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 7th 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), concluded his oral evidence to the Inquiry. He began by talking about a meeting he had with Janet Maher, General Manager, Directorate of Surgery, UBHT, in mid 1994, at which she told him she had been approached by Dr Stephen Bolsin, Consultant Anaesthetist, about his concerns regarding paediatric cardiac surgery. He then spoke about the correspondence between Dr Peter Doyle, Senior Medical Officer, Department of Health and Professor Gianni Angellini, Professor of Cardiac Surgery, University of Bristol, the origins of that communication and his subsequent response to it. He then described his views on the balance between his managerial and professional responsibilities. Dr Roylance next discussed his involvement in the discussions surrounding the decision to operate on Joshua Loveday to proceed in January 1995. He told the Inquiry about the independent review of the paediatric cardiac unit carried out by Mr Stewart Hunter, Paediatric Cardiologist and Professor Marc de Leval, Consultant Paediatric Cardiothoracic Surgeon and his involvement in the publication of the report. He concluded by describing his actions to restore professional relationships within the Trust after the publication of the Hunter/deLeval report. Dr Norman Halliday, former Medical Secretary, Supra-Regional Services Advisory Group came to the Inquiry today to give further evidence about his and SRSAGs involvement in the designation of Supra-Regional Services and the responsibilities for monitoring the activity and quality of designated centres. He told the Inquiry of the occasion when concerns about the Bristol service were raised with him by the Chief Medical Officer for Wales in 1987. He concluded by commenting on the 1992 Royal College of Surgeons Working Party report on the infant and neo-natal cardiac surgical service, which recommended continuing designation of the service and described the discussions he had with the authors of the report and Sir Terrence English, former President of the Royal College of Surgeons. He explained that SRSAG agreed to de-designate the entire national service in 1992.

FULL TRANSCRIPT

   1                Day 89, Tuesday, 7th December 1999
   2   (9.40 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF: Good morning, sir.
   6           DR JOHN ROYLANCE (RECALLED):
   7         EXAMINED BY MR LANGSTAFF (CONTINUED):
   8   Q. Dr Roylance, when we finished yesterday, we were talking
   9     about the anaesthetists' letter in the middle of 1994
  10     and the suggestion, the evidence given to us by Dr Monk
  11     which conflicts with your recollection that he gave you
  12     a copy of that letter.
  13        That was the middle of 1994. Shortly before that
  14     was an incident which I have not yet canvassed with you
  15     in evidence, Janet Maher came to speak to you I think
  16     around 1994; is that right?
  17   A. Yes, I cannot give you a precise date, but, yes,
  18     somewhere about 1994.
  19   Q. Spring 1994, somewhere round then. Did she say that
  20     Dr Bolsin had been to see her and that he had figures
  21     which suggested to him that the results in paediatric
  22     cardiac surgery were not so good in Bristol as they were
  23     in other centres?
  24   A. I do not think she used quite those words but certainly
  25     we discussed what to her was a surprising conversation

   1     from somebody from a different directorate approaching
   2     her when she was General Manager of Surgery when she
   3     would have thought the normal conversation would be
   4     between him and the General Manager of Anaesthetics.
   5     So, yes, she was puzzled.
   6   Q. What was it then that she said to you as you recollect
   7     it?
   8   A. I cannot give you the precise words but something to the
   9     effect that Dr Bolsin thought that the results in
  10     Bristol were not as good as the best in other places,
  11     something I already knew.
  12   Q. Did she mention that he had figures which showed this?
  13   A. No, no.
  14   Q. Are you sure?
  15   A. Yes, and I do not think she was shown any figures.
  16     I mean by implication if somebody says "The results are
  17     not as good as in other places" one could say "Well,
  18     that must be talking about numbers, results are numbers"
  19     but she did not reveal what I subsequently discovered,
  20     and that was that he was performing a secret audit,
  21     I think that is the easiest way I can say.
  22   Q. If you had understood from her that he had figures,
  23     would you have taken any steps in consequence?
  24   A. If she had told me he had independent figures which he
  25     was generating himself, that would have concerned me.

   1     The fact he had figures did not surprise me because
   2     I knew that the results in Bristol were sent to the
   3     Cardiac Society where they were totalled up nationally
   4     in order to produce a big enough series to produce any
   5     sensible view of outcome and those figures were returned
   6     to cardiac units and were made available to people
   7     within the cardiac unit. So if I had been told that he
   8     had figures I would have been far less surprised than if
   9     I had been told he had not got any figures because
  10     I knew that was the way paediatric cardiology, and
  11     I think adult cardiology behaved. They summated their
  12     figures nationally.
  13   Q. I do not wish to be unfair to you, so let me show you
  14     what you said when you thought about this at leisure in
  15     WIT 108/127, it is paragraph 38. You deal with the
  16     conversation, second line:
  17        "I do not remember the conversation very well but
  18     I believe Mrs Maher told me that Dr Bolsin had been to
  19     see her to tell her that he had figures which he felt
  20     showed that results in [Bristol] paediatric cardiac
  21     surgery were not as good as in other centres."
  22        Your recollection a moment ago was that figures
  23     were not mentioned, plainly your recollection at leisure
  24     was that they were?
  25   A. I am sorry, I am not being clear, I was hoping to be

   1     clear. I am conscious of the fact that when Dr Bolsin
   2     is mentioned and figures are mentioned, there is
   3     a tendency to talk about his, Bolsin/Black audit. If
   4     somebody says to me that the results in Bristol are not
   5     as good as in other centres, that must be a numerical
   6     assessment, it must be figures. Do you understand what
   7     I am trying to say?
   8   Q. Perfectly.
   9   A. I knew Bolsin had access to figures, everybody in the
  10     unit had access to figures, they were national figures
  11     in which they were returned and they were anonymised so
  12     that each unit would know its own figures because they
  13     had sent them to it but nobody would know anybody else's
  14     figures, just the overall group. It is possible to look
  15     at that figure and see that ours as a contribution to it
  16     did not actually put the average up.
  17        In terms of figures, yes, results must mean
  18     figures. In terms of a personal secret audit it would
  19     never have occurred to me that that was the case.
  20   Q. Can I explore this a little further? If indeed you are
  21     right and the figures that Janet Maher was talking about
  22     were no different from the figures that were available
  23     through the returns to the Cardiothoracic Register,
  24     there would be nothing remarkable in his having those
  25     results?

   1   A. No.
   2   Q. There would have been no particular reason for her to
   3     have mentioned to you anything about him coming to her
   4     saying "I have figures which suggest that paediatric
   5     cardiac surgery is not as good as it ought to be"?
   6   A. I am sorry, that is not quite true. I have to remind
   7     you that all the directorate managers as well as the
   8     clinical directors I saw as people who I needed to
   9     assist to be successful. They referred to me sometimes
  10     just for reassurance, sometimes for help and so that
  11     I was constantly talking to them on how they should
  12     conduct their management activity, how they should make
  13     decisions, pursuing this new concept of pushing
  14     decisions to as near the bedside as possible.
  15        Janet Maher found it extraordinary that Dr Bolsin
  16     chose to share with her his anxiety that the results in
  17     Bristol were not as good as the best in other parts of
  18     the country. Now I have explained to you that I knew
  19     that. The facts of what he was saying were not odd or
  20     surprising. The fact he had chosen to have
  21     a conversation with Janet Maher, she did not
  22     understand. So she said "What do I do?" I would have
  23     said "What have you done?" and she said "I told him if
  24     he has anxieties he should go and talk to the Directors
  25     of Cardiac Surgery and of Anaesthetics, namely

   1     James Wisheart and Chris Monk", and I reassured her that
   2     that was an entirely proper response.
   3   Q. At this time I think it may have been Mr Dhasmana, might
   4     it not, the Associate Director of Cardiac Surgery?
   5   A. Yes, yes, I beg your pardon.
   6   Q. In any event you would have been surprised, do I take
   7     it, that an anaesthetist, part of the team providing
   8     cardiac surgical services who ought to have had free
   9     access and free discussion of the surgical results for
  10     the units --
  11   A. Did have; not ought to have, did have.
  12   Q. -- was going to the Manager and saying something about
  13     his concerns based upon figures which he had; that is
  14     the way you report it in paragraph 38.
  15   A. Yes.
  16   Q. If one takes the language you have used at paragraph 38
  17     the impression one may be given from it, if you will
  18     forgive me for saying so, is that the figures which
  19     Dr Bolsin had were figures personal to Dr Bolsin because
  20     otherwise there would seem to be little point in her
  21     coming to you to tell you that he had been to her with
  22     figures from which he drew a particular conclusion.
  23     Would it not follow her concern was that he had not
  24     spoken with the clinicians involved, the implication is,
  25     about the figures?

   1   A. I am sorry, if you draw that conclusion from that
   2     English, then I apologise for the English. It is not
   3     what I meant; it is not what I thought I said.
   4   Q. I am simply concerned, Dr Roylance, to have your
   5     evidence as clear as we can and what you are telling me
   6     is that to draw that implication from that paragraph
   7     would be wrong. We have that evidence and I shall move
   8     on.
   9   A. I did not wish to infer that. It is my statement. As
  10     I say, I apologise if it means that. What was bizarre
  11     about the situation is that if Dr Bolsin had an anxiety
  12     of any sort, of all the places to go and discuss it and
  13     all the people to discuss it, Janet Maher did not seem
  14     to be in any way appropriate; that was the nub of the
  15     matter. I think I remember that she actually said he
  16     ought to go and talk to Roger Baird as well who was her
  17     Director of Surgery. In other words, go and talk to the
  18     people he ought to talk to.
  19        She did not show any lack of concern, but just
  20     thought it was a funny way because this was not just
  21     a chance chat at a social meeting or some other meeting,
  22     he actually sought her out to share with her that he
  23     thought the results in Bristol did not meet the "gold
  24     standard" being achieved in some other centres.
  25   Q. Why was she mentioning this to you, do you think?

   1   A. Because I was very close to her and if something strange
   2     happened that was beyond her normal experience, she
   3     would share it with me in case I had a view,
   4     a suggestion that she might have told him something
   5     different, might have said something different, might
   6     have done something different.
   7        All the general managers constantly shared their
   8     anxieties and their enthusiasms and their successes with
   9     me. We had a very close relationship. It was the only
  10     way, I believe, to create this new concept of general
  11     management in an organisation which had a very different
  12     culture.
  13   Q. Your approach, as I follow it, is to tell her what she
  14     should then say to Dr Bolsin. You did not think it
  15     right to say anything to Dr Bolsin yourself?
  16   A. No, no, if Dr Bolsin had wanted to talk to me, I was
  17     available. He knew I was available, everybody knew
  18     I was available. This was a matter of a conversation
  19     between Dr Bolsin and Janet Maher which Janet Maher, she
  20     was a psychologist, found curious and when she found
  21     something curious she would share it with me.
  22        I said "What did you say to him?" and she said "Go
  23     and talk to --" yes, it may well have been
  24     Janardan Dhasmana, I do not know, but certainly it was
  25     Roger Baird and Chris Monk and she indicated to him that

   1     if he had that sort of anxiety, that is where he ought
   2     to discuss it.
   3        I think she gleaned from him he had not so done
   4     and that struck her as odd as well.
   5   THE CHAIRMAN: Dr Roylance, just for my understanding:
   6     looking at the paragraph that is on the screen, when it
   7     says that "Dr Bolsin had been to see her to tell her
   8     that he had figures", as I understand it you are saying
   9     that would not be particularly surprising because those
  10     figures were as it were publicly available common
  11     knowledge.
  12        It might be, therefore, that instead of saying "to
  13     tell her that he had figures", your account would be
  14     better understood as "he had seen the figures which were
  15     generally available". But you said "he had figures"
  16     which might suggest they were other than the figures
  17     generally available?
  18   A. I apologise if that is a possible conclusion. It is
  19     a matter of trying to be succinct and not be too wordy
  20     in giving you my evidence, I apologise for that if it is
  21     misleading.
  22   MR LANGSTAFF: You picked up from Mrs Maher that Dr Bolsin
  23     had not been talking to the appropriate people about
  24     concerns which he was expressing to her. Did you pick
  25     up from her, Mrs Maher, any sense that the concerns were

   1     ones which she felt were potentially very serious?
   2   A. No, I do not think so. I knew at the time and whether
   3     she did -- I suspect she did -- that we recognised that
   4     there were ways in which paediatric cardiac surgery
   5     could be improved. We were pressing very hard and by
   6     that time, April 1994, we were well advanced in seeing
   7     a way to achieve that improvement.
   8        We would not have gone to all that trouble if we
   9     thought the results in the unit met or exceeded the
  10     "gold standard". I am quite sure that while Ash Pawade
  11     who is there now, will want more resources and so on he
  12     would not base it on the fact that his results were
  13     worse than the best in the country, they happen to be
  14     better.
  15   Q. The reason why I ask about your sensitivity to the way
  16     that Mrs Maher regarded the issue arises from her own
  17     statement which I will just show you. WIT 153/20, to
  18     put it in context, if we scroll down so we have
  19     paragraph 6 at the top.
  20        We can see she is describing here a conversation
  21     you were not party to when Dr Bolsin came to her and
  22     repeatedly referred it appears to data upon which he
  23     based the concerns but did not explain what it was. She
  24     sets out her overall impression at 7. Then 8:
  25        "The potential seriousness of what Dr Bolsin was

   1     saying made me feel extremely uncomfortable. I asked
   2     Dr Bolsin if he had shared this information with
   3     paediatric cardiac surgeons, or if he had shared the
   4     information with anybody else. I could not get a clear
   5     response from Dr Bolsin on this point."
   6        You did not have the sense, then, did you, that
   7     she took it in this particular way as she describes it
   8     here?
   9   A. No, I mean that may be because I would have reassured
  10     her that the statement that we were not reaching the
  11     quality of the best in the country was something that
  12     was widely known and I knew. So having reassured her,
  13     I do not remember her by the time she talked to me being
  14     other than curious rather than extremely uncomfortable.
  15     She may have been and she may have concealed that fact
  16     from me. I mean I would not wish to challenge what she
  17     felt at the time. I would say that she did not convey
  18     any sense of extreme anxiety to me.
  19   Q. She deals with what she said to you and how you reacted
  20     at WIT 153/24, paragraph 17. She says that when she
  21     spoke to you, this is the third line down, she repeated
  22     what Dr Bolsin had said to her. Then she says this:
  23        "I got the impression that Dr Roylance may have
  24     been in a similar position to Dr Monk, that is someone
  25     who is starting to get to know there is something being

   1     raised as a concern, but the detail of that concern was
   2     still very unclear. I would not have expected
   3     Dr Roylance to indicate to me how he planned to deal
   4     with this information. Quite rightly I believe he
   5     needed time to assess the best approach. My
   6     understanding was that he intended to take time and talk
   7     to the key people involved, probably including Dr Monk
   8     and Mr Wisheart. I did not know if he would go directly
   9     to Dr Bolsin or not. I cannot remember any other
  10     details."
  11        The way she describes the meeting is as someone,
  12     a manager who has gone to you to report what Dr Bolsin
  13     has said, that you had received the information but have
  14     not indicated to her how, and she looks to you to be
  15     doing something in response to the information, that is
  16     the way she puts it.
  17        Your recollection is rather that you say to her
  18     "This is what you should tell Dr Bolsin to do"?
  19   A. When I would talk to Janet Maher, the nature of the
  20     conversation would be for me to ensure that her
  21     position, her action, her conversations were what
  22     I would have wished of her. That would be the nature of
  23     the conversation.
  24        I would not be discussing with Janet Maher and
  25     asking her for her advice on what I was going to do.

   1     That would not have been part of the conversation, which
   2     is why she says she would not have expected me to
   3     indicate what I was going to do. That was not the
   4     nature of the conversation. I did not meet general
   5     managers in order for them to make me a better Chief
   6     Executive. I hope the meetings enabled them to be
   7     better general managers.
   8   Q. The understanding she refers to there, "My understanding
   9     was that Dr Roylance intended ..." and she goes on, was
  10     that something you think you conveyed to her or not?
  11   A. No, I would not have conveyed anything to her about what
  12     I was going to do, I was concerned with what she had
  13     done. I was, at that time, and talking to Chris Monk
  14     and James Wisheart and a number of other people early in
  15     1994, pressing ahead with the recognised solution to the
  16     problem. I did not find it surprising that people
  17     thought there was a need for the solution. We were
  18     driving it forward, and I would have been talking to
  19     Chris Monk and James Wisheart. I did not see this as
  20     the surprising, you know, the difficult position that
  21     Janet Maher thought it was because I knew we were not
  22     investing all that money because we were the best in the
  23     country, but that we were in the lower regions of the
  24     band of quality that was being provided across the
  25     country.

   1   Q. I cannot properly ask you why it was she had
   2     a particular understanding because you cannot comment on
   3     other people's understandings, save to ask this: was
   4     there anything in your conversation or anything which
   5     you did, do you think, which might have given her the
   6     understanding which she sets out here?
   7   A. I cannot say. I cannot say. I can say that I was
   8     reassuring to her and in that reassurance she may well
   9     have felt "Thank you very much, he is satisfied with
  10     what I have done, it is now on his table". That may
  11     have been her understanding, I cannot say that. It was
  12     not my intention and never was to say to people "The way
  13     you manage is to come and give me your problems and
  14     I will take them away", it was never my practice to do
  15     that because I do not think that was a way to develop
  16     managers.
  17        I actually would always discuss what they had
  18     done, should do and how they should approach things.
  19     I cannot say why. I expect she trusted me and she had
  20     the degree of anxiety which she had not conveyed to me,
  21     she may well have felt my reassurance meant that I was
  22     going to deal with it.
  23   Q. Can I move on? You told us yesterday that
  24     Mr Peter Durie and you enjoyed a very close
  25     relationship?

   1   A. Yes.
   2   Q. That arose in the context of the conversations which
   3     Martin Elliott said that he had with Mr Durie as
   4     a result of which the reflection was not, it seems,
   5     given to you of any sense of danger in the way in which
   6     the paediatric cardiac services were provided.
   7        Overnight we have had -- and I will have it on the
   8     screen now, this I think is your first chance to have
   9     a look at it, and I am sorry. Can we have WIT 108/150
  10     and I will give you a moment to look at his e-mail to
  11     the Inquiry. I will read it through because it may be
  12     difficult for those watching on the screen to follow the
  13     words. It gives his address and says:
  14        "Feedback. I read with interest the transcripts
  15     of the Inquiry proceedings on 6/12/99, particularly
  16     paragraphs 88 through 97 of Mr Roylance's evidence.
  17        "I should like to comment on the semantic debate
  18     which took place over the phrase 'potentially dangerous
  19     which I used when declining formally to apply for the
  20     Chair of Cardiac Surgery in Bristol in 1991/2 [and he
  21     gives the reference to the document we saw yesterday].
  22        "I wish to make it quite clear that I considered
  23     and still consider that the separation of services on to
  24     two sites was inappropriate and actually dangerous.
  25     I was not being asked to make a formal critique of

   1     Bristol services, rather to express my personal reasons
   2     for declining the Chair. The debate over the use of the
   3     word 'potentially' is misleading, since I was of the
   4     opinion that the services were potentially dangerous for
   5     the individual child as I described in my written
   6     evidence to the Inquiry. I thought the risks were too
   7     great, that the organisational will was not there to
   8     make the necessary change at that time, hence my
   9     decision to decline the Chair."
  10        I showed you it for two reasons, one to ask if you
  11     had any sense from what you were told by Mr Durie or
  12     from what you read at the time that there was danger in
  13     the sense that Martin Elliott now tells us he intended?
  14   A. Can I first of all say that I may have been guilty in
  15     drawing inferences from a bit of "doctor's English"
  16     which was not meant to imply what I inferred.
  17        I have to say I find this very sad, this comment.
  18     I really cannot understand how somebody can come, an
  19     expert in paediatric cardiac surgery, form the judgment
  20     that practices are dangerous in Bristol, put his hat and
  21     coat on and go home. I really find it hard to
  22     understand that.
  23        I have to say if I had gone and visited
  24     a department with a view to being a Professor of
  25     Radiology and looked round the department and thought

   1     "that was dangerous" I would have called in to the
   2     College of Radiologists on my way home.
   3   Q. If it is to be suggested what he did was to tell the
   4     Chairman of the Trust and the Medical Director, what
   5     else would you suggest that he should have done?
   6   A. I think he should have told the Royal College. I am
   7     sorry, I think he should have -- if he felt that, he
   8     should have ensured that the proper medical professional
   9     machinery was activated to put it right. I find that
  10     quite an astonishing thing. Peter Durie did not tell me
  11     "I have just seen a chap who says we have a dangerous
  12     service in paediatric cardiac surgery". I knew him
  13     extremely well. It would have been quite out of
  14     character for him to have received that information and
  15     sat on it. I find that, I must say, I find that very
  16     sad. I really am very disappointed in that remark,
  17     those remarks there, I am extremely sad.
  18   Q. It would appear Mr Wisheart had a document in his hand
  19     which used the words "potentially dangerous".
  20   A. Yes.
  21   Q. Did he, in your words, "sit on it"?
  22   A. No, I think his understanding was the same as my
  23     understanding, that there was a potential for danger to
  24     occur and by that I mean that if you take the necessary
  25     steps you avoid that potential arising. I am sorry,

   1     I really have to defend -- you will be able to ask
   2     James Wisheart yourself, but I have to defend his
   3     interpretation that something he says is potentially
   4     dangerous actually means is dangerous.
   5        I do not know why you put the extra word in. The
   6     extra word must -- I am not being semantic, I am
   7     actually explaining what inference was drawn. If you
   8     say to me I should have formed the judgment that
   9     somebody, some time after he had been, wrote a letter to
  10     say why he did not want to come in the unit and what he
  11     meant to say was "Please, that service is dangerous" and
  12     that is all he did, then I do not think I should express
  13     further my view, but I think you can infer what my
  14     feeling is.
  15   Q. I think you have made your feelings very clear on that.
  16     Can I go forward to UBHT 61/246? 12th May 1994. It is
  17     a letter to Mr Durie. Shall we have a look at what it
  18     says?
  19        "As you know, Gianni Angelini has been to see
  20     me ..." This is a letter as you can see from the bottom
  21     of the page, 247, it is from Professor Vann Jones and it
  22     has a second signatory of Professor Angelini.
  23        Can we go back to 246?
  24   A. The middle of 1994, was it? I beg your pardon, I am
  25     trying to put this thing in perspective.

   1   Q. This is 12th May 1994. It is, as the initials at the
   2     top suggest, from Professor Vann Jones and it is to the
   3     Chairman.
   4        "As you know, Gianni Angelini has been to see me
   5     at your behest to discuss the problems that we have with
   6     paediatric cardiac surgery."
   7        Stopping there, what that sentence suggests is
   8     that Professor Angelini had spoken to Mr Durie or
   9     Mr Durie to him and that Mr Durie had directed
  10     Professor Angelini to go and talk to Professor Vann
  11     Jones.
  12        Did you know that any of that had gone on?
  13   A. This is at a time when we were -- sorry, I have to give
  14     a slightly long answer. This was at a time when we were
  15     actively initiating two things: the move up the hill and
  16     the appointment of a paediatric cardiac surgeon, we were
  17     actually looking for ways of doing it and so on and
  18     I was looking at the date to see if I could actually fit
  19     it into where we were at that time. I do not think
  20     I ever saw this letter because if they said "We accept
  21     the reality of the position, it is unlikely that
  22     paediatric cardiac surgeons will move to the Children's
  23     Hospital" I would have said I do not understand why they
  24     are of that view because Gianni Angelini was actually on
  25     the Working Party planning the move.

   1        I think this is a letter -- you must correct me if
   2     I am wrong -- about which there is some doubt about
   3     because I think Peter Durie is of the view he never
   4     actually received this letter. But the content of it,
   5     the subject matter of it I was aware of but not through
   6     this letter.
   7   Q. Can I go further then to the subject matter of this? It
   8     reads on, he talks about the history of -- that is the
   9     problems with paediatric cardiac surgery, "It has run
  10     along in a rather half-baked fashion". It deals with
  11     the move to the Children's Hospital which it says is
  12     unlikely. Then the line beginning:
  13        "However our present problem is that we have good
  14     units on our doorstep, namely, in Southampton and in
  15     Cardiff and if paediatric cardiac surgery is to survive
  16     in Bristol, the surgical side certainly needs a very
  17     major shake-up. As you know at present it is run by two
  18     part-time adult/part-time paediatric surgeons, but it is
  19     now such a highly specialised completely different
  20     speciality from adult cardiac surgery that the option is
  21     a very poor second to what is required."
  22        Then it deals with the idea which
  23     Professor Angelini was putting forward of appointing a
  24     senior lecturer.
  25        Did you know that there was a perception at least

   1     on paper that there was a problem relating to having
   2     good units on the doorstep and needing as it were to
   3     compete if paediatric cardiac surgery was to survive in
   4     Bristol?
   5   A. I knew there were other -- I am not sure about the unit
   6     in Cardiff, whether they had a paediatric cardiac
   7     surgical unit then?
   8   Q. I think in 1994 they did have one.
   9   A. They were just beginning it, were they not?
  10   Q. I think so.
  11   A. I think they needed to say it was a unit that was going
  12     to be a good unit in Cardiff. I knew there was a good
  13     unit in Southampton, I visited it twice and possibly
  14     three times and talked to the senior cardiac surgeon
  15     down there.
  16        So I knew there were places, and that is no
  17     different from the argument that when the radiologists
  18     wanted an MRI scanner, they said "the units in the US
  19     have MRI scanners and we have not", it is the sort of
  20     argument that is presented and I believe if we had
  21     stayed behind in this evolution of cardiac surgery when
  22     other places were appointing specialist paediatric
  23     cardiac surgeons, it is quite reasonable to say in the
  24     fullness of time we would have fallen out of the band of
  25     results and been left behind; I do not find that

   1     a strange reflection of the thinking at the time.
   2        We were actually moving very hard to improve the
   3     unit. But the purpose of this letter was not to achieve
   4     the change, it was to suggest that funding a consultant
   5     senior lecturer on soft money for a couple of years
   6     would solve our problem because this is addressing how
   7     to solve the problem. Provided I was (a) able to
   8     promise in advance that that consultant senior lecturer
   9     would be appointed an NHS consultant in two years time
  10     and (b) that I could promise to take responsibility for
  11     his salary from that point on.
  12        The truth of the matter is that if the only
  13     problem of getting a paediatric cardiac surgeon was two
  14     years of non-recurring money, I could have found that;
  15     the problem was the recurring money and I could not
  16     promise that I could appoint him to a consultant post
  17     that at that time did not exist because of the
  18     regulations, the legal requirement was that NHS
  19     consultant posts are appointed in competition, open
  20     competition at a selection committee which I could not
  21     control.
  22   Q. Do you know what had prompted Mr Durie to go to
  23     Professor Angelini and ask him to go to Professor Vann
  24     Jones to discuss the problems with paediatric cardiac
  25     surgery?

   1   A. Not with certainty now. Peter Durie was very useful in
   2     the Trust and certainly very useful to me because one of
   3     the functions he liked to fulfil was to go, as he called
   4     "walkabout". Often if there was any area that I had
   5     the slightest anxiety about I would ask him would he
   6     mind picking that particular area for his next
   7     walkabout, just go and talk to everybody. I would even
   8     forewarn him sometimes what I thought the problem was so
   9     that he could evaluate it as an outside caring Chairman,
  10     and because he was non-managerial and a Chairman and
  11     I was managerial, it was at times very much more
  12     effective for me to ask him to go.
  13        So I cannot tell you whether I asked him to go or
  14     whether this unit was in the rota, I cannot tell you now
  15     whether I asked him to change his rota but I have to
  16     tell you that I did from time to time say "there is
  17     a problem in radiotherapy" I might say to him, "would
  18     you mind changing your programme, go and stroll round
  19     there, this is what I think it might be, go and find out
  20     for me". And he would come back and type me a file
  21     note, dictate a file note for me.
  22   Q. This letter to him obviously as Chairman, is this the
  23     sort of letter you would expect to find its way into
  24     your files?
  25   A. Yes, if Peter Durie had received that he would have

   1     given it to me. I cannot now tell you whether we would
   2     have saved filing space by leaving it in his file to
   3     which my personal assistant had access or whether we
   4     would have duplicated it or whether we would have filed
   5     it in my file. We were in the same suite of offices, it
   6     would have been filed in Headquarters and I would have
   7     seen it.
   8   Q. So the system would be that if it came to Peter Durie
   9     then you would have had a copy of it and it would have
  10     been filed?
  11   A. Yes, and we would have discussed it, it would have been
  12     on his list of points for discussion the next time we
  13     had what he used to call his "one-to-one".
  14   Q. You did not in fact see this letter?
  15   A. No, he tells me he did not see it. I do not know, he
  16     told me, but he has given evidence that he did not see
  17     this letter either and I cannot explain that.
  18   Q. It is of complete curiosity that a letter of this length
  19     in particular by busy people should be written and not
  20     sent, if it was not?
  21   A. I said it was curious. I cannot offer any explanation
  22     I could accept as to why he did not receive it, but he
  23     did not and he did not show it to me. What I am saying
  24     is the fact I did not see the letter does not mean I did
  25     not know the thinking of those two and this scheme which

   1     of course I remember because it solved the problem
   2     I could solve and left me with the problem that I could
   3     not solve and ...
   4   Q. You tell us that perhaps the inspiration for Peter Durie
   5     going to see Professor Angelini may well have been at
   6     your own instinct that there were problems and concerns
   7     that he might like to go and talk to Professor Angelini
   8     about?
   9   A. I have no memory of asking him to, I was merely saying
  10     as a matter of honesty that not all Peter Durie's visits
  11     were as spontaneous as they appeared to others to be.
  12   Q. Do you have any recollection of having then been aware
  13     of something moving and some problems, some concerns
  14     that you asked Peter Durie to have a walkabout and have
  15     a look at?
  16   A. Not particularly then. I knew problems arose with this
  17     move and with staff anxiety which moves always produce
  18     and so I do not think we got that far to have disturbed
  19     the staff, so you used the words "I may well have asked
  20     him to go". That is true and I may well not have asked
  21     him to go.
  22   Q. Can we have a look at WIT 86/38? Can we scroll down,
  23     please? This is Mr Durie's statement to us.
  24     Paragraph 11:
  25        "Despite there being many routes for someone who

   1     wished to voice concerns approaching me about paediatric
   2     cardiac surgery, I can only recall one person doing so.
   3     That was Professor Angelini in May 1994 who voiced his
   4     concern about the clinical outcomes in paediatric
   5     cardiac surgery", and he goes on to describe the
   6     concerns about what you then call "walkabout".
   7        "12: When informed about any issue --
   8   A. That does suggest to me that his memory is that I did
   9     not ask him to go, is it not?
  10   Q. It suggests that.
  11        "When informed about any issue there were
  12     a number of options open to me as Chairman. If
  13     I considered a problem to be acute and clear-cut I would
  14     instruct the Chief Executive to take action, otherwise
  15     I would request the Chief Executive to look into the
  16     issue.
  17        "13. As the concern about paediatric cardiac
  18     surgery outcomes, voiced by Professor Angelini was the
  19     first I had heard, I chose the latter option" that is
  20     requesting you to look into the matter.
  21        "At my next meeting with Dr Roylance, I told him
  22     about the Professor's concern and I asked him to look
  23     into it."
  24        Is that right, did that happen?
  25   A. I am sure it would. I have no reason to doubt that,

   1     no. That is what he regularly did. He also -- I mean,
   2     to show how close it was, he said if ever he slipped and
   3     made a management decision then he left me with full
   4     authority to cancel it if I did not agree with it.
   5     There was a time when we tended to overlap a little
   6     bit.
   7        So he would go and have a visit and it seems this
   8     was part of a group of visits in which he went to talk
   9     to all the professors and then having done so, if there
  10     was anything that arose he would actually type what he
  11     called the file note, quite an informal note and we
  12     would discuss it the next time we met.
  13   Q. What he is saying there is that some time, I would
  14     imagine shortly after speaking to Professor Angelini in
  15     May 1994, he says to you "I have had concerns expressed
  16     to me about outcomes in paediatric cardiac surgery,
  17     would you look into it"; did you do so?
  18   A. Yes, yes.
  19   Q. How did you look into it?
  20   A. Well I talked to him. At that time I was talking to
  21     Angelini very frequently and I remember quite clearly
  22     his view was the solution was to appoint a paediatric
  23     cardiac surgeon; that is what we needed, banging on the
  24     table "we need a paediatric cardiac surgeon", and I said
  25     "yes, that is what we are trying to do". He said "the

   1     first thing you need to do is to decide whether there is
   2     a need to appoint a paediatric cardiac surgeon" and
   3     I would say "no, no we have gone past that stage, the
   4     Board has agreed, everybody has agreed, we are actually
   5     going to do it" and he seemed to think that if we could
   6     strengthen the argument, the case for appointing
   7     a paediatric cardiac surgeon that in itself would
   8     generate the money. It is a sad fact about the Health
   9     Service that certainly that does not happen, you have to
  10     identify the money.
  11   Q. At this stage, in May 1994, the decision in principle
  12     had been taken you say to appoint a paediatric cardiac
  13     surgeon, does that mean the funds had then been found?
  14   A. Yes, we would not have got that far. Looking back, I am
  15     sorry, Ash Pawade was appointed some time towards the
  16     end of 1994 -- the Appointments Committee, was it, just
  17     remind me?
  18   Q. 20th September 1994 was the Interviewing Committee. He
  19     did not take up office until May 1995 as you know?
  20   A. No, but he was appointed by the Interviewing Committee.
  21     There is then always a delay when they give notice,
  22     finish what they are doing and so on and we hope they
  23     come. So he was appointed. The selection committee
  24     happened you say in September.
  25   Q. Yes.

   1   A. The shortlisting would have happened almost certainly in
   2     July because after the shortlisting references would
   3     have to be taken up and appointments made to interview
   4     the candidates, so that that is when the shortlist would
   5     be.
   6        Now we have to say before that there is an advert
   7     with enough time for applications to be in in time for
   8     the shortlist, and I am trying to work backwards, and
   9     I think this was quite a period before we formed the
  10     decision.
  11        So that I am trying to convince myself and work it
  12     out that by May 1994 we must have had identified where
  13     the money was coming from, we must have been through the
  14     process, the Medical Committee approval of the job
  15     description and all the rest of it. So that by that
  16     time we must have been well on our way to appointing
  17     a paediatric cardiac surgeon.
  18   Q. If we go back to the letter we were looking at a moment
  19     ago, it is dated 12th May and certainly the feeling
  20     behind that letter is from that of two persons concerned
  21     for the future of paediatric cardiac surgery who did not
  22     understand that at that stage a final decision had been
  23     taken to make the appointment. I do not know whether
  24     that helps at all, would it have been around that time?
  25   A. It does help. Please, I am sorry. I am sorry I cannot

   1     give you the dates. I would have to look up the health
   2     -- the Trust Board minutes and the records in personnel
   3     and so on.
   4        But in principle, during the course of that year
   5     we must have identified the funds. That would have been
   6     through the negotiation of the next year's contracts for
   7     cardiac surgery and that was done substantially before
   8     the end of the year, so that would have been done.
   9        Reading this it looks as though either we have not
  10     identified the money but certainly that they do not
  11     think we have. As the letter did not come I cannot date
  12     it to that. But there would be a time when I met
  13     Gianni Angelini, virtually from the time when he arrived
  14     when he was pressing me for the appointment of
  15     a paediatric cardiac surgeon.
  16        I feel that is getting a bit close to when we
  17     actually initiated it and I cannot see this time for
  18     this letter to have been written and then us to identify
  19     the money and then actually get him appointed in
  20     September. You can understand my difficulty, but I have
  21     not got the dates of this particular event. There were
  22     a lot of other things happening and at this time there
  23     was no dispute about paediatric cardiac surgery, which
  24     I knew, except the wish to improve it.
  25        So I have not got those dates firmly in my mind.

   1     Certainly I remember -- and it may well have been before
   2     this that Gianni was talking to me and so on -- but
   3     I remember Gianni being very impatient at the thought
   4     I would allow -- the fact I could not pay a paediatric
   5     cardiac surgeon to prevent me recruiting him.
   6   Q. Can I move on a little, we are examining events in May?
   7     I have already asked you about the events in June when
   8     the anaesthetists' letter was or was not shown to you.
   9        Mr McKinlay took over as Chairman, did he, in July
  10     of that year?
  11   A. I cannot remember the precise date but I would not
  12     dispute that, and I expect you know when he took...
  13   Q. 1st July 1994 he tells us?
  14   A. Yes, I would accept that, yes.
  15   Q. Can we have a look at WIT 102/27, which is his statement
  16     to us. Paragraph 15:
  17        "From my briefing by Mr Durie before I joined
  18     [that is before 1st July] I knew there were concerns
  19     about whether the duration of operations on very young
  20     children, as performed by Mr Wisheart, had a negative
  21     impact on the outcome. Within my first 3 months
  22     I discussed this point with Dr Roylance and Mr Wisheart
  23     who stated that within the profession there was no firm
  24     conclusion on this point, and that meticulous work was
  25     inclined to take longer, which was regarded by some as

   1     a positive factor."
   2        Pausing there, did Peter Durie ever express to you
   3     the view that there were concerns floating around about
   4     the duration of operations on very young children?
   5   A. I expect it is much more likely that I expressed that to
   6     him.
   7   Q. So you had a concern about it?
   8   A. No, I would not put it that way: I knew that some people
   9     found James Wisheart a slow surgeon. I do not want to
  10     give a tutorial about this. James Wisheart was
  11     appointed to raise the quality of paediatric cardiac
  12     surgery and adult cardiac surgery, he was the first all
  13     cardiac surgeon to be appointed in Bristol. He was, at
  14     that time, the equivalent of the young whiz kid, the
  15     dedicated cardiac surgeon which would only just be
  16     coming on the stream at that time and at that time my
  17     understanding is that with these difficult operations on
  18     small children, and adults for that matter, a meticulous
  19     attention to surgical detail was a prerequisite of
  20     getting a result. He had been appointed as -- supported
  21     by his referees and the Royal College -- as a very
  22     competent cardiac surgeon.
  23        I could not personally form a judgment as to
  24     whether his slowness was a risk factor or merely kept
  25     anaesthetists in theatre a long time.

   1   Q. Who was it then who was suggesting that he was an
   2     unusually and disadvantageously slow surgeon?
   3   A. I do not know. I mean I remember talking to Mr Hutter
   4     and asking him about Mr Wisheart and he said "he is one
   5     of the three surgeons that I would ever allow do
   6     a coronary artery bypass graft on me" and he was
   7     a cardiac surgeon.
   8        The fact he was a slow surgeon I knew. The
   9     implication that by definition this was a risk factor
  10     was by no means clear.
  11   Q. Something made you go to discuss that issue with
  12     Mr Hutter?
  13   A. Yes, somebody makes a comment about people I also have
  14     to go along and say "what is the strength of it". I was
  15     talking to people in all specialties not just this one,
  16     and if something comes up and -- I cannot remember who
  17     made the thing, it may have been (inaudible), I cannot
  18     remember who said it, but it was general knowledge that
  19     he was a slow surgeon.
  20        It was also known that his patients very rarely
  21     went back to theatre and some of the operations that
  22     took less time finished up back in the theatre in the
  23     evening. There were conversations about this. I could
  24     not judge about it. Nobody ever came to me and said
  25     "stop him operating".

   1   Q. There seems to be a link, from what Mr McKinlay recalls,
   2     being made by some people to Mr Durie -- however
   3     unjustified it may have been -- there seems to be a link
   4     between the slowness of the surgery and negative
   5     outcomes?
   6   A. No, I do not think that was the atmosphere at the time.
   7     There was a link between the wish to get one of these
   8     new super young whiz kids who did cardiac surgery and
   9     did three cases in the afternoon instead of one and that
  10     was part of the argument, the support for getting one of
  11     the new breed of paediatric cardiac surgeons. My
  12     understanding is now that they do more operations in
  13     a session and this was part of the argument to get
  14     a paediatric cardiac surgeon.
  15        It was generally recognised -- I do not know who
  16     told me and when it came up and so on -- but I knew the
  17     intention was, when the new paediatric cardiac surgeon
  18     was appointed Mr Wisheart was going to concentrate his
  19     efforts in adult cardiac surgery, but the conversations
  20     -- I have to emphasise this -- the conversations never
  21     strayed into the realm of "what is happening at the
  22     moment is unacceptable". "What is happening at the
  23     moment can be improved" is a conversation that happens
  24     whenever a more specialised clinician is swapped to
  25     replace what happens before.

   1        So these sorts of conversations would have
   2     happened when the thoracic surgeon was replaced by
   3     a cardiothoracic surgeon, they happened when the general
   4     surgeon was replaced by a thoracic surgeon; the whole
   5     process that I have been privileged to witness and
   6     within radiology take part in, of specialisation in
   7     medicine is something that has been going on for a very
   8     long time. The belief is, it has not always been
   9     confirmed by subsequent review, but the belief is that
  10     if you appoint a paediatric radiologist you will get
  11     a better service than a general radiologist who does the
  12     paediatrics and this is the discussion that was going on
  13     there.
  14        I really have to caution anybody against picking
  15     these bits to pieces and saying "conversations were
  16     taking place that the service was unacceptable". The
  17     first evidence I have ever seen of anybody saying the
  18     service was unacceptable was what we have just seen.
  19   Q. Dr Roylance, forgive me for asking you to pause, the
  20     question I was asking was simply this: did someone,
  21     however justified or unjustified it may have been,
  22     suggest to you that there was a link between
  23     Mr Wisheart's slowness of surgery and negative outcomes?
  24   A. I do not know. I do not think it was ever expressed to
  25     me in those terms and I was trying to explain why that

   1     was not the tone of conversations.
   2   Q. You are discussing the issue with Mr Hutter from the
   3     conversation that you recall where Mr Hutter says "if it
   4     was me I would like Mr Wisheart to operate on me because
   5     although he may be slow he is a very good surgeon",
   6     suggests that you were raising some concern as to
   7     a potential link between outcome and time of surgery;
   8     were you or not?
   9   A. No, I was asking him to explain the background to what
  10     I had been saying. It would have been quite wrong for
  11     me at any time to jump to conclusions about what was
  12     going on in paediatric cardiac surgery or adult cardiac
  13     surgery; I could not do that. But if somebody says to
  14     me "James is a slow surgeon" then I have to naturally in
  15     my informal conversation with colleagues say "what is
  16     this about James being a slow surgeon", and they say "he
  17     is a very good surgeon" --
  18   Q. You cannot answer for any particular view that Mr Durie
  19     may have formed are the reasons for it, but do you know
  20     of any reason why Mr Durie for his part may, as
  21     Mr McKinlay recollects, have drawn a link between
  22     slowness of surgery and a possibility that that might
  23     have affected outcome?
  24   A. The outcome there might have been that they spent rather
  25     longer in intensive care, which children did; I knew

   1     that, that is why they had an impact on the adult
   2     service. In terms of negative impact on outcome, it is
   3     not my memory that anybody (if I can put it bluntly) was
   4     saying "patients are dying because James Wisheart is
   5     a slow surgeon". That was never raised, if it was
   6     I would remember that absolutely clearly.
   7   Q. Can we move on to UBHT 61/273 --
   8   THE CHAIRMAN: I wonder while we are pausing there for
   9     a moment if I can explore with Dr Roylance whether
  10     I understand his approach clearly: you say if someone
  11     had said "Mr Wisheart is a slow surgeon" you might have
  12     said to someone "what is all this about James being
  13     a slow surgeon"; how does that fit in with your notion
  14     that some things are professional and some things are
  15     managerial and it really was not your role and your job
  16     to get involved in the professional, and I assume
  17     slowness or speed of surgery is a professional matter?
  18   A. Yes, yes. You are quite right to show that there was no
  19     way one can produce an absolute line between one and the
  20     other. What would have happened is that I had been
  21     there a long time, I knew everybody and I had informal
  22     conversations as John Roylance with John Hutter. It
  23     would not have been a conversation of the Chief
  24     Executive talking to one of the staff and saying "give
  25     me a report".

   1   THE CHAIRMAN: That is what I imagined you would say. Does
   2     it follow from that that others working in the
   3     organisation might not know what mode you were prepared
   4     to be in, namely sometimes Chief Executive, sometimes
   5     John Roylance and whether they could approach you in one
   6     manner and be told "that is a professional matter" or
   7     alternatively be listened to?
   8   A. Clearly I cannot guarantee that nobody ever
   9     misunderstood, but I was in the habit, the regular habit
  10     of telling people whether they were talking to
  11     John Roylance, whether they were talking to Dr John
  12     Roylance or whether they were talking to
  13     the Chief Executive. One of my phraseologies used to
  14     be, if it was in my office "the office is not bugged,
  15     there are no minutes, have a chat with me and then we
  16     will decide whether to tell the Chief Executive". It
  17     was a relationship I had previously had with the Deputy
  18     District Administrator, I remember on one occasion he
  19     said "you must not talk to me because I cannot take the
  20     hat off".
  21        So I tried to make sure everybody knew all the
  22     time whether we were having a formal conversation or
  23     whether we were just having an informal chat.
  24   THE CHAIRMAN: One last question to pursue that:
  25     I understand that and that is very helpful, how could

   1     one send that signal out at the beginning of
   2     a conversation short of wearing a badge saying I am X or
   3     Y?
   4   A. I did not because it might have been a conversation
   5     about football or something else I was interested in.
   6     If it became a topic I would always as a matter of
   7     routine -- I hope I did it every time, please, I cannot,
   8     that is why...
   9        But if they started talking about something
  10     I would do the equivalent of what the media do, "can
  11     this be off the record", "can we just have a chat and
  12     then if necessary we will have a proper conversation,
  13     a formal conversation" and it was the topic of the
  14     conversation which would precipitate it.
  15   MR LANGSTAFF: This letter from Professor Angelini to
  16     Dr Doyle, if we look at the second page, 61/274, is
  17     copied to you and you have ticked receipt of it?
  18   A. No, that is the tick of the secretary to say this is the
  19     one she is sending.
  20   Q. Can we go back to the first page. It has your writing
  21     on it?
  22   A. Yes.
  23   Q. So you saw this letter, you got this copy and you would
  24     have noticed -- can we scroll down, please -- that
  25     a senior medical officer in the Department of Health had

   1     written to Professor Angelini on 21st July expressing,
   2     it appears in the second paragraph, concern about some
   3     of the paediatric cardiac surgical work and
   4     Professor Angelini, admitting to him "there had been
   5     audits which had shown a greater mortality than perhaps
   6     could be expected in a particular surgical procedure.
   7     A matter of concern, although we tried very hard in the
   8     last few months to implement changes aimed at improving
   9     our results."
  10        He sets out the first change which is the
  11     appointment. He is obviously aware by now that that is
  12     taking place.
  13        The bottom of the page, a suggestion that a move
  14     to the Children's Hospital would be fortuitous. If we
  15     go overleaf, the second sentence "no doubt in my mind
  16     that the problem we have been experiencing is something
  17     which we can address".
  18        When you got this letter you would have realised
  19     that the Department of Health had been writing to
  20     a Professor of Cardiac Surgery in relation to concerns
  21     expressed about the unit, a unit in the hospital of
  22     which you were the Chief Executive; did that concern
  23     you?
  24   A. Yes. I did not know that Peter Doyle thought he was
  25     writing as an individual and not as a member of the --

   1     not as a senior medical officer in the Department of
   2     Health.
   3        I felt that if he was concerned about the quality
   4     issue within the unit, if for no other reason than
   5     common courtesy, he should have told me. The correct
   6     line of communication would have been through the
   7     regional medical officer and through the regional
   8     medical officer to me. Therefore I found this a bizarre
   9     letter, writing to somebody who at that time was the
  10     most junior NHS consultant who was an adult cardiac
  11     surgeon about problems in paediatric cardiac surgery.
  12        So my response to this was first of all to say to
  13     James politely "what on earth is going on" and,
  14     secondly, to write immediately to Peter Doyle so he
  15     wrote to me.
  16   Q. Did you speak to Professor Angelini?
  17   A. No. No, I did not want to be part of a conversation
  18     between the Department of Health and Angelini; I thought
  19     that was improper and I did not want to be in that line;
  20     I wanted to be in a proper relationship with the
  21     Department of Health.
  22   Q. Did you ask to see the letter which Peter Doyle had
  23     written to Professor Angelini?
  24   A. No.
  25   Q. Why not?

   1   A. Because I did not want to be part of this improper
   2     communication which I did not understand between him and
   3     Angelini. My letter was written so that if he had
   4     anything to say he would say it to me.
   5   Q. Here was the Department of Health apparently writing,
   6     expressing concern about part of the operation of which
   7     you were the Chief Executive and you deliberately chose
   8     not to see the letter?
   9   A. Yes, I think I have explained that, please, that I did
  10     not want to be part of an improper line of communication
  11     with what I thought was the Department of Health. I did
  12     not at that time know this was a personal correspondence
  13     between Peter Doyle acting, as he thought, in a personal
  14     capacity and talking to Gianni Angelini. I did not know
  15     that and I hope you can forgive me for when I see
  16     a letter addressed to him as Senior Medical Officer,
  17     Department of Health that is the capacity in which the
  18     conversation sprung up.
  19   Q. I appreciate that. Are you the sort of person, would
  20     you say, to whom the formalities are more important than
  21     the substance?
  22   A. No, I am concerned in the substance and I could not see
  23     any benefit, any merit, any anything between somebody in
  24     the Department of Health writing of all people in the
  25     Trust to Gianni Angelini. If he had written to the

   1     Medical Director I could have understood that. If he
   2     had written to the Chairman of the Medical Committee who
   3     was I think at that time different, I could have
   4     understood that.
   5   Q. However improper the correspondence, why did you not
   6     want to know what the concerns actually were?
   7   A. Because I wanted Peter Doyle to tell me, I wanted him to
   8     tell me. In the event, as you will know he wrote back
   9     to me and said "everything is fine, I am satisfied", end
  10     of correspondence.
  11   Q. UBHT 61/278. This is your letter then to Dr Doyle, is
  12     it?
  13   A. Yes.
  14   Q. Can we have a look at the text? Where in that letter do
  15     you ask Dr Doyle to tell you what the problem is?
  16   A. I do not.
  17   Q. You tell him in fact, do you not in the first paragraph,
  18     or you imply that you have actually seen the letter he
  19     wrote to Professor Angelini?
  20   A. I am sorry, if my English is inadequate I apologise and
  21     I have apologised before. I did not wish to imply that
  22     I had seen anything but what I had seen, and that was
  23     Gianni Angelini's letter that he had sent to
  24     Peter Doyle. If you would be happier that I had said "a
  25     copy of the letter he has recently sent to your

   1     department", I would be very happy for that amendment of
   2     English, but I did not wish to infer that I had seen the
   3     letter he had since sent to Gianni Angelini, I have not
   4     seen it so I would not have wished to imply that.
   5   Q. Can we go back to the letter? You say you wanted
   6     Dr Doyle to tell you what the problem was?
   7   A. No, I did not say that. I am sorry I did not say that.
   8     If I did say that I apologise, I wanted Dr Doyle to
   9     write to me is what I hoped I had said.
  10   Q. What you said twice, the question I asked you was
  11      "however improper the correspondence, why did you not
  12     want to know what the concerns were?" You said:
  13     "Because I wanted Peter Doyle to tell me, I wanted him
  14     to tell me. In the event, as you will know, he wrote
  15     back to me and said 'everything is fine, I am
  16     satisfied', end of correspondence." That is when I took
  17     you to your letter where --
  18   A. Yes, I did not say I wanted him to tell me the problem,
  19     I wanted him to explain the problem, I actually said
  20     I hope I wanted him to write to me, which I think I had
  21     a legitimate expectation, that if he wished to write
  22     about paediatric cardiac surgery to UBHT he should write
  23     to me, not to a professor of adult cardiac surgery.
  24   Q. Did you or did you not want to know what problems the
  25     Department of Health as you thought officially saw that

   1     your paediatric cardiac unit faced?
   2   A. At that time the problems in the paediatric cardiac
   3     surgery I knew was that we were wishing to improve it,
   4     and I keep saying this, that that was the problem. We
   5     had been struggling with it for a long time and it was
   6     a problem.
   7   Q. I do not think that is an answer to the question. The
   8     question was --
   9   A. I am sorry I hoped it was.
  10   Q. You have not answered the question, may I repeat it?
  11   A. I misunderstood it, I am sorry.
  12   Q. The question was: did you or did you not want to know
  13     what the Department of Health had by way of concerns
  14     about your paediatric cardiac unit?
  15   A. If they had any -- I have to say, I do not know how to
  16     answer that question. I wrote to Peter Doyle so that he
  17     would write to me. He wrote to me to say he had not any
  18     problems. I do not think at that time I thought "that
  19     is funny, would he tell me what the problems are".
  20        I am sorry, my mind did not work that way, that
  21     was not the issue and I think as a matter of record that
  22     Angelini's letter to him was wrong in that he said he
  23     did not know anything about the move to the Children's
  24     Hospital. I know he was on the project group overseeing
  25     it, I can only presume he never went to it.

   1   Q. Dr Roylance, let me try again for the last time: did you
   2     or did you not want to know what particular concerns the
   3     Department of Health had that had prompted them to write
   4     to Professor Angelini?
   5   A. No. No, not what had prompted him to write to Angelini,
   6     no. I did want him to tell me if he had any problems,
   7     and he did not. He actually wrote to say he did not
   8     have any problems.
   9        What you are asking me is, I think -- can
  10     I clarify this because I really feel very guilty if I am
  11     not answering your question because I really am trying
  12     to -- I think you are asking me did I want to know the
  13     nature of the conversation that Doyle was having with
  14     Gianni Angelini?
  15   Q. No, what I was asking you was did you want to know what
  16     concerns the Department of Health had that prompted them
  17     to write; that is the question?
  18   A. No, not that prompted them to write Gianni Angelini.
  19     I certainly gave him every opportunity to tell me if he
  20     had any problems.
  21   Q. Let me put the question another way: did you want to
  22     know what concerns the Department of Health had about
  23     your paediatric cardiac surgical unit?
  24   A. Yes, if they had any, and they told me they did not.
  25   Q. We have not finished looking at your response and your

   1     reply and we will do that after we have had a break
   2     which is now I think somewhat overdue.
   3   THE CHAIRMAN: Shall we take 15 minutes, until 5 past 11,
   4     thank you.
   5   (10.50 am)
   6               (A short break)
   7   (11.10 am)
   8   MR LANGSTAFF: When you wrote this reply on 12th September
   9     1994 to Dr Doyle and you write in the second
  10     paragraph that you felt you should write to confirm the
  11     Trust Board's awareness of this problem, from what you
  12     said you did not know what the problem was that the
  13     Department of Health had in mind.
  14   A. I thought I did. I mean, I thought there was no doubt.
  15     If you read Gianni's letter, he says there is
  16     a particular treatment with which they have had very
  17     poor results. That could only have meant, in my belief
  18     at the time, the neonatal switch procedure, which had
  19     stopped. That is what Gianni Angelini said. There was
  20     one problem, as I remember -- I cannot remember his
  21     exact words, but there was one problem of treatment,
  22     which was being addressed -- something like that.
  23     I knew, because we were at that time, as it says,
  24     seeking a paediatric cardiac surgeon to reinstitute
  25     neonatal switches.

   1   Q. The words he used were "a greater mortality than perhaps
   2     could be expected in any particular surgical procedure"?
   3   A. In "a particular surgical procedure", yes. I knew
   4     a particular surgical procedure was neonatal switches.
   5     It was part of the work-up to the appointment of
   6     a paediatric cardiac surgeon. So I thought I was
   7     entirely aware of what the conversation was about.
   8   Q. Did you know that the neonatal switch had in fact
   9     ceased the previous October?
  10   A. Yes.
  11   Q. A year before this, almost?
  12   A. Yes.
  13   Q. When you say you write to confirm the Trust Board's
  14     awareness, did you tell the Trust Board at this time of
  15     this correspondence?
  16   A. I do not know. I do not know. I may well not have
  17     done. I may have told them informally, but I certainly
  18     told the Trust Board about not doing neonatal switches.
  19     It was part of the case for the new consultant.
  20   Q. And the last paragraph: you continued to monitor the
  21     situation with Gianni Angelini. What were you
  22     monitoring?
  23   A. The arrival of the new surgeon and the move up the
  24     hill. I am sorry to say the Health Service has a long
  25     track record of not achieving its firm decisions, and

   1     that was what I was monitoring.
   2   Q. So we read "continue to monitor the situation" as
   3     meaning to ensure that these two promises are kept?
   4   A. Yes.
   5   Q. You get your response back from Dr Doyle, UBHT 61/279,
   6     which thanks you and leaves the matter to the Trust to
   7     effect the proposed changes as quickly as possible?
   8   A. Yes.
   9   Q. In the last paragraph, it looks forward to seeing "some
  10     greatly improved paediatric cardiac surgical audit
  11     results in the near future."
  12   A. Yes.
  13   Q. By now at any rate, were you particularly concerned to
  14     see what the audit results would in effect show, or
  15     not?
  16   A. No.
  17   Q. Because that was still a matter for the clinicians?
  18   A. It was still a matter, and it was a matter for the
  19     Department of Health. I think at that time we were
  20     still a supra-regional service.
  21   Q. What Mr McKinlay has told us in evidence is that he, as
  22     Chairman, was unaware of the correspondence between
  23     yourself and the Department of Health. Do you think he
  24     may be right on that?
  25   A. Yes, I think that is entirely possible. He did not

   1     develop a very close relationship the moment the new
   2     Chairman arrived. I do not want to be critical of him.
   3     He had other commitments at the time he took up his
   4     post, so he did not have a continuation of the close
   5     relationship I had had with his predecessor.
   6   Q. I appreciate there would have been many things you and
   7     he would need to discuss about the many other aspects of
   8     the Trust. Was correspondence such as this not
   9     something it was appropriate to show to your Chairman?
  10   A. No, I do not think so. I mean, I think that letter
  11     there does not raise in my mind anything other than an
  12     agreement that all is satisfactory. I do not think
  13     I would go and tell the Chairman everything that was
  14     satisfactory.
  15   Q. What Mr McKinlay also tells us -- before I deal with
  16     that let me just ask you for your help on one further
  17     issue which arises in respect of the Doyle
  18     correspondence, if I can call it that. You had asked
  19     James Wisheart for his comments?
  20   A. Yes.
  21   Q. You got those at UBHT 61/276. If we go overleaf,
  22      UBHT 61/277:
  23        "I have discussed it with Gianni and I shall
  24     discuss the source of information to the Department of
  25     Health with you on my return."

   1        Did he, Mr Wisheart, ever discuss with you,
   2     Dr Roylance, the source of information to the Department
   3     of Health?
   4   A. I do not remember him ever answering that question. He
   5     may have talked about the issue, but I do not remember
   6     him saying "this is the line of communication" or
   7     anything like that. No. I do not remember that. I may
   8     be wrong, but I do not remember that.
   9   Q. Why was it a matter of interest who should have been the
  10     source of the information, particularly if the
  11     information itself was not a major concern of yours in
  12     the sense of need to go and see what the Department of
  13     Health had written?
  14   A. Well, it was not of interest to me, but it clearly was
  15     something that was of interest to James. I mean, I have
  16     to say, we had a large Trust and it would not matter to
  17     me who had been talking to the Department of Health.
  18   Q. Was it a matter which upset you that whoever had spoken
  19     to Dr Doyle in order that he might contact Professor
  20     Angelini should have gone through other routes that were
  21     available to him or her in the Trust?
  22   A. I do not think my mind ever went as far as that, because
  23     I did not know in the sense, the source of information,
  24     that suggests the source of information was one person
  25     within the Trust, who I thought ought to have talked to

   1     me. I did not know what the source of information was.
   2     He was in the Department of Health and they knew the
   3     activities of our Trust in terms of neonatal and infant
   4     paediatric surgery, so -- I do not think that line ever
   5     exercised me at all.
   6   Q. Can we look at WIT 102/28? This is the witness
   7     statement of Mr McKinlay. Can we scroll down to the
   8     bottom and look at paragraphs 19 and 20?
   9        "When Dr Roylance returned from holiday, I raised
  10     the points made at the meeting with him and latterly
  11     with Mr Wisheart. Their position remained the same as
  12     before but I began to hear from Dr Roylance for the
  13     first time that the anaesthetists had concerns; the name
  14     Bolsin; and the name Peter Doyle from the Department of
  15     Health."
  16        Stopping there, did you think that Mr McKinlay is
  17     right about that?
  18   A. No, I do not, I am sorry to say.
  19   Q. He says he believes that you were very concerned about
  20     the situation, but not to the point that you agreed with
  21     those "both internal and external who were seeking an
  22     independent Inquiry."
  23        What is your response to that?
  24   A. I knew at that time that the anaesthetists were amongst
  25     the vociferous chorus of people who wanted to improve

   1     paediatric cardiac surgery. I knew that. I am not sure
   2     I understand what he is trying to say here, but if he is
   3     trying to say that some time in whenever it was -- when
   4     was it; before Christmas 1994 -- I was sharing with him
   5     any specific concerns of the anaesthetists, I am sure
   6     I was not. I do not want to read into there what
   7     I understand. I was sharing with him the whole issue of
   8     the wish to improve paediatric cardiac surgery and for
   9     somebody with no experience of the Health Service,
  10     I would have spent time taking him through that whole
  11     process, so that he understood.
  12   Q. Paragraph 20. There is a point on timing which I have
  13     already canvassed with you, where Mr McKinlay's
  14     recollection is that by the time he went home for
  15     Christmas, he and you had agreed that there should be an
  16     independent inquiry. That does not coincide with your
  17     recollection; I am not going to come back to that.
  18   A. Not at all no.
  19   Q. What he goes on to say is that -- it is the fourth line
  20     down:
  21        "There were telephone and letter exchanges between
  22     Dr Roylance and Dr Doyle and there were meetings between
  23     Dr Roylance and Dr Bolsin. Dr Roylance was upset that
  24     Dr Bolsin seemed to be making comments to Dr Doyle in
  25     a social atmosphere, which were then addressed to

   1     Dr Roylance by Dr Doyle. I was certainly annoyed at
   2     this triangular process and failed to understand why the
   3     Department of Health did not take some form of executive
   4     action if their concerns were as great as they seem to
   5     have indicated to Dr Roylance."
   6        At some stage were there conversations by
   7     telephone between yourself and Dr Doyle?
   8   A. Yes, but they were all in 1995.
   9   Q. In relation to the Joshua Loveday operation?
  10   A. Yes. That is why -- I am sorry to say, I do not want to
  11     be critical, there is a time slip in this. There is no
  12     doubt at all that we had a letter exchange which we have
  13     gone through in part detail, earlier in 1994. The
  14     subject was closed.
  15   Q. We shall see, coming on to it, that there was further
  16     correspondence between yourself and Dr Doyle after the
  17     Joshua Loveday operation.
  18   A. I had no contact of any sort by letter or telephone with
  19     Peter Doyle until January. None at all. So although
  20     there were telephone and letter exchanges and so on,
  21     there were, but they were all in 1995.
  22   Q. Albeit that this may then be talking about 1995 rather
  23     than 1994, Dr Roylance says Mr McKinlay was upset that
  24     Dr Bolsin seemed to be making comments to Dr Doyle in
  25     a social atmosphere, which were then addressed to

   1     Dr Roylance by Dr Doyle; is that right, do you think?
   2   A. No, I do not quite understand that, because the time
   3     that I was concerned, and would have talked to Bob
   4     McKinlay, particularly at the time when I was going away
   5     on leave to Australia, that this is all after the
   6     Hunter/de Leval report, this issue about Dr Bolsin.
   7   Q. What was the issue then, albeit after the
   8     Hunter/de Leval report, about Dr Bolsin, that you
   9     recall?
  10   A. Let me try and -- that was the issue then, about his
  11     secret audit, but I want to be clear. When Dr Doyle
  12     rang me about Joshua Loveday, I am quite sure he relayed
  13     to me Dr Bolsin's anxiety and he probably told me that
  14     that was supported by Gianni Angelini, I do not know,
  15     but I knew at that time that -- I mean, all Peter Doyle
  16     was doing was being messenger and relaying back to me
  17     anxieties he had heard from within the Trust. It is
  18     interesting that Dr Bolsin did not actually speak to me
  19     about the operation; he spoke to Peter Doyle.
  20   Q. And Peter Doyle spoke to you?
  21   A. That was the line of communication between Bolsin
  22     and I. I think that if I had been, as they say,
  23     "upset", I am quite sure I was disappointed that Bolsin
  24     chose to speak to me via the Department of Health.
  25   Q. You said a moment ago that it was interesting that

   1     Dr Bolsin chose to speak to Dr Doyle, and Dr Doyle then
   2     to you?
   3   A. Yes.
   4   Q. What was the particular point of interest in it for you?
   5   A. I am sorry, that is a slight euphemism. It is to me an
   6     unnecessary path of communication.
   7   Q. Are you conscious of anything which you may have done or
   8     said that would or might have led to that path of
   9     communication being used?
  10   A. No. None at all.
  11   Q. Are you conscious of any particular reason, from your
  12     knowledge of the Trust, its personalities and
  13     structures, why that method of communication might have
  14     been used?
  15   A. No.
  16   Q. One matter which perhaps I should take up with you
  17     before you move on to the Joshua Loveday operation.
  18     I had asked you whether you knew that the neonatal
  19     switch had ceased the previous October, a year before
  20     correspondence with Dr Doyle and you said yes, you did.
  21     Do you remember when it was that you first knew that the
  22     neonatal switch programme had stopped?
  23   A. No, I am not certain, but I do know I was aware of it
  24     and it was part of the conversation when we were
  25     developing the concept of appointing a paediatric

   1     cardiac surgeon.
   2   Q. So that must have been in the earlier part of 1994?
   3   A. Yes. I mean, I cannot be honest; if somebody found
   4     a record that I knew it in November the previous year,
   5     I would not dispute it.
   6   Q. Because it must have been some time before that that you
   7     knew, but you cannot say when?
   8   A. It was sufficiently long after the event not to be of
   9     any acute concern to me.
  10   Q. So the best we can do in terms of precise time is some
  11     time between October and May?
  12   A. Yes. I would think it was February/March, but I cannot
  13     really say.
  14   Q. It is unfair to ask you to speculate.
  15   A. I was just offering a feeling, if that was of any use.
  16     But clearly I knew when we were developing the case and
  17     going through the process of developing the job
  18     description and so on of the cardiac surgeon.
  19   Q. Can we turn, then, to the operation on Joshua Loveday?
  20     Before the operation took place, you were contacted,
  21     were you, by a number of concerned individuals?
  22   A. The ones I remember distinctly are James Wisheart, from
  23     whom I got the news. I am quite sure the first person
  24     who spoke to me was James Wisheart, and I remember that
  25     because if anybody else had spoken to me I would have

   1     sought out James Wisheart, and I did not. He told me.
   2        I am fairly sure -- I am certain -- that Gianni
   3     Angelini reinforced the message some time later, in my
   4     office. He came to my office.
   5   Q. By "reinforced the message", there are two messages: one
   6     is that the operation is going to take place; the second
   7     is that it is a matter of debate, discussion, concern?
   8     What is the --
   9   A. No, his view -- James Wisheart told me that he received
  10     advice, the view, that the operation should not take
  11     place and it was quite proper that they should tell him
  12     and he told me. Gianni Angelini came and I remember him
  13     taking the view that a switch is a switch is a switch
  14     and if they have trouble with neonatal switches, they
  15     should not do infant switches. There would have been
  16     other parts of the conversation, but that is an element
  17     of it that I remember, because it puzzled me, and
  18     I did -- I was going to say take advice. It would have
  19     featured in the conversation that I had with James
  20     later.
  21   Q. You were spoken to on the phone by Dr Doyle?
  22   A. Yes.
  23   Q. And that was, as you recollect it, Dr Bolsin talking to
  24     you through Dr Doyle?
  25   A. Yes. I mean, he was the messenger, and his phone call

   1     came later. The only way I can date that is to say it
   2     was after the clinical case conference had started, or
   3     I thought had started. That was the time Peter Doyle
   4     rang me. He relayed to me the message I had already
   5     heard.
   6   Q. Why do you think Mr Wisheart, Professor Angelini,
   7     Dr Doyle, were all speaking to you about it?
   8   A. I think there were different reasons. I think James
   9     Wisheart would tell me because he was the Medical
  10     Director and this was a unique situation, and he would
  11     have shared it with me, because he was the Medical
  12     Director. You are asking me why I think that.
  13     I believe the others asked me because they thought it
  14     was my responsibility to command that the operation
  15     should not take place. I cannot be sure of that, but
  16     I assume that is what they thought, that if operations
  17     were stopped, it was Chief Executives who stopped them.
  18   Q. Were they not right about that?
  19   A. Yes and no, I think. I could not stop an operation,
  20     I do not think -- I have not taken full legal advice on
  21     this, but my belief is that I could not stop the
  22     operation. What I could do is suspend a consultant so
  23     he was no longer in our employ. I suppose I could have
  24     suspended the anaesthetist or whatever, but I only had
  25     very coarse instruments and I could only use those on

   1     clear unambiguous advice.
   2   Q. So who was it, or was there no-one, that could have said
   3     "This operation will not go ahead"?
   4   A. I am not sure I am the right person to ask. It is my
   5     belief that at that time consultants were employed to
   6     exercise independent clinical judgment, and that
   7     management could only -- this happened elsewhere in the
   8     country, I do not know the full details -- can suspend
   9     consultants. That, I think, is possible. I do not
  10     know -- really, I mean, I cannot help you -- I do not
  11     know that anybody has ever said to me that I had the
  12     authority to interfere with clinical judgments as
  13     a Chief Executive. I do not think I did. The question
  14     did not arise, so I did not in a sense take advice on
  15     that.
  16   Q. If you had no absolute power, either yourself or on
  17     behalf of the Board, if that is in any case different,
  18     you would at least have had considerable influence and
  19     authority?
  20   A. Well, influence, yes.
  21   Q. Was it your view that it was appropriate to use that
  22     influence and possibly, I suggest, the authority that
  23     you had, to affect the outcome of whether there should
  24     or should not be an operation?
  25   A. If the clinical case conference had said -- I hope

   1     I answer your question -- "We do not think this
   2     operation should take place" and the surgeons concerned
   3     and the anaesthetists said "We do not believe that, we
   4     are going to do it", I hope I would have exercised my
   5     good offices and I hope I would have prevailed, so
   6     I would have used influence in that situation. I hope
   7     it would never have arisen in the sense that the group
   8     had said the operation should not take place, I cannot
   9     imagine the surgeons as I knew them would have gainsaid
  10     that, but you asked me a hypothetical question and
  11     I have given you a hypothetical situation in which
  12     I could have responded in the way I think you are
  13     suggesting.
  14   Q. Again, speaking hypothetically, the Trust controlled the
  15     facilities within which the operation was to be
  16     conducted?
  17   A. Yes.
  18   Q. And employed not only the consultants but also the
  19     nurses and so on.
  20   A. Yes.
  21   Q. Therefore, it might be suggested that the Trust could,
  22     if it wanted -- it is very hypothetical -- have said,
  23     "If you are going to do that operation that is a matter
  24     for you, but you are not going to do it here"?
  25   A. I am not sure how we could have implemented that view

   1     without, as I say, using my good offices. I think I was
   2     sufficiently influential. There were times when other
   3     clinicians had difficulty when I would, I think the
   4     modern term is "counsel" them, until they had formed
   5     a judgment which I think was healthy for them. But I am
   6     not sure, if you say to me, I could say "You are not
   7     doing it here", if the surgeon says "Oh, yes, I am". If
   8     we are talking about a real dispute, I do not know what
   9     I am supposed to do.
  10   Q. In any event, none of that arose, whether it might have
  11     done or not, because your view, as I understand it, was
  12     that "This is a matter for the clinicians, and the
  13     clinical conference, the conference, the meeting on the
  14     evening of the 11th will decide whether the operation
  15     goes ahead or not".
  16   A. Saying it is a matter for clinicians is a slightly
  17     shorthand way for saying I was faced with a conflict of
  18     clinical opinion and I thought -- it is a perfectly
  19     orthodox way of treating patients, although this was
  20     a very unusual situation for it to be used -- for the
  21     experts concerned, all the experts concerned, to review
  22     the situation in the light of the opinions that had been
  23     expressed and to form a judgment what was in the best
  24     interests of the patient.
  25   Q. Did you, being a doctor, have any responsibility, as you

   1     saw it, for the best interests of the patient?
   2   A. I had a responsibility, but I had no ability to
   3     determine what was in the best interests of the
   4     patient.
   5   Q. Mr Wisheart, I think, telephoned you after the meeting.
   6     Can we look at what you say about it at WIT 108/130? It
   7     is the top of the page:
   8        "Mr Wisheart telephoned you and reported to you
   9     that the outcome of the meeting had been that the
  10     operation was urgent because the patient was at
  11     increasing risk of a thromboembolic event".
  12        Those words, "a thromboembolic event", were they
  13     words he actually used?
  14   A. I do not know which shorthand he used. He might have
  15     said "He is at risk of having a stroke". I do not
  16     know. He may have used those words. He certainly
  17     conveyed to me the urgency of the problem, and the
  18     nature of the cause of that urgency. I cannot tell you
  19     which words conveyed that information, but whether we
  20     talk about a stroke, whether we talk about a vascular
  21     disaster, I do not know what terms he used. The fact is
  22     that the patient had persisting increasing cyanosis,
  23     which results in increasing erythrocytosis, that is,
  24     increasing red cell blood count, until the blood gets
  25     into a condition where it may clot at any moment, and

   1     having clotted, the clot may move elsewhere. This is
   2     a recognised complication of long-term cyanosis.
   3     I cannot tell you what precise words he used, but I have
   4     no doubt what he meant.
   5   Q. The reason I focus on those words, I think it is the
   6     second time you have used them. That is the way you
   7     explained it at the GMC when you were asked about this
   8     particular event, but although you may not be able to
   9     say what words he used to give you that impression, what
  10     was your idea of the urgency of the operation?
  11   A. I am sorry, I can only recall what I was told, the
  12     urgency of the operation and the need for it. I was
  13     told that it was the view of those -- I am not sure
  14     of -- what emerged at the case conference was that this
  15     child was not fit to wait for a transfer to another unit
  16     or to wait for the arrival of Ash Pawade. Those were
  17     the only two options.
  18   Q. What, if anything, was said to you about the possibility
  19     of transfer to another unit?
  20   A. I am sorry, that is what I have just said. He was not
  21     fit to wait for transfer to another unit, and not fit
  22     to --
  23   Q. My apologies.
  24   A. I am sorry, I may not have explained it well.
  25   Q. It is not your fault; I am sure it is mine. Mr Wisheart

   1     was plainly reflecting to you what the sense of
   2     a meeting or the meeting or the view of others was, was
   3     he?
   4   A. Yes.
   5   Q. When the operation continued and the sad result became
   6     known, you then had, I expect, phone calls and letters
   7     to deal with.
   8   A. Yes. I think there were people who expressed their
   9     disappointment with events, yes.
  10   Q. The event of having a meeting such as that to deal with
  11     the question of whether the operation should or should
  12     not go ahead was, as you describe it, extraordinary.
  13   A. In paediatric cardiac surgery, yes. In other areas
  14     where there is commonly difficulty in determining care,
  15     it is a very common process.
  16   Q. And it came against the background of concerns to
  17     a greater or lesser extent expressed to you. You knew,
  18     for instance, that part of the arterial switch programme
  19     had stopped. You knew that the Department of Health had
  20     been in correspondence with Professor Angelini about
  21     that as a matter of concern, and you knew that steps had
  22     been taken to rectify just that as part of the
  23     appointment of a new paediatric cardiac surgeon.
  24   A. Yes.
  25   Q. In retrospect, do you think you might, or indeed should,

   1     have used such influence as you had to persuade those
   2     involved that the operation should not go ahead?
   3   A. No. The reason for that is that I understood, and it
   4     was made quite clear to me that this child could, at any
   5     moment, have had a devastating vascular accident, which
   6     could either have been lethal or leave him permanently
   7     severely disabled.
   8   Q. Did anyone tell you that the operation had been
   9     scheduled on the ordinary elective surgery list?
  10   A. Oh, yes. That is how the thing arose. He had been on
  11     the waiting list some time. I now know that there had
  12     been agitation about expediting it. He had been
  13     admitted as an elective case and the operation was
  14     planned for a particular time. That was the space.
  15     I knew that. So the question arose: could this patient
  16     wait or would it be dangerous for him to wait? I was
  17     told that it was dangerous for him to wait.
  18   Q. Did you know that neither surgeon nor cardiologist had
  19     examined him, at any rate since the end of November when
  20     Dr Martin had last seen him for any examination?
  21   A. No.
  22   Q. Would it have made a difference if you had known that?
  23   A. No. I have to say that -- I am not a cardiologist and
  24     I am not an expert, but I do know, even from my medical
  25     student days, that the progression of these conditions

   1     is inexorable and that there was no way that his degree
   2     of cyanosis would suddenly have changed, or the
   3     progression of the erythrocytosis would have stopped.
   4     So that is a time-scale. If a cardiologist says --
   5     actually through Mr Wisheart -- that he has reached
   6     a stage where it is dangerous to wait, I would not have
   7     said, "Have you seen the patient?"
   8   Q. What was it that decided you to have a review?
   9   A. The fact that the case conference had disagreed with the
  10     other views expressed within the Trust. Can I just say
  11     that had the case conference met and been told "You are
  12     not to do this" and they had said, "We have had another
  13     look at it and we accept that advice, it is absolutely
  14     right", I would not at that stage have required a review
  15     because the solution would have been there.
  16   Q. So you required a review in order to sort out what
  17     appeared to be an internal difference of opinion?
  18   A. A persisting difference of opinion. I clearly was aware
  19     that the paediatric cardiac service was going ahead with
  20     an operation in the light of the fact that
  21     non-paediatric experts, as I understood them, but
  22     including one anaesthetist, who was in that group, there
  23     was a persisting view that that was not the right thing.
  24   Q. Consistent with your view that clinical matters were
  25     matters for a professional clinician, why was it not

   1     something you regarded as appropriate for the
   2     professional clinicians to sort out amongst themselves?
   3     Why was it something that, as you then saw it,
   4     necessitated an outside and independent review?
   5   A. It was, and they arranged it. The position is not
   6     a conflict. I did not personally arrange the review,
   7     but if you like, I used my influence to ensure that
   8     a proper way of going ahead was pursued. I mean,
   9     I cannot remember whether James said to me, "I am going
  10     to have a review" and I said "Good egg", or I said to
  11     him, "You have to have a review" and he says "I agree",
  12     or we talked and said "What are we going to do about
  13     this?" and it emerged in the conversation, but we were
  14     activating a clinical solution to a clinical problem.
  15   Q. As a management action?
  16   A. No. Why is it a management action?
  17   Q. If it was Mr Wisheart saying to you, he was Medical
  18     Director, that was the function presumably which you and
  19     he were talking about this operation --
  20   A. Well, it is not a management action, I am sorry. We can
  21     spend a long time on it. Mr Wisheart was a professional
  22     adviser to the Trust Board and apart from appointing
  23     consultants, did not exercise management
  24     responsibility.
  25   Q. So he advises you that in his view, if that is the way

   1     it happened, there should be a review; you think that is
   2     a good idea?
   3   A. Yes.
   4   Q. And a review occurs because you wish it. Is that not
   5     right?
   6   A. No, because it is wished. It is the right step
   7     forward. No, I --
   8   Q. Who does the wishing?
   9   A. I think everybody. I do not think this was a unilateral
  10     action imposed on anybody. It was my job to make people
  11     successful. I accept that. There was not a manager
  12     involved in the review, it was a clinical review.
  13     I knew it was happening.
  14   Q. I am not concerned with those involved in the review,
  15     I am concerned with the nature of the process, the
  16     decision to have one, and what you are I think saying to
  17     me is, "Well, it was a decision by everyone because it
  18     was the right thing to do", and what I think I am asking
  19     you is, well, whose decision was it? It could not take
  20     place without your influencing it at any rate --
  21   A. That is not true. James Wisheart could invite the
  22     Cardiac Society, I think it was -- it may have been the
  23     Royal College -- to nominate two independent assessors
  24     to come and review paediatric cardiac surgery. That did
  25     not need my authority. Why I am in difficulty is at the

   1     time we did not sit down and say who has made which
   2     decision and on what authority. We were moving forward
   3     properly and it was my job, I had the responsibility
   4     clearly to make sure things happened, but it did not
   5     make the review a management decision or a management
   6     process. It was activating a form of professional
   7     review and support.
   8   Q. Dr Doyle tells us, in any event, that he spoke to you
   9     by telephone.
  10   A. Yes.
  11   Q. He was asking you to have a review and he says that you
  12     agreed to do so. If that is right, the agreement to
  13     have a review was something which occurred during the
  14     course of his phone call with you.
  15        Is that or is that not your recollection of
  16     history?
  17   A. No, as far as I remember, he rang a day or two later.
  18     I am quite sure the day Joshua Loveday died did not
  19     close without a decision for a review having been
  20     taken.
  21   Q. You had correspondence -- we ought, I think, to look at
  22     a letter, UBHT 61/282, 25th January, the middle of the
  23     page:
  24        "From information received, including your letter
  25     of 12th September, I [Dr Doyle] had understood that

   1     steps had been taken to rectify the problem by the
   2     appointment of a new paediatric cardiac surgeon and
   3     transfer of the service to the Children's Hospital.
   4     I had assumed, mistakenly it would appear, that (at
   5     least high risk) neonatal and infant surgery would have
   6     ceased pending the arrival of the new consultant and the
   7     transfer.
   8        "As you know, I learned last week that far from
   9     this being the case, that surgery has continued at the
  10     Bristol Royal Infirmary."
  11        He deals with the conversation of the 11th, in
  12     which he says in this letter:
  13        "These suggested that under the circumstances it
  14     might not be advisable to proceed."
  15        Stopping there, is that in fact, as you recall it,
  16     an accurate reflection of what he was saying to you on
  17     the phone on the night of 11th January?
  18   A. Yes, I think "it might not be advisable to proceed" is
  19     probably a fair reflection of our conversation.
  20   Q. He then says:
  21        "We spoke again following that extremely
  22     unfortunate incident about the necessity of setting up
  23     an immediate inquiry using outside experts."
  24   A. Yes.
  25   Q. He goes on. Then your reply, HA(A) 146/109, the next

   1     day, underneath (c):
   2        "The Trust has decided not to perform complex
   3     neonatal or infant open-heart surgery until there has
   4     been resolution of the conflicting professional advice.
   5     We would reserve the right to exercise our judgment in
   6     the best interests of the patient in an emergency
   7     situation."
   8   A. Yes.
   9   Q. Was it, then, the Trust's decision as to what operations
  10     would or would not be performed?
  11   A. No. "The Trust" is used as a generic term for everybody
  12     in the Trust. The Trust had decided, because the
  13     decision, the place where that decision was made, was
  14     with the two paediatric cardiac surgeons and the support
  15     of their colleagues. If you mean the Trust Board has
  16     decided, then that is not the case.
  17   Q. So it is saying this, to Dr Doyle: you were in fact
  18     saying "all the relevant clinicians have decided"? Is
  19     that the effect of it?
  20   A. I am not sure. I mean, I was assisted by James Wisheart
  21     in the writing of this letter, and he assured me that
  22     they were not going to do any more complex neonatal or
  23     infant open-heart surgery. At that time, I had already
  24     talked to them and they told me that they were not going
  25     to do any high risk surgery, which was the way

   1     I satisfied myself that they understood -- we did have
   2     a conversation, can I explain, as to whether they should
   3     not do complex surgery. When I had a conversation with
   4     Janardan Dhasmana and James Wisheart, they said "Where
   5     do you draw the line, what is a complex operation?"
   6     I said "I have no idea, nor does anybody else. What
   7     I understand is that you would be ill-advised until
   8     after this review to take on any high-risk surgery at
   9     all". In fact, I think I used the term "I do not want
  10     another child to die until we have had the review and
  11     know what we ought to be doing". That was the
  12     conversation, not an instruction on my part.
  13     I satisfied myself at that time they had made that
  14     decision, because if they had not made the decision,
  15     I could not implement it.
  16   Q. So if the clinicians themselves, let us suppose, and
  17     purely hypothetical, suppose James or Janardan had said,
  18     "Well, look, I have got another couple of these
  19     operations on my operating list. I think it is
  20     important for the sake of the child that the operation
  21     is done. I propose to do it, one next Tuesday, one next
  22     Thursday". There was nothing you could have done about
  23     it, do you think?
  24   A. I would have used my good influences, but you are
  25     postulating a situation that would not occur and had not

   1     occurred, because they had both assured me they would
   2     not perform any high risk surgery, full stop. They had
   3     made that decision. I was satisfied they had made that
   4     decision.
   5   Q. Messrs Hunter and de Leval came to carry out their
   6     report?
   7   A. Yes.
   8   Q. You arranged that in the hope, did you, of having an
   9     independent report in your hands which gave you the
  10     fullest of information?
  11   A. Yes. I wanted their professional advice, yes. And
  12     I wanted it very quickly.
  13   Q. Did you use the phrase, in relation to the inquiry that
  14     you were commissioning, that it was to be "quick and
  15     dirty"?
  16   A. Yes, I did, but I would not want other people to
  17     misunderstand that. That is jargon which most people
  18     I think understand and that is, I think, that it is not
  19     a refined, formal report. It is accurate and proper,
  20     but we will not waste time polishing it. Perhaps it is
  21     an unfortunate term to be used in public, but it is
  22     a jargon term of "That is what we want: a quick and
  23     proper answer".
  24   Q. So that was arranged. Did you understand it to be an
  25     inquiry into the whole of the paediatric cardiac

   1     surgical service?
   2   A. Yes. I mean, they were kind enough to see me at the
   3     outset and I explained to them personally and
   4     informally, we did talk, and I said, "There are three
   5     things I need to know: first of all, is it right that
   6     the appointment of the paediatric cardiac surgeon is
   7     a proper solution to the problem? Is that the
   8     solution? Secondly, is moving up the hill proper?
   9     Thirdly, what should the Trust, the service, do between
  10     the time of then reporting and the arrival of Ash
  11     Pawade?"
  12        I mean, the whole basis of this clinical argument
  13     is that all cases should wait until Ash Pawade arrived,
  14     and I wanted outside advice to say, what should we do in
  15     that time, which is why it was urgent.
  16   Q. Were you present at all during the inquiry which
  17     Messrs Hunter and de Leval carried out?
  18   A. No, they came to my office. I think I summoned the
  19     local management, and wished them well, and I left them
  20     with the words that they could go anywhere, look at
  21     anything, and if anybody put up a barrier, they were to
  22     ring me and I would knock it down. I did not see them
  23     again.
  24   Q. At WIT 89/99, paragraph 24, we have the recollection of
  25     Rachel Ferris, who says after a meeting at which

   1     Dr Bolsin and Mr Wisheart were present during the visit
   2     of Messrs Hunter and de Leval, she was, and she could
   3     not when she was asked about it, recall quite how the
   4     walk began, but recalls walking over to Trust
   5     Headquarters with you, and you making some comment that
   6     you should not really have let James [Mr Wisheart]
   7     organise the day, but thought it might be good for him.
   8        Did you say that?
   9   A. No.
  10   Q. Who was it who did organise the day?
  11   A. Primarily, the visitors. I gave them full authority to
  12     ask for anything and guaranteed the Trust would provide
  13     them. I sent them off, I am fairly sure, with this
  14     manager as a sort of guide so they did not get lost.
  15   Q. Do you want to say anything about her perception of you
  16     as having had a casual approach to the day, and of, as
  17     she describes it, being seemingly unconcerned?
  18   A. Well, that is quite wrong. It has just occurred to me
  19     that in my clinical days, if we were dealing with
  20     a very, what shall I say, "dangerous" situation, I was
  21     known to become very relaxed and not get excited and to
  22     calm everybody so that everything went well. She could
  23     have known that, at times when there were difficulties,
  24     I would be like that, but it could not possibly have
  25     been in that situation. I would not have discussed,

   1     with her, the review. I certainly would never have
   2     discussed with her my asking James to organise the day,
   3     which he did not, as far as I know. I certainly would
   4     not have said to her, of all people, that it might be
   5     good for him. This is unthinkable. I cannot explain it
   6     but I have to say it is wrong.
   7   Q. It is not something you would have said if you were in
   8     "I am John Roylance" mode as opposed to Dr Roylance or
   9     Chief Executive mode?
  10   A. I would not discuss James with her behind James's back.
  11     I would not. You could not stay Chief Executive with
  12     any Trust at all if you behaved in that way. This is
  13     unthinkable. It is quite wrong.
  14   Q. You expected, as I understand it, you tell us in fact,
  15     it is WIT 108/130, the foot of the page, that you wanted
  16     Mr de Leval and Dr Hunter to be completely frank and
  17     blunt if necessary in their report and for that reason,
  18     you told them the report should be confidential to you?
  19   A. Yes.
  20   Q. So it was their report to you as Chief Executive?
  21   A. That is right.
  22   Q. And that is your understanding of what the relevant
  23     clinicians, the Trust, whoever it was that wished the
  24     review to take place, wanted?
  25   A. Yes. Yes.

   1   Q. When the report arrived, you were away on holiday?
   2   A. Yes.
   3   Q. The report had had some circulation.
   4   A. Yes.
   5   Q. Did you regret that it had the width of circulation that
   6     it did?
   7   A. I do not want to be critical of those who handled the
   8     report while I was away. I certainly was disappointed
   9     that I had been away and I did not think the report had
  10     come until I got back, to be perfectly honest. I wish
  11     I had been in the Trust Headquarters when the report had
  12     arrived, yes.
  13   Q. If it had come in, confidential to you, you would have
  14     seen it?
  15   A. Yes.
  16   Q. What would you have done with it?
  17   A. I would have read it and then I would have discussed the
  18     recommendations in whatever area I wanted. It mean, it
  19     actually advised me that, apart from the switch
  20     operation, a full service should be continued until the
  21     arrival of Mr Pawade, as I remember. It is a while ago
  22     now. As I remember the report, it advised that no
  23     switch operation should be undertaken until after the
  24     arrival of Mr Pawade. That did not strike me as odd.
  25   Q. It described Mr Wisheart as a "higher risk" surgeon.

   1   A. Yes.
   2   Q. And I think it made particular reference, did it not, to
   3     the AVSD operations with which he had principally been
   4     concerned?
   5   A. Yes. That is not entirely the thing, but, yes, it did.
   6   Q. What would you have done with that information had the
   7     report come to you confidentially, as you had hoped it
   8     would?
   9   A. If I did not already know, and I am not sure I did,
  10     I would have satisfied myself that James had already
  11     made the decision not to undertake another AVSD
  12     operation and have them all referred to Janardan, whose
  13     results were good.
  14   Q. Who was it who decided that after 1st May, when
  15     Mr Pawade came, that Mr Wisheart, save in some
  16     exceptional circumstances, would no longer operate on
  17     paediatric cases?
  18   A. I think Mr Wisheart. That had been his intention for
  19     some considerable time and he merely implemented his
  20     stated intention. There clearly was not room for three
  21     paediatric cardiac surgeons with the workload that was
  22     there, and he had already made it absolutely clear to
  23     everybody, the Trust Board knew, and everybody knew --
  24     I say everybody, everybody within that particular
  25     service knew, that it was James's intention to give up

   1     paediatric cardiac surgery.
   2   Q. Did you come back to a degree of discussion about
   3     whether the report could be accepted by the Trust
   4     Board?
   5   A. No. No. I think that was already -- those sort of
   6     discussions, it is slightly muddled in my mind what went
   7     on when I was away. We were well beyond that sort of
   8     stage.
   9   Q. You know that the report was changed?
  10   A. Yes.
  11   Q. From a first report, which was much more highly critical
  12     in some respects than a second report?
  13   A. Yes.
  14   Q. How did those changes come about?
  15   A. I informed the authors that a decision had been made to
  16     make their report public and asked them whether they
  17     would wish to modify it in that knowledge.
  18   Q. What do you have to say about the source of some of the
  19     alterations which were made? Suggestions I think were
  20     made to you about matters they might wish to change.
  21   A. I think they discussed, they were helped in their
  22     rewriting by some of the consultants, but the decision
  23     on what the report should be was made by, I think,
  24     Marc de Leval. I think it was only a telephone
  25     conversation with his colleague at that time.

   1   Q. Do you know who suggested the revisions to the original
   2     draft?
   3   A. No. No.
   4   Q. Did it concern you that a report which had been critical
   5     in a number of respects, on redraft was much less
   6     critical?
   7   A. No. No. I mean, that was the purpose of inviting them
   8     to look at the report in terms of its being made
   9     public.
  10   Q. I thought the purpose was that it should be "quick and
  11     dirty"?
  12   A. It was, but that was to be confidential. They wrote me
  13     a report which was going to be totally confidential to
  14     me and therefore it was not refined, it was blunt, it
  15     was clear and it was helpful to me. Had I been there
  16     when it arrived, it would have remained confidential to
  17     me. But having told them it would not see the light of
  18     day, it would not be made public, I returned from
  19     Australia to be told that it had been promised to HTV.
  20     It was clear to me that that would not have been
  21     a proper step.
  22   Q. Let me take it in stages. The purpose of having the
  23     report was to have something quick, dirty, confidential
  24     to you?
  25   A. Yes.

   1   Q. You, having had that report, were going to be no doubt
   2     considering what action you would take to implement its
   3     recommendations, and to discuss it with others?
   4   A. Yes.
   5   Q. If the report revealed serious concerns about particular
   6     aspects of cardiac surgery, or of a cardiac surgeon, was
   7     that not a matter which it was important for others to
   8     know?
   9   A. Which others? I am sorry, do you mean the public, the
  10     people on television?
  11   Q. Was it important for the Trust Board to know?
  12   A. Yes.
  13   Q. Would it have been important for the Medical Director to
  14     know?
  15   A. Yes.
  16   Q. Would it have been important for the clinicians working
  17     in the cardiac surgical services to know?
  18   A. Yes.
  19   Q. Since they collectively, as you put it earlier, had been
  20     responsible for agreeing that there should be this
  21     report, was the decision whether to make it public or
  22     not, not their decision?
  23   A. No.
  24   Q. Why not?
  25   A. Because I had invited some two outside experts to make

   1     a report to me and for the purposes of speed and to make
   2     sure there were no punches that were pulled, I promised
   3     them they could say whatever they liked and it would
   4     remain confidential to me, and I would act on their
   5     advice. That was the sort of conversation I had.
   6        I arrived back to be told that the local BBC
   7     television station had been promised the report. There
   8     was no way I could give them the report without
   9     contacting the authors and saying, "I am sorry, my
  10     promise cannot be kept". It was their decision -- their
  11     decision -- what report they were prepared to be made
  12     public, not mine.
  13   Q. If you have -- this is touching on the issue we have
  14     just mentioned -- an authoritative independent report
  15     which is critical of aspects of the Trust, is that not
  16     something which, in your view, anyone concerned with
  17     seeking treatment or providing treatment at that Trust
  18     should know?
  19   A. Yes. Yes, I have no difficulty with that.
  20   Q. So the last thing you would wish to be party to is any
  21     form of cover-up of any such report?
  22   A. There was no cover-up, no. I would not have tolerated
  23     that.
  24   Q. The distinction you are making between your suggesting
  25     or telling Messrs de Leval and Hunter that their report

   1     was to be made public and knowing that in some way
   2     changes had been made which toned down the criticism in
   3     it and the example I have just put to you, is that in
   4     the first place the report was intended to be
   5     confidential to you.
   6   A. Yes.
   7   Q. So this was entirely a reflection of the confidentiality
   8     with which you had first sought the report?
   9   A. It was a promise I had given to free them up from
  10     refining the report. I did not want to waste time. It
  11