is at fault. I must say that
10 must be a figment of her imagination because I cannot
11 relate any event to that comment. No cardiac surgeon
12 retired early; there was no identification of any
13 individual and I have to say that a circumstance of that
14 nature is not something that would have slipped my mind
15 subsequently. I cannot explain in any way, except she
16 was a very busy Regional General Manager with the
17 responsibility across the whole region, I cannot explain
18 where that concept came from but it did not come from
19 Bristol.
20 Q. She linked it to the appointment of Mr Dhasmana.
21 A. Yes, that was a new appointment that replaced nobody;
22 that was an expansion of the service.
23 Q. The other thing she told us about this period is that
24 the Region were active in resisting moves to expand the
25 service, the cardiac service in Bristol in general
0057
1 because of their concerns about the nature of the
2 service provided; can you help on that?
3 A. I did not know at the time and it does make a number of
4 previously inexplicable things perhaps understandable.
5 It was known, recognised nationally as well as locally
6 that the South West was grossly underfunded for
7 cardiological and cardiac services for adults and we
8 were constantly pressing Region to fund more
9 realistically the service pressure on the department.
10 I was aware that there were considerations of
11 creating a second centre at Plymouth, there is no secret
12 about that. But at that time the traditional referral
13 pattern for the south of the region was east to London
14 and not north to Bristol. I do not know about the
15 actual distances but the journeys were of a similar
16 problem, similar time.
17 So there was south of the region referred to
18 London and the north of the region referred to Bristol
19 but the cardiac department, particularly James Wisheart
20 who led it, were constantly in negotiation with Region
21 to expand the service to be more comparable with the
22 demand. I could never understand why that funding did
23 not materialise because the need was quite clear and
24 opening a unit at the south of the region was not going
25 to address that issue because it would absorb,
0058
1 presumably referrals which were currently going to
2 London and actually not being funded by the South West
3 Region and I did not find that understandable at the
4 time and I think it is more understandable now.
5 So we did discuss the issue of adult cardiac
6 surgery over the years and you can understand if there
7 is a grossly underfunded service of a very real
8 seriousness in terms of condition, then you run into the
9 difficulties of long waiting lists, of taking off the
10 waiting list only those who are most urgent, of
11 referring the low risk cases who could travel elsewhere
12 and so on. There was a whole body of consequences of
13 a chronic underfunding of cardiac services.
14 Q. One of the consequences would be this, would it not: the
15 over 1s who were not funded by top-slicing through the
16 designation system would have to form part of the
17 overall budget that you had for cardiac services
18 generally, would they not?
19 A. They were such a small element that they were always
20 funded to the full, there was never an issue with
21 children. The under 1s, the neonatal and infant ones
22 were funded centrally at the time I was involved and the
23 over 1s were always funded. There was no waiting list
24 deriving from a resource issue in the circumstances of
25 paediatric cardiac surgery.
0059
1 Q. So any waiting lists that derived for the over ones
2 would be as a result, would it, of adult pressure on
3 beds?
4 A. That is right, competition within the unit of highly
5 urgent cases being taken off the adult --
6 Q. In that sense the lack of funding that there was for the
7 adults had an impact on the over 1s, did it?
8 A. Well, all of them. All of them, because children, as
9 I understood it then and understand now, tended to stay
10 longer in intensive care following surgery than adults
11 did and therefore there was a very real problem for the
12 cardiac surgeons to balance the waiting list pressures.
13 What I am saying from a managerial point of view,
14 children were totally funded and all treated. The
15 issues I had with Catherine Hawkins and the issues she
16 had with me and what we discussed was the adult cardiac
17 surgery.
18 Q. Sticking for a moment, if I may, with the funding
19 issues: where one had an adult emergency, the adult
20 emergency would be dealt with no doubt at the expense of
21 any elective case whether an adult or over 1?
22 A. I suppose so. I was never aware of that situation;
23 I was never aware that adults were impeding the care of
24 children. If you say "Could it have happened, may it
25 have happened?", I have to say that it may well have
0060
1 done, but it was not an issue of which I was aware.
2 I cannot say that I do know of any child that waited
3 because of the adult pressure, but if you say "Is it
4 reasonable it might have happened?", it might have
5 happened.
6 Q. We have heard a substantial amount of evidence in the
7 Inquiry thus far to suggest that children's waiting
8 lists were as long as they were for paediatric surgery
9 when the BRI and the BCH were separate units, to suggest
10 that the children were suffering as a result of the
11 adult workload and occupation of beds in the BRI. But
12 you say if that happened it is not something that was
13 brought to your notice by anyone at the time?
14 A. No, what was brought to my notice and what I and a lot
15 of other people worked hard on was to resolve the
16 problem which was a funding problem for adult cardiac
17 surgery, it was not a funding problem for children's
18 surgery of any age.
19 Q. We will leave what Ms Hawkins says she said to you in
20 1987. We will come back to a letter she wrote to you
21 later.
22 In 1989 there was a further working party report.
23 Again we will identify that, if we may. It is
24 WIT 74/1083. Did you, do you think, see this?
25 A. No, I was certainly not on its circulation list.
0061
1 Q. If we go to page 1087, the foot of the page:
2 "The tendency for mortality to be higher in the
3 units performing the smallest number of cases in the
4 group of infants undergoing open heart surgery under
5 1 year of age [figure 3]. This was one of the
6 anticipated results of supra-regional specialisation in
7 this field, but similar results were not affected in the
8 other categories."
9 Then WIT 74/1089. Conclusion 3, the second line:
10 "Two centres, Newcastle and Bristol have a less
11 than average turnover of work and should be encouraged
12 to increase their numbers annually."
13 Was that recommendation, that encouragement,
14 something that reached your ears?
15 A. No, and I would have remembered it because there is an
16 intrinsic paradox in it.
17 Q. What is that?
18 A. As I understand it they say the results in the low units
19 are poorer than the big units and therefore more
20 patients should be referred to the low volume units.
21 That is something which I think would have struck me as
22 a paradox and I may well have asked a few relevant
23 questions. I am speaking now in a lay position for
24 this. I find that -- at least an interesting
25 professional view. I certainly did not see this at the
0062
1 time, I did not.
2 Q. If we look at page 1090, there are a number of bar
3 charts showing the numbers of operations and particular
4 categories that were done. Open under 1 year. The
5 second from left, it is done alphabetically, is
6 Bristol. The first one is Birmingham, then it is
7 Bristol?
8 A. "29" it says.
9 Q. 29. If we take a long shot at the page, get the whole
10 page on if you can, you can see the second column, the
11 top is open under 1 year, open over 1 year, closed under
12 1 year, closed over 1 year.
13 It would be apparent from I think anyone looking
14 at that table Bristol obviously did not have a great
15 number and justifies the text. If we bear in mind the
16 figure of 29 and go to page 1092, turn it sideways, the
17 second from the left is where we find 29 coinciding with
18 the mortality point estimate and the confidence
19 intervals around it shown by the bars. Just under
20 40 per cent.
21 Did you know at the time that Bristol related to
22 other centres in this way for open operations under the
23 1 year group?
24 A. No, no, I did not know at all.
25 Q. Is that something you would have wished to know, do you
0063
1 think?
2 A. I wish now I knew but at the time I do not know -- there
3 was a national organisation designating supra-regional
4 services and accepting advice from the Royal Colleges'
5 Working Party derived from the Colleges and I do not
6 think I at that time would have seen it as proper for me
7 to second-guess and judge their advice.
8 Q. Why then do you wish now that you had known this?
9 A. Right now I wish I knew because I think I might have
10 taken the opportunity to ask some pertinent questions of
11 why centrally they wished to refer more patients to
12 a unit which they saw as performing badly. I find that
13 an interesting concept. But if you said to me, did
14 I think that at the time, no, I did not have this
15 information and therefore I had no reason at the time to
16 think I wanted to see it.
17 Q. I follow that. If I can explore the hypothetical answer
18 you gave me as to what pertinent questions you would
19 have asked if you had known at the time: you think you
20 might have asked who, people in the supra-regional
21 services administration, the Department of Health?
22 A. I cannot tell you now which way round I would go. There
23 were several routes. The Department of Health normally
24 was approached by a region. That may well have been the
25 pathway I would have pursued it. I cannot tell you
0064
1 which way because we have not filled in the hypothetical
2 situation in a way that I can answer. But I do think
3 I would have welcomed the opportunity of asking the
4 advice that was given be explained.
5 Q. The logic of the position might be perhaps that rather
6 than send more patients to the small unit where the
7 results were worse, the numbers in the small unit might
8 go elsewhere where the results were better?
9 A. The whole concept as I understood it then and understand
10 it now of supra-regional designation was that in high
11 risk/low volume services, better results are obtained by
12 concentrating those services in a limited number of
13 centres so that the expertise can be sustained and the
14 results can be improved; that I understand.
15 As a result of the information that I have
16 acquired at this very late stage, it does seem to me
17 that there were concerns about the number of designated
18 centres and whether there was sufficient volume to
19 sustain expertise in all of them. I do not understand
20 now why, if these were the sorts of figures -- and I do
21 not know whether they persist -- which were being seen,
22 the view should be taken that the service should be
23 de-designated.
24 I personally as a manager did not have
25 a managerial view and a managerial responsibility to
0065
1 second-guess the professional advice of professional
2 activities. But as an individual I am just confessing
3 to a wish that I might have asked some pertinent
4 questions.
5 Q. And the pertinent questions would have been about the
6 service as a whole and its designation, or the unit and
7 its designation, do you think?
8 A. I think the whole principle behind this designation.
9 I think I might have wanted to talk to the Chairman, the
10 head, the officer in charge of supra-regional
11 designation to ask him what he thought the system was.
12 But it was not my job to and it certainly was not my
13 responsibility to. But as an individual I just find
14 some of the advice here extraordinary; I do not think
15 I am the only one.
16 Q. If the clinicians delivering this service in Bristol
17 knew of this particular view and considered it, do you
18 think they should have been asking the relevant
19 pertinent questions or not?
20 A. I do not know because I do not know the background to
21 this and I do not want to say what their views should or
22 should not have been. I do not really understand today
23 the philosophy which explains the events; they may have
24 done, I do not know. I do not even know whether they
25 knew these figures and I do not think I could reasonably
0066
1 say what the professionals who actually understood the
2 service would think. I am, in this, completely lay.
3 Q. In 1990 -- that was 1989, as you know -- you received
4 a letter, UBHT 61/19. 25th July 1990. It is from
5 Dr Bolsin. The first two large paragraphs are dealing
6 with matters of particular interest, research interests
7 and equipment. The third paragraph:
8 "Finally, as a paediatric cardiac anaesthetist,
9 I would have thought the management directive to
10 improving quality of patient care should have attempted
11 to address the unfortunate position of the South West
12 Regional cardiac centres' mortality for open heart
13 surgery on patients under 1 year of age. This, as you
14 may not know, is one of the highest in the country, and
15 the problem should be addressed."
16 When you got this letter did you take any steps to
17 address what is there referred to as "the problem"?
18 A. I rang Bolsin up and talked to him about this letter and
19 I asked him to talk to the Chairman of the Medical
20 Committee about its contents. I knew at the time of
21 a widespread wish to appoint a paediatric cardiac
22 surgeon and to consolidate the service at the Children's
23 Hospital.
24 I told Dr Bolsin, as I did everybody, I tried to
25 tell them very honestly about the influence and the
0067
1 impact of Trust status, that Trust status would neither
2 facilitate nor hinder our attempts to improve paediatric
3 cardiac surgery.
4 Q. You saw this as a letter about Trust status?
5 A. It was about Trust status. I spoke to him about it.
6 You have to read the final thing:
7 "I look forward to your reply which I hope will
8 help to persuade me of the benefits of Trust status for
9 the cardiac unit."
10 It was part of a quite massive consultation with
11 the consultant medical staff.
12 Q. In that last large paragraph, the one beginning
13 "Finally ...", he is describing the comparative
14 mortality at Bristol and the rest of the country. Was
15 he, did you know, right to say that the mortality of the
16 under 1s in Bristol was one of the highest in the
17 country?
18 A. No, I was accustomed to this sort of exaggerated
19 statement to support the improvements that individuals
20 wanted. Please, I did talk to him. If I misunderstood
21 this as anything other than a letter about the effects
22 of Trust status, he did not disagree with me at the time
23 and I actually -- I know this was about Trust status.
24 Q. When you were first asked about this letter at the GMC
25 I think you could not recollect having received it and
0068
1 the memory came back in the course of the hearing. Do
2 you actually have a clear recollection of what you might
3 have said to Dr Bolsin in the conversation that
4 followed?
5 A. I cannot remember a verbatim conversation and do not
6 pretend to, but I do know that the content of the
7 conversation contained two important elements: one was
8 would he discuss his anxieties with the Chairman of the
9 Medical Committee who was responsible for giving me the
10 professional advice of the consultant staff.
11 I also told him, and I am quite sure I cannot
12 remember the words I used, that I could not claim that
13 the creation of Trust status would have any impact on
14 our desire and our attempts to introduce the two
15 improvements to paediatric cardiac surgery.
16 Q. He does not link it in that paragraph to anything to do
17 with the appointment of a new paediatric surgeon or for
18 that matter the amalgamation of the operating theatre
19 with the Children's Hospital cardiological facilities?
20 A. He did not have to because he knew that was what we
21 wished and I knew that is what we wished.
22 Q. In saying the problem should be addressed one might have
23 thought the answer, given your answer to me, would be to
24 say "the problem actually has been addressed, we are
25 doing what we can, we cannot do any more"?
0069
1 A. Yes, but that was not the question, the question was
2 whether by becoming a Trust our attempts would be
3 expedited or impaired; that was the question, not
4 whether we were trying to do something about it; he and
5 I both knew what we were trying to do.
6 Q. It is a separate item, is it not, in that third
7 paragraph asking for "the problem", as he calls it, to
8 be addressed?
9 A. Yes, but the final paragraph is saying he would like me
10 to reply to these three things to persuade him of the
11 benefits of Trust status; that is the thrust of the
12 letter, and the answer is that I could not tell him that
13 Trust status was going to address the final issue.
14 The first two issues were exceptions he took to
15 the application that we had circulated for consultation
16 because the appendix which had been written by the
17 operational services, in other words, the cardiologists
18 and the cardiac surgeons had written those appendices
19 and he took exception to what they said. I could not
20 arbitrate on that. I referred him back to his
21 colleagues through the Chairman of the Medical
22 Committee.
23 Q. The reference to a specific category, the "open heart
24 surgery on patients under 1 year of age", might suggest
25 there were figures available, might it not?
0070
1 A. I do not know why.
2 Q. It is a specific category, it has been singled out for
3 some reason?
4 A. I do not follow that, I am sorry.
5 Q. The suggestion that it is one of the highest in the
6 country led to your saying to him as I understand it
7 "take your anxieties to Mr Dean Hart, the Chairman of
8 the Hospital Medical Committee and explore them there"?
9 A. Yes.
10 Q. You understood that there were separate anxieties,
11 anxieties which went beyond the question and issue of
12 Trust status that he was expressing, did you?
13 A. I knew of the anxieties beforehand, I did not need
14 a letter to know that there was a wish widely through
15 the Trust, not involving everybody in the Trust, but
16 widely in the Trust, a wish to improve paediatric
17 cardiac surgery. He knew that and I knew that.
18 His question is "Will Trust status change our
19 ability to address that?" I told him it did not, we
20 still had the same issue.
21 Q. You describe the statement which he makes as "a sort of
22 exaggerated statement"?
23 A. Yes.
24 Q. To support the improvements that he wanted. So you
25 assumed this was an exaggerated statement, did you?
0071
1 A. They were similar statements to what everybody was
2 making about their service, yes. I think that issues
3 are put to, what they saw as management, in emotive
4 terms; they always did.
5 Q. Why did you assume that he from whom you had not heard
6 before, should be exaggerating even if others were?
7 A. I do not understand the question. The atmosphere at the
8 time, two things coincided. One was a genuine wish
9 (which I respected, supported and hoped to find
10 a solution to) to improve the facilities within
11 paediatric cardiac surgery, which I have explained.
12 The second issue was that Kenneth Clarke had said
13 that he would not accept any application for Trust
14 status unless it had majority consultant support. At
15 a time when we knew the one issue, the new issue came
16 and we circulated this and Christopher Dean Hart was
17 charged with determining the level of consultant support
18 for Trust status.
19 A lot of people spoke to him, a lot of people
20 spoke to me, to try and evaluate what the impact of
21 Trust status was. This was such a letter. I had a lot
22 of them, of people wanting to know whether Trust status
23 would make their aspirations more realistic or less
24 realistic and I told them it would not affect that.
25 He, I understand it, said what I actually said to
0072
1 him is that his views would have no impact on Trust
2 status, which is a complete inversion of the situation.
3 It was not whether his service would have an impact on
4 Trust status, but whether Trust status would have an
5 impact on the issue which he, amongst other people,
6 wished to see addressed. I do not think there was any
7 misunderstanding between us.
8 Q. Tell me, you did not as we know say to him "show me your
9 evidence" or "what is your basis for saying that this is
10 one of the highest in the country"; why not?
11 A. Because we were discussing Trust status, not figures
12 within paediatric cardiac surgery; that is the nature of
13 the conversation. I have to say that he did not address
14 the same issue to me again until halfway through 1995.
15 Q. So you never thought because you took this letter as
16 being about Trust status that there was an assertion
17 here in this penultimate large paragraph that needed
18 either to be verified by statistics or figures or at any
19 rate taken further by you?
20 A. No, he did not ask me to, I mean, we were discussing at
21 that stage solutions, not evidence to support
22 solutions. What he actually said is "one of the
23 worst". That meant to me -- I am trying to find the
24 exact words "it is one of the highest in the country",
25 "one of the highest".
0073
1 That suggests to me that there are several in the
2 band of outcome as Bristol. In other words, we were one
3 of those units. Of course he and I would always want us
4 to be at the gold standard or above it. I mean
5 I understood that and I understood the solution and he
6 understood the solution.
7 Q. You say the solution was a paediatric cardiac surgeon
8 and the amalgamation of the sites?
9 A. Yes, that was the advice I had at the time and
10 I accepted it, yes.
11 Q. Can you help me: when in fact Mr Keen was retiring and
12 there was an appointment sought as a cardiac surgeon, it
13 was just that that was advertised, was it not, a cardiac
14 surgeon's post as opposed to a paediatric cardiac
15 surgeon?
16 A. No, the plan when Mr Keen was retiring, is that we would
17 appoint a Heart Foundation -- I think it was the British
18 Heart Foundation -- funded Professor and we would use
19 the resources, the salary of Mr Keen to appoint
20 a supporting senior lecturer.
21 It was an arrangement with the university we
22 commonly pursued, and that is the university would pay
23 for a Professor and we would pay for a consultant senior
24 lecturer which was, the university felt, a minimum
25 requirement for an academic unit. As a result of that
0074
1 deal, if you like, the university would have a whole
2 time equivalent of one consultant for their academic
3 purposes and the Trust would have a whole time
4 equivalent for NHS work by each of us paying for an
5 individual and having half their services shared.
6 I hope I have made that clear.
7 Mr Keen was replaced, his salary was used as
8 a supporting consultant senior lecturer. It would have
9 been very nice -- and that was the intention -- that we
10 wished to appoint a paediatric cardiac surgeon to the
11 chair and then we would have appointed a consultant
12 senior lecturer in adult cardiac surgery to support him
13 in the academic unit.
14 When that failed we were in no position to renege
15 on the agreement that I had with the university that we
16 would appoint a consultant senior lecturer through the
17 Professor.
18 Q. The reason I asked the question I did was that it has
19 been asserted on a number of occasions by a number of
20 different people -- there is plenty of company for the
21 view you have expressed to us -- that it was sought at
22 this stage to appoint a paediatric cardiac surgeon.
23 What I was simply asking you was: if that is the
24 case why is it, as I suggest, that any of the
25 documentation surrounding the seeking of candidates for
0075
1 the appointment should refer not to a paediatric cardiac
2 surgeon or to someone with an expertise in paediatric
3 cardiac surgery, but simply to a cardiac surgeon without
4 any indication as to whether it would be adult,
5 paediatric or what?
6 A. The university always took the view that they wished to
7 appoint the best applicant and were uneasy about
8 specifying too narrowly the speciality of the potential
9 Professor. So that, if I can explain it out of this,
10 that when a Professor of Gastroenterology retired,
11 a Professor of Medicine who was a gastroenterologist
12 retired, we finished up with his replacement Professor
13 as an endocrinologist. That always produced a certain
14 amount of stress on the NHS side because we had to
15 continue to provide the gastroenterology and to
16 establish an endocrinology service.
17 There were issues, but the university (and quite
18 properly) wanted the best academic and would not
19 normally conform to our wish to narrow the speciality
20 down in the advertisement. But we were hoping that the
21 best applicant would be a paediatric cardiac surgeon.
22 I am sorry does that answer the question?
23 Q. It is an answer to the question, yes, and it is
24 helpful. I will come back I think to the issue of how
25 as it happens Professor Angelini was appointed and some
0076
1 circumstances surrounding that after the lunch break, if
2 I may.
3 One matter I would like to deal with first, if
4 I can, is to move forward from 1990 to UBHT 38/430,
5 which is a letter -- I told you we would come to it --
6 from Miss Hawkins to yourself. It is dated
7 20th November 1991. Can I look at the text?
8 "I have just finished the interim reviews of DHAs
9 and FHSAs region-wide and, at all but one review, we
10 heard how poorly Bristol trust is now performing on
11 cardiac surgery contracting, and as a consequence some
12 are shifting their contracts this coming year, others
13 plan to shift them in 1993."
14 The third paragraph:
15 "As currently, we at Region are reviewing cardiac
16 units and our needs, and the fact we have invested in
17 Bristol to serve the region not just Avon, I would more
18 than welcome your comments and action if you feel you
19 are not in sympathy with the current rate and quality of
20 performance of the cardiac unit. I am sure Mr Wisheart
21 would like to be made aware of the gross dissatisfaction
22 region-wide ...", and it talks about "further
23 deterioration and siphoning off to Oxford and London".
24 This letter involved, did it not, questions of
25 quality performance?
0077
1 A. Yes, but I do not think it involved questions of
2 clinical outcome.
3 Q. What did you understand to be meant by "quality of
4 performance"?
5 A. At the time -- this is the early days of the Trust, the
6 relatively early days of the Trust and we were making
7 enormous efforts to measure everything in terms of
8 service that could be measured in order to improve it.
9 It is very difficult to define a term, but these were
10 all the facets of health care excepting the outcome, the
11 clinical outcome of the service: how long people waited
12 on waiting lists, how long they waited in outpatients
13 before they were seen by a doctor, how long they waited
14 in the admissions area before they were taken into
15 hospital, food and all the other things, all that mass
16 of supporting service, the environment in which clinical
17 care was given, which I think there was (quite properly)
18 anxiety at the time that they had been sacrificed to the
19 altar of clinical care from the altar of clinical
20 outcome and there was an immense effort at that time.
21 So when we used the term "quality" at that time we
22 were talking about things which eventually got swept
23 into the charter mark negotiations; that is what
24 "quality" was.
25 Q. That is the way you read it you say?
0078
1 A. No, you must not say that it is the way I read it;
2 I discussed this with Catherine Hawkins, I knew
3 precisely what the problem was and this was a letter
4 which she wrote in order to be supportive of me in
5 trying to resolve the situation. That was the way we
6 worked; I used to see her once, twice a week about
7 issues and we discussed this.
8 I have explained to you that we had a problem when
9 we created a Trust of the very substantial underfunding
10 of adult cardiac surgery. That was then transferred
11 from regional funding, which was at least
12 a straightforward discussion with Region -- it was not
13 very productive for the reasons we have discussed -- but
14 now that money had been delegated to all the districts
15 in the South West who had individually to agree
16 contracts with us for cardiac surgery, and the money
17 they got did not match the service they required and we
18 had difficulty in transferring from the previous
19 centrally funded service to this system of contracts
20 with a whole series of local districts.
21 Q. You asked Mr Wisheart to draft you a reply to this?
22 A. Yes.
23 Q. He produced three drafts. Shall we have a look at them
24 UBHT 38/432? If we go right down to the bottom of the
25 page, it is the first draft "Quality." He has looked at
0079
1 the expression "Quality" used in Catherine Hawkins'
2 letter. He divides it, as we will see, into
3 "(a) outcome (medical)" and (b) -- go to GMC 4/48 for
4 the next page -- "Quality of care (organisation: e.g.
5 Waiting times)".
6 Go back to UBHT 38/432, the foot of the page:
7 "Outcome (medical). The outcome of our work is
8 at a quality level similar to that expected nationwide,
9 as documented in the UK cardiac surgical register."
10 He is reading it as a question not only of quality
11 of performance in the wider sense, but also in terms of
12 quality of outcomes?
13 A. Yes, I did not dispute that and at that time, and
14 I believe still, the clinicians in the service believed
15 that outcome (medical) as he said was infinitely more
16 important than this new influx of
17 non-clinical/non-medical care measures of quality.
18 Q. He gave you three drafts and he gave you the right to
19 choose between them?
20 A. Yes.
21 Q. You did not disabuse him you say of his view of quality
22 but you did change or amend his drafts to make one of
23 your own. We pick that up at UBHT 38/426.
24 A. Yes, on this situation I picked out the relevant part of
25 his longer suggested letter and put it in inverted
0080
1 commas so there was no question that that was his view;
2 that was one of the things that Catherine Hawkins was
3 rather anxious I should ascertain and I topped and
4 tailed that contribution.
5 Q. If we have a look at UBHT 38/427 because this is your
6 final editing of his drafts. You include in your reply
7 what he says about "quality (medical)" so you were
8 adopting it?
9 A. No, I was transmitting information he wished me to give
10 to the Regional General Manager. I do not see that as
11 changing the basis of Catherine Hawkins and my original
12 conversation and what we were addressing.
13 Q. If your letter was not about quality in that sense at
14 all, why respond to it in those terms?
15 A. I was quoting James Wisheart's response and I do not
16 think there was any reason to take that element out of
17 it.
18 Q. Your letter in response to hers contains, in part,
19 a response which is off the point but which you included
20 simply because Mr Wisheart drafted that for you?
21 A. No, but I do not think Mr Wisheart would have thought it
22 was off the point and I was not going to suggest to him
23 that suddenly his wish to maintain high quality of
24 outcome was irrelevant. I am sorry, but I saw no reason
25 -- and see no reason now -- why I should have edited
0081
1 that statement.
2 MR LANGSTAFF: Sir, I notice the time. It is now I think an
3 appropriate moment for a further break and may I suggest
4 a longer one so that we may have lunch?
5 THE CHAIRMAN: Thank you. Shall we say until 2.00?
6 (1.20 pm)
7 (Adjourned until 2.00 pm)
8 (2.05 pm)
9 MR LANGSTAFF: Dr Roylance, a little while after this letter
10 from Miss Hawkins, you got a letter from the South West
11 Regional Health Authority from a Mr Wilson. Can we look
12 at that? It is UBHT 38/411. The date in the top
13 left-hand corner is misleading, 31st January 1991.
14 I think I can say that for two reasons: it has your date
15 stamp on it dated 7th February 1992, as you can see on
16 the left-hand side and in the first paragraph of the
17 text it talks about published professional advice in
18 November 1991.
19 So I think we can date this letter as 31st January
20 1992. I will show you in a moment your reply to it.
21 That letter comes.
22 If we scroll down:
23 "With regard to the advice on the development of
24 a second cardiac centre and additional catheterisation
25 services, I am now working with those from the south of
0082
1 the region on proposals."
2 He is writing to invite you to produce
3 a proposal for cardiac services that takes into account
4 (a) increased capacity; (b) unification of children's
5 services; (c) steps to meet quality and cost concerns of
6 purchasers.
7 Pausing there, did you read this letter as talking
8 about quality in the sense that you had understood
9 Miss Hawkins' earlier letter to be talking about
10 quality?
11 A. I cannot be certain. I do know at that time the medical
12 profession as a whole were restive about the quality
13 measures as applying to everything but the business we
14 were in, which was getting patients better. Therefore,
15 I do not know to what extent the letter I had written
16 had influenced the writer of this in writing this.
17 I need to see the supporting papers he says he has sent,
18 or I think he has sent. So I cannot tell whether Arthur
19 Wilson had moved forward as we were trying to move
20 everybody forward at that time.
21 Q. Your reply to him is at UBHT 38/406. That enables you
22 to see the reference at the top.
23 A. Yes, it does help.
24 Q. Can we go back and look at the reference and you can let
25 us int