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 8th 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, the Inquiry heard from Dr Hyam Joffe, Paediatric Cardiologist, Bristol Children’s Hospital, United Bristol Healthcare NHS Trust (UBHT). Dr Joffe told the Inquiry he was appointed to the Bristol Children’s Hospital in January 1980. He outlined his experience in other centres and commented on the facilities in Bristol compared to other units. He then discussed the results recorded for paediatric cardiac surgery in Bristol during the 1980s and 1990s and spoke about the low number of referrals to the centre. Next he focussed on the issue of the split site, commenting on the effect on the paediatric cardiological input at the BRI and the funding implications of unifying the paediatric service in one hospital. He explained that the desire to unify the service and to appoint a dedicated paediatric cardiac surgeon existed from the early 1980s but was not fulfilled until the mid 1990s. Dr Joffe then told the Inquiry about the staffing levels in the paediatric cardiac unit and also commented on referrals by the paediatric cardiologists to other centres outside Bristol. He then focussed on Bristol’s bid to be a designated Supra-Regional centre for paediatric cardiac surgery and outlined the reasons given to justify its inclusion. He then told the Inquiry about concerns raised by Welsh cardiologists about the standards in the Bristol unit and the subsequent response to it by the Bristol clinicians. He went on to speak about audit and its establishment at both the BRI and BCH. He commented on the reaction in the Trust to the publication of criticisms of results for paediatric cardiac surgery in the magazine Private Eye. He concluded by discussing the introduction of the Arterial Switch programme in Bristol. Dr Joffe’s evidence continues tomorrow.

FULL TRANSCRIPT

   1               Day 90, Wednesday, 8th December 1999
   2   (9.50 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF: Good morning, sir. Can I apologise to
   6     Dr Joffe for having kept everyone waiting just a little
   7     this morning.
   8        Dr Joffe, would you be so kind as to stand to take
   9     the oath?
  10             DR HYAM JOFFE (SWORN):
  11            Examined by MR LANGSTAFF:
  12   MR LANGSTAFF: Dr Joffe, your full name, please?
  13   A. Hyam Simon Joffe.
  14   Q. You have given a number of statements to this Inquiry
  15     which cover the entire period of this Inquiry's interest
  16     because from Day 1 of our terms of reference to the last
  17     day, you have been engaged at Bristol?
  18   A. Yes.
  19   Q. As a cardiologist, have you not?
  20   A. That is correct.
  21   Q. Can we have a look at the first of those on the screen,
  22     it is WIT 97/1. If we turn to page 18, the foot of the
  23     page, that is your signature?
  24   A. Yes.
  25   Q. That deals with the split site. There are appendices,

   1     I think from page 19 to page 130. At page 131 do we
   2     find your statement in respect of Issue B, broadly
   3     management and administration?
   4   A. Yes.
   5   Q. And page 169, the foot of the page, your signature on
   6     that?
   7   A. Yes.
   8   Q. There are appendices to that statement which take us
   9     through to page 288. At page 289 do we have your
  10     statement on Issue D relating to referrals?
  11   A. Yes.
  12   Q. Which you sign, page 294 -- you do not sign at 294, it
  13     seems.
  14   A. There should be another page there with a signature.
  15   Q. Can we go on to the next page? In any event, you adopt
  16     that as your statement?
  17   A. Yes.
  18   Q. Page 295, Issue E which is preoperative management, we
  19     go through to page 308. Again do you adopt this as your
  20     statement on preoperative management?
  21   A. Yes.
  22   Q. Anyone who finds this statement on the Internet will see
  23     that there is an appendix which is missing, but it has
  24     been supplied to the Inquiry and it is not made public
  25     for reasons of patient confidentiality.

   1   A. Yes.
   2   Q. Issue G, we have your statement. That is at page 309,
   3     post-operative care. Does that go through to page 314?
   4     Again is that your statement on that issue?
   5   A. Yes, it is. The signed copies I think have not been
   6     incorporated by yourselves.
   7   Q. There is an appendix at page 315. Page 316, Issue I,
   8     your statement in relation to the treatment of families,
   9     which goes through to page 318.
  10   A. Yes, I accept that.
  11   Q. Page 319, your statement in relation to medical and
  12     clinical audit and the review of cases?
  13   A. Yes.
  14   Q. Which takes us through to page 329?
  15   A. Yes.
  16   Q. At page 330, your statement on the expression of
  17     concerns which takes us through to page 338?
  18   A. Yes.
  19   Q. Do you adopt those statements as your evidence to this
  20     Inquiry?
  21   A. Yes.
  22   Q. You will probably know from having read the proceedings
  23     of the Inquiry, and if you do not I shall tell you, that
  24     those statements are taken as read. The Panel have read
  25     them; they are evidence and so you will forgive me if

   1     I do not deal with every dot and T that is contained in
   2     the statements.
   3   A. I understand.
   4   Q. The questions I ask will focus upon particular parts of
   5     them.
   6        Can I begin by asking one general question: you
   7     I think have been recorded as saying late in the 1990s
   8     that the children treated at Bristol were no different
   9     from the national experience?
  10   A. I believe that to be the case, although I have no
  11     intimate knowledge of other centres' experience, but
  12     generally speaking I can see no reason why our material
  13     should not be very similar to the experience noted at
  14     other centres.
  15   Q. Therefore one might expect a broadly similar case mix to
  16     those --
  17   A. I would expect so, except for the treatment of Down's
  18     syndrome children during the mid/late 1980s and early
  19     1990s perhaps where we were happy to provide
  20     intervention while some other units in the country were
  21     not.
  22   Q. That was one of a differential practice, was it?
  23   A. Yes.
  24   Q. Some units not providing operative care and Bristol
  25     being one of those that did?

   1   A. Yes.
   2   Q. Again just so the record is straight on this: children
   3     presenting who needed a transplant operation plainly
   4     would not be treated in Bristol?
   5   A. Yes.
   6   Q. They would be referred, as no doubt would those
   7     suffering from a hypoplastic left ventricle?
   8   A. Yes, that is correct. The transplant centres were only
   9     few in this country, Harefield, Great Ormond Street and
  10     the Cambridge centre and they did not do transplants in
  11     children. So there were really just two in the country
  12     as far as transplantation is concerned and hypoplastic
  13     left heart is a large issue, which we will come back to
  14     in detail.
  15   Q. I have already said, and as you have agreed is the case,
  16     that your experience straddles the entire period that we
  17     focus on.
  18        Can I go straight to the end of that period? At
  19     that time we had Mr Ash Pawade operating as essentially
  20     the paediatric cardiac surgeon?
  21   A. Yes.
  22   Q. In the Children's Hospital. Was the perception that his
  23     results were better than the results which had been
  24     obtained by the unit before he came?
  25   A. Yes, that is correct, given the various changes that had

   1     taken place in addition to his appointment, namely, the
   2     move to the Children's Hospital for all closed and open
   3     heart surgery and the immense changes in the Intensive
   4     Care Unit in terms of the staffing of both consultant
   5     and junior medical grade and nursing staff is concerned.
   6   Q. The improvement you put down to a number of factors:
   7     one, no doubt the unification --
   8   A. Yes.
   9   Q. -- of surgery on one site. Secondly, you say the
  10     developments in intensive care; thirdly, the staffing?
  11   A. Yes.
  12   Q. Fourthly, I think you do not exclude the personality or
  13     the skills of the surgeons themselves?
  14   A. Yes, I would agree with the skills. I do not think the
  15     personality has anything to do with it.
  16   Q. Any other factor that you can identify?
  17   A. I believe that the fact that Alison Hayes joined us
  18     i.e. a younger person who was trained in the Brompton
  19     and then Toronto led us to an additional stimulus of
  20     up-to-date and new elements in investigation and
  21     diagnosis, yes. So it was a comprehensive change.
  22   Q. In the latter part of 1995, not only Mr Ash Pawade, but
  23     also Mr Dhasmana were available to take referrals from
  24     cardiologists --
  25   A. Yes.

   1   Q. -- for surgery, were they not?
   2   A. They were.
   3   Q. Is it the case that the cardiologists generally ceased
   4     referring case or many cases to Mr Dhasmana?
   5   A. It was a process of change. When Mr Pawade started on
   6     May 1st, 1995, the unit at the Children's Hospital with
   7     a new surgical theatre, which incidentally is a fifth
   8     point, was not yet complete and so there was a period
   9     until October 1995 where Mr Pawade operated at the BRI.
  10     So the total benefits that the unit achieved at the time
  11     of moving to the Children's Hospital were not yet
  12     apparent until October and during that time period cases
  13     were referred to both surgeons, that is Mr Pawade and
  14     Mr Dhasmana, and there was ongoing discussion about how
  15     the future should proceed in terms of referral.
  16   Q. After October?
  17   A. After October I believe by then Mr Dhasmana was no
  18     longer operating and events then unfolded where he did
  19     not continue the paediatric practice.
  20   Q. There is a suggestion in the papers which we have had in
  21     the Inquiry that cardiologists were choosing not to
  22     refer to Mr Dhasmana when they might have done but were
  23     instead referring to Mr Pawade?
  24   A. I cannot comment on Dr Martin or Dr Hayes's response,
  25     I think they would have to answer themselves for that.

   1     My own practice was to continue referring patients to
   2     Mr Dhasmana.
   3   Q. If one looks at the entire period from 1984 to 1995 you
   4     will have seen that this Inquiry has carried out
   5     statistical analyses as best it can. For the period for
   6     which it can compare the results in Bristol with those
   7     in the United Kingdom, broadly speaking the results of
   8     open heart surgery in the under 1 age group appears to
   9     be about twice the national figures. Is that something
  10     that you would accept or you would contest?
  11   A. Well, I would contest a broad statement of that sort.
  12     The figures fluctuated year by year. I do not believe
  13     it was twice the rate each year during that period and,
  14     secondly, you are comparing the outcomes in Bristol with
  15     an average of the national figures and not with
  16     a range. In other words, we do not know who was
  17     achieving the top and who was achieving the bottom rate
  18     of that range, nor do we know what the precise figures
  19     were for those success rates or failure rates, but we
  20     have an average and that is the only guideline that we
  21     can compare it with.
  22        So whether it was precisely twice the average,
  23     that would not I think reflect on the comparison with
  24     Bristol with each particular unit in the country.
  25   THE CHAIRMAN: Mr Langstaff, just to make it clear, you said

   1     in your question "the results for open heart surgery
   2     appeared to be twice the national average".
   3   MR LANGSTAFF: The under 1s.
   4   THE CHAIRMAN: You did not mean the results, but something
   5     else?
   6   MR LANGSTAFF: I meant the outcomes in terms of mortality
   7     rates. I am grateful because the question was
   8     infelicitously phrased.
   9        I think you understood it in the way I meant it,
  10     just so there is no misunderstanding?
  11   A. Yes.
  12   Q. You tell us in your statements that there were figures
  13     which were available year on year from, certainly from
  14     1986 onwards but relating to the period 1984 through to
  15     1995. Did you yourself see the figures produced by the
  16     unit in terms of mortality rates in the different
  17     categories, the under 1s, the over 1s, open and closed
  18     for each year as each year fell?
  19   A. They were certainly available year on year. I do not
  20     recall that we had a meeting to discuss them each year,
  21     but the figures were made available to all the
  22     cardiologists. Access to those figures is by the
  23     surgeons only, that is the UK national register, so that
  24     we could only respond to those figures as they were
  25     shown to us by the surgeons.

   1   Q. You got the figures for the unit which were collective
   2     figures?
   3   A. Yes.
   4   Q. And you would have known instantly if there was anything
   5     very oddly wrong with those figures?
   6   A. Yes.
   7   Q. There would be a comparison which you would be told of
   8     by the surgeons because they had access to the
   9     comparison figures for the UK generally?
  10   A. Yes.
  11   Q. And you say that they were made available; what do you
  12     mean by that?
  13   A. I believe that they were sent around or copies of the
  14     results were sent around to the cardiologists for
  15     perusal and so not every year was there an in-depth
  16     discussion about those results. There were years of
  17     course where there were in-depth discussions.
  18   Q. It would have been possible had you had a file on your
  19     shelf marked "outcome results" or "annual outcome
  20     results" for you to put in one year after the other?
  21   A. Yes, I believe so.
  22   Q. It follows that you year on year would have been aware
  23     at least in the sense of having received the information
  24     of those outcome results?
  25   A. Yes.

   1   Q. Did you for your part ever make a comparison to see how
   2     one year related to the others if it had not been done
   3     on the piece of paper that came round to you?
   4   A. Well, I certainly took note of the figures that were
   5     shown each year and I would have been aware and looked
   6     at previous years to see what the trends might be, yes.
   7   Q. One of the problems I suspect of understanding how
   8     Bristol related to the rest of the United Kingdom would
   9     be the size of the unit and the inevitable variability
  10     one might have when analysing small figures?
  11   A. Yes.
  12   Q. In order to get a view as to whether the variability was
  13     mere chance or whether there was some other systematic
  14     reason underlying it, you would have to compare a number
  15     of years together?
  16   A. Yes.
  17   Q. Over what sort of period would you look at results in
  18     a unit like Bristol with the throughput in Bristol in
  19     order to think to yourself "Well, we now have enough
  20     here to make a comparison which needs to tell us
  21     something and the difference between Bristol results and
  22     that of the United Kingdom is either obviously a cause
  23     for congratulation because we are doing something very
  24     right or it is a cause for concern because we might be
  25     doing something wrong"; what sort of period?

   1   A. As you have probably seen on the data that was passed
   2     around, I do not remember the precise dates, but I think
   3     it was 1984 to 1987, results were collated together in
   4     order to produce a bigger number for comparison with
   5     a much larger national figure and, for instance, the
   6     1988 figures themselves would be noted as well as the
   7     range 1984 to 1987 or 1984 to 1988 and certainly from
   8     that time on, I cannot recall before then, comparisons
   9     were made with the UK average figures as well.
  10   Q. If we have a look, it is UBHT 55/8. These were the
  11     figures for a period from 1984 to 1986. It is I think
  12     a three-year period. If we scroll down a bit, we can
  13     see the total for open heart surgery, over 1 year,
  14     7.9 compared to the UK for 1984. That would be the last
  15     year for which figures were then available?
  16   A. Yes.
  17   Q. 6.9. Not a marked discrepancy at all there. The
  18     under 1 year, 26.5 to 21.8. How did people react to the
  19     under 1 figures across the spectrum under 1s at that
  20     time, given that on one view there is a small percentage
  21     difference, on another 21.8 is four-fifths of 26.5, or
  22     put it the other way round, it is one and a quarter
  23     times as high a percentage rate in Bristol?
  24   A. I believe that the disparity, given the small numbers
  25     even between 1984 and 1986 between Bristol and the UK

   1     figure is not significantly great. I have not done the
   2     statistical evaluation, but I doubt very much whether
   3     there would be a statistical difference there, and not
   4     knowing the makeup of all the UK groups as compared with
   5     our groups, there was insufficient data there to make
   6     a meaningful comparison, but I would have said we are in
   7     the ball park of what is being achieved in the national
   8     figures.
   9   Q. Let us go on to the next year, 1987, UBHT 55/9. I will
  10     show you where it comes from and then we will go to
  11     page 18. It is the annual report. This is an annual
  12     report which you, the cardiologists I think handled?
  13   A. Yes.
  14   Q. Was it your brainchild?
  15   A. Yes, it was. I felt the need in 1986/1987, well the
  16     1987 report was the first one, to produce an annual
  17     report with a survey of the activity in the unit and
  18     also to include outcome measures as well if at all
  19     possible.
  20   Q. Annual reports were produced from 1987 until the
  21     1989/1990 report and that was the last one?
  22   A. Yes, that is correct. Unfortunately I then found myself
  23     with additional duties having become Clinical Director
  24     of the Children's Services within the United Bristol
  25     Healthcare Trust and given the workload of the cardiac

   1     requirements plus that, I did not feel I had the time to
   2     devote to continuing with these annual reports, which
   3     I very much regretted.
   4        There was some discussion, if I may say, with my
   5     colleagues and particularly Dr Jordan and I think there
   6     was a loose understanding that he would try and continue
   7     the process year by year. But in fact he was overloaded
   8     as well and it did not continue.
   9   Q. I was going to ask you why it was that nobody else in
  10     the unit carried it on. You have said Dr Jordan himself
  11     was overloaded with work?
  12   A. Yes.
  13   Q. There was nobody else?
  14   A. Dr Martin was with us from 1988 onwards and he was new
  15     and was himself becoming busy very rapidly and had
  16     a large role in developing interventional techniques in
  17     cardiac catheterisation in our unit and I did not feel
  18     it was right to ask him to take it on at that point.
  19   Q. It, sadly, lapsed?
  20   A. That sadly is correct, yes.
  21   Q. At page 18 you see the results, this time for the
  22     four-year period, 1984 to 1987. In the under 1
  23     category, mortality 27 per cent. For the over 1 year,
  24     8 per cent.
  25        If we compare that with the figure in fact

   1     produced by the United Kingdom, we will find that at
   2     UBHT 55/262, that is the register figure for 1986 where
   3     the total open is 11.2, the under 1s, 21.2. So if we go
   4     back to page 55/18, very much the same sort of picture
   5     being painted in 1987 as had been the case for the
   6     period 1984 to 1986?
   7   A. That is correct.
   8   Q. Bristol being higher than the United Kingdom. Again,
   9     was there any discussion or thinking about these results
  10     and how they compared to the national figures?
  11   A. Yes. Yes, there was a general discussion, if not at
  12     a meeting specifically allocated for this purpose, at
  13     one of our evening meetings that (as you have heard from
  14     others) was held two or three, sometimes four times
  15     a year where we were able to discuss strategy and policy
  16     matters.
  17        We were aware of course that our under 1 year
  18     figure was not excellent and was not at the level of the
  19     UK average, although not far from it and so there was
  20     ongoing discussion at many of these meetings about how
  21     we should make changes if we thought there were changes
  22     to be made and what we should do to improve that
  23     figure.
  24        It was an ongoing debate rather than a single
  25     defined meeting to discuss just that issue.

   1   Q. If we can go ahead to the next annual report, we find
   2     that at 55/22. The annual report was obviously produced
   3     for someone; who got it?
   4   A. The idea was to send the reports to the then District
   5     Health Authority, both the local one and peripheral
   6     centres, particularly to the paediatric paediatricians
   7     around the region with whom we were related, so to say,
   8     by virtue of the peripheral clinics that we held at
   9     these various centres and we wanted them to have a view
  10     of what we were doing and of our figures and our
  11     enterprises.
  12   Q. It would follow, I suppose, that they, if they had kept
  13     the reports from one year to the next, would have seen
  14     the same comparison figures as you might if you had done
  15     that exercise, or others within the unit might?
  16   A. Yes, I believe so.
  17   Q. Within the unit, what circulation did the report have?
  18   A. It was freely available to the members of the cardiology
  19     team. I think on the first page of each of those annual
  20     reports there is a list of the people who make up the
  21     totality of the cardiac unit and if we might see
  22     perhaps, it is the next page after this one --
  23   Q. Let us turn to page 23.
  24   A. Those are the individuals who would have received copies
  25     and, indeed, others who requested copies who might not

   1     be on the list would have received them too. There was
   2     no sense of restricting access to this report, it was
   3     meant to be open.
   4   Q. Can we scroll down to make sure we have the entire
   5     list? Thank you. That speaks for itself. Did anyone
   6     who was occupying a management role in the Health
   7     Authority at this time receive a copy, the District
   8     General Manager --
   9   A. Yes, certainly.
  10   Q. You say the idea was to send the reports to the then
  11     District Health Authority, both the local ones and the
  12     peripheral centres. That was what you described as the
  13     idea; was it also the reality or not?
  14   A. Yes, we sent them out.
  15   Q. Do you know whether they went to individual
  16     paediatricians who might refer cases to Bristol?
  17   A. I believe so. I really cannot recall exactly how the
  18     mechanism worked, but I believe my secretary or
  19     a secretary within the cardiology department would have
  20     been asked to send these reports to these people plus
  21     the referring paediatricians.
  22   Q. In this report if we go to page 35, this time we are
  23     looking at a five-year period, 1984 to 1987/1988 and
  24     comparing it with the four-year average of the United
  25     Kingdom.

   1        30-day mortality in the open heart surgery under
   2     1 year of age and the Bristol experience in 1988 showing
   3     a downturn to 37.9 compared to a rolling United Kingdom
   4     average of about 22.1.
   5        So it is more than one-and-a-half times, getting
   6     on for but not quite twice as high a figure in
   7     percentage terms than the UK. When those figures came
   8     out and were appreciated, did it cause any alarm?
   9   A. Yes, this one began to look as if our figure not only
  10     was, by comparison with the UK higher, but intrinsically
  11     it was higher than our previous annual figures and that
  12     did cause quite a lot of consternation and we, I recall,
  13     did discuss this at one of our meetings. I do not
  14     remember exactly which one.
  15        You will note also, although the difference is not
  16     much, that the UK average itself has gone up from the
  17     previous year slightly.
  18   Q. Yes.
  19   A. So it of course does not match the difference in the
  20     mortality that we had, but we felt that it was something
  21     again that we had to consider and try and identify
  22     reasons for the change but we did not feel given the
  23     accuracy or inaccuracy of the UK data, that we needed to
  24     make a major change at that point, but that this was
  25     something we had to look at very carefully in terms of

   1     what was happening the following year.
   2   Q. So if we go to the following year which we can find at
   3     JDW 3/79. That is what we are looking at. This was, as
   4     I understand it, is an appendix to a draft annual
   5     report. If we scroll down. There the figure, if we go
   6     down further please, it is broken down by diagnosis.
   7     The total, 15/40 in the total category for 1989 is
   8     37.5 per cent. That compares with the United Kingdom
   9     Cardiac Surgical Register of 18.8 per cent, so it is now
  10     approximately double in Bristol?
  11   A. Sorry, could you remind me what the percentage was of
  12     46/1?
  13   Q. 15/40 is 37.5 per cent.
  14   A. Yes.
  15   Q. That means that in 1988 there has been 37.9 per cent,
  16     1989, 37.5 per cent, a consistent picture, consistently
  17     high compared to the United Kingdom performance which is
  18     round about 20 per cent but dropping a bit.
  19        At this stage, 1989 -- we can pick up the actual
  20     37.5 per cent in another place, UBHT 55/80. You see the
  21     same figures, 15/40, 37.5 per cent, it is not just my
  22     calculation on my feet.
  23        Did that cause a reaction, because you say you
  24     were keeping the early figures under review?
  25   A. Yes, could we go back to the previous table?

   1   Q. Certainly. The previous table, JDW 3/75.
   2   A. Indeed, we were again anxious about the total
   3     mortality. We had the benefit on this occasion of
   4     a breakdown into the various conditions and there are
   5     a few conditions, as you can see, where the mortality
   6     was high.
   7   Q. There is only one, is there not, on the crude figures or
   8     the 1984 to 1989 mortality where the mortality in
   9     Bristol was better than that in the United Kingdom: that
  10     is the Sennings class?
  11   A. Yes, that is correct, but at the same time truncus
  12     arteriosus was high throughout the country.
  13   Q. Yes.
  14   A. And the "miscellaneous" group can include a variety of
  15     conditions so it is difficult to say that the case mix
  16     is the same in that particular small group as it is,
  17     there is only four cases, but nonetheless they all
  18     died. So it was essentially the AVSDs and the
  19     miscellaneous group and total anomalous pulmonary venous
  20     drainage, I think VSD plus PS only three cases, a single
  21     case makes a huge difference in percentage terms.
  22        So there were a few conditions that worried us
  23     particularly. The AVSD and the TAPVD were the two that
  24     we thought about a good deal at the meetings at that
  25     time.

   1        This was a period where I think the AVSDs were
   2     generally having poor results. This is anecdotally by
   3     listening to various cardiologists or cardiac surgeons
   4     discuss informally their results and in fact we might
   5     come to it, but at the meeting in Frimley Park where the
   6     surgeons got together in 1991 to discuss various
   7     conditions including AVSDs, Mr Dhasmana attended that
   8     meeting and came back saying that "all centres seem to
   9     be getting very bad results". I think he was thinking
  10     in terms of 25 per cent mortalities, which is not far
  11     off the 19.6 and only one centre was doing well, that
  12     was Birmingham, Mr Brawn, and it was at that time that
  13     the idea to operate at an earlier age was put forward as
  14     a possible cause or reason for the success in Birmingham
  15     and this was a year or two before, but we had already
  16     heard, again informally, of the view that infants had
  17     better results if they were done earlier, not only AVSDs
  18     and this came from people like Castaneda in Boston.
  19        So I think our response was that we ought to be
  20     moving to a younger age even at this time and that
  21     possibly would improve the results but we were worried
  22     about it at that time and we tried to move in the
  23     direction of operating at a younger age as a response to
  24     that.
  25   Q. That is focusing of course on a particular operation?

   1   A. Yes.
   2   Q. Was there any view as to whether the overall pattern
   3     which, as I have demonstrated throughout the 1980s, was
   4     if one takes a point estimate, consistently higher it
   5     would appear than that of the average of the
   6     United Kingdom?
   7   A. Yes, but I want to stress that compared with the average
   8     of the United Kingdom.
   9   Q. What I am interested to know is whether the approach was
  10     to say "We do have figures which on the face of it look
  11     very much worse" or "worse", it does not matter which
  12     way one puts it "than the United Kingdom, but really
  13     what we need to address is the individual component here
  14     which is troubling us most and if we sort that out, then
  15     we may find that the overall results would improve and
  16     bring us back into some form of reasonable
  17     comparability", or whether it was to say "Here we have
  18     figures which looked at across the board appear to be
  19     lower, if one takes the total of the open heart
  20     operations under 1"?
  21   A. Yes.
  22   Q. "We are not doing very well, we have not done very well
  23     for a period of time; is there a systematic problem we
  24     need to address?"
  25   A. Yes.

   1   Q. Was there any talk along those lines that you can
   2     recollect now?
   3   A. Other than the fact that we wanted to operate earlier,
   4     not only AVSDs, but also VSDs, that was essentially the
   5     direction in which we moved, and tied in with that of
   6     course was the decision that if diagnosis could be made
   7     earlier or issues could be facilitated by doing the
   8     investigations differently, was there any way in which
   9     we could provide the surgeons with more information;
  10     there were those kinds of discussions going on, but in
  11     effect it was an attempt at an overall improvement in
  12     the provision of services which I think all units have
  13     as an aim and ambition.
  14        To answer your question briefly: I do not believe
  15     there were other particular specific changes that we
  16     undertook at that time.
  17   Q. If one looks at the AVSD figures, 61.5 over a five-year
  18     period or maybe six years, compared to the United
  19     Kingdom average mortality in 1988. To be fair, it is
  20     1988 mortality for the United Kingdom. The difference
  21     in percentage terms is quite stark. I appreciate that
  22     the numbers are small and one may not necessarily have
  23     statistical significance for it. From what you were
  24     saying, the understanding at the Frimley conference in
  25     1991 was that the rest of the United Kingdom also,

   1     Birmingham apart, were operating at about the same time
   2     in the child's life as you were?
   3   A. Yes, I believe so.
   4   Q. If that was the reason for getting an improvement in
   5     Bristol, the same reason would apply elsewhere?
   6   A. Yes.
   7   Q. If those figures are at all reflective of a true
   8     situation, there may be some other reason why in Bristol
   9     those particular operations were not turning out as
  10     satisfactorily; did anyone talk along those lines?
  11   A. No, because we reviewed -- all these patients or I think
  12     the vast majority of them, those that died, very
  13     comprehensively at the autopsy pathology meetings that
  14     we held on a monthly basis and it seemed to all of us,
  15     that is the pathologists and the cardiologists, cardiac
  16     surgeons, occasionally the anaesthetists, that the
  17     actual repair technically speaking looked extremely
  18     good, that looking at the specimen in the hand the
  19     insertion of the patches in the atrial and the
  20     ventricular septa, the repair of the mitral valve that
  21     is required in this operation, it looked really very
  22     good and this was a repeated experience. So that one
  23     came away from the meeting quite often with a feeling
  24     "Well, what went wrong; why did this baby (in most
  25     cases) die?" And we were unable in that forum to come

   1     to a conclusion as to what the answer was.
   2   Q. I have taken you up to 1989, 1990 --
   3   THE CHAIRMAN: May I interrupt for a second? I took that to
   4     be the force of Mr Langstaff's question, that if others
   5     were operating at more or less the same time and you on
   6     examination discovered that the operation technically
   7     had been performed well, I took the purport of
   8     Mr Langstaff's question as: was the question asked,
   9     "could there be other factors larger than merely the
  10     operation which were engaged here?"
  11        You began your answer by saying "No" and then you
  12     merely went on to say that the operation was well done.
  13     I wondered whether you could perhaps engage with that
  14     question again?
  15   MR LANGSTAFF: You focused on the surgery.
  16   A. Yes.
  17   Q. What about other factors?
  18   A. I understand. One of the factors that we struggled with
  19     throughout this period was the split site and the
  20     question of whether that was a factor in producing worse
  21     results than there should have been and while it was
  22     very difficult to identify specific issues, I think
  23     there was an overall feeling that if the unit was
  24     centralised and under one roof, so to say, and if the
  25     staffing was at its optimal levels, that we may be able

   1     to get or we should get better results. But that was
   2     the situation that there was at that time and although
   3     the request or the recommendation was made for
   4     unification of paediatric cardiac surgery from as far
   5     back as 1981, certainly when I arrived after 1980, there
   6     was no progress at that stage for a variety of reasons.
   7     Probably the major one being the fact that the unit at
   8     the BRI were needing to increase its adult throughput
   9     because at that time in the early 1980s the South West
  10     Region I think had the lowest number of cases, adult
  11     cases done compared with other regions.
  12        So that I at least understood that there was
  13     a problem in having to provide a service for both the
  14     children as well as the adults in tandem and that we
  15     anticipated quite soon, within a few years, that the
  16     site would come together on one location. But that was
  17     a very general feeling. Again, we had no specific
  18     information on which to base that in terms of could that
  19     have made a difference to a child's success or
  20     otherwise. So it is a general response. But that was
  21     the situation at the time.
  22   Q. It may be a little unfair, and if it is please say so,
  23     to move forward because we are in 1989 in the course of
  24     our discussions, to reflect on what was said by Martin
  25     Elliott on 3rd January 1992 and what may have been the

   1     view of Dr Shinebourne when he visited in I think 1991.
   2     Certainly in 1991 the view -- I think it was -- of
   3     Dr Shinebourne was that there would not be a Senior
   4     Registrar in cardiology essentially because of the split
   5     site?
   6   A. Yes.
   7   Q. And the view expressed by Martin Elliott -- I will show
   8     you on the screen -- JDW 3/106, the bottom of the page,
   9     in a paper which he wrote to Mr Wisheart describing his
  10     reasons for rejecting the opportunity to be considered
  11     for the post of a Chair in Cardiac Surgery:
  12        "The separation of open and closed paediatric
  13     cardiac surgery must be inefficient and is potentially
  14     dangerous."
  15        Strong words, 1992 or the very end of 1991. But
  16     were those views -- the views of Dr Shinebourne, the
  17     views of Martin Elliott -- very much the sort of views
  18     you had in 1989 about the potential for risk to children
  19     of the split site arrangement?
  20   A. Well, I certainly would not have put it in as strong
  21     terms as this. As I suggested in my previous answer, in
  22     my view at that time it was more a feeling that this was
  23     possibly a factor. But Martin Elliott is an experienced
  24     and eminent cardiac surgeon and he would have seen it
  25     I think from the viewpoint of the Great Ormond Street

   1     unit and the fact that obviously it was a single
   2     combined paediatric surgical and cardiological cardiac
   3     service so that his perspective I think would be
   4     different from mine but ultimately I think we were both
   5     thinking in the same direction.
   6   Q. Back in 1981 in October, let us have a look at
   7     WIT 97/203, you together with Dr Jordan published
   8     a paper. The conclusion, we can go to it at page 206:
   9        "It would be a tragedy for this region if Bristol
  10     loses the opportunity to become a major force in
  11     paediatric cardiology in this country. The basic
  12     foundations have been laid and the Area Health Authority
  13     has supported development in this field by appointing
  14     a second consultant cardiologist committed to paediatric
  15     cardiology two years ago."
  16        That was you, was it?
  17   A. Yes.
  18   Q. "However, without further support and improved
  19     facilities, top grade medical and other personnel will
  20     not be attracted and the service will stagnate and
  21     deteriorate."
  22        That is what you foresaw as a consequence?
  23   A. Yes.
  24   Q. "Failing such support the only other avenue for funding
  25     these developments would be through private donations,

   1     this would be an unsatisfactory alternative."
   2        The development of the facilities that you were
   3     looking for was, we can see from the top of the page,
   4     surgical expansion at the Children's Hospital.
   5        Were you looking there in, for instance (b),
   6     future developments, to the development which finally
   7     took place in 1995 with the move of the operating
   8     theatre for open heart surgery from the BRI to the BCH?
   9   A. Yes.
  10   Q. Were you looking at (a) for the development that took
  11     place in 1995 for the appointment of Mr Ash Pawade?
  12   A. That does not -- sorry, the second (a)?
  13   Q. Yes.
  14   A. Can I read that, it is a long time ago that this was
  15     drawn up?
  16   Q. Certainly.
  17        What you are saying is without a dedicated
  18     paediatric cardiac surgeon the standards to which you
  19     would aspire as a unit dealing with paediatric open
  20     heart cases could not be achieved?
  21   A. Yes, that was my view at that time certainly.
  22   Q. And you describe the additional theatre facilities at
  23     the Bristol Children's Hospital as "essential"?
  24   A. Yes.
  25   Q. So although you do not necessarily endorse the strong

   1     words that Martin Elliott used, these are themselves
   2     strong terms?
   3   A. Yes, I felt strongly about it, particularly at that time
   4     because I had arrived in Bristol from Cape Town where
   5     I had just been through the same process of fighting for
   6     children's services. At that point, if I may amplify,
   7     the paediatric cardiac surgery was at the Children's
   8     Hospital in Cape Town, which was separate from Groote
   9     Schuur Hospital, which was the adult unit. What was
  10     separate was the investigative facilities which were
  11     only in the adult hospital and not in the Children's
  12     Hospital. I battled very hard to develop the cardiac
  13     catheter service at the Children's Hospital and that was
  14     achieved in -- it started there in 1970, in about 1978.
  15        So it took eight years to attain the goal in Cape
  16     Town and on the other hand I could see the benefits of
  17     having cardiac surgery which Professor Barnard had
  18     started from the onset of the Red Cross Children's
  19     Hospital performing there in the Children's Hospital,
  20     open heart and closed, and I believed that we should
  21     have the same unified service in Bristol.
  22        So I was fired up, but I might say that it took
  23     7/8 years and I believe that in this kind of venture,
  24     especially when you are negotiating with a state Health
  25     Service which was the same in South Africa as here in

   1     the NHS, these issues I am afraid do take an enormous
   2     amount of time, your argument has to be put repeatedly
   3     and one understands and accepts that there will be
   4     rejections on a frequent basis and ultimately if one
   5     persists -- for the benefit of the children, I emphasise
   6      -- it can be achieved, and this is the process that
   7     I am afraid one has to go through in order to attain
   8     ample facilities.
   9   Q. You sound, if I may say so, in that last answer almost
  10     as though you were apologising for the failure as though
  11     it was your own. The fact is: here you were in 1981
  12     saying "these issues, these matters are essential"?
  13   A. Yes.
  14   Q. Can you tell us from your own perspective why you think
  15     they did not happen?
  16   A. I am afraid I cannot answer that. It needs the answers
  17     of management and the NHS and, indeed, the Government in
  18     power to make a response to that kind of question.
  19   Q. You were pushing at the door because you thought it
  20     would improve the quality of care; you thought it was
  21     necessary for the quality of care of the children that
  22     you were treating?
  23   A. Correct, but that is all I could do.
  24   Q. Therefore you had, did you not, some appreciation of the
  25     reasons that were given to you as to why what you

   1     wanted, what you thought of as necessary and essential
   2     was not happening; what reasons were given to you?
   3   A. It was usually a question of finance.
   4   Q. "Usually"?
   5   A. Almost invariably.
   6   Q. What about something you mentioned in an answer five or
   7     ten minutes ago, what about the impact of the adult work
   8     upon the facilities?
   9   A. Clearly this was part of the financial problem in that
  10     the Health Authority at that time had decided that the
  11     Bristol service should be improved and in 1984 I was on
  12     the working party that participated in the discussions
  13     about enlarging the adult service and records will show
  14     that they moved from 250 cases, I think it was in the
  15     early 1980s, to 750 by about five years later. That was
  16     costly but that, at that time, as seen by others who
  17     made those decisions, was the priority.
  18        As it happens the paediatric developments, firstly
  19     the transfer of the cardiac catheterisation laboratory
  20     to the Children's Hospital and, secondly, the move of
  21     open heart surgery from the BRI to the Children's
  22     Hospital were both achieved on the back of adult
  23     developments and that was the priority given to
  24     paediatric cardiology and cardiac surgery.
  25        You will have to ask others why that should be.

   1   Q. You mean the absence of priority, do you not?
   2   A. It is a low priority, shall we say.
   3   Q. In comparison with the adult service it was the orphan
   4     service, was it?
   5   A. Yes, it was the step child, it always has been; it was
   6     the same experience in Cape Town. The adult specialty
   7     departments, cardiology cardiac surgery and
   8     gastroenterology and neurology were all seen to be the
   9     province of physicians who cared for both adults and
  10     children at the same time and as the specialisation
  11     evolved in paediatric services, so there was a battle
  12     and a tension between children and adults and this is
  13     ubiquitous throughout medicine, I would say, in any
  14     country in the western world.
  15        So it evolved one step behind adult services, that
  16     is children's services. That was common knowledge and
  17     that is part of the battle to achieve what
  18     paediatricians would want to achieve, namely, a service
  19     dedicated to children because children are different
  20     from adults, especially babies.
  21   Q. You have told us essentially the only reason given for
  22     not taking these two steps earlier was finance?
  23   A. So I was informed.
  24   Q. What one needed was a source of finance and if it did
  25     not come directly from the district or the Trust (when

   1     there was a Trust), you would no doubt be alert to other
   2     possible sources?
   3   A. Yes.
   4   Q. Can you tell me why it was that it was not until I think
   5     1993 that you then put in an application on behalf of
   6     the unit to the supra-regional services funding agency
   7     Advisory Group seeking for the year, I think 1993 to
   8     1994, funding in order to secure the unification of
   9     surgery with cardiology on one site and, funding being
  10     the problem, why that did not happen earlier?
  11   A. That is a good question. I was aware that the
  12     supra-regional services were already expending
  13     a considerable sum on the centres that had been
  14     designated and much of that funding was utilised on an
  15     annual basis to improve and increase the throughput of
  16     infants at the BRI surgically, although of course it had
  17     some impact on paediatric cardiology at the children's
  18     as well but much less, and I was not aware, I must say,
  19     of the opportunity to request capital sums from the
  20     supra-regional services group until 1992/1993 when it
  21     looked as if this was a potential option or alternative
  22     for achieving or acquiring funds for such a purpose.
  23        So it was really my ignorance I think of that
  24     opportunity that I did not consider it at an earlier
  25     stage.

   1   Q. Did you ask at an earlier stage?
   2   A. No, I do not believe I did, no, I just --
   3   Q. Do you think, reflecting on it, that somebody in
   4     management or administration might have told you of the
   5     possibility?
   6   A. Indeed, yes.
   7   Q. If you wanted to give us a broad identity of the office
   8     held by such a person who might have told you, who would
   9     you have in mind?
  10   A. The individuals changed over this total period under the
  11     Inquiry, but in terms of the office it presumably would
  12     have been the finance, the chairman or manager of the
  13     Finance Department of the Health Authority or later the
  14     Trust or the Chief Executive, I am not sure who.
  15   MR LANGSTAFF: Sir, I notice the time. We have been going
  16     for about an hour and a quarter; it is now perhaps time
  17     for our first break.
  18   THE CHAIRMAN: Shall we say until 11.15, then?
  19   (11.00 am)
  20               (A short break)
  21   (11.15 am)
  22   MR LANGSTAFF: Dr Joffe, did it then remain a matter of
  23     concern, to you, until the events of 1994/95, that you
  24     had not achieved what you and Dr Jordan had hoped to
  25     achieve as recorded in 1981?

   1   A. Yes. Clearly after those initial comments in 1981, it
   2     was a concern, until we eventually achieved it. But we
   3     did achieve it. And I hasten to add, before the media
   4     publicity of 1995.
   5   Q. Because the appointment of the cardiac surgeon was
   6     determined some time in --
   7   A. 1994.
   8   Q. Mid-1994, or early 1994?
   9   A. Indeed, yes.
  10   Q. Looking forwards to matters we will come to, when was it
  11     that the decision was eventually taken to amalgamate,
  12     unify, surgery and cardiology on the same site?
  13   A. I believed it had happened on several occasions before
  14     1995. The one was when the Chair was established with
  15     the very specific aim of appointing a paediatric cardiac
  16     surgeon to that Chair, and the understanding was that
  17     anyone worth his salt, so to say, getting that post,
  18     would demand as a primary requirement the unification of
  19     the children's services.
  20        So I think, had Martin Elliott taken the Chair,
  21     that would have happened then. It appeared, on several
  22     occasions, once before then as a possibility, and
  23     subsequently in the early years of the Trust, 1992/93,
  24     that that issue could be resolved, but immediately prior
  25     to the actual achievement of that aim, it was during

   1     1994, spring/summer, that the Trust Board agreed to this
   2     move of open-heart children's surgery to the Children's
   3     Hospital.
   4   Q. Tell me, did you see the change to Trust status, both in
   5     the dislocation it may have caused in the run-up to
   6     Trust status and the early years of Trust status, as
   7     having represented something of a setback for
   8     development plans such as that?
   9   A. I think it did influence the potential move in
  10     1989/90/91, when the debate was going on regarding the
  11     Chair, and as I think you know from other records, it
  12     took Martin Elliott well over a year for him to decide
  13     whether he should accept the offer.
  14        So it did take a while, and then, of course, in
  15     1991/92, all the changes of potential Trust status, and
  16     then Trust status, did, I think, have an impact on the
  17     process of achieving the unification.
  18   Q. And the impact: an adverse or positive one, would you
  19     say?
  20   A. Ultimately positive, but there was a phase of
  21     reorganisation which disturbed many departments in many
  22     ways, changes of having to run one's own budget, for
  23     instance, and a stronger management but at the same
  24     time, a stronger clinical input by way of Clinical
  25     Directors, Medical Directors.

   1   Q. So the focus, really, was elsewhere during those years,
   2     was it?
   3   A. Yes.
   4   Q. Coming to terms as clinicians with issues of management?
   5   A. Yes.
   6   Q. With new directorate structures, with the whole question
   7     of purchaser/provider and working out what the
   8     implications were?
   9   A. Yes.
  10   Q. What that might amount to is, as it were, taking one's
  11     eye off the ball of the long-term aim. Is that fair?
  12   A. I think that is fair, yes -- fair from the viewpoint of
  13     management, let alone from our viewpoint. We were going
  14     on making as many recommendations as possible to try and
  15     achieve that, but I think from the point of view of
  16     reorganisation, that affected everybody.
  17   Q. I have taken you up to 1989 in the review of the figures
  18     that we can see in respect of the outcomes of surgery,
  19     particularly on the under 1s.
  20        We have digressed into talking about the problems
  21     of the split site and what you might describe as the
  22     systematic difficulties in achieving some better
  23     outcomes.
  24   A. Yes.
  25   Q. Can we return to the question of the results? In

   1     1990 -- we pick those up at UBHT 55/88 -- there one has
   2     a perspective first of all of 1984 to 1989, that six
   3     year period, 32.2 per cent, but in 1990, 12.8 per cent.
   4   A. Yes.
   5   Q. The UK, for 1984 to 1988, 21.2, so two messages,
   6     I suspect, this would have given. One is that
   7     historical performance of Bristol is one and a half
   8     times as high as that of the UK but 1990 appears to be
   9     a very satisfactory year?
  10   A. Yes, correct, which I think accentuates the point I made
  11     earlier, that looking at figures purely for one year at
  12     a time does not give you a full picture, and indeed,
  13     this table indicates that in this, adversely so to say,
  14     if one looked at the longer period in order to get more
  15     cases into the group, the outcome looks far worse than
  16     it was in 1990 itself.
  17   Q. I suppose it would only be a period of time that would
  18     let one know whether the 1990 figure was a "blip",
  19     a one-off success, or whether it truly represented the
  20     point you have been making, that in 1988/89, with small
  21     numbers, it was just an artefact of chance?
  22   A. Could be, but I think we need to look at the isolated
  23     groupings of conditions to analyse that a little more
  24     carefully.
  25   Q. Then let us look at page 84. This is over 1s; it is

   1     a different group. The only thing of interest there is,
   2     looking at the complex surgery in the over 1s, where,
   3     1984 to 89, 26 per cent; 1990, 45.5 and UK 1988, 18.2.
   4     This might have been influenced by the early experience
   5     of the non-neonatal arterial switch?
   6   A. Yes. It might have. Again, we do not have the
   7     identified groups which would be helpful.
   8   Q. Because the disturbing thing about the 1990 statistics
   9     is that in the under 1s it is very good, but in the
  10     over 1s, the blip, if I can call it that, goes the other
  11     way?
  12   A. Yes, but with respect, you have not focused on the
  13     over 1s in any of the previous years in order to make
  14     comparisons.
  15   Q. I was just drawing this to your attention to ask
  16     whether this, as you recollect it, in any way acted
  17     as a counterpoint to the enthusiasm over the under 1
  18     results in 1990.
  19   A. Well, it would have been noted, certainly, but one
  20     really needs to see the individual groups to take that
  21     further.
  22   Q. Can we run through quickly and see what happened in
  23     1991/92? If we go to 1991, UBHT 55/113, the 30-day
  24     mortality for under 1 age for 1991 is now 30 per cent.
  25     If we go to page 114 in the same report, that gives us

   1     not only the breakdown by operation but also the United
   2     Kingdom figures and the United Kingdom average at the
   3     bottom of the page. So the picture must have been
   4     depressing, following the success in 1990.
   5   A. Well, yes. It is a significant change, again.
   6   Q. Was it seen that way?
   7   A. Yes. I believe that we would have taken note of that
   8     and looked to identify what the main problem was. Or
   9     problems. The one area again is the truncus arteriosus
  10     with a mortality of 75 per cent, but the national
  11     mortality is near 60 -- 58 per cent. And as you pointed
  12     out, the non-neonatal switches which were the
  13     transposition plus VSDs, although there was only one
  14     case in 1991, the group outcome was poor.
  15   Q. That is one case in the under 1s, it has to be said.
  16   A. Yes. By then, of course, the AVSDs, which had been,
  17     I believe, reasonably good up to then, we were beginning
  18     to see some deterioration in that particular operation.
  19        So again, we would have focused on those areas and
  20     as cardiologists, I think we would have considered what
  21     we could possibly do in terms of investigative
  22     modalities or interventions or appraisals that could be
  23     helpful to the surgeons. We had not yet gone into the
  24     neonatal switches, but we will come to that, no doubt.
  25     As far as AVSDs were concerned, the important element

   1     was then, and has continued to be, the issue of
   2     pulmonary hypertension and pulmonary vascular resistance
   3     problems, and we made a decision then that we should
   4     again catheterise earlier and if possible, operate
   5     earlier.
   6   Q. 1992, UBHT 55/126: the under 1s, 23.2 per cent.
   7   A. Can I just point out that the over 1s is 3.5 per cent?
   8   Q. Yes. If one were to look at this as, as it were,
   9     a graph going from 1984/85 through to 1992, at this
  10     stage one has had a graph which, with the exception of
  11     the one year in 1990, is consistently in the 20s or the
  12     high 20s, twice in the 30s.
  13   A. Yes.
  14   Q. The comparison, with the exception of the 1990 year,
  15     consistently above the United Kingdom figures overall?
  16   A. Yes.
  17   Q. We see that again, so far as the overall United Kingdom
  18     figures are concerned, I think if we go to page 129. If
  19     we scroll down, there again we have the United Kingdom,
  20     1990 mortality. The figure for 1990 for the United
  21     Kingdom is 15.8; for Bristol in 1992, 23.2. The picture
  22     that appears to be painted is that in the United Kingdom
  23     as a whole, mortality generally is declining a bit each
  24     year?
  25   A. Yes.

   1   Q. So anyone looking at those as crude figures would say,
   2     if we want to get a fix on where the United Kingdom is
   3     in 1992, it is probably a bit less than 15.8 -- it may
   4     not be very much, but a bit less?
   5   A. Yes.
   6   Q. Again we are looking at the Bristol figure, one and
   7     a half times as high as the United Kingdom?
   8   A. Yes, as the average.
   9   Q. Yes, as the average. If I were to suggest that this
  10     was -- again using a crude everyday phrase -- 'business
  11     as usual' restored after the success at 1990, that might
  12     give an overall reflection on the crude figures.
  13        Did people within the unit see it that way, or
  14     not?
  15   A. We appreciated that this was the sort of level that we
  16     were achieving, which was higher than the average UK,
  17     and of course we wanted to improve our results, but at
  18     the same time, as you pointed out, other units were
  19     improving steadily. So the 23 per cent given there is,
  20     to a degree, better than the 30, 32 per cent mortalities
  21     previously.
  22        So depending on how you look at it, on the one
  23     hand the ratio between the UK and Bristol is roughly the
  24     same, but we were of a mind, I believe, that as long as
  25     we were improving, then that was not good, but

   1     acceptable, as long as that trend was maintained.
   2   Q. So what would be unacceptable would be for Bristol to
   3     cease improving?
   4   A. Well, I would not know if that was unacceptable until
   5     I saw the figures.
   6   Q. I am just picking up on what you were saying.
   7   A. Yes.
   8   Q. I suppose also, when one looked at these figures, it
   9     would be appreciated that the United Kingdom figures
  10     would have included not only all the other units doing
  11     this particular work in the country, as reported to the
  12     UK register, but also Bristol?
  13   A. Yes, indeed.
  14   Q. So if Bristol was higher than the average and you, as it
  15     were, removed Bristol from the United Kingdom figures,
  16     the United Kingdom overall average would go down a bit?
  17   A. Yes, that is a statistical fact.
  18   Q. But you have said a couple of times when I have been
  19     asking you about these figures, "Well, that is the UK as
  20     a whole, and there may have been other --", I think the
  21     implication is that there may have been other units
  22     which were performing in very much the same way as
  23     Bristol?
  24   A. Yes, I believe so. I think that perhaps I should have
  25     said this before: there is a difference possibly in the

   1     approach between a unit like Bristol and other units who
   2     were achieving excellent results. That is in the case
   3     of selection of cases. You asked me right at the
   4     beginning about whether the case mix is generally the
   5     same throughout the country and I answered that it was,
   6     and indeed, it is internationally so.
   7        I was thinking in those terms when you asked me
   8     the question: internationally, the same kind of
   9     congenital heart disease occurs whether it is in Africa
  10     or India or the UK. There are some small variations in
  11     conditions, but by and large it is very much the same
  12     case mix. In terms of the results and the series in the
  13     country itself is concerned, we do not know how
  14     selective the excellent units are. I think it is common
  15     knowledge that in some centres, if a case is offered
  16     which is complex in terms of, let us say, a particular
  17     condition, double outlet right ventricle, of which there
  18     are varieties which are easier to correct than others,
  19     that a decision might be taken that this patient may not
  20     be operable and, if I can put it crudely, may sway my
  21     statistics. That is a factor that I can only put in in
  22     very general terms, but anecdotally, we knew happened.
  23        I think that Bristol always has felt that these
  24     are children who are going to die anyway. Patients with
  25     transposition unoperated have a mortality rate of 90 per

   1     cent at the end of one year. Tetralogy of Fallot have
   2     a natural history of life, average of 12 years. They
   3     are all fatal conditions -- not all; I exclude the VSDs
   4     and some others, but a large number of these complex
   5     anomalies are fatal. They are perhaps not perceived
   6     that way when you compare them with children with
   7     leukaemia, for instance, which is easily understood to
   8     be fatal, but these are. I think in Bristol, as
   9     exemplified by the Down's cases, we did feel that if the
  10     child was physiologically and haemodynamically operable,
  11     however difficult the case, we should take it on.
  12        So there are subtle differences of that kind which
  13     I would put into the argument in terms of overall
  14     results and outcomes.
  15        I am afraid statistics on its own are facile and
  16     unless one gets down to the nature of the cases and the
  17     nature of the decisions, it is not possible to make
  18     entirely valid conclusions or comparisons.
  19   Q. What is needed is, is it, a rigorous and questioning
  20     approach to what may lie behind the crude statistics?
  21   A. Yes.
  22   Q. Because what you are saying to me is that the statistics
  23     are, on the face of it, crude; they may be very
  24     misleading?
  25   A. Quite.

   1   Q. But equally, knowing that statistics are crude and may
   2     be very misleading, it might be a matter of ease or
   3     convenience to analyse the statistics away, by, for
   4     instance, breaking it down into small groups and saying
   5     there is no problem except in that small group and that
   6     is for a particular reason?
   7   A. Yes.
   8   Q. And logic of that sort. And that is obviously a danger,
   9     is it not, because one may equally be misled by that
  10     approach?
  11   A. Yes, that is true up to a point, but I think the more
  12     you do go down that road of evaluating individual groups
  13     of patients, and indeed, variations within that group,
  14     statistically it becomes perhaps less important, but in
  15     terms of a particular case, it is all-important.
  16   Q. Statistics can tell you nothing about the individual
  17     case, can they?
  18   A. No.
  19   Q. Because they are compilations of a number of individual
  20     cases?
  21   A. Yes.
  22   Q. If individual cases are different, as individuals are,
  23     it is unhelpful to look at them in isolation. The whole
  24     purpose, I suspect, of figures like these is to get an
  25     overview, is it not?

   1   A. It is a guide.
   2   Q. And the guide, presumably, is for the purpose of posing
   3     questions which then need to be answered?
   4   A. Yes, indeed. And we do not have a "miscellaneous"
   5     group on here, I am not quite sure why, but I think it
   6     would be worth looking at the size of the miscellaneous
   7     groups in the different group statistics or unit
   8     statistics. For instance, no doubt we will come to the
   9     transpositions, but included in those non-neonatal
  10     transpositions were cases of double outlet right
  11     ventricle, Taussig-Bing anomaly. These are not strictly
  12     transpositions. I do not know if other units are
  13     putting them into the "miscellaneous" group. It is
  14     quite possible -- in fact quite likely, I would
  15     suggest. It depends what you are including in your
  16     group and how up-front you are about putting the figures
  17     on the face of it.
  18        I think it is generally acknowledged that the
  19     Bristol figures were very acceptable, and I believe --
  20     this is hearsay -- that the response from the UK Cardiac
  21     Register organiser, usually the secretary of that group,
  22     was that our figures were reliable.
  23        So there are all kinds of questions. I simply
  24     want to make the point that statistics alone are
  25     insufficient in making an evaluation or judgment of any

   1     unit's performance.
   2   Q. The point that I was taking up from you -- not wishing
   3     to debate that particular issue with you, was that if
   4     that is right, then what is important is the way that
   5     one approaches the information the statistics are
   6     capable of giving.
   7   A. Yes.
   8   Q. The whole point of collecting data like this is not to
   9     say that data shows we are out of step, or for that
  10     matter to the positive side, as to the negative, and
  11     ignore that, the point is to flag it up and then say,
  12     "Why is this?"
  13   A. Yes.
  14   Q. The danger in asking "Why is this?" is that it may be,
  15     I suspect, comfortable to analyse away the difference,
  16     because there are always individual reasons for
  17     individual cases that one might find?
  18   A. Yes.
  19   Q. No doubt the same is true in whichever unit in the
  20     country one was seeking to analyse?
  21   A. Yes, but if the suggestion is that we were comfortable
  22     along the analytical process over the years, I would
  23     reject that.
  24   Q. The proposition I was putting to you is that that is
  25     a danger.

   1   A. It is a danger, yes.
   2   Q. It is a danger that has to be guarded against to make
   3     sure one does not, as it were, explain away adverse
   4     data.
   5   A. I quite agree.
   6   Q. You raise the point about the comparison of Bristol with
   7     other units. Is it perhaps the case that excellent
   8     centres, those, that is, that produce a low level of
   9     mortality on the crude outcome data, may be under,
  10     perhaps, more pressure to take high risk cases because
  11     of the very fact of their apparently good results?
  12   A. Yes. Indeed, that happens.
  13   Q. If a centre develops a reputation which no doubt is
  14     based partly on hearsay, but also partly on knowledge of
  15     figures, that might very well be likely to happen, might
  16     it not?
  17   A. Yes, it might do. Again, one has to look at the
  18     specific condition. Certain units have become
  19     recognised, as you say, both anecdotally and partly
  20     through statistics, for a particular good condition,
  21     good results with that condition, so there would be
  22     a tendency in that case to refer all cases, let alone
  23     difficult cases of, let us say, hypoplastic left heart
  24     syndrome, to one institution.
  25   Q. If anyone had asked you in, let us say, 1988, "Which is

   1     the best paediatric cardiac centre in the UK?" what do
   2     you think you would have said?
   3   A. I do not know enough, or I cannot place sufficient
   4     credence on the figures as I have suggested before, to
   5     be able to answer that. I can tell you that there is
   6     a group of units who were achieving excellent results,
   7     largely anecdotally; very little of this is actually
   8     published in peer review journals, and they would
   9     include Great Ormond Street, Brompton, Liverpool.
  10     Birmingham would be just beginning to come out of a very
  11     low ebb in the mid-1980s, that you might recall was
  12     responded to by, if I can put it this way, blowing up
  13     a particular case that was not able to be operated upon,
  14     and Birmingham were able to achieve almost overnight an
  15     expansion of their service and a new post of cardiac
  16     surgeon, i.e. Mr Brawn. We in Bristol chose a different
  17     route.
  18   Q. I think you may have answered the question that I was
  19     asking from the perspective of 1989.
  20   A. Yes.
  21   Q. If anyone had asked you in 1988 with the knowledge that
  22     you recollect you had then, what would you then have
  23     said?
  24   A. I think I was responding to 1988.
  25   Q. You were.

   1   A. Yes.
   2   Q. Because you did, from time to time, as you tell us in
   3     your statements, refer patients to other units?
   4   A. Yes.
   5   Q. And you did that, no doubt, in the belief that those
   6     patients would be better served in those other units?
   7   A. Yes.
   8   Q. A variety of other units you chose?
   9   A. Yes.
  10   Q. What was the basis for your choosing them?
  11   A. A variety of reasons, including a personal connection
  12     between someone who had trained, let us say, at the
  13     Brompton, knew the surgeon and knew he did an operation
  14     particularly well; the overall perception that
  15     cardiologists, as a group, would have of a particular
  16     unit's performance on another condition. The
  17     relationship between one surgeon and another, because
  18     these cases would be referred either by the
  19     cardiologists or after our joint meetings, by a cardiac
  20     surgeon, with whoever he or she, in this case he, was
  21     referring that patient to.
  22        So it is a variety of reasons, but I think, as you
  23     will see at that time, it was mostly Great Ormond
  24     Street, sometimes the Brompton, but later on
  25     Birmingham.

   1   Q. Dr Jordan, in his evidence to us, in describing the
   2     1980s, when he was asked about Bristol and the
   3     performance of Bristol, gently, I think, indicated in
   4     reply that Bristol was not the very best of cardiac
   5     centres.
   6        Would you have said the same had you been asked,
   7     let us say, by a referring paediatrician in those years?
   8   A. Yes.
   9   Q. Did you in fact do so?
  10   A. Yes, if asked, I would have done so, certainly.
  11   Q. A very difficult question, perhaps: had you, yourself,
  12     had a child requiring, let us suppose an AVSD correction
  13     in 1988, where do you think you would have referred that
  14     child?
  15   A. I think that is a question that is hypothetical --
  16   Q. It is.
  17   A. I simply am unable to answer that. I have had a child
  18     with a congenital anomaly, since you asked the question,
  19     that could have been fatal. It was not cardiac. So
  20     I have been there myself. Fortunately, my son is very
  21     well today.
  22   Q. May I ask where, if the anomaly was corrected, where was
  23     it corrected?
  24   A. This was in Cape Town, corrected by Professor Jannie
  25     Louw who soon after became the doyen of general

   1     paediatric cardiac surgery in South Africa.
   2   Q. Again, because it may give us a reflection of what you
   3     felt at the time, had that situation arisen in England,
   4     after you had come to England, rather than asking you
   5     where you would have sent your son, would you, do you
   6     think, have referred your child to Bristol?
   7   A. Again, I am unable to answer that. It was not
   8     a congenital heart defect. Our relationship with
   9     Professor Louw was one of tutor/student mentor. We were
  10     trained in Cape Town and we knew him, and there was just
  11     no question about whom we would have gone to.
  12   Q. In July 1989 -- can we have WIT 74/1083 -- we have the
  13     interim report of the Working Party on neonatal and
  14     infant supra-regional cardiac surgical units in England
  15     and Wales. This is a report to the Supra Regional
  16     Services Advisory Group. Did you ever see it?
  17   A. Can we scroll down a bit more? I am not sure I have.
  18   Q. What you might remember, and I will take you straight to
  19     it, is WIT 74/1090, the table at the back. The original
  20     writing at the top is "Figures for 1988 by centre
  21     (alphabetical)". The rest of the writing is added later
  22     by someone's hand?
  23   A. Yes. I have not seen this before.
  24   Q. You have not?
  25   A. No.

   1   Q. It is, as it happens, the second column from the right
   2     in each of these particular classes. The first is open
   3     under 1 year and the next is open over 1 year. Perhaps
   4     we can just take a long view of the sheet. That is
   5     Bristol and the other bars are those other centres which
   6     were designated at the time.
   7   A. Yes. I am sorry, I really do not know what is being
   8     represented, whether it is operations or --
   9   Q. These are numbers of operations.
  10   A. Yes. Under 1?
  11   Q. The top is under 1, the second is over 1, and then
  12     closed operations at the bottom.
  13   A. Yes, I beg your pardon, you said Bristol was second from
  14     the right. I was looking under Newcastle.
  15   Q. Second from the left. (Highlighted on screen).
  16   A. Yes.
  17   Q. If we bear in mind the top figure, the 29, and just go
  18     to WIT 74/1092, turn it sideways, these represent point
  19     estimates of mortality in 1988 and confidence intervals
  20     around them demonstrated by the bars.
  21        It shows, limited to 1988, the relative
  22     performance in terms of mortality of the different
  23     units. For that year, we have seen the figure 37.5 per
  24     cent?
  25   A. Yes.

   1   Q. And we can see the second from the left, as it happens,
   2     is again Bristol.
   3   A. Yes.
   4   Q. It appears to represent that the better units tend to be
   5     those doing a larger number?
   6   A. Yes.
   7   Q. And that was not surprising, I suspect, or would not be
   8     surprising?
   9   A. Yes, that is correct.
  10   Q. You did not see this at the time.
  11   A. No.
  12   Q. Did you have any idea at the time how other individual
  13     units were actually performing?
  14   A. No, not at all.
  15   Q. If you had seen information such as that in order to put
  16     the information you got each year from the annual report
  17     into some sort of context, you would have been able to
  18     compare Bristol year by year, depending on what the
  19     other years looked like with the performance of other
  20     units?
  21   A. Yes.
  22   Q. If that showed that Bristol as a unit was consistently
  23     either the worst or one of the worst, what reaction do
  24     you think you would have had to that?
  25   A. I would have been very disappointed, naturally, but

   1     I would need to see this on a year by year basis before
   2     making a confirmed response. But of course, it would be
   3     one of disappointment, but again, it would be a case of,
   4     as you pointed out, fewer turnover of patients, and
   5     again, as I have mentioned, we would have reviewed this
   6     looking at the particulars of the cases in detail, as
   7     indeed we did.
   8   Q. Let me give you a hypothesis. If this pattern, or
   9     something rather like it, were repeated over most years,
  10     to what reason do you think would you ascribe the
  11     relative low performance of Bristol? For what
  12     particular reasons?
  13   A. I do not think I can add to those we have discussed. We
  14     talked about the split site, et cetera.
  15   Q. So the split site; the absence of a dedicated paediatric
  16     cardiac surgeon?
  17   A. Yes.
  18   Q. And one of the things you mentioned, which I would like
  19     to explore a little more with you, is the question of
  20     staffing, because so far as cardiology was concerned, it
  21     was a consultant-led service?
  22   A. Yes.
  23   Q. Pretty well consultant only, was it not?
  24   A. Pretty well consultant only, yes, for most of the time.
  25   Q. Did you feel the need to have junior staff supporting

   1     the consultant cardiologists?
   2   A. Yes, of course.
   3   Q. What sort of support do you think you needed that you
   4     did not have?
   5   A. We needed a Senior Registrar, for a start, someone
   6     trained in paediatric cardiology. We did, from time to
   7     time, have fellows and outside UK, in other words,
   8     foreign doctors occasionally as fellows, either to do
   9     research or to get experience, but we did not have
  10     a regular substantive post as Senior Registrar until
  11     1992 or 1993. And of course this put us all under great
  12     duress. We had applied, I think, two or three times and
  13     the final one, or pre-final one, the penultimate, was
  14     when Dr Shinebourne came to visit Bristol to assess the
  15     centre with a view to recommending to the Joint
  16     Consultants' Committee that such a post should come into
  17     existence.
  18        So we struggled as a result of that.
  19        With regard to House Officer staff, over the years
  20     it varied from having, if you like, one third of an SHO,
  21     who also worked for two other specialty paediatric
  22     departments, to eventually a dedicated SHO for
  23     cardiology alone, or cardiology and cardiac surgery at
  24     the Children's Hospital alone.
  25   Q. When was that, roughly?

   1   A. Early 1990s -- late 1980s or early 1990s, I am not
   2     sure. The reason for the difficulty with SHO staff was
   3     that there was a set number of SHOs for paediatrics of
   4     all kinds, each accepted post had been allocated to
   5     either the general paediatric unit or the paediatric
   6     plus some other specialty unit, neurology, et cetera,
   7     and it was very tough competition to argue the case with
   8     the general paediatricians in the hospital to get them
   9     to accept that we had a similar need, if not greater,
  10     because they, understandably, wanted to hold on to their
  11     SHO. So there was a problem at that level.
  12        So far as the Senior Registrar is concerned, to go
  13     back to that, there is an anomalous situation whereby
  14     paediatric cardiology is the only specialty paediatric
  15     cardiac service that falls under adult cardiology. All
  16     the other subspecialties, neurology, gastro, oncology,
  17     fall under paediatrics. So in order for us to achieve
  18     a post in paediatric cardiology, the request would have
  19     to go via the adult wing or phalanx. We were therefore
  20     in competition with adult Senior Registrars allocated to
  21     the South West Region, of which there were one or two
  22     for the whole region. So clearly, we were regarded as
  23     being either too small or not of equal right, so to say,
  24     to be given a substantive post.
  25        So it was a tremendous struggle. The acquisition

   1     of junior staff all along was difficult.
   2        On the other hand, the noises coming through the
   3     centre for -- it must have been units that were very
   4     different from ours -- for services to be consultant-led
   5     and for consultants to put a greater share of their time
   6     into their work, and for middle grade staff to be
   7     essentially there for tuition rather than for service
   8     commitments, that became the order of the day. So we,
   9     if you like, preceded that advice by some years, and
  10     continued in that way.
  11   Q. What difference do you think it would have made to have
  12     had a Senior Registrar, a Registrar, and/or a dedicated
  13     House Officer in your discipline?
  14   A. It would have made an enormous difference in terms of
  15     much of the routine work required in any patient
  16     admission and workup and so on, but there is a level
  17     above which one cannot expect, certainly an SHO, and
  18     even a Senior Registrar, to go. I am thinking of
  19     cardiac catheterisation, or even echocardiography, to
  20     begin with, when a Senior Registrar has been trained.
  21     There is a level above which only a consultant really
  22     can do, so I think paediatric cardiology in any case is
  23     a service which depends probably more than others on the
  24     senior staff being committed to doing a large amount of
  25     the work.

   1   THE CHAIRMAN: I was going to put the other side of the coin
   2     to you, Dr Joffe, and say, if there is a level of work
   3     which is for consultants alone; presumably you are
   4     saying there is also other work which consultants should
   5     not, all things being equal, have to be involved in?
   6   A. Yes.
   7   MR LANGSTAFF: Because you began by saying there is an
   8     enormous difference?
   9   A. Yes.
  10   Q. Which is the routine work which presumably took up
  11     a degree of your time you wished it had not?
  12   A. Yes.
  13   Q. If you had that time, you would have wanted to devote
  14     that to what is properly consultant work?
  15   A. Yes.
  16   Q. One of the impacts of that would be that you did not
  17     have the available time on every occasion to go to the
  18     Royal Infirmary from the Children's Hospital where you
  19     were based in order to see one of your patients
  20     post-operatively?
  21   A. Yes.
  22   Q. Is that a matter of, looking back on it, regret?
  23   A. Yes, although, I must say on the other hand, that in my
  24     experience in South Africa, the paediatric cardiac
  25     surgical unit was run entirely by the surgical

   1     department, and we would be available when requested to
   2     perform whatever was needed or to give an opinion about
   3     a patient, and the treatment of the patient.
   4        So, when I came to this country, I had come from
   5     a culture that was possibly slightly different from the
   6     one operating in this country, and I think even in this
   7     country, the input of consultant cardiologists --
   8     paediatric cardiologists -- to the immediate
   9     post-operative care, has grown year by year. In the
  10     early 1990s, late 1980s, consultant paediatric
  11     cardiologists were not available, for instance, to do
  12     echos in theatre. This has come with the development of
  13     the specialty.
  14        But to answer your question directly, I do regret
  15     it. I think we may have made a difference to the
  16     overall outcomes, but it is very hard to put hard
  17     figures on to that, so it is an impression. But I wish
  18     we had the time to have spent in the BRI for that
  19     purpose. Unfortunately, we did not.
  20   Q. If you had had the available time, then would it have
  21     become a matter of routine, do you think, that there
  22     would have been post-operative echos?
  23   A. Yes. There are several aspects. As far as echos go, we
  24     knew that there was a facility available, Dr Wilde and
  25     later on, in addition, Paula Murphy, both had the

   1     expertise and the knowledge to provide that service.
   2     They were based at the BRI, in the Radiology
   3     Department. They were both interested, and I think part
   4     of their job description was cardiac radiology, and
   5     imaging, and so they provided that service. It was not
   6     as if there was no available echo service at the BRI,
   7     but they were not as available as perhaps paediatric
   8     cardiologists might have been under different
   9     circumstances. But the service was there, so we had
  10     some security of knowing that if a patient was
  11     deteriorating and the surgeons wished to have an echo,
  12     it could be done.
  13        I have lost the trend of the other part of your
  14     question.
  15   Q. I was suggesting that if you had had the available time,
  16     that it might have been the case that post-operative
  17     echos were a matter of routine?
  18   A. Yes. Well, ultimately. I mean, it was not a matter of
  19     routine, I would say, in most UK centres until probably
  20     the early 1990s, if not later. Dr Houston, of course,
  21     is here, who is an expert in this area and he might like
  22     to comment on that.
  23   Q. We will have the benefit of his company this afternoon.
  24   A. He is not here?
  25   Q. He is downstairs, in fact, but not in the hearing

   1     chamber. I do not want to mislead you. He is not
   2     physically here.
   3   A. Thank you. I am glad to hear I am not alone!
   4   Q. What would you say was the comparative expertise of
   5     Dr Wilde and later Dr Murphy as compared with the
   6     expertise of yourself, Dr Jordan, Dr Martin, in taking
   7     and analysing an echocardiogram on a young child?
   8   A. I do not know Dr Murphy as well as Dr Wilde, so I cannot
   9     really comment on her, although I have heard second-hand
  10     opinions which are very favourable, but I know
  11     Dr Wilde's work extremely well, and I would say, if
  12     anything, he is better than two of the three paediatric
  13     cardiologists, because this is an area of his interest
  14     and he has written a textbook on the subject, and
  15     indeed, I have attended courses that he has taught in.
  16   Q. How often were you ever asked to perform an
  17     intraoperative echo?
  18   A. Not at all when open-heart surgery was done at the BRI.
  19   Q. Do you think that that experience is one shared by your
  20     cardiological colleagues?
  21   A. I do not know for a fact, but if not, it must be on rare
  22     occasions, I think. But I really do not know. I cannot
  23     answer for them.
  24        May I go back? I forgot to mention in terms of
  25     the question about the availability of paediatric

   1     cardiologists at the BRI that Dr Jordan specifically
   2     made a point of going to the BRI every day and often
   3     twice a day, so it was not as if there was no presence
   4     whatsoever at the BRI.
   5        He found it slightly easier than I could because
   6     earlier on he was still involved in adult cardiology,
   7     had an office at the BRI, and needed to be there anyway,
   8     and indeed, he and later Dr Martin were running an
   9     outpatient clinic for adolescents and adults who had
  10     grown from the childhood period, usually post surgery,
  11     at the BRI. Therefore, they had some time when they had
  12     to go. So, apart from the weekends, I would say that on
  13     a daily basis there was at least one call by
  14     a paediatric cardiologist who would look at all the
  15     patients, not only his or her own, but all paediatric
  16     cardiac cases, and make recommendations about
  17     management, if necessary.
  18        In addition, we, or certainly I, tried I think on
  19     two occasions to establish a regular routine ward round
  20     at the BRI, twice or three times a week, and discussed
  21     this with Mr Wisheart at the time, and the intention was
  22     there, on both sides, but with all our other demands and
  23     the variation between timetables of surgeons and
  24     paediatricians, et cetera, it was just not possible to
  25     organise. So I simply mention that as part of the

   1     intention, but apart from that, the paediatric
   2     cardiologists did visit on a fairly regular basis.
   3   Q. When did you make those attempts?
   4   A. It must have been in the mid-1980s to late 1980s.
   5   Q. You made them because you thought no doubt that it would
   6     be desirable that you should have?
   7   A. Yes.
   8   Q. And hence your regret, expressed to us some 10 minutes
   9     or so ago, that because of circumstances, as you
  10     described, you were not able to?
  11   A. Yes.
  12   Q. To what extent was it the physical separation of the two
  13     buildings, one being up the hill, one down the hill,
  14     that made it difficult for you? You mentioned that
  15     Dr Jordan had an office down at the BRI which meant that
  16     he did go to the BRI?
  17   A. Yes, for a time. That stopped in the late 1980s,
  18     I think.
  19   Q. You did not have such an office?
  20   A. Well, I did initially, when we first started --
  21   Q. But thereafter not?
  22   A. No.
  23   Q. Was it the physical separation that made a difficulty?
  24   A. Yes, the physical separation was real, although of
  25     course not insurmountable. The distance between the two

   1     hospitals was really quite small: 150, 200 metres,
   2     maybe. But the hill, when you were walking up it, felt
   3     as if it was almost half a mile, rather than 200
   4     metres. It was extremely steep, so it was difficult
   5     coming back up; it was easy going down. This may sound
   6     trite, but it does make a difference, and it also makes
   7     a difference in terms of the ordinary communication that
   8     exists in a unit where consultants and various doctors
   9     can meet with each other and bump into each other in
  10     a corridor, and so on, which facilitates overall
  11     management.
  12   Q. Can I change tack a little? You were involved in the
  13     discussions, I think, that led to the designation of
  14     Bristol as a centre for neonatal and infant cardiac
  15     surgery?
  16   A. Yes.
  17   Q. We have seen on the screen which is still there,
  18     a snapshot in 1988 of the mortality figures which
  19     suggests that throughput and success in terms of
  20     relatively good outcomes tend to go together in the
  21     under 1 open-heart operations. You did not find that
  22     surprising as a concept?
  23   A. No.
  24   Q. Can we look at DOH 4/28? Turn it sideways. This is
  25     surgery performed under 1 year of age, divided as you

   1     can see into open, palliative and definitive types of
   2     surgery. This is Bristol. For open-heart surgery one
   3     looks at the figures from 1980 through to 1985. It
   4     scrapes into double figures at the end of that period.
   5     It is just on the double figure mark in 1981 and 1982.
   6   A. Yes.
   7   Q. In 1983, as it happens -- you rightly draw attention in
   8     what you say in your statement to the fact that earlier
   9     in this Inquiry we have focused upon that figure, or
  10     indeed a figure of 3, which --
  11   A. Yes -- 4.
  12   Q. Well, there are two figures for that year. It may
  13     depend whether one takes the financial year or not.
  14   A. Right.
  15   Q. One is 3, the other 4, but a very low figure, however
  16     one looks at it?
  17   A. Yes.
  18   Q. Those figures, without some confidence that they might
  19     be increased, would give one no real expectation of ever
  20     having a sufficient throughput of case in this category
  21     to develop or maintain the essential expertise. Would
  22     that be right?
  23   A. Yes. It needed to increase in order to improve overall
  24     performance.
  25   Q. If we have a look at ES 2/6, there is a minute of

   1     a meeting of representatives of designated
   2     supra-regional centres, Wednesday 5th December 1984, the
   3     first year of designation. The fifth name on the left
   4     is yours.
   5   A. Yes.
   6   Q. Can we go to the next page? Paragraph 1.3:
   7        "When the question of designating neonatal and
   8     infant cardiac surgery as a supra-regional service had
   9     been referred to the Advisory Group, there had been no
  10     hesitation in recommending that the service [as a whole]
  11     met the criteria laid out in HN(83)36. The specialty
  12     had already been looked at by a number of bodies ... the
  13     London Health Planning Consortium ... recommended three
  14     London centres. The Joint Consultants' Committee in
  15     1981 who had recommended 8 centres (the present ones
  16     less Bristol) and the Regional Medical Officers ... who
  17     had recommended the existing 9 centres."
  18        Do you know why it was that Bristol had not been
  19     recommended by the Joint Consultants' Committee?
  20   A. No, I do not, and I am afraid you would have to ask that
  21     committee.
  22   Q. Do you know how it was that Bristol's name came to be
  23     added to the 8 to make the 9?
  24   A. Yes. I had a hand in that. When we knew that these
  25     centres were being designated, I believed it was

   1     important, if possible, for Bristol to provide one of
   2     these designated services, partly because of
   3     geographical reasons; partly because I believed the unit
   4     had the potential to become an outstanding unit; and
   5     I was secondly, I suppose "appalled" is the word, at the
   6     fact that there had been no attempt by the people who
   7     were making the designations to visit Bristol and see
   8     the centre and find out what it had to offer. So
   9     I wrote a letter which was supported by Dr Jordan to the
  10     individual that I thought was the Chairman of this
  11     supra-regional group.
  12   Q. Can I just ask you to pause there? Can we look at
  13      JDW 1/150? That is a memorandum. If we go quickly to
  14     152 and then back to 150, at 152, the last paragraph:
  15        "We believe, therefore, that Bristol has an
  16     irrefutable claim for recognition as a supra-regional
  17     cardiac centre for neonates and infants ..."
  18        There are three signatories: yours is the first,
  19     Dr Jordan and Mr Wisheart?
  20   A. Yes.
  21   Q. Back to 150, please. Is that the letter that you had in
  22     mind?
  23   A. Yes -- well, it is one of them. There were several at
  24     the time.
  25   Q. So here you were, not long arrived in Bristol:

   1     a paediatric cardiologist, facing the decision which was
   2     or was not going to be made to designate Bristol.
   3   A. Yes.
   4   Q. You set out at the top of the page, the second
   5     paragraph, the number of open-heart operations taken as
   6     the major criteria for designation?
   7   A. Yes.
   8   Q. You deal, then -- let us scroll down -- with other
   9     important factors you say should have a bearing:
  10     geographical position, communications, association with
  11     the University Department of Child Health, historical
  12     evolution, ties with paediatricians, anticipated
  13     expansion and development?
  14   A. Yes.
  15   Q. And standards of associated paediatric and neonatal
  16     services. You point out the actual surgical operation
  17     is only a part of the overall management?
  18   A. Yes.
  19   Q. You deal then with arguments which you put forward.
  20     If we go to page 151:
  21        "Practical developments in the extension of
  22     cardiac facilities for children in Bristol which have
  23     a bearing on the issue include ..."
  24        You say a new Intensive Care Unit and a plan to
  25     develop the cardiac catheterisation facilities.

   1        The Intensive Care Unit was at the Children's
   2     Hospital?
   3   A. Yes.
   4   Q. Open-heart surgery, when you wrote this, would be
   5     performed at the Royal Infirmary?
   6   A. Yes.
   7   Q. In the paper, in the advantages of pushing the case for
   8     Bristol, do you recollect including that consideration?
   9   A. I do not recollect if I did in this letter, but
  10     certainly in other missives that point is made. Could
  11     we scroll through the whole one?
  12   Q. Yes, look at the bottom of the page. While we are on
  13     that, can I ask you a couple of questions about what is
  14     there under "Neonates and infants".
  15        In the second paragraph:
  16        "There are two main reasons for the relatively
  17     small number of infants subjected to open-heart surgery
  18     at present. One is our conservative approach to
  19     operating on small babies when similar results can be
  20     achieved at a slightly older age."
  21        You then describe transposition of the great
  22     arteries and the correction, which then would have been
  23     a Mustard or Sennings?
  24   A. Yes.
  25   Q. And point out that that takes place older rather than

   1     younger, as it does elsewhere. Was there then such an
   2     approach at that time?
   3   A. Such an approach to --
   4   Q. A conservative approach to operating on small babies?
   5   A. Yes, I mean, it was not only in Bristol; it was,
   6     I think, national, but certainly under the circumstances
   7     at that time in Bristol, that was definitely an
   8     approach.
   9   Q. You are dealing with a relatively small number?
  10   A. Yes.
  11   Q. So you are, I think, are you not, saying it would be
  12     more conservative than other places?
  13   A. Yes, I think so, in general. I was not comparing
  14     specific centres, yes.
  15   THE CHAIRMAN: Should the last word on the third line be
  16     "younger" rather than "older"?
  17   MR LANGSTAFF: No. I think, if I may ask Dr Joffe on that,
  18     what is being said here "We operate older rather than
  19     younger", is it?
  20   A. Yes. It was seen at that time to be an advantage to
  21     operate on bigger, more mature infants, so we did the
  22     Sennings over a year whereas some other units were
  23     correcting at under a year. So in effect, the number of
  24     infants in relation to the supra-regional services
  25     definition could be skewed one way or the other,

   1     depending on whether you made a selection to operate on
   2     cases like transposition for Sennings.
   3   THE CHAIRMAN: I was trying to make sense of that sentence
   4     in the light of the one that followed it, but maybe
   5     I will have to go away and read it again.
   6   DR JOFFE: I might have to do the same, I think.
   7   MR LANGSTAFF: However the language might read and be
   8     interpreted, the point you were making was, was it, that
   9     in Bristol at the time you were operating older rather
  10     than younger?
  11   A. Yes.
  12   Q. That for the future, one might increase the number of
  13     children in the appropriate category by operating
  14     younger rather than older?
  15   A. Yes.
  16   Q. That might be done without disadvantage to the child?
  17   A. To the patients, yes: the same may be said, if I could
  18     just interject, for ventricular septal defect babies as
  19     well.
  20   Q. Thank you. You go on, later on down that paragraph:
  21        "The more important factor, however [the second
  22     main reason for the relatively small number of infants
  23     subjected to open-heart surgery] is the lack of
  24     facilities for cardiac surgery generally."
  25   A. That is adult and paediatric.

   1   Q. Yes, but you were saying in the letter, in the July 1982
   2     memorandum, that one of the reasons for not treating as
   3     many children as you might was that there was a lack of
   4     facilities for cardiac surgery generally, adults, in
   5     other words, having an impact upon the ability of the
   6     unit to treat children. That is the point, is it?
   7   A. Yes.
   8   Q. That is why the proposal to double the overall cardiac
   9     surgical output -- that is again adults, with some
  10     children -- might have a positive effect on the number
  11     of children treated. That is the point?
  12   A. That is correct, that is the point.
  13   Q. You then go on, at the bottom of the page, we can turn
  14     over as you wanted to do earlier to 152:
  15        " ... uniform support from throughout the region
  16     for a supra-regional paediatric cardiac centre to be
  17     based in Bristol. Secondly, it was emphasised that
  18     seriously ill babies referred for suspected heart
  19     disease often had other pathology as well, or developed
  20     non-cardiac problems, and required broadly based
  21     paediatric expertise."
  22        Of course, you had the Children's Hospital.
  23   A. Yes.
  24   Q. You say:
  25        "It is noteworthy that Bristol already functions

   1     as the regional referral centre for other specialties...
   2        "Thirdly, the favourable system of
   3     communications..."
   4   A. Yes.
   5   Q. Essentially, that paragraph at the top of page 3 is what
   6     one might describe as a "geographical case", is it?
   7   A. At the top of that page, yes.
   8   Q. You conclude that Bristol has a --
   9   A. Well, in addition, pardon me, to the availability of
  10     other paediatric services.
  11   Q. Well, that itself is a reflection, is it not, of
  12     location?
  13   A. Yes.
  14   Q. So the points made at the bottom of 151 and 152 are:
  15     we have the ability to expand because first of all we
  16     can start doing some children, doing their operations at
  17     a younger age, without disadvantage to the child?
  18   A. Yes.
  19   Q. Secondly, we will now be getting the facilities which we
  20     have lacked in fact, so that the block on the number of
  21     children's operations will be lifted?
  22   A. Yes.
  23   Q. So we are likely to do more cases in the future.
  24     Secondly, there are points on location.
  25   A. Yes.

   1   Q. You summarise it:
   2        "We believe, therefore, that Bristol has an
   3     irrefutable claim for recognition ..."
   4        You refer to the demand and the effect of not
   5     giving a centre designated status in Bristol, which you
   6     say would lead to the demise of meaningful paediatric
   7     cardiology in Bristol?
   8   A. Yes.
   9   Q. Have I missed any main reason that you were putting
  10     forward as part of the "irrefutable" claim?
  11   A. I do not believe so. At that time, those were my
  12     thoughts, very clearly expressed there, I think, at that
  13     time.
  14   Q. You felt, did you, that the lack of designation would
  15     actually lead to the demise of a paediatric
  16     cardiological centre in Bristol?
  17   A. I must say, I meant that in two ways. I think the
  18     emphasis is not necessarily on the demise of paediatric
  19     cardiology per se, i.e. the centre will not survive; it
  20     is the demise of meaningful services for the paediatric
  21     population in Bristol and the South West.
  22   Q. So you were, or were not, saying in effect: here am I,
  23     a paediatric cardiologist. Unless Bristol has
  24     designation, I may be left without a job to do?
  25   A. No, it was not that at all.

   1   Q. So far as you are aware, was there any other reason,
   2     other than those that you advance in that memorandum,
   3     which persuaded the powers that be to designate Bristol
   4     as a centre?
   5   A. Well, not that I am aware of.
   6   Q. Did you, in the light of what you were saying about the
   7     need to increase throughput, the numbers of operations
   8     done in that particular age group, have any
   9     encouragement, as you recall it, thereafter, from the
  10     Department of Health or the Supra Regional Services
  11     Advisory Group or the Royal Colleges, to do that?
  12   A. To increase numbers?
  13   Q. To increase the number of operations done?
  14   A. Well, yes, there was a guideline, I think produced by
  15     the Supra Regional Services Committee, that in order to
  16     fulfil a service of the type that required designation,
  17     one ought to be reaching a total of either 40 or 50 --
  18     the figure varied -- per year of under 1 year open-heart
  19     operations.
  20   Q. Which Bristol, as it happens, never did until the 1990s?
  21   A. I think in common with a few other centres.
  22   Q. We have been told by Dr Halliday, amongst others, that
  23     the number of cases dealt with by Bristol hereafter
  24     remained a matter of concern?
  25   A. So he says.

   1   Q. Did it remain a matter of concern to you in Bristol?
   2   A. Yes.
   3   Q. He attributes it in part to a failure -- this again is
   4     putting it rather crudely -- to market the services
   5     available in Bristol through those who were involved in
   6     cardiology at Bristol.
   7   A. I do not know if he made that comment.
   8   Q. That is what he told us. What is your comment on that?
   9   A. I think he may be partly correct. I think we were all
  10     so overworked that the idea of doing a marketing job was
  11     not uppermost in our minds. I think we were more
  12     concerned about managing the service that we were
  13     operating.
  14   MR LANGSTAFF: Sir, on that note, again, having regard to
  15     the time, would it be an appropriate time to take
  16     a lunch break?
  17   THE CHAIRMAN: Yes. Shall we say, then, until about 1.20?
  18   (12.40 pm)
  19            (Adjourned until 1.20 pm)
  20   (1.30 pm)
  21   MR LANGSTAFF: Dr Joffe, so that those watching you
  22     understand, I think you are the first tea drinker we
  23     have had publicly displaying your abilities. You have
  24     a sore throat, I think?
  25   A. Yes, I do and warm liquid is better than cold, thank

   1     you.
   2   Q. If you find your throat is giving out and you need
   3     a replenishment, please indicate it and let us know, it
   4     will not be taken amiss.
   5   A. Thank you.
   6   Q. We were looking, amongst other things, at the timing of
   7     surgery. It appears from what you say that the timing
   8     in which children came to surgery was a matter of some
   9     importance as to mortality or morbidity about which
  10     views changed during the period we have been looking at.
  11   A. Yes.
  12   Q. Would you say, looking back again at the period before
  13     the split site was rectified, that the timing of surgery
  14     for children was by the standard applied generally in
  15     the UK at the time, optimal?
  16   A. Yes, I cannot again answer for the national figures.
  17     I do not know whether comparatively speaking we were
  18     behind or in front or operating on younger or older
  19     ages, but it was --
  20   Q. Can I change the question in this way and say: were you
  21     always able to operate upon children at the age that you
  22     wished to operate or did you find that, perhaps because
  23     of adult demands, surgery was pushed back to later?
  24   A. Yes, we would have wished to operate at an earlier age
  25     in certain conditions.

   1   Q. What was it that prevented that taking place; was it as
   2     I have described the pressure of the adults?
   3   A. Yes, I believe it was ultimately the pressure of the
   4     adults. As you may know, the patients are discussed in
   5     detail at joint meetings of cardiac surgeons and
   6     paediatric cardiologists and others and decisions are
   7     jointly come to in the vast majority of cases. Then the
   8     patient is either accepted or not, usually accepted, by
   9     one or other surgeon and then that patient's name goes
  10     on to a surgeon's list, not on the waiting list yet but
  11     an acceptance that the surgeon will see the family in
  12     outpatients and it is at that time, once the surgeon has
  13     had an opportunity to discuss the details of the risks
  14     with the families, that they effectively go on to the
  15     waiting list.
  16        So there would be a time period between the joint
  17     meeting which itself usually occurred within two to
  18     three weeks or so of the cardiac catheter study, if one
  19     is done or otherwise on the basis of echocardiographic
  20     findings, the paediatric cardiologists would put that
  21     patient into the list for discussion, so there is
  22     a short period of delay there inevitably in the system
  23     and then once the surgeon has accepted the patient after
  24     seeing the family, it goes on to their waiting list.
  25        So from that point on the cardiologists really

   1     have no handle on the timing of surgery, which is also
   2     different from my experience in Cape Town; it was the
   3     cardiologists who actually held the waiting lists and
   4     therefore we would, of course, also in addition to the
   5     surgeons, know which patients were priority or not and
   6     in a sense that information was no longer in our hands.
   7        Now I understand perfectly well in Bristol why
   8     that should be. Again it comes to the split site, the
   9     adult service, the fact that both surgeons had to fit
  10     those paediatric cases into a broader list with adults
  11     who might be on their waiting list with coronary artery
  12     disease for a long period of time, a year perhaps or
  13     more, and it was a balance -- for them a very difficult
  14     balance -- of having to identify which patients should
  15     get the priority, or be operated earlier or later.
  16        So from our point of view it unfortunately
  17     I believe in a sense was not possible for us to hold the
  18     reins in that aspect.
  19   Q. What happens now?
  20   A. Now, because we are on one site the operations can be
  21     done much more readily because we are not competing with
  22     adults. So the turnover is much quicker so the waiting
  23     time is reduced to a month or two for virtually any
  24     case. So it is no longer an issue, the patient is
  25     operated upon pretty well at what we would now regard as

   1     the optimal time.
   2   Q. When it was an issue, when there was the split, from
   3     much of the evidence we have heard there seems to have
   4     been very little voice raised in favour of maintaining
   5     the split, save on financial or similar administrative
   6     grounds.
   7   A. Yes.
   8   Q. In terms of care of the patient, the views broadly are
   9     one way?
  10   A. Yes.
  11   Q. And coincide with yours. The question arises: whilst
  12     the split site was recognised to be a problem, what in
  13     the way of management of the difficulties that it caused
  14     might have alleviated some of the worst aspects of it?
  15     What you are suggesting, I think in terms of the delays
  16     in surgery which would occur because of the impact of
  17     two things, one the split site and, secondly, the fact
  18     that the surgeon to whom the children were referred
  19     would be operating on adults as well as children; what
  20     might have been done do you think to so organise matters
  21     that that was not the same problem for children; would
  22     it have been to hand over the operating list for
  23     a particular session to the cardiologist?
  24   A. That might be an option, but it is much more complex
  25     than that because frequently, not all that frequently,

   1     but in a significant number of cases, in both adults but
   2     particularly children, a patient might come in in
   3     readiness for surgery and pick up an intercurrent
   4     infection, as occurs frequently in babies or children
   5     and have to in fact defer the operation.
   6        So there are changes happening all the time to the
   7     list and it is really only the individual who is at that
   8     point having to make the decision about who to operate
   9     on, it is only that person who can actually adjust the
  10     list effectively and realistically.
  11        So I do not think handing over the list to us
  12     would have been a practical solution.
  13   Q. Even though it seemed to work in South Africa?
  14   A. Yes, well, in South Africa it was all on one site.
  15   Q. So it was the single site that made the entire
  16     difference?
  17   A. Yes, quite. Or shall I say it was the lack of
  18     competition by adults.
  19   Q. If we go back to what we have on the screen, in 1984
  20     when you make the plea on the basis that you do here in
  21     this document for supra-regional status to be given to
  22     the under 1s, you have a situation where you regarded it
  23     as essential that there should be a dedicated paediatric
  24     surgeon and there was not?
  25   A. Yes.

   1   Q. You regarded it as a sine qua non that there should be
   2     a unification of surgery and cardiology on the one site?
   3   A. Yes.
   4   Q. And there was not. You did not anticipate from your
   5     experience in South Africa that that would happen soon,
   6     indeed, you had something of a timescale of 8 years in
   7     your mind?
   8   A. For a cardiac catheter laboratory, it took 8 years in
   9     Bristol.
  10   Q. You also faced, I think, and it may be we will have to
  11     go into some detail on it, problems perhaps with
  12     equipment, some of the equipment was old, was it; was it
  13     always a battle to get new equipment?
  14   A. Yes, it always was. Again, without the assistance of
  15     charitable organisations such as the British Heart
  16     Foundation and the Bristol and South West Heart Circle
  17     and the Guild of Friends of the Children's Hospital,
  18     these were all bodies that gave us assistance
  19     financially and helped to acquire echocardiography
  20     equipment particularly, but also other machines.
  21   Q. You did not have in the early 1980s the numbers which,
  22     on the face of it, would justify having a supra-regional
  23     centre; you had the problems with staffing support that
  24     you have spoken about and a difficulty, for the reasons
  25     you have mentioned, an inevitable difficulty as you

   1     describe it about which little could be done in any
   2     administrative way in terms of timing of an operation at
   3     an optimal time for the child concerned.
   4        Thinking back on it, should Bristol, do you think,
   5     ever have been designated as a centre for neonatal and
   6     infant cardiac surgery?
   7   A. My opinion is clearly, yes, and that is why I made the
   8     application. The point about numbers, your first point
   9     of patients I think was common to four or five of the
  10     other centres at that time that became designated and
  11     I think if you refer to the document -- I do not recall
  12     if it is the Regional Medical Officer's or the one
  13     before that, I think it is the one before, there is
  14     a figure, a graph which shows that the number of centres
  15     in 1982 -- 1981/82, I believe, this is going back
  16     a while, were roughly the same as several other
  17     centres.
  18        So in terms of numbers and throughput, I do not
  19     think we were really different. The other aspects of
  20     staffing and bringing together a single combination of
  21     the surgical site was something that we expected to
  22     happen, it was anticipated, this is back in the early
  23     1980s and there was no reason at that time for us to
  24     know that outcome, that it was going to take that long
  25     for the site to become unified.

   1        So, again with a retrospectoscope it is easy now
   2     to sit back and say we should not have even put in an
   3     application. At that time it was very much, I believe,
   4     on a par with the other centres that were making the
   5     same bids.
   6   Q. I think there are perhaps two matters there. Leave
   7     aside for the moment that Bristol may have been on a par
   8     with other units, which is a matter which will have to
   9     be resolved from evidence about other units as best the
  10     documents can reflect it to us.
  11        So far as Bristol itself was concerned, it was
  12     essential to have one paediatric cardiac surgeon,
  13     a sine qua non to have a unified site --
  14   A. In due course, yes --
  15   Q. Neither had b