|
|
|
|
 Home
Page
Search
Final
Report
Interim
Report
Evidence
- Transcripts
- Witness Statements
- Submissions
- CCNR Report and associated
documents
- Statistical Reports and associated
documents
- Background Papers
- Expert Papers
Inquiry
Seminars
About
the Inquiry
Help
|
 |
Daily transcripts
Hearing summary
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 into the secret of what you get from that?
0083
1 A. "AM" is the typist, "JDW " is the source of the
2 information, and "JR" means I signed it.
3 Q. We go to the second page, 407, the first paragraph,
4 about seven lines down:
5 "However, we were confused and disappointed to see
6 the repetition of the statement, and that 'some district
7 health authorities are dissatisfied with the service
8 from Bristol on both cost and quality grounds ...'
9 (Ischaemic Heart Disease, paragraph 5), as we believe
10 that this is both unfounded and potentially damaging to
11 us. Surprisingly, in the next section of the same
12 paragraph it is stated that 'there are no waiting list
13 pressures'; as I stated in my letter to the RGM, waiting
14 time is the glaring problem."
15 Is your letter to the RGM part of the same
16 correspondence we have been looking at in response to
17 Catherine Hawkins' letter to you in November 1991?
18 A. Yes, I think this is the next stage of having written
19 back to Catherine, that there is a consideration of
20 whether they were going to increase the funding to adult
21 cardiac surgery. This is the first steps in that sort
22 of negotiation.
23 I think that there is a confusion here -- at this
24 distance I cannot tell you where on the spectrum it
25 was -- because I do know that in management circles
0084
1 quality had nothing to do with patient outcome. In
2 consultant circles that was not happily accepted -- not
3 that the non-clinical quality measures were not
4 important, but they were not the most important and we
5 were doing our best to keep introducing into the
6 conversation that the purpose of a contract was not
7 waiting time in outpatients, but patients getting
8 better.
9 Q. We can go on in the paragraph beginning "Just one
10 purchaser ..."
11 Let us look at the full paragraph:
12 "Just one purchaser (Exeter) has complained to us
13 and that is specifically about waiting times. The
14 Regional Committee in Cardiac Services had no issue to
15 raise with UBHT other than waiting times. As
16 a consequence, I am not quite sure what you have in mind
17 for the comparative exercise in quality and therefore
18 would need to discuss with you the whole issue before
19 offering specific advice or suggestion. If medical
20 outcomes are an issue, then authoritative advice would
21 be needed which could be obtained by inviting the Royal
22 College of Surgeons, the Society of Cardiothoracic
23 Surgeons to nominate a suitable senior person; if an
24 assessment by mid-March is needed it might be best for
25 the HHA or the RHA with the UBHT ..."
0085
1 It goes on.
2 At least a paragraph of your response, albeit
3 drafted on information received from Mr Wisheart,
4 appears to be about quality issues in the outcome sense?
5 A. No, there is an "if" outcomes issue. This is trying to
6 clarify a confusion. I think it confirms what I have
7 just said to you, although I have not read this recently
8 and that was, there was at that time a concept of
9 quality within the Health Service within this new
10 general management function which had been imported from
11 Sainsburys, Marks & Spencers and elsewhere, that total
12 quality management should be done, and the managers were
13 instructed to measure all what I call the "non-clinical"
14 elements of the service to ensure that patients were
15 being properly treated, but they specifically excluded
16 patient outcomes, what the people in service thought was
17 the business we were in.
18 There was a conflict at that time. When we have
19 statements from Region to say they are unhappy about
20 quality measures, there is an issue there, what quality
21 measures are you talking about? And if medical outcomes
22 are an issue -- not "they are, it is accepted", but if
23 they are an issue, then there is an indication there of
24 the proper way of addressing such an issue, which is
25 what I would say this shorthand was activating the
0086
1 proper professional approach to an issue of that
2 nature.
3 Q. The proper professional approach you identify in your
4 letter is that if there is an issue, we will need to
5 have an outside report on it.
6 A. That is right. Because of the new concept of
7 competition which was more fictional than real, it is
8 suggested here that to take the nearest units, Oxford
9 and Southampton, to come and make a comment on whether
10 they think patients should go to Bristol or Southampton
11 or Oxford was not a constructive way forward.
12 Q. It is a bit like asking your competitors to say whether
13 they are proper competition?
14 A. I do not know how much they were competitors, but
15 certainly there was an encouragement in those years that
16 we should pretend we are all competing.
17 Q. If one goes back to the letter which sparks this off,
18 the letter of 31st January, UBHT 38/410, just scroll
19 down again, what led to the detailed discussion as to
20 whether it might be necessary to have some sort of
21 outside investigation was the suggestion by Mr Wilson
22 that you might produce a proposal for cardiac services
23 taking into account steps to meet quality and cost
24 concerns of purchasers, whatever that meant.
25 A. That was the issue: what did it mean?
0087
1 Q. If you go overleaf, because I think it may also have
2 been this you were responding to, UBHT 38/412, the first
3 paragraph:
4 "In addition, in order to ensure that the best
5 quality standards are identified and built in, I am
6 asking for your support and co-operation in
7 commissioning an agency to carry out a comparative
8 appraisal [this is I think is where the idea comes from]
9 of these standards between yourselves and other
10 centres."
11 That is what gives rise to you saying, "Is it
12 outcomes? If it is, this is the way to go about it"?
13 A. Yes, and in fact there is the implication, which there
14 always was at that time, that we would rather occupy our
15 time on outcome measures of quality than the other
16 elements of quality.
17 Q. What you appear to be recognising in these two letters
18 is that if there were a serious concern about the
19 outcome measures resulting from cardiac surgery, that
20 the appropriate step would be some form of appraisal or
21 investigation by outside authorities who were truly
22 independent and could give you another view?
23 A. That is right. It is reminding Arthur Wilson, and
24 through him the people concerned, that managerial issues
25 were my concern, professional issues were the concern of
0088
1 the profession.
2 Q. Does it follow that if any such concern had been
3 expressed about a particular aspect of cardiac surgery,
4 such as paediatric cardiac services, to you at this
5 time, 1991/92, that you would have suggested the same
6 professional route, that is an appraisal by outside
7 independent experts?
8 A. Depending on who said it, I would have either suggested
9 it or enacted it, if you follow me. It depends who said
10 what to whom. If anybody had brought to my attention
11 a concern about quality, then I would have referred that
12 to those who could advise me. Could I remind you, I was
13 a Fellow of The Royal College of Radiologists and had
14 been on their Council, and I was quite accustomed to the
15 responsibilities of Royal Colleges for quality. I would
16 have had no difficulty and no hesitation to use the
17 Royal College as the assessors of quality, and not
18 management.
19 Q. It was later in 1991 that the advertisement was sent out
20 seeking applicants for the post of Professor of Cardiac
21 Surgery?
22 A. Yes.
23 Q. It had been hoped, as you have said, to attract
24 a paediatric cardiac surgeon to the post. What happened
25 is -- tell me if this is right -- that a Martin Elliott
0089
1 was thought might be interested in the post and he came,
2 he saw and he declined, for reasons which he expressed
3 in writing?
4 A. Yes.
5 Q. Can we look at JDW 3/104. This is what he wrote. There
6 are parts of it I want to take you to in a little
7 detail. Did you ever see this?
8 A. Not at the time, but I did see it some time later.
9 Q. Can you remember when, roughly?
10 A. No, I do know I did not see it at the time I was
11 involved as part of the team, which was making the
12 appointment for the University. I used to represent the
13 Trust on the appointments processes for clinical
14 Professors, but I did not see this at that time. I did
15 know that the cardiac surgeons had hoped to produce an
16 applicant whom the University would find appointable,
17 but that was not part of my responsibility.
18 Q. Can we look at JDW 3/102? This is a letter from Martin
19 Elliott to Mr Wisheart dated 3rd January, spoken to you
20 about the Chair, decided not to apply, reasons are:
21 (1) cannot afford it; (2) his prospects are reasonable;
22 (3) lingering doubts about the security of the
23 paediatric volume; (4) a worry about the separation of
24 cardiology from cardiac surgery which he thinks would
25 take some time to resolve."
0090
1 If we go to JDW 3/104 -- did you see that letter
2 at the time?
3 A. I do not think so, not at the time.
4 Q. Can you help us as to roughly when you may have seen
5 this paper about the Chair of Cardiac Surgery?
6 A. I think it may have been shown to me in the work-up to
7 the appointment of an NHS consultant as part of the
8 background to addressing this issue again, rather than
9 in the work-up to the appointment of a Professor of
10 Cardiac Surgery.
11 Q. So by "NHS consultant", you mean the appointment of
12 Mr Ashmore?
13 A. That is right. It was some time in the early foothills
14 of that ascent, if I can put it that away, of achieving
15 the appointment of an NHS consultant. If I try and
16 explain: by that time there was always this issue of
17 whether we created a single department and then
18 advertised for somebody to come and work in it. We
19 advertised for the person to come and work in it, so we
20 could take his advice on what was needed. It was
21 a major investment, and it was for the successful
22 applicant. There is always this problem of whether you
23 create something that will attract somebody or you
24 attract somebody and ask their advice on how you create
25 it. There was this chicken-and-egg issue. There was
0091
1 also an issue of funding.
2 Q. I suppose if you have someone who might be interested,
3 who says "I will press my application if you do X and
4 Y", then you make the decision to do X and Y in order to
5 attract him?
6 A. Yes. That sometimes strengthens the ability to do X
7 and Y.
8 Q. The time that you saw this would have been what, 1994,
9 do you think?
10 A. Probably. I cannot tell you.
11 Q. Do you remember earlier, we said the interviews for the
12 post which Mr Ash Pawade succeeded in securing were
13 20th September 1994.
14 A. I cannot say. It could well have been when Gianni
15 Angelini had been appointed and we were readdressing the
16 problem and trying to determine what our actions should
17 be. One of the issues there was this timing of the
18 centralisation with the advertisement. This was an
19 issue which would emerge saying "Hold on, we will go on
20 and do the same with an NHS consultant that we would do
21 with a University Professor". So it was after the
22 appointment of Gianni Angelini and before the job
23 description for Ash Pawade. It is not something which
24 would have a great impact on me in terms of date.
25 Q. What Mr Elliott does say, at JDW 3/106, under "Clinical
0092
1 Services, Current Situation", it says it is not unified
2 in the manner of the Freeman Hospital, et cetera.
3 "It is carried out on a number of sites, however
4 close to each other, and this imposes a number of
5 artificial constraints ... This is most marked in the
6 separation of paediatric closed cardiac surgery at the
7 Children's Hospital from the paediatric open-heart
8 surgery performed at the Bristol Royal Infirmary."
9 Then he assesses it. If we go down, the first
10 point I think speaks for itself:
11 "Adult throughput is adversely influenced by the
12 number of children ... Children will by and large have
13 a longer Intensive Care Unit stay and have a greater
14 nursing requirement ... Paediatric nursing expertise is
15 diluted ... Third, the separation of open and closed
16 paediatric cardiac surgery must be inefficient and is
17 potentially dangerous."
18 Pausing there, this is a clinical expert in
19 particular in the field of paediatric cardiac surgery,
20 who is describing the present arrangement as potentially
21 dangerous, is it not?
22 A. Yes.
23 Q. So if you had seen this, if you had known of this at the
24 time, you would have taken the steps you told us earlier
25 you would do if any respectable and reputable source
0093
1 identified an aspect of the service as being dangerous
2 or potentially dangerous, would you?
3 A. I certainly discussed this with them. It was used as
4 evidence of the now urgent need to achieve the two steps
5 we were doing. I think the advice at the time, which
6 was rather late in the day in terms of we were already
7 producing a solution, is that nobody was able to
8 identify any child who had actually suffered from this
9 potential danger. We were unable to establish any real
10 danger. I do not know whether that sort of
11 conversation -- clearly it was the sort of talk we had,
12 because Bristol was not the only unit in which that sort
13 of separation exists.
14 Q. Can I remind you of what you said earlier this morning?
15 I asked:
16 "Suppose you had a letter or document from
17 a reputable and respectable source which suggested that
18 the way in which paediatric cardiac surgical services
19 was being delivered was dangerous, potentially
20 dangerous, to the children, would you have taken some
21 action as Chief Executive?"
22 You said:
23 "Absolutely. I would have activated the proper
24 professional pathways to deal with that situation."
25 I asked you what they would have been and you
0094
1 said:
2 "They would have been the local people to start
3 with, who 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 A. Yes, that is absolutely true.
10 Q. So had you known of these words at the time they were
11 written, because you did not see them for a while, is
12 that the action that you would have taken?
13 A. When I did see them, I did discuss what, in everybody's
14 view, was potentially dangerous. It does not say it is
15 dangerous, he says it is potentially dangerous. What
16 was the potential? As I say, the advice I had, and was
17 consensus advice, was that although the quality of care
18 in terms of the peace of mind of parents and so on had
19 a lot to be improved, in terms of patient outcome, there
20 was at the time no evidence that the separation itself
21 was an issue. And it was at a time when we were pushing
22 through the solution to the problem.
23 So I think in terms of timing and in terms of
24 statements, clearly by the time any review had been set
25 up and done, we would have actually changed the
0095
1 situation. There is a time-scale to what you are
2 talking about. I am quite sure by the time we had
3 achieved any proper external review of the situation,
4 the situation itself would no longer exist.
5 Q. So the answer is, is it, that had you known of this at
6 the time, you would have taken the steps you identified
7 to me earlier this morning?
8 A. Yes.
9 Q. When you did become aware of it, you already had matters
10 in hand and it would have taken so long to have the
11 inquiry, that by then, anyway, the position would have
12 been remedied.
13 A. Yes, but I have to go back to your original concept.
14 This says "potentially dangerous", it does not say
15 "dangerous" and he could have said "dangerous", but he
16 did not. He says there is the potential for danger.
17 That is rather different from a clear statement that
18 a dangerous situation is being tolerated. It is quite
19 different.
20 Q. I did put the questions to you in both terms of
21 "dangerous" and "potentially dangerous" this morning.
22 A. Well, if I had failed to observe at the time the
23 difference, I would like to correct that omission now.
24 I actually think that the suggestion that there are
25 circumstances which are potentially dangerous is very
0096
1 different from somebody saying it is dangerous.
2 Q. When you came round to assessing the potential for
3 danger --
4 A. I would not assess the potential danger. If I have
5 given that impression, then I am sorry. I could not
6 assess the danger; I could only take professional
7 advice. There is a difference.
8 Q. I follow the point. What I was referring to was your
9 earlier answer, when you said that when you did come to
10 know this you did have discussions and if I say you
11 assessed the potential danger, I may not mean you
12 assessing it, but you taking advice as to what the
13 potential danger might be. Whom was it that you spoke
14 to?
15 A. I think the clinicians within paediatric cardiac
16 surgery. If Hyam Joffe was not one of them, because he
17 was one of the enthusiasts for centralising the
18 situation --
19 Q. So you think Dr Joffe was one?
20 A. No, I am not narrowing it down. I took the view of the
21 group. If I had to say one person at this distance,
22 I would not like to be sure that there was not somebody
23 within the cardiology or cardiac surgery network I did
24 not talk to, but I would have taken wide advice. But
25 the fact of the matter is that the view is, and I think
0097
1 it has been expressed quite forcibly by Gianni Angelini,
2 that the situation is not in itself dangerous to
3 patients; it is inconvenient, it is unhappy and the view
4 is that children should be treated in a paediatric
5 environment and so on, and we were trying to improve
6 qualitatively the service so that -- the fact of the
7 matter is, on advice I was given at that time and the
8 way I read it, the idea of alerting the Royal College or
9 the supra-regional designation group did not occur to me
10 at that time to be a sensible approach.
11 Q. I am interested in that view, because if we look at
12 UBHT 61/161, this is an audit meeting of what is
13 described as "Paediatric Cardiology". We see it has the
14 surgeons and the cardiologists largely there. It is on
15 25th March 1992, so just after Martin Elliott's paper.
16 If we scroll down, paediatric cardiac surgical
17 mortality is being reviewed for 1991. It gives the
18 action taken and clinical changes instituted. Point 3:
19 "Problem of split site identified as important in
20 mortality for sick neonates and infants. Press for full
21 integration of service."
22 A. Yes.
23 Q. Although that is obviously a shorthand view of a longer
24 discussion, if it is accurately recorded it appears to
25 be a suggestion that the clinicians at the time took the
0098
1 view that the fact of the split site did lead to
2 mortality which would not have taken place otherwise.
3 A. Can I say that this is audit, which was specifically
4 confidential to the providers of the service, and
5 I would not have seen this. I do know that we were
6 endeavouring to achieve the improvement they are talking
7 about, "Press for full --" I do not know what that word
8 is.
9 Q. "Integration", I think.
10 A. "Full integration of service". They were pressing for
11 it and we were trying to do it.
12 In terms of the people who wrote this, of whether
13 to continue to provide the service, it was their
14 clinical judgment. I have no reason to doubt that they
15 exercised that judgment to the best of their very
16 considerable abilities.
17 I did not see this. I do not think there is any
18 point of asking me my view of what is written there,
19 because quite specifically I would have not seen that.
20 What I did know is that there was a difference between,
21 what shall I say, "capable of improvement" and
22 "unacceptability". Unacceptability was a concept which
23 did not arise.
24 Q. Dr Roylance, I am quite happy to accept your assurance
25 you did not see this particular document, but the
0099
1 purpose of my showing it to you was really following on
2 the line of questioning that I have been having with you
3 in respect of the paper from Martin Elliott. The
4 questioning in essence was along these lines: there is
5 Martin Elliott identifying part of the service as
6 potentially dangerous.
7 A. Yes.
8 Q. You are saying, "Well, I did not see that at the time;
9 I did see it later". If you had seen it at the time,
10 your earlier answer this morning was that you would have
11 taken advice on it from the Royal Colleges --
12 A. In a static situation, yes.
13 Q. -- and obviously talked to the local service first?
14 A. Yes.
15 Q. And the local service would have told you presumably, on
16 that assumption, if this is a fair indication of what
17 they were saying to each other, they would say, "Well,
18 yes, this is important in mortality".
19 A. Well, you are speculating now, and I have to say, you
20 are speculating beyond the reality. Nobody at that
21 time, and I can say this absolutely clearly, gave me the
22 sort of clear-cut advice that there was anything
23 unacceptable about the service offered in Bristol. They
24 certainly gave me very enthusiastic advice on how it
25 could be improved, but no suggestion that the service
0100
1 was dangerous, was unacceptable. There is a very big
2 difference, and I do know that that second was not the
3 case.
4 The people who were writing this were continuing
5 to refer people from up the hill down the hill for
6 treatment. I do not accept, and cannot accept, that
7 they were doing so in the clear knowledge that that was
8 dangerous. I do not accept that. Certainly, they did
9 not say that to me, and had they done so, then I would
10 clearly have said, "Why haven't you referred them
11 elsewhere? If you think it is dangerous, why have you
12 not referred them elsewhere?"
13 What Martin Elliott said was why the service to
14 which he was being invited was not to his satisfaction.
15 I do regret that Martin Elliott did not see me. It was
16 customary for people applying for consultant posts as
17 well as for Chairs to meet the Chief Executive and
18 before that the District General Manager long before
19 shortlisting and interview. I understand he had been
20 misled or he misunderstood -- I do not know which it
21 is -- the prospects in Bristol, but he did not see me
22 and I did not see him. Nor did he ever suggest to me,
23 you see, that he thought I should interfere or have an
24 external inquiry into the circumstances in Bristol.
25 That is what I would call a clear statement: if he had
0101
1 come along and said "This ought to be stopped", he would
2 have told me, not introduced a series of reasons why he
3 did not want to come and work in Bristol. That is
4 a quite different concept. I hope you can appreciate
5 that.
6 Q. If a consultant who has the respect of a number of
7 clinicians, as Martin Elliott it would appear did, of
8 the sort to attract him as a post, writes to the
9 Clinical Director, or Associate Clinical Director of the
10 service, and says, "I think this is dangerous or
11 potentially dangerous in some respects", would you, as
12 the Chief Executive, expect to be told of the danger or
13 potential danger?
14 A. Yes, I would expect Martin Elliott to tell me. I cannot
15 perceive of the circumstance where somebody visiting
16 Bristol and finding a service he thought was dangerous
17 was not sharing that view with me. I do not understand
18 the hypothesis behind that.
19 Q. If he tells the Medical Director rather than you
20 directly, would you expect the Medical Director to pass
21 it on?
22 A. If he had, yes. I would challenge whether he did. That
23 is where we are having difficulty. I think your
24 interpretation, or the interpretation you are putting to
25 me of his letter is not valid.
0102
1 Q. We have a statement from Martin Elliott to the Inquiry.
2 I will show you part of it. It is WIT 467. If we go to
3 page 5, can we scroll down to the bottom? He expresses
4 at paragraph 9 his opinion that it was effectively
5 possible to develop adequate neonatal surgery at the BRI
6 site; and he deals with the complexity of administrative
7 arrangements et cetera, concerned at paragraph 11 about
8 the effects on the surgeons; and paragraph 12:
9 "Thus to me, the split site issue was one of the
10 major reasons not to apply for the post. I thought it
11 inefficient, archaic, inhibitory to progress, and
12 potentially dangerous. I made this clear in verbal and
13 written communication to the team in Bristol. I might
14 have been prepared to go to Bristol if the issues
15 outlined above had been addressed prior to my arrival
16 and if I thought that senior management were in favour
17 of such change. The next section addresses these
18 issues ..."
19 He then --
20 A. Can I just say, please, he would have been prepared to
21 come to Bristol with the circumstances as they were if
22 he had been satisfied that senior management were in
23 favour of such a change. He did not talk to senior
24 management and therefore he remained unaware that senior
25 management was in favour of such a change.
0103
1 Q. Would the Chairman of the Trust qualify as senior
2 management?
3 A. No, he is not a manager at all. The Chairman and
4 non-executive set policy and supported management, which
5 was performed by the executive directors. There was no
6 question about that.
7 Q. Can we go to page 7? This again is Martin Elliott's
8 statement. He says:
9 "As I indicate in my letter to Mr Wisheart on
10 3/1/92", perhaps we ought to look at that, JDW 3/102,
11 before we come back to this. The very bottom of the
12 page:
13 "There seems no way that Peter Durie can bend the
14 resources and thus I have to decline."
15 So that is what he says about Mr Durie. Can we go
16 back now to WIT 467/7:
17 "I had had a meeting with Mr Peter Durie,
18 representing the senior management of the Trust to
19 discuss both my concerns about the split site issue and
20 the remuneration package on offer."
21 A. Please, you must not ask me to explain why he does not
22 understand the difference between a Chairman and a Chief
23 Executive in terms of management, but there is no doubt
24 that the non-Executive Director and the directors with
25 us, in other words, the Trust Board set policy, and it
0104
1 was left to the Managers to implement it. We were the
2 managers. The Trust Board did not manage anything.
3 There is a very big difference. If you want to set
4 aside some time for me to explain the difference,
5 I will, but the Trust Board was a policy making body.
6 I headed the management function to implement that
7 policy. I did not expect the Trust Board to manage and
8 they did not expect to.
9 There are a number of things -- as I read this --
10 that he misunderstands. I have to say, I greatly regret
11 he did not talk to me. There was clearly
12 a communication deficit between the Chairman and Martin
13 Elliott. I think he misunderstood what the Chairman was
14 saying. That is a pity.
15 Q. Was there also possibly a communication deficit between
16 the Chairman and yourself?
17 A. No, not possible at all. We met very frequently.
18 Q. Do you know how it came about that Peter Durie met
19 Martin Elliott?
20 A. No. I can only assume -- I think it says somewhere he
21 visited the Trust on one occasion only. I can only
22 assume I was elsewhere at that time. Unfortunately
23 Chief Executives are not able to spend the whole of
24 their time within their own Trust. Certainly I would
25 have expected to see him and he would have expected to
0105
1 see me, so there must have been some reason I cannot
2 explain now, but most likely I was not there at the time
3 he arrived.
4 Q. If you were not there and Peter Durie spoke to him,
5 Peter Durie would have told you about that meeting,
6 would he?
7 A. I am sure so. He told me about everything. We
8 exchanged considerations, yes.
9 Q. He, Peter Durie, would have told you no doubt what
10 Martin Elliott had said to him, or at least the main
11 thrust of what he said to him?
12 A. Well, I do not know. He would have told me he had seen
13 him and told me what he said to Martin Elliott. Martin
14 Elliott, so far as I can see, would have been asking
15 questions Peter Durie would have been answering, so
16 I suspect he would tell me more what he said to him.
17 Q. If we go down to paragraph 7, he says:
18 "Mr Durie outlined the structure of the new Trust
19 organisation and the financial arrangements. He stated
20 that there was no way that resources could be made
21 available to correct the split site issue in the short
22 or medium term (I can't remember whether we discussed
23 what this meant)."
24 If it had been you rather than Mr Durie who had
25 been seeing Martin Elliott, would you have said that to
0106
1 him?
2 A. No, I do not think Mr Durie did, either. I think what
3 Mr Durie was outlining was the constraints of contracts
4 and the inability to cross-fund between contracts:
5 a concept that some clinicians have difficulty with.
6 What our plans were -- and we eventually achieved
7 it, was that -- we could not negotiate an increase in
8 paediatric cardiac surgery; we were doing all the cases
9 referred, but there was a capacity to meet much more of
10 the demand for adult cardiac surgery. The scheme was
11 for the adult cardiac surgery, when we could get that
12 funded, to be provided for within the space occupied by
13 paediatric cardiac surgery and use the additional
14 resources, capital and revenue, to relocate the
15 children. So we were using capital and revenue to
16 provide adult cardiac surgery, but doing it in a way
17 that reprovided paediatric cardiac surgery. That may
18 have been a difficult concept to be understood at that
19 time and I was not there to explain it. I cannot tell
20 you what words were used, but I do know that what
21 Mr Durie would have been saying was that in terms of
22 paediatric cardiac surgery, the only resources available
23 were in the contract for paediatric cardiac surgery, and
24 that remains so.
25 Q. One of the difficulties we have in discussing this -- we
0107
1 only have what Mr Elliott says was said to him in the
2 course of a conversation to which you were not a party,
3 but his recollection of what was said about that
4 particular issue you have just been discussing is that
5 he -- the very last sentence of paragraph 7 -- pointed
6 out, talking about the children's services being
7 centralised away from the BRI "would free up resources
8 to increase throughput of and potentially income derived
9 from adult practice."
10 So he appears to have suggested in 1991, coming up
11 for 1992, the very device which was eventually to lead,
12 as we understand it, to the move of children's surgery
13 from the BRI to the BCH?
14 A. Except that he has got it the wrong way round, as a lot
15 of clinicians did at that time, that we provided the
16 service and that would attract the funds. In fact, we
17 had to attract the funds in order to provide the
18 service. It had to be that way round. The idea that we
19 were in a free market and could invest in some
20 speculative development in the hope that it could
21 attract patients, and having attracted patients the
22 responsible purchaser would pay the money, was
23 a misunderstanding of this jingle that they had that
24 money would follow the patient. Money only followed the
25 patient if the patient was preceded by a contract.
0108
1 Q. It is a bit chicken-and-egg, is it not, because there
2 would be no contracts for a thousand operations per year
3 unless there was the capacity to do 1,000 operations
4 a year?
5 A. The UBHT was able to provide whatever service was
6 funded. There is no doubt about that. We put ourselves
7 into a position where we could respond to whatever
8 demand was made on us. The trouble was that the demands
9 made on us in adult cardiac surgery did not meet the
10 clinical need. But I think that there was a lot of
11 misunderstanding about how the so-called internal market
12 worked. We were not free agents, speculatively
13 providing services in the hope of attracting customers;
14 we were rather more a tied supplier -- I do not want to
15 quote things, but we were a tied supplier that would
16 produce whatever our purchaser demanded of us.
17 Q. Would you have a look now at paragraph 8, if we just get
18 that all on the screen? Perhaps the easiest way is for
19 you to read it through to yourself, and then tell us
20 whether you think you might have said that, had you been
21 there at the meeting.
22 A. It does not say what he said, actually. What this says
23 is what he understood, "... made it quite clear that it
24 would be up to him, a new incumbent, to generate the
25 income to pay for the changes required."
0109
1 No, I am quite sure Mr Durie did not actually say
2 that, but it depends what changes he was talking about.
3 He says what you have to do is to make the changes and
4 then get the income. There was a very real problem here
5 of having a fixed contract with a number of purchasers
6 for a volume of work which was not actually changing,
7 and wanting to invest in that.
8 I do not know what the conversation was, but we
9 certainly were not looking to pay for the
10 centralisation, the amalgamation of the whole unit on
11 the Children's Hospital, to pay for that out of an
12 increased contract for paediatric cardiac surgery. That
13 was not an option and it was not what we were pursuing.
14 If you ask me who got it wrong, Mr Durie or Martin
15 Elliott, or whether they both got it a bit wrong,
16 I cannot tell you.
17 Q. Well, you can give me your comment, bearing in mind your
18 knowledge of the time, as to what is said in
19 paragraph 9. It is the last sentence. He says:
20 "Faced with a management ethos like this", and
21 "like this" is what he, Martin Elliott, has understood
22 in the previous paragraphs, and you rightly point out
23 that understanding may be imperfect. "Faced with
24 a management ethos like this, it is easy to imagine why
25 the clinicians had failed to persuade the high levels of
0110
1 the health authority that change was required."
2 A. There are two things to say. What he says Mr Durie told
3 him was absurd, and I do not believe Mr Durie said it.
4 The next thing is that "Faced with a management
5 ethos like this, it is easy to imagine why the
6 clinicians had failed to persuade the high levels...",
7 they had persuaded the high levels of the health
8 authority that change was required. That is
9 a misapprehension. We all knew change was required; we
10 were addressing how to achieve it.
11 There are a number of people who feel that if you
12 are, what shall I say -- blaming the fact that there is
13 no money for something is simply a superficial excuse
14 and if something is needed, you just fund it. That was
15 a very common view of doctors. If I could reinforce it
16 by -- I think it was one of Mr Stark's articles at the
17 end used the classic expression that it must be
18 remembered that patients' health is more important than
19 hospital financial health. In other words, "Don't talk
20 to me about money, just do it".
21 This was a financial barrier which we were
22 addressing. The fact that he did not understand how we
23 were addressing it and what we were going to do is
24 a pity, but the consultants at that time did have great
25 difficulty with their understanding of what was called
0111
1 the "internal market".
2 Q. Can I come back from the last sentence in paragraph 9 to
3 the second sentence of paragraph 7?
4 Was it right, at the time, 1991, to say that there
5 was no way that resources could be made available to
6 correct the split site in the short or medium term,
7 whatever that might mean?
8 A. No, because -- I do not know what "short" or "medium"
9 term meant. He says he did not discuss what it meant
10 and those terms have no precise meaning. What I do know
11 is that we actually did correct the split site in what
12 I would think in Health Service terms was certainly
13 medium and possibly short term.
14 So it is wrong, it was wrong, and I cannot divine
15 at this distance how that failure of understanding
16 occurred. But this is full of management would resist
17 it. It was a typical consultant approach: because you
18 had not done it by yesterday, it must be because you do
19 not want to or do not understand. Do not talk to me
20 about money.
21 Q. Mr Elliott wrote to Mr Wisheart, who has it happened was
22 Medical Director. As Medical Director, was he not part
23 of management?
24 A. In theory he was. In practice, the only thing he
25 managed was, I think, matters of medical staff
0112
1 employment. It had always struck me that, with a very
2 big Trust -- and I have said this in a number of
3 places -- the Medical Director behaved much more in
4 practice as a non-executive director, advising and
5 giving the Trust Board the benefit of their wisdom.
6 To complete the paradox, there was one of the
7 non-executive members interested in finance and
8 property, who was behaving at times like an executive
9 director.
10 So in a sense, I cannot answer your question "Yes"
11 or "No". His title was "Executive Director". His
12 function did not include executing anything, except
13 perhaps the appointment of consultant staff.
14 Q. Mr Wisheart has expressed to him in writing, as we have
15 seen, a number of reasons why the split site is
16 undesirable, amongst them a suggestion that it is
17 potentially dangerous.
18 A. Yes.
19 Q. Mr Elliott tells us that he spoke to Mr Peter Durie,
20 the Chairman of the Board, and expressed similar views
21 orally.
22 A. Yes.
23 Q. You saw Mr Wisheart regularly as Medical Director,
24 did you?
25 A. Yes.
0113
1 Q. You have already told us about your close working
2 relationship with Peter Durie.
3 A. Yes.
4 Q. Did you know that Mr Elliott had expressed the views
5 that I have revealed in this line of questioning, that
6 there was, as he saw it, disadvantage in the split site
7 to the point of potential danger?
8 A. Yes, but not to the point of danger. As I have already
9 explained to you, I did not actually see the paper
10 written by Martin Elliott until after the appointment of
11 Gianni Angelini, or some time around there, but he did
12 not say it was dangerous, he said there was the
13 potential for danger. I clearly read that in
14 a different way from what you are suggesting. Quite
15 clearly, I do.
16 Q. If it were suggested to you, then, revisiting my earlier
17 question, that the service or part of the service was
18 a potential danger to patients in a particular respect,
19 is that something that you -- as a manager unable to
20 reach a clinical view because you were not a clinician
21 in that particular service -- would nonetheless wish to
22 take advice upon?
23 A. If the gist of the advice I was given throughout was
24 that a situation was undesirable but in no way
25 unacceptable, then I would regret the undesirability and
0114
1 attempt to correct it.
2 If anybody had suggested to me that they were
3 describing a situation that was unacceptable, then
4 I have told you what I would do about it. Just at the
5 top there [indicating screen], I do not know what it
6 refers to, "was totally unacceptable to me",
7 not "totally unacceptable". The tone of this and the
8 implication was that he supported our view that
9 consolidation of the service on one site was highly
10 desirable. He at no stage says, "and you should not be
11 providing the service the way you are". It is not
12 said. I think if he thought we should not have been
13 providing the service in the way that we were, he would
14 have told me. He would have told somebody, not just the
15 person providing the service.
16 Q. The last question, perhaps, before we have our afternoon
17 break: a situation in which a service may be potentially
18 dangerous, or is potentially dangerous: is that
19 acceptable or unacceptable, would you say?
20 A. It depends what the words mean. The words as
21 I understand them, it means acceptable but undesirable.
22 You are putting to me that is different. I do not
23 believe anybody who believes that a service is dangerous
24 and should be stopped would ever leave that ambiguity.
25 MR LANGSTAFF: Sir, I am going to move on to a slightly
0115
1 different topic. It is perhaps a shade early, but not
2 very much, for an afternoon break.
3 THE CHAIRMAN: Yes, until 3.15, then, thank you.
4 (3.00 pm)
5 (A short break)
6 (3.20 pm)
7 MR LANGSTAFF: Dr Roylance, after this in January 1992 you
8 saw Professor Prys Roberts, either on 14th February or
9 5th March or both occasions. On one of those occasions
10 I think it is common ground between you and him that you
11 discussed paediatric cardiac surgical services; that is
12 right, is it not?
13 A. Yes.
14 Q. The difference between the two of you is what precisely
15 it was about paediatric cardiac surgical services that
16 was discussed?
17 A. So I understand, yes.
18 Q. Your recollection is what?
19 A. My recollection is that at the end of the second meeting
20 which he had arranged, the meeting was arranged to
21 discuss the research floor and the rearrangement
22 thereof, that he urged me to renew my efforts to appoint
23 a paediatric cardiac surgeon because at that time we had
24 just failed to achieve that end in the appointment of
25 a Professor.
0116
1 Q. At that stage, the appointment of the Professor was not
2 yet secure as I understand it because funding was in
3 some doubt, the British Heart Foundation may not have
4 been willing at that stage finally to finance Professor
5 Angelini's post?
6 A. Technically I suppose that is true, but there was very
7 close collaboration with the Heart Foundation. In fact
8 I believe a representative of that group attended the
9 appointments committee or certainly attended some of the
10 early meetings of shortlisting and so on. So there was
11 a very close relationship and it was one of those
12 interesting situations where the university would not
13 appoint Professor Angelini and then find that his
14 quality was found to be inadequate by the Heart
15 Foundation, that would never do and the Heart Foundation
16 clearly could not financially support anybody that the
17 University had not already found acceptable. We were in
18 that situation where the University offered a post
19 subject to the agreement of the Heart Foundation and,
20 indeed, they assisted Gianni Angelini in his statement
21 to the Heart Foundation.
22 Q. Do you recall Professor Prys Roberts saying anything to
23 you about data or figures that Dr Bolsin was collecting?
24 A. No, no.
25 Q. May we have a look, please, at WIT 382/2, the bottom of
0117
1 the page. At the top of the page he has described how
2 his recollection is that Dr Bolsin showed him some
3 preliminary data which he had gathered. Then he
4 describes, under the heading "N4", I will come to the
5 part I want to ask you about, how he says the
6 conversation with you went.
7 First, would it have been a matter of surprise to
8 most clinicians that somebody in one department and
9 discipline was collecting figures or data which related
10 to the success or otherwise of another department or
11 discipline without necessarily telling that other
12 department or discipline about it?
13 A. I think that would be met with total surprise. If for
14 no other reasons, it fell well short of common courtesy.
15 Q. So it is something which would have been remarkable in
16 that way to any experienced senior clinician?
17 A. Yes. I hope it would appear unique to any experienced
18 clinician.
19 Q. If Professor Prys Roberts had been approached by
20 Dr Bolsin and shown data, figures in respect of outcomes
21 in paediatric cardiac surgery and you and he, that is
22 you and Professor Prys Roberts were discussing
23 paediatric cardiac surgery, would you expect, given what
24 you know of Professor Prys Roberts, that he would have
25 told you something about that?
0118
1 A. Yes. I would not describe Prys Roberts and his
2 relationship with me as reticent.
3 Q. One of the points you make in response to what Professor
4 Prys Roberts says here at WIT 382/2 is:
5 "Dr Bolsin has said he did not start his
6 collection of data for analysis until July 1992 so
7 Professor Prys Roberts could not have mentioned it at
8 this stage".
9 Dr Bolsin when he gave evidence to us indicated
10 that he had investigated figures and outcomes before
11 July 1992 even though he had not proceeded with an
12 analysis until the summer of 1992. So it may be the
13 point you make has some but rather less force if that
14 evidence is true.
15 Can I ask you about what is said here? He says
16 that he, this is Prys Roberts, "explained to you
17 Dr Bolsin had been collecting data and in my
18 [Prys Roberts] opinion he [Dr Bolsin] was correct to
19 express concern about cardiac surgery in babies. He did
20 not have the data, told Dr Roylance Dr Bolsin would be
21 prepared to show them to him. Dr Roylance said I should
22 leave the matter with him and he would deal with it."
23 Did that take place?
24 A. The final sentence is true but what precedes it is quite
25 wrong and I have no doubt about this because it was at
0119
1 a time when we were actively trying to introduce the
2 concept of audit. One of the prerequisites, and it was
3 quite clear at the time, emphasised not only nationally
4 but re-emphasised very much more strongly by the
5 Regional Hospital Medical Advisory Committee, that the
6 figures of audit, the actual data of audit must remain
7 confidential to those who were creating those data and
8 were not to be released to management.
9 I was at great pains to reassure everybody by
10 action as well as word that I would not involve myself
11 in the data. That was necessary because of my
12 relatively unusual position in the Health Service at
13 that time, being a senior consultant in background
14 within the Trust and somebody that it was known knew his
15 way around the information systems and the records
16 department and could himself have got the information
17 out.
18 So that if anybody had attempted to involve me
19 with data there were a whole variety of reasons why that
20 would have made a big impact on me and why I would have
21 responded quite immediately to where that data should
22 be. I also have to say if he said to me that Dr Bolsin
23 had data about cardiac surgery, it is quite
24 inconceivable that I would not have immediately referred
25 the matter to James Wisheart and talked to him about it
0120
1 and I did not because I was not given that information.
2 Q. The first point you make -- I appreciate the second,
3 that you would have spoken to Mr Wisheart, but the first
4 point essentially is you would have reacted by saying
5 "This data really should go to the surgeons and not to
6 me"?
7 A. That is right, "You must not show me the data".
8 Q. "Not for me"?
9 A. "You must not show me the data".
10 Q. Therefore because there is no echo of that in what
11 Professor Prys Roberts has said, you think he must on
12 that footing alone be wrong in his recollection?
13 A. Yes, I am trying to explain why I do not have any doubt
14 about the accuracy of my memory in terms of what did not
15 happen at the meeting. I cannot tell you the precise
16 words of what did happen, but I have no doubt at all
17 that the suggestion that I should concern myself with
18 data at that time, I would have viewed as very
19 counterproductive to a major initiative I was pursuing
20 with a lot of other people throughout the Health Service
21 of introducing what was then medical audit and became
22 clinical audit.
23 Q. What Professor Prys Roberts said when he was asked about
24 this at the General Medical Council was this, I will
25 read it out to you and I will take it slowly if I can so
0121
1 you can follow it. He says:
2 "On the basis of what I had seen, which was at
3 that stage Dr Bolsin's raw data, it had not been
4 analysed, they had not been validated, I felt there was
5 something to answer. I think the phrase I used was that
6 one could not 'sweep this matter under the carpet' any
7 more and that there was sufficient concern from
8 consultant anaesthetists within the Trust and consultant
9 anaesthetists from outside the Trust who had been
10 consulted by other consultant anaesthetists from Bristol
11 that I felt that as the Chief Executive he should have
12 done something about it, it is a question of what one
13 should have done at that stage."
14 Do you recollect Professor Prys Roberts ever
15 having a conversation with you in respect of paediatric
16 cardiac surgery in which, at whatever time it happened,
17 he used the phrase "one cannot sweep this matter under
18 the carpet any more"?
19 A. No, I would have taken very great exception to that,
20 possibly not openly, but I would have found that quite
21 an offensive remark that he would suggest that I as
22 Chief Executive would sweep something under the carpet.
23 It is a wholly unattractive concept and it is not
24 language that was ever used to me.
25 Can I add, because the whole of this I find
0122
1 extraordinary, he also said that I was a busy person and
2 that he could not make an appointment to see me about
3 his view that the outcome of cardiac surgery in babies
4 was unacceptable, but he did have time to make an
5 appointment to see me about a few square metres of floor
6 area in the research floor.
7 I mean I just do not find this hangs together at
8 all and he certainly never spoke to me again about
9 paediatric cardiac surgery. So I am just trying to
10 explain why I am absolutely confident that what is
11 alleged here is totally without foundation.
12 Q. In March 1992 we have I think at SLD 2/3 an extract from
13 Private Eye. You may recognise the left-hand column --
14 perhaps I should read it so you can follow it:
15 "Before the Department of Health bestows its mark
16 of excellence on UBHT it may wish to ponder the perilous
17 state of its paediatric cardiac surgery."
18 It goes on at the bottom of that column:
19 "Recently the unit failed to provide a paediatric
20 cardiac surgery nurse for post-operative care because it
21 was assumed the baby would not survive the operation and
22 although Liverpool surgeons have successfully operated
23 on 160 babies with Fallot's tetralogy and congenital
24 heart abnormality, the Bristol mortality rate is between
25 20 and 30 per cent, hardly the stuff of commendations".
0123
1 Actually May 1992.
2 Did you see that particular article?
3 A. Yes, some time later, I cannot tell you precisely when,
4 but I was shown it. I have to say I do not read that
5 particular publication and did not at the time and it
6 was not included in our newspaper cutting service --
7 that was I think in its infancy at that time but which
8 we tried to develop, but we were aware of what was being
9 said in the media, but somebody brought it to my
10 attention at some stage, yes.
11 Q. Do you recollect when, at what stage that was?
12 A. Not precisely. No, I cannot give you a date. I feel it
13 was soon after the date of publication. It certainly
14 was not on the day of publication or the day after, it
15 may have been the week after, it may have been within
16 the month, I do not know.
17 Q. You say in your statement, WIT 108/124, the bottom of
18 the page:
19 "The column in which the articles about
20 paediatric cardiac surgery appeared was recognised as
21 representing a sustained attempt to denigrate and
22 undermine newly created NHS Trusts by a series of
23 satirical articles."
24 Who recognised it as representing that?
25 A. I think every Chief Executive of Trusts at that time.
0124
1 Perhaps some more than others, but ...
2 Q. Did that necessarily mean when it quoted figures the
3 figures were necessarily wrong?
4 A. I think what was published there was necessarily, in
5 fact totally without foundation and without a source.
6 I do not know that I understand it to be necessarily
7 wrong, but I think not very likely to be right.
8 Q. When you had that brought to your attention did you take
9 any steps to see what the true figures were so that
10 those in Private Eye might be refuted either publicly or
11 privately?
12 A. It was brought to my attention with the question of
13 should the Trust institute proceedings against the
14 journal, the magazine, whatever you call it, and my
15 advice was "No".
16 Q. Who asked you that?
17 A. Probably James Wisheart -- almost certainly James
18 Wisheart and others. I cannot remember whether a group
19 came or he came but when it was brought to me it was
20 brought with a very serious consideration of whether
21 this defamatory information should be reacted to and my
22 advice was "No".
23 Q. You had it brought to you with the information that it
24 was defamatory and therefore inevitably wrong?
25 A. Can I say -- we had not mentioned, if you read the first
0125
1 thing, I was personally involved in the orthopaedic
2 waiting list: that is factually totally wrong.
3 Everything I knew was misreported in that column,
4 I think it is not unreasonable to conclude therefore
5 that which I did not know was also wrong.
6 Q. Perhaps we ought to establish what articles you did
7 see. Can we have a look at WIT 283/14, this is February
8 1992. This on the left-hand side, it talks about
9 waiting lists. It deals with you in particular.
10 Did that come to your attention, do you think?
11 A. Please, I am trying to be as honest as I can and I have
12 been shown the whole series of these subsequently and
13 I cannot in my own mind be certain of the totality of
14 the ones I was shown. I have a suspicion that that
15 particular one I was not shown, but I may have been,
16 I cannot be certain.
17 Q. I will go through them, if I may, quickly and if you
18 cannot remember because of what you have seen since, by
19 all means please say so.
20 A. I rather feel that may be the answer.
21 Q. JDW 3/141. Can we look at the right-hand side.
22 "Dr John Roylance, so angered" et cetera. I wondered
23 if you might remember that because it refers to you
24 specifically?
25 A. No, I do not think this was shown to me.
0126
1 Q. The next one was the one we have already looked at, May.
2 SLD 2/5. This is July. The relevant passage
3 begins two paragraphs at the bottom of the left hand
4 column, "Mrs Bottomley claims..." It talks there about
5 the switch operation, the arterial switch, comparing the
6 Bristol rates with those in Birmingham ... Bristol it
7 says 30 per cent.
8 Do you think you may have seen that at or about
9 the time or not?
10 A. Do I think I may have seen it?
11 Q. Do you think you did see it?
12 A. No, I do not think I did see it, but I would not like to
13 say I did not see it. It was not my favourite reading
14 at the time, though I knew of it.
15 Q. SLD 2/6. This is the 9th October. It is the bottom
16 left-hand, second bullet point from the bottom "The
17 sorry state of paediatric cardiac surgery". Again if
18 you have a look at that. It talks about tetralogy of
19 Fallot and transposition of the arteries.
20 A. Curiously I remember the bit about Filofax and Parker
21 pen, though I cannot tell you when I saw that. I am
22 sorry to be a poor witness, but I really cannot answer
23 your questions other than in a speculative way.
24 I remember seeing --
25 Q. I do not invite you to speculate if you cannot say you
0127
1 saw it --
2 A. I apologise, I am fairly sure I saw the first one soon
3 after it was published. I do remember being aware of
4 one or two others, but I do not remember studying
5 a series. The trouble is I have been shown these
6 subsequently and any memory I might have had in detail
7 has rather been spoiled.
8 Q. It was not long after this, after seeing or being told
9 of the articles from Private Eye, that you got a letter
10 from Ms Binding of the Corporate Affairs of the NHS
11 Management Executive. We looked briefly in another
12 context at that letter this morning. That is JDW 3/134.
13 Can we edit the last two words of the first
14 paragraph?
15 That enclosed I think a letter which I showed you
16 very briefly this morning, I am not going to take you to
17 it again, which complained about a parent having read in
18 a recent edition of Private Eye a report about the
19 paediatric cardiology unit at Bristol, you recall.
20 So the matter was brought to your attention by the
21 NHS Management Executive in June 1992, presumably the
22 article to which it referred was the first I showed you
23 which you think you saw some time round about the time
24 it was published?
25 A. Yes.
0128
1 Q. Would I be right in assuming that at any rate by the
2 time you got this letter, if you had not seen it you
3 then saw it?
4 A. Yes.
5 Q. Because you needed to respond to it?
6 A. I am quite sure at that time. I think before that I had
7 seen it but I can guarantee when this arrived I would
8 have seen it then.
9 Q. Was there much discussion amongst those in management
10 about the Private Eye articles?
11 A. No.
12 Q. Was there any concern about the sorts of figures which
13 apparently were being quoted in the satirical press?
14 A. Well, I understood very much later that there was
15 concern within the audit process that what were supposed
16 to be confidential discussions with provisional numbers
17 being thrown about had appeared in Private Eye, not
18 validated numbers, not conclusions and I understood some
19 time later that that had been a setback in the
20 development of open discussion in audit, yes. I did not
21 know at the time.
22 Q. How much later did you know of that?
23 A. I do not know.
24 Q. Roughly?
25 A. No, I do not know, I think it would be wrong for me to
0129
1 guess.
2 Q. At the time you spoke to Mr Wisheart about it?
3 A. Yes.
4 Q. What was Mr Wisheart's view as to the fact that matters
5 which perhaps might have been confidential to cardiac
6 surgery appeared to be bandied about in the press?
7 A. I do not think at the time we had that conversation in
8 the way you suggest it. At this time that I talked to
9 Mr Wisheart we were concerned about the misunderstanding
10 that had been given to the parents of the child and
11 steps were taken to correct it.
12 Q. You are concerned about the accuracy of the information?
13 A. Well, the effect of the information; the concept that it
14 was accurate never occurred to me.
15 Q. The reply which is written is at JDW 3/157 and 158. Can we
16 scroll down? Perhaps we ought to pick up the reference
17 at the top of the page.
18 A. Yes, I did do that en passant.
19 Q. Again the information comes from Mr Wisheart?
20 A. Yes.
21 Q. So the process would have been his drafting a reply and
22 your considering it and signing it if necessary. The
23 middle of the page:
24 "I am happy to report to you that Mr & Mrs
25 [whoever] have met Dr Joffe and Mr Wisheart together
0130
1 with Mrs Helen Vegoda on Tuesday 21st July, had a full
2 and very frank conversation. Each item raised in
3 Private Eye of 8th May was fully discussed, in
4 particular the results for children in general in the
5 late 1980s and for Fallot's tetralogy in particular were
6 discussed in detail. We were able to inform the
7 [whoevers] of the outcomes in Bristol in relation to the
8 outcomes in the United Kingdom as a whole." If we turn
9 over:
10 "Further, we were able to discuss the specific
11 procedure, which ... will undergo in the near future,
12 namely the Fontan operation".
13 You then enclose copies of the figures.
14 "... overall results extremely close to the UK
15 results but our results for Fallot's tetralogy appear to
16 be less good than the national results is chiefly
17 because of an excess number of deaths occurring in the
18 treatment of this condition in 1990."
19 It goes on to say that the parents were
20 reassured.
21 Second last paragraph: "Turning to the more
22 general considerations ... we have made a firm decision
23 to enter into absolutely no discussion or debate with
24 Private Eye." Who made that firm decision?
25 A. In the first instance me, I suspect, but my advice was
0131
1 taken so it became a wider firm decision than mine.
2 Q. It is "we" in the letter and you are writing on behalf
3 of the Trust?
4 A. You are asking who made that decision and I suspect it
5 was me, which was then shared with the Trust Board.
6 Q. Did the Trust Board, do you remember, ask about the
7 figures?
8 A. Nobody at the time saw this publication as anything but
9 a satirical column choosing the Trust, the new Trusts as
10 targets and there were different views about the level
11 of humour. I did not find them remotely funny, but that
12 is a personal view. I do not think it was looked upon
13 as a serious contribution of any sort, it was not even
14 thought to be.
15 Q. The change in practice to which you refer at the second
16 last paragraph, I take it, was a change of practice that
17 from now on it was likely that you would circulate to
18 paediatricians a regular report on results?
19 A. Yes.
20 Q. Whose suggestion was that?
21 A. I think that was from James Wisheart and/or Hyam Joffe.
22 There was a concern between them on a professional basis
23 that they may be able to improve the communications with
24 the referring clinicians who were paediatricians
25 throughout the South West. Paediatricians tended to see
0132
1 the child first and refer them to the paediatric
2 cardiologists who would then evaluate them and refer
3 them to the paediatric cardiac surgeons and I think that
4 was a consideration that they had in mind at the time,
5 that they could improve the feedback to the referring
6 paediatricians.
7 Q. Mr Durie's title is taken there in that collection. He
8 therefore obviously knew of the discussion and approved
9 it. Was there any follow-up by you or by him or by the
10 board to see this was actually done?
11 A. Not that I remember. Not that I remember.
12 Q. Do you know why not?
13 A. I cannot remember, so I cannot remember. If I could
14 remember not following it up I would remember why that
15 was so. I have to say I cannot remember what transpired
16 after that, it was a suggestion to the paediatricians,
17 and how they met that I do not know. They certainly did
18 peripheral clinics, as I think everybody knows and did
19 meet paediatricians. So I do not know.
20 Q. Can you help me, going back up the page as we see it on
21 the screen to the second paragraph. The bit about
22 Fallot's tetralogy appearing to be less good than
23 national results chiefly because of "an excess number of
24 deaths occurring in the treatment of this condition".
25 In what sense did you understand "excess deaths"?
0133
1 A. My understanding at this time was that they had had poor
2 results in 1990 and had reviewed the situation. I have
3 forgotten the date of that but as a result of that
4 review and a reconsideration of the whole process of
5 management, the results improved. Whether one was cause
6 and the other effect I do not think I was ever able to
7 know. But certainly there was concern in 1990 of what
8 proved to be a transient fall in the success of
9 treatment of Fallot's tetralogy. I do not know whether
10 that was in part a severity factor or was a coexisting
11 problem or what it was.
12 This sort of thing I now know happens in these low
13 volume high risk series and that from time to time there
14 is a poor run. I do not think anybody quite knows
15 whether there is a local cause for it or it is just the
16 distribution of risk factors, well, I do not know.
17 Q. The document which was enclosed with this letter in
18 reply -- JDW 3/159, can we scroll down for "Fallot's
19 tetralogy" -- shows the mortality in 1995 out of 18
20 high, as you say.
21 That is what you recall, is it, of being the
22 reason for the apparent excess, 6 per cent difference
23 between Bristol and the UK, double the overall mortality
24 rate?
25 A. Yes, I remember being told that there had been a problem
0134
1 with that particular operation in 1990 and I think it is
2 true to say following that the results improved.
3 Q. Who told you?
4 A. I do not know. I would presume it was James Wisheart at
5 the time of this letter and subsequently I presume, but
6 I really would not like to say that that is a firm
7 statement.
8 Q. One of the suggestions that has been made to us in the
9 course of this Inquiry is that a consequence of the
10 publication in Private Eye of material which appeared to
11 come from or to reflect discussions at audit meeting
12 within the cardiac surgery department blighted the
13 process of audit that took place thereafter. And part
14 of it was a concern that private conversations might get
15 publicly reported.
16 After this letter to Ms Binding at the NHS
17 Management Executive, did you yourself have any sense
18 that those sorts of issues were being raised or that
19 sort of matter was being said?
20 A. No, no, I did not and I do not. I know now but at the
21 time I did not.
22 Q. We know that there was no audit return made to the
23 Trust's Audit Committee in respect of the outcomes for
24 cardiac surgery for the years 1992 and 1993, although
25 let it be said that returns continued to be made to the
0135
1 Cardiac Surgical Register for those years.
2 Did you know that there had been an absence of
3 such a return by the unit to the Trust's Central Audit
4 Committee?
5 A. Not at the time. You must remember this was the very
6 early days of audit and I was not included in the actual
7 audit process at all, I was merely informed by the
8 Chairman of the Audit Committee through the Medical
9 Committee that audit was progressing and that no
10 management action -- when management action was required
11 -- was needed.
12 In other words the reporting process was from the
13 Chairman of the Audit Committee through the Medical
14 Committee to advise on any management action that was
15 required.
16 Q. But part of the report that the Chairman of the Audit
17 Committee would be giving was not so much in relation to
18 outcomes but in relation to the process. You would be
19 saying "we are undergoing the process of audit so you
20 can be satisfied we are doing it"; that was part of the
21 function, was it not?
22 A. No, he had to be satisfied, I did not. He had to tell
23 me he was satisfied.
24 Q. He had to tell you he was satisfied that audit was being
25 undertaken?
0136
1 A. That is right, it was very much divorced from me. This
2 was a function that consultants were charged with
3 pursuing, overseen and monitored by a committee which
4 was a committee of consultants and at that time
5 a subcommittee of the Medical Committee. My role was to
6 respond to any management action that arose thereby. It
7 would have been quite counterproductive for me to
8 monitor audit.
9 Q. The failure, let us suppose it to be, of a unit,
10 a directorate or associate directorate to respond to the
11 Trust Audit Committee saying "We are indeed engaged upon
12 a process of audit, we have discussed the various
13 matters over the year and had so many meetings" and so
14 on, the failure of that unit to respond would not be
15 a management issue concerning you?
16 A. No, it would not and quite specifically not, but if the
17 Chairman of the Audit Committee required my assistance,
18 he was charged with asking for it and he did on a number
19 of issues. You are jumping or appear to be inviting me
20 to jump into a position whereby management at that time
21 had the direct responsibility for audit. Curious as it
22 may seem at this stage, it did not.
23 Q. Thus far we have looked at 1992, the beginning of 1992,
24 towards the middle of 1992 Private Eye and the response
25 there was here to Ms Binding.
0137
1 At the end of 1992 Mr Dhasmana went off to
2 Birmingham in order to be retrained or to observe an
3 operation of the neonatal arterial switch series. He
4 went again the following July, July 1993.
5 Did you know that either of those events had
6 happened at the time?
7 A. No, no, no. I did know that it was standard practice
8 for consultants on the staff to use their study leave in
9 a variety of ways, one of which was to go to other
10 departments. When I was an active consultant I would do
11 the same but I would not have told the District
12 Administrator as it was at that time and he would not
13 have told me. This was orthodox pursuit of what is now
14 called continuing medical education.
15 Q. Did any whisper reach you do you think in 1993 that
16 Dr Bolsin was not only collecting data but analysing it?
17 A. No, I did not know about Dr Bolsin's activities until
18 after the external Inquiry by Marc de Leval and
19 Stewart Hunter. That is when it emerged and I did not
20 know of his activities before that date.
21 Q. Professor Angelini recollects having had at least two
22 conversations with you, one of them in the presence of
23 Dr Monk. Dating is not entirely easy with those but the
24 second appears to be March 1994, the meeting between
25 Dr Monk, Professor Angelini and yourself. The first, if
0138
1 it happened, perhaps towards the end of 1993.
2 Do you recollect having spoken to
3 Professor Angelini and Dr Monk about the issue of
4 paediatric cardiac services at about that time?
5 A. I have a vague recollection of meetings. I have
6 a recollection of meeting Professor Angelini on far more
7 than two occasions. I met him very frequently after
8 this point.
9 Q. Did he talk to you about paediatric cardiac surgery?
10 A. Amongst other things, yes.
11 Q. What in general was the tenor of his views?
12 A. I think I can summarise it by saying that he arrived and
13 had come up with what he thought was an entirely novel
14 idea that he had generated and came to me to press, that
15 I should appoint a paediatric cardiac surgeon. I told
16 him, I think clearly but possibly unsuccessfully, that
17 that was an initiative we had been pursuing. Indeed his
18 own appointment, his own post had existed with the
19 initial aim to appoint a paediatric cardiac surgeon.
20 We did have, and I remember on a whole variety of
21 things some difficulty in our conversation in terms of,
22 how shall I put it, the freedom to fund what was to him
23 a glaringly obvious requirement. That did not only
24 apply to a paediatric cardiac surgeon, it applied to
25 a lot of his early needs.
0139
1 Q. Do you recall why it was that he thought it was so
2 glaringly obvious and important?
3 A. No, except that was the sort of language he used.
4 Q. What was he saying about the state of paediatric cardiac
5 surgery that warranted the step of appointing a further
6 paediatric cardiac surgeon as a matter of importance?
7 A. I think he was repeating to me what everybody else had
8 said to me: that was that paediatric cardiac surgery had
9 now developed to a stage where it was best done by
10 somebody specialised in that sphere only and that the
11 mixed post which had hitherto been the standard practice
12 of an adult cardiac surgeon also doing paediatric
13 cardiac surgery was an evolutionary stage that we ought
14 to move beyond.
15 Q. He was putting it down to developments in treatment,
16 developments generally?
17 A. Yes, I mean paediatric cardiac surgery over the years
18 had developed in this way, as had a whole series of
19 other paediatric services. So it was not a strange
20 concept that there was pressure in all the specialities
21 within neurology, that they should be provided by
22 paediatric specialists rather than adult specialists who
23 did paediatrics. It applied to neurology, general
24 surgery, orthopaedics, neurology and so on. Over time
25 we were appointing specialists in paediatric
0140
1 specialities rather than to replace the work being done
2 by adult experts who extended their sphere of activity
3 into the paediatric group as well.
4 Q. Do you recollect whether he supported his view that such
5 an appointment should be made by any reference to
6 concern about the outcomes of paediatric cardiac
7 surgery?
8 A. Not in terms of -- I do not know, I expect we both
9 assumed that we expected the service to be better.
10 Whether it was ever specified that that would be
11 a significant change in mortality I do not remember
12 discussing. But we were using terms like "better".
13 Q. What Dr Monk recollects of a conversation he says
14 occurred, is this -- this is Day 73 at page 146. He
15 said, in answer to my telling him that his evidence to
16 the GMC was to the effect that the discussion between
17 him, Professor Angelini and yourself involved him urging
18 the desirability of having a paediatric cardiac surgeon
19 and consolidating the service within the Children's
20 Hospital as a way forward. He said he could not
21 disagree with that, that the conversation would have
22 been about the whole paediatric service.
23 "We were talking about concurrent paths, one path
24 is ... 'Let us try and resolve the differences of
25 opinion against audit', another path we were working
0141
1 very hard on was 'Let us solve the problem'" and he
2 agrees that the solution felt to be most appropriate was
3 "to move the cardiac service to the Children's
4 Hospital, to appoint a new cardiac surgeon to try and
5 integrate the service and that meant changing the
6 paediatric intensive care ..." and so on.
7 I asked him, did he discuss figures and outcomes,
8 even if he did not present the data. He said he did not
9 give you the audit figures. "We went into a loop where
10 we would raise a problem that we have concerns, then we
11 would come back to it being a clinical problem.
12 Therefore I did not get past go in order to put forward
13 these figures."
14 His response effectively was to say, "well, what
15 you said to him when you raised differences of opinion
16 about audit, about outcomes was to say 'this is
17 a clinical issue for clinicians to discuss.'"
18 May he be right about that?
19 A. In part, yes. The part that he was right on is that
20 I would be urging him that if there were a difficulty
21 with audit there were processes within the Trust at
22 which those differences could be dealt with and that
23 that would not involve or could not involve at that time
24 management.
25 To suggest, as I think you did that therefore
0142
1 I would have no interest in it I think would be wrong.
2 It would have been my aim and intention to, as far as
3 I possibly could, make Chris Monk successful in his
4 dealing with the problem, not for me to deal with it but
5 that he would be successful in dealing with it. He was
6 a very good Clinical Director and if he had presented me
7 with the issue of an audit difference, that particular
8 element of it, then I would have made it absolutely
9 clear that the right place to discuss that was with his
10 anaesthetic colleague Trevor Thomas who was overseeing
11 the introduction of the clinical audit and himself being
12 on the Region Audit Committee as well, was absolutely
13 adamant that numerical issues of audit should not stray
14 outside the clinical sphere.
15 So if he had given me figures or wanted to discuss
16 figures -- I do not think he did -- but if he had
17 I would have referred him in the first instance to
18 Trevor Thomas to resolve what he now says there was
19 a dispute about. What we were talking about, and I have
20 no doubt about this, was the desirability of the two
21 proposed improvements to paediatric cardiac surgery.
22 Q. When you say "we were using terms like better, making
23 the service better", such terms might suggest there was
24 something wrong with the service to require it to be
25 made better?
0143
1 A. Yes, I think there is no doubt that we all agree the
2 service should be improved. There was nothing strange
3 about this concept, that was a concept being put to me
4 from every service in the Trust, that there was room for
5 improvement, that improvement should be sought.
6 Q. Do I have an accurate picture: there are these two
7 individuals, Professor Angelini and Dr Monk, they are
8 discussing shortcomings in paediatric cardiac surgery in
9 particular, resolution of those shortcomings which
10 involve the appointment of a dedicated paediatric
11 cardiac surgeon and the move from the Royal Infirmary to
12 the Children's Hospital as one site and also probably
13 some concern, or telling you about concerns about
14 differences in respect of audit?
15 A. No, that was the bit I said was not the case and if
16 I did not make that clear I am sorry.
17 Q. I want to get your evidence clear on it.
18 A. Yes, there is no doubt that there was a great deal of
19 impatience, understandable impatience, impatience with
20 which I entirely sympathised, for a recognised
21 improvement to a service which had not materialised. It
22 was a very, even in Health Service terms it was a long
23 gestation before we achieved the improvement and people
24 were pressing me as though I had a magic wand to
25 implement the improvement.
0144
1 The issue of audit is quite separate from that and
2 that was not discussed with me. I would remember if it
3 were.
4 Q. If it had been you say you would have said "this is
5 a clinical matter for clinicians to resolve"?
6 A. Yes, I would have helped them with some guidance on how
7 that resolution should be achieved.
8 Q. Do you think that would be a sufficient answer if the
9 concern or the dispute were between the directorate of
10 anaesthesia on the one hand and the directorate of
11 cardiac surgery on the other?
12 A. If that was -- yes, we are pursuing a hypothetical
13 position and I cannot do it without some meat on the
14 bones, but I do not think because the difference of view
15 existed between anaesthetists and surgeons would
16 complicate or render the situation more difficult,
17 because in paediatric cardiac surgery they all worked as
18 a team: cardiologists, surgeons and anaesthetists,
19 pathologists and radiologists, they were a team. The
20 fact they were in separate directorates did not actually
21 stop the professionals working together as a team.
22 Q. If they cannot actually agree amongst themselves as to
23 the interpretation to be put on figures in the Trust as
24 it was in 1994, how was that to be managed, if it was to
25 be managed?
0145
1 A. I am not sure I understand the question, in the sense
2 that in a teaching hospital it thrives on dispute.
3 A consensus is a rare commodity in a teaching hospital,
4 all striving for improvement, all looking for change and
5 the fact that there was a debate going on would not have
6 struck me as distinguishing that particular service from
7 any other.
8 Q. The picture that has been painted to us in other
9 evidence is that the anaesthetists and
10 Professor Angelini felt that the outcome results as they
11 saw it were unacceptable, that others were taking the
12 view that although there were shortcomings it was not
13 unacceptable, although it needed to be improved and
14 might be improved by the steps that all were agreed
15 upon; where there was a dispute of that sort as to
16 whether figures were acceptable or unacceptable --
17 a matter of analysis and interpretation -- what do you
18 see as having been the proper role of management?
19 A. You have changed the supposition now, you have
20 introduced the view that they said and thought the
21 service was unacceptable. I believe if they thought
22 that they would have an absolute responsibility to
23 ensure that that unacceptability was addressed and they
24 knew as well as I knew the professional channels through
25 which that could be addressed: District Medical Officer,
0146
1 Regional Medical Officer, the Central Designation Unit,
2 the working party of the college, the college
3 themselves.
4 Q. Not the Chief Executive?
5 A. No, no, it was a professional matter and (as you are
6 postulating) is a professional dispute, that one group
7 of consultants have a view that the performance of
8 another group of consultants is unacceptable. That was
9 not in the first instance an issue for the Chief
10 Executive.
11 If they had told the Chief Executive -- and they
12 did not, but in other Trusts this has happened -- the
13 Chief Executive's only response would be to suspend the
14 activities and request outside evaluation. Had they so
15 told me that is what I would have done, I would have had
16 no choice.
17 What I am concerned about is the postulate that
18 there were two people at least, possibly three within
19 the Trust, who found a service unacceptable and did
20 nothing about it. If that is true, then I would have
21 very strong views about it.
22 Q. Let me move forward for a moment to the letter from the
23 anaesthetists which you I am sure have seen on more than
24 one occasion in one or other of its forms. 21st June
25 1994, UBHT 61/6. That is one of its forms. Go to 61/7,
0147
1 look at the bottom, please, another of its forms because
2 it has different signatories though no copy that we can
3 discover and no copy you can recall with all six
4 signatories on it.
5 Let us focus on this one, 61/7. Five of the
6 anaesthetists -- we have seen the sixth in 61/6 have put
7 his name to the same text "were expressing concern at
8 a particular part of the programme. June 1994,
9 mortality high" and they are seeking -- this is the
10 fourth and fifth line down "an open and thorough review
11 of the results so far".
12 You never saw this letter at the time, you never
13 saw it until after the Loveday operation you have told
14 us?
15 A. I did not see it until after I had retired. I did not
16 see this when I was a Chief Executive.
17 Q. If you had seen it would you have ordered or done your
18 best to secure appropriate medical advice as to whether
19 there should indeed be a review as requested?
20 A. Certainly I would have been astonished if I had been
21 shown this and I would have reacted very quickly and
22 very strongly. What their belief is, it says, is
23 a confidential review amongst the consultants within the
24 service: cardiac anaesthetists, cardiac surgeons,
25 paediatric cardiologists and the director of cardiac
0148
1 services and they believed that was a responsible
2 approach and if I had seen it I would have asked the
3 result of that review, not whether it was taking place
4 because there was no impediment to having such a review
5 if they wanted one.
6 Q. Such a letter as this would be extraordinary, would it
7 not?
8 A. It would be unique and I found it astonishing and I have
9 to say I still feel that astonishment.
10 Q. The fact that it was written let alone signed must be
11 staggering to you?
12 A. It is still.
13 Q. And the fact that it was signed must demonstrate,
14 I suppose, that there was an astonishing degree of
15 concern being felt by the signatories which they thought
16 was not being addressed one way or another, whoever's
17 responsibility it was; you would agree with that I am
18 sure?
19 A. Yes, yes.
20 Q. Such a letter as this, if there were no impediment to
21 having a review between the anaesthetists, the surgeons,
22 the cardiologists and the director of cardiac services,
23 would never have been written in the first place, would
24 it?
25 A. You are asking me to explain a letter which I find
0149
1 unique and cannot imagine why it was written.
2 Q. No, I am actually testing what you have said would have
3 been your reaction to it. Your first reaction to it
4 would have been to say "look, this asks for
5 a confidential review between these groups of people,
6 I would say there is no impediment to this, go ahead and
7 do it and tell me what the result is"?
8 A. Yes.
9 Q. I am, I think, suggesting that the very fact of the
10 letter being written at all shows there must have been
11 some difficulty in securing that?
12 A. I would not share that because you are drawing
13 a conclusion I cannot draw.
14 Q. With your experience and management you would not have
15 drawn that conclusion that this was a --
16 A. There was not an impediment so I would not draw
17 a conclusion there was. I do not know if anybody can
18 suggest what the impediment was but I have to say there
19 was not an impediment, I speak as a radiologist who
20 spent his time reviewing results of treatment, I know
21 I was pursuing the radiological element of it, I spoke
22 to people whose cases I reviewed and there was no
23 impediment to having a discussion about it. There was
24 no impediment, that is why I say this is astonishing.
25 Q. If there were, as has been suggested to us there might
0150
1 have been, resistance from the cardiac surgeons to
2 having any review; that would have been an impediment,
3 would it not?
4 A. If that had been the case it would have been an
5 impediment, but I am quite certain it was not the case,.
6 Q. Why are you so certain it was not?
7 A. Because the cardiac surgeons being involved in a new
8 speciality were characterised by review of their
9 results, it was bread and butter to them, I knew that.
10 They had regular meetings to review things. If you say
11 if I had thought about it now, this was written some
12 time after the neonatal switch programme had been
13 aborted and my understanding is they did not know that
14 and assumed -- so that series was going on.
15 I do not understand that breakdown in
16 communication but these things sometimes do happen and
17 I know nothing came of this letter. So I can offer
18 explanations but I really cannot accept any suggestion
19 that there was any impediment if it was asked for to
20 have this confidential internal review.
21 Q. Would you have read this letter as indicating
22 a breakdown in relationships between the groups?
23 A. Not at the time. I mean it was a possible thing, but
24 I would not have read anything into this, I would have
25 tried to find out the background to it. I think I now
0151
1 know the background to it but at the time I did not see
2 it and if it had just been put to me as you put it to me
3 at the time, I would have been astonished and
4 investigated the situation.
5 Q. How often did you see Dr Monk?
6 A. Once a week, twice a week, sometimes more.
7 Q. He told us that he took the letter to you?
8 A. I am surprised he said that. This is not the sort of
9 letter that I could conceivably forget.
10 Q. He maintained, although pressed on the point, that he
11 gave the letter to you?
12 A. No.
13 Q. And you pointed out, as is the case, that it was not
14 addressed to you and therefore handed it back to him?
15 A. That is nonsense, all he had to do was write on the
16 bottom "copy to Dr Roylance" and I was stuck with it;
17 I do not find that remotely feasible, I am sorry.
18 Q. He tells us that when he took the letter to you, as he
19 says he did, he told you about the concerns in it and
20 that he supported them?
21 A. He is mistaken. I do not think I ought to speculate as
22 to how that mistake comes about but I have absolutely no
23 doubt that I did not see this letter until after I had
24 retired.
25 Q. I asked him what was the response when you [that is
0152
1 Dr Monk] showed him [that is you Dr Roylance] the
2 letter. His answer was "the response was that it
3 remained a clinical problem, but he was the Chief
4 Executive of the Trust and it was for the clinicians to
5 solve"?
6 A. If you believe that you would believe anything. I mean,
7 the suggestion -- please, the suggestion that I would
8 see a letter like this, astonishing as it is,
9 inexplicable as it is and say "I do not want it, nothing
10 to do with me" I find offensive.
11 Q. Dr Roylance, on that note I think we have come to
12 a stage where we ought to adjourn for the evening and
13 begin again, if we may, at 9.30 in the morning.
14 THE CHAIRMAN: Thank you Dr Roylance. 9.30 tomorrow
15 morning. Good afternoon, everyone.
16 (4.25 pm)
17 (Adjourned until Tuesday, 7th December 1999 at 9.30 am)
18
19
20
21
22
23
24
25
0153
1
2 I N D E X
3
4
5 MR LANGSTAFF re INQUIRY'S APPROACH TO MORBIDITY ... 1
6
7 DR JOHN ROYLANCE (AFFIRMED):
8 Examined by MR LANGSTAFF ..................... 10
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
0154
Return to top of page
Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001