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Daily transcripts
Hearing summary
15th December 1999
This morning the Inquiry heard from Cedric Prys-Roberts, Professor of
Anaesthesia at the University of Bristol and Honorary Consultant Anaesthetist, United
Bristol Healthcare NHS Trust (UBHT). He discussed the concerns raised with him by Dr
Stephen Bolsin, consultant anaesthetist, about mortality rates in paediatric cardiac
surgery. He then told of a meeting he had with Dr Roylance in order to raise Dr
Bolsin’s concerns with him. Prof. Prys-Roberts was then asked about concerns raised
by people other than Dr Bolsin and about a letter from the Southampton Cardiac unit
detailing the concerns of "3 young cardiac anaesthetists". Prof. Prys-Roberts
also discussed Dr Bolsin’s application for a post in Oxford and his suggestion that
Dr Andy Black, University of Bristol, contribute to Dr Bolsin’s data collection.
Mr James Wisheart, former Medical Director, UBHT, completed his
evidence today. He began by discussing clinician’s aspirations, and reasons behind
them, to appoint a dedicated paediatric cardiac surgeon and to transfer all paediatric
cardiac surgery to the Bristol Children’s Hospital (BCH) from the Bristol Royal
Infirmary. He went on to comment on the discussions of a meeting held in July 1991, at
which concerns were raised by the cardiac anaesthetists about high mortality rates for
some paediatric cardiac operations. He commented on concerns raised in the South West and
Wales about the waiting times for both adult and paediatric procedures, the scheduling of
operative lists and comparisons of the number of referrals for each age group. Mr Wisheart
then described attempts made to gain supra-regional capital funding. Next he spoke
generally about communications and concerns raised about paediatric cardiac surgery
externally, focussing on the consequences of the article in the magazine, Private Eye. He
continued his evidence by telling the Inquiry about the period following the review of
paediatric cardiac surgery in 1995 carried out by Dr Stewart Hunter and Professor Marc de
Leval, focussing his evidence on his working relationship with clinical colleagues. He
concluded by discussing the issue of consent for retention of tissues.
|
FULL TRANSCRIPT
1 Day 94, Wednesday, 15th December 1999
2 (9.10 am)
3 THE CHAIRMAN: Good morning, everyone. Good morning,
4 Miss Grey.
5 MISS GREY: Good morning, sir. Before we resume with the
6 evidence of Mr Wisheart today we have first the evidence
7 of Professor Prys Roberts, if I could invite him to take
8 the witness stand, please?
9 Professor, we have asked witnesses to sit if they
10 feel comfortable while giving evidence, but to stand
11 please when taking the oath
12 PROFESSOR PRYS ROBERTS (SWORN):
13 Examined by MISS GREY:
14 Q. Professor, you have provided a statement to the Inquiry;
15 if we look please at WIT 382/1, is the document that you
16 have in front of you on the screen the first page of
17 your statement?
18 A. Yes, it is.
19 Q. If we turn to page 5, please, is that your signature
20 there?
21 A. It is.
22 Q. Are the contents of this statement true to the best of
23 your knowledge and belief?
24 A. To the best of my knowledge, that is correct, yes.
25 Q. Professor, if we could turn back to page 1 of the
0001
1 statement and scroll down, please, to the bottom of the
2 page, we see there an account of an approach to you by
3 Dr Bolsin in 1989. This I think was the first occasion
4 that you can recollect when Dr Bolsin came to you
5 expressing concerns about paediatric cardiac surgery or
6 anaesthesia at the BRI?
7 A. That is correct, yes.
8 Q. When Dr Bolsin gave evidence to the GMC, he did not
9 speak of or specifically recollect any encounter between
10 the two of you as early as this. Can you remember
11 clearly such an early encounter?
12 A. I can remember clearly the encounter in 1989 because
13 Stephen Bolsin had only recently been appointed as
14 a consultant in the BRI and of course we lived together
15 in the same building and we meet each other regularly
16 and on this particular occasion, of course I cannot
17 remember the precise date, he came to me and expressed
18 what I regarded even at that stage as very serious
19 concerns which in a way were simply saying "I have been
20 trained at the Brompton, I have been doing five cases
21 a day on seriously ill babies and they have been doing
22 well and here I am, a new consultant in Bristol and I am
23 seriously worried I am only dealing with one patient
24 a day and that patient is not doing very well". That
25 was his main concern at that time.
0002
1 Q. That was a concern based on his experience of
2 anaesthetising patients?
3 A. Yes.
4 Q. Rather than any formal study or data at that stage?
5 A. No, purely his own experience.
6 Q. In your statement you talk about his expressing his
7 concerns to you about problems following cardiac surgery
8 by Mr Wisheart. Were his concerns specifically focused
9 upon Mr Wisheart or upon both cardiac surgeons?
10 A. I think he was referring more -- I cannot remember
11 precisely because there were only two cardiac surgeons
12 apart from the Senior Registrars. So I think by
13 implication he was referring more to Mr Wisheart with
14 whom he was doing paediatric anaesthesia. I think he
15 was doing more with Mr Wisheart than with Mr Dhasmana
16 because of the days in which he actually provided
17 cardiac anaesthesia. There was no specific reference to
18 Mr Wisheart at that stage.
19 Q. If we went back to your evidence to the GMC you said
20 there that Dr Bolsin said, and I am quoting now,
21 "something to the effect that 'I do not know what I am
22 going to do because I am doing the best I can and all
23 these children are dying.'" Is that a phrase you can
24 recollect?
25 A. Something similar to that, yes. I mean that was the
0003
1 sort of expression he made to me in 1989; that I think
2 he had just had a death on the table, that is the child
3 had not come off the table and gone back to ICU and he
4 was absolutely distraught about it because he did not
5 think it was his fault.
6 Q. The implication of that phrase is that he was at least
7 questioning his practice as an anaesthetist and
8 therefore the potential impact his practice might be
9 having upon death rates. Do you think at that stage he
10 was questioning his own performance as it were as
11 a cardiac anaesthetist?
12 A. I think we would all question our own performance under
13 those circumstances. I mean at any time a patient does
14 not survive for whatever reason, we question, did we do
15 the right thing, what was the reason and so on and he
16 felt he wanted to unburden himself a little bit and he
17 was treating me simply as a senior colleague.
18 Q. He is questioning his own performance as well as that of
19 the unit or other people involved in cardiac surgery.
20 At that stage did you have any sense of what he felt
21 might be the reasons for the problems he was perceiving
22 or watching?
23 A. Not really. I think he felt that the surgery was taking
24 so much longer in Bristol than it had been in the
25 Brompton where he had been trained and he felt that the
0004
1 longer duration of surgery, when it might be tolerated
2 well by adults, was tolerated less well by small babies.
3 Q. If we turn over the page to page 2 we can see at the top
4 of the page that you advised him, rather than create
5 waves with little credible evidence he should collect
6 prospective data. Why do you use the phrase "create
7 waves"?
8 A. Steve was a person who wanted to broadcast everything
9 and make the whole world aware of what was going on
10 right from the outset. He was not somebody who was
11 introspective about these things. My concern at that
12 stage was that he would say something which he might
13 later regret without having the evidence to back it up
14 and I suggested to him -- because I think this is proper
15 medical practice -- that what he should do would be to
16 keep records of what he was doing so that at a later
17 date, if things turned out to be as they certainly have
18 done, he would have evidence in the form of a logbook,
19 in the form of other data that he may have collected on
20 a prospective basis, but this was a personal thing. We
21 all keep -- I say "we all", I keep a personal logbook of
22 every anaesthetic that I give and I follow up the
23 patients. I think this is proper medical practice and
24 I was advising Steve to do the same.
25 Q. Did he not keep a logbook already?
0005
1 A. I do not know.
2 Q. Who was he thinking of raising the problem with at this
3 stage?
4 A. I cannot remember at that stage, but certainly later on
5 he was wanting to go public, in other words to speak to
6 the press and I and others advised him that he did not
7 have enough credible evidence to go public at that
8 stage. Certainly in 1989 I do not think I would have
9 said that he wanted to go to the press at that stage.
10 Q. If at a later stage he wanted to go to the press, can
11 you date that sort of conversation?
12 A. We certainly had a conversation in mid 1992 because he
13 and I and Dr Brian Williams had a conversation or
14 a meeting, slightly more formal than otherwise and we
15 were trying to persuade him that it was not appropriate
16 for him to go and present Bristol in a bad light in the
17 public press at that stage. The problem was that he was
18 extremely frustrated at not being able to improve things
19 to the standards that he expected things should be
20 improving to.
21 Q. You advised him to collect prospective data; what did
22 you know about the availability of figures within the
23 cardiac surgery unit, and by the "unit" I include the
24 anaesthetists, at that time?
25 A. I knew that the unit would be keeping data because all
0006
1 surgical units would have to present their annual data
2 to the DHSS in a hospital report. I knew there would be
3 logs kept by the perfusionists, I knew some of the
4 anaesthetists would keep their own personal logbooks.
5 I was not aware, nor would I have access to any of the
6 specific data in the cardiac unit because I was not in
7 any sense involved with cardiac anaesthesia or that
8 team.
9 Q. If I ask to be brought up on the screen, please,
10 UBHT 55/22, you can see there the first page of an
11 annual report for 1988, so shortly before you spoke to
12 Dr Bolsin, although it would not necessarily have been
13 available before 1989.
14 If we turn to page 31 we can see there the sort of
15 results that are being collected by the unit and
16 incorporated in this report. Was any of that material,
17 material which you had seen at that time?
18 A. No.
19 Q. Or were aware of its existence?
20 A. I was aware that this type of material would exist in
21 any hospital, but, as I say, because I was not directly
22 involved in cardiac surgery or cardiac anaesthesia,
23 I would not have seen that data. I would have seen data
24 from the surgical units that I worked with, in vascular
25 surgery and so on but not the cardiac data, no.
0007
1 Q. But if you were aware that this sort of data, that is
2 figures about numbers of operations, deaths existed, why
3 advise Dr Bolsin to collect his own data?
4 A. Simply because he wanted to have information of his
5 own. These data would normally be publicly available,
6 presumably even within the cardiac unit be available.
7 They would be retrospective, maybe by as much as one or
8 even two years by the time the data has been collected,
9 collated and published.
10 What I was suggesting to him: by keeping
11 prospective data you enable yourself to keep an eye on
12 what is going on now and keep it on a running basis so
13 that you can at least correlate what you have with
14 whatever other information you subsequently find.
15 Q. Was it the immediacy of the data and the possibility
16 perhaps of examining trends as they developed that was
17 the important feature?
18 A. Yes.
19 Q. Was there any suggestion that the data that Dr Bolsin
20 might collect might incorporate new elements or
21 different features that might not necessarily be
22 available in the unit's data? By that I might suggest,
23 say, two factors: one would be length of time on bypass
24 or cross-clamp times --
25 A. Yes, that is certainly true that if he collected his own
0008
1 data he would, I would guess, as a cardiac anaesthetist,
2 keep a record of time on bypass because that is a very
3 important factor. The other thing he might also have,
4 by gathering the information and knowing the
5 stratification of patients into various classes for
6 different operations, which would be better stratified
7 than simply "simple", "moderate" and "complex" and so
8 on, so things like that.
9 Q. When you went and gave evidence to the GMC, in
10 discussing the conversation with Dr Bolsin in 1989 you
11 talked about the fact that you advised him to collect
12 data. You went on to say:
13 "I was aware at the time he came to see me that
14 he had presented some preliminary data to the Trust, at
15 least it was not the Trust in those days, it was the
16 District Health Authority, and that his concerns had
17 been turned down, he was very worried about that."
18 Did you mean to date that perception on your part
19 of being rebuffed or turned down by the Trust or the
20 Health Authority to that initial encounter in 1989?
21 A. No, no, I think with hindsight -- I cannot remember what
22 precisely I said at the GMC Inquiry, I may not have
23 specifically addressed the dating of that. I mean I was
24 aware that Steve had approached the Trust, or the Health
25 Authority as it was at that stage. I was aware that he
0009
1 had been asked to talk to Mr Wisheart and had been sort
2 of dressed down. I cannot remember precisely what dates
3 those were, but he was certainly very concerned from
4 that time onwards that he had the finger on him and that
5 he had been told something to the effect that "this is
6 no way to behave if you want to make your way in this
7 sort of unit".
8 Q. Can we look at two elements of that. The first is the
9 timing of your awareness of that rebuff. Is this
10 something that you were aware of as having happened by
11 1989?
12 A. No.
13 Q. Or was it something that you became aware of at a later
14 stage?
15 A. At a later stage. I cannot be precise as to how much
16 later, but I would have guessed at least a year later.
17 Q. If we look at GMCT 11/90, which is a page from the GMC
18 transcripts --
19 A. I think I say here, "I think it was in 1990" which is
20 what I have been saying. I cannot be absolutely certain
21 of that.
22 Q. If we scroll down a little, you say: At what stage in
23 1990, you cannot be certain at what stage it was (that
24 is the event), because you were not involved in it, it
25 was simply that it was told to you at a later time when
0010
1 Dr Bolsin discussed it with you subsequently in 1992.
2 Could that be a more accurate chronology of
3 events, that the incident Dr Bolsin was referring to
4 happened in 1990 and you were told about it in 1992?
5 A. It certainly could be. I would have to stress that
6 Dr Bolsin and I did not simply meet in 1989/1990/1992,
7 we lived on the same corridor, we were involved in
8 research, we were involved in many other things,
9 teaching and so on and when I have specifically referred
10 to dates it is when we had a specific meeting at which
11 he addressed a specific problem, but I may well have
12 been aware of it at some stage that I could not
13 precisely date.
14 Q. You talk about the fact you were aware he had been asked
15 to talk to Mr Wisheart and had been "sort of dressed
16 down".
17 First of all, can you recollect any further detail
18 of what you were told about that incident?
19 A. No, not going back that far, no.
20 Q. Are you able to help us any further than that which you
21 have just told us: that these were general conversations
22 occurring quite frequently?
23 A. Yes.
24 Q. About the time at which Dr Bolsin told you that that was
25 the reception he had had?
0011
1 A. I cannot be precise about the time in which he told me.
2 Q. You say he had been asked to talk to Mr Wisheart and
3 "had been sort of dressed down"; was it Mr Wisheart who
4 had given him that reaction?
5 A. It is very difficult to be certain what I recollect from
6 the time and what I recollect from reading statements
7 and things which have occurred since then, so I cannot
8 be precise about that.
9 Q. If we go back then please to your statement, page 2, you
10 talk about having further discussions with Dr Bolsin who
11 showed you some preliminary data that he had gathered
12 between 1989 and 1991. Again, if we go back to the GMC,
13 it is GMCT 11/82, please we can see that? If we scroll
14 down, you talk about "expressing concern":
15 "He was expressing concern towards the end of
16 1991 and specifically at the beginning of 1992 he showed
17 me some of the data that he had collected".
18 Again, can you help us a little further on whether
19 or when you recollect being shown data by Dr Bolsin?
20 A. I cannot be specific about whether it was the end of
21 1991 or the beginning of 1992, I know that it was before
22 I subsequently spoke to John Roylance and that would
23 have been early February or March 1992. There were
24 a number of events which occurred around the end of 1991
25 and the beginning of 1992, but as I have said and it
0012
1 says there, we would meet in the corridor and talk about
2 things. So I cannot be precise. But there was
3 certainly an occasion, I would say it is more likely
4 that it was early 1992 because it was very shortly
5 before I went to see John Roylance, which was an
6 opportunistic event.
7 Q. At that time, Dr Bolsin has given evidence that the data
8 he would have had would have been, firstly, some annual
9 reports of the type we have just looked at; secondly,
10 his own logbook data; and thirdly, perfusionists' data,
11 data he had received from the perfusionists which we can
12 have a look at at WIT 80/423.
13 If we can look at the top, you can see, Professor,
14 the headings that run along the top. The name of the
15 patient has been blanked out for obvious reasons of
16 confidentiality, but that is a list which is generated
17 we can see from October 1990. It gives details of
18 operations, the type of operation being performed and
19 the death on table or death in hospital in the last
20 column. Again the details have been blanked out but
21 when there is an entry there is a black bar across it.
22 If we turn on to the last page we can see firstly
23 that drawn on by Dr Bolsin is a graph showing deaths
24 against the number of patients. Secondly, that the
25 series stops in February -- if we go back to the
0013
1 previous page we can see that is February 1992. Go
2 forward again, please. We have blanked out the exact
3 date in February that the last operation was performed
4 according to this table, but I can tell you, Professor,
5 having examined the document, that this document could
6 have been generated at or by the end of the first week
7 in February but not before.
8 A. Yes, that would be entirely consistent with what I have
9 said.
10 Q. You have seen this document I think for the first time
11 today?
12 A. Yes.
13 Q. Does it accord with your recollection of the data that
14 Dr Bolsin was showing to you, you say?
15 A. Yes, it would be consistent with it because the data
16 that Steve showed me at that time was handwritten, rough
17 tabular form and simply summarising. We did not go
18 through detailed lists like this, he did not show me the
19 perfusionists' data. I was aware he had used
20 perfusionist data, I was aware he was using his
21 logbook. He was showing me what he thought at that time
22 was his summary of the facts he had gained by that time.
23 Q. What he was showing you was a handwritten tabulation
24 which you understood to have been drawn from his logbook
25 data and the perfusionists' data and whatever you saw,
0014
1 it certainly was not this document because that is not
2 handwritten?
3 A. Yes, that is correct.
4 Q. How were the figures collected? Were they collected
5 into categories of operations?
6 A. I cannot recall precisely. My guess is that I was
7 looking at a single sheet of paper with the rough
8 numbers showing, number of patients done, type, age,
9 above 1 year, below 1 year and numbers of deaths and it
10 was this figure of the number of deaths that was causing
11 him concern and I said at that time "I am sufficiently
12 convinced by what you have got that there is something
13 to be concerned about".
14 Q. This data was handwritten; its sources were not apparent
15 on their face; it had not been validated?
16 A. Correct.
17 Q. Is that all correct?
18 A. That is absolutely correct.
19 Q. Why was this data of a nature that you thought was
20 appropriate to bring to the attention of Dr Roylance?
21 A. Simply because Steve asked me whether I could intervene
22 in some way, and I said to him "Well, I will be seeing
23 Dr Roylance" -- I cannot remember whether he was the
24 Chief Executive or the Chief Officer of the Health
25 Authority at that stage. I knew we were going to have
0015
1 two meetings and I said "Well, look, I will talk to him
2 and try and persuade him that there is something to be
3 concerned about and you may wish me to do that" and he
4 said "Yes". He was not willing for me to go and speak
5 to Mr Wisheart directly because of the rebuff that he
6 had had on a previous occasion.
7 Q. You have described a series of meetings with Dr Bolsin
8 and cautioned us against trying to put them into rigid
9 boxes of particular dates when you saw him frequently.
10 You appreciate, I am sure, that Dr Roylance on his part
11 denies any mention being made to him of figures --
12 A. Yes.
13 Q. -- when you went to see him. Why is it that you can be
14 confident that you had seen some sorts of figures,
15 albeit handwritten and tabulated by Dr Bolsin by the
16 time you had seen Dr Roylance rather than seeing them at
17 a later stage when there was further discussion of
18 the need to conduct an audit?
19 A. The main reason that I offered to speak to Dr Roylance
20 was on the basis of the information that he had shown me
21 and he could only have shown me data. I did not have
22 a piece of paper to take to Dr Roylance, Steve did not
23 want the piece of paper to go out of his hand. He had
24 shown it to me, I was convinced. What I believe I said
25 to Dr Roylance was "Dr Bolsin has data which I think you
0016
1 ought to look at and ought to be concerned about". My
2 recollection is that he said he would do something about
3 it.
4 Q. Still staying with the conversation with Dr Bolsin
5 rather than coming forward to that with Dr Roylance,
6 what did Dr Bolsin say to you about the mortality rates
7 he was tabulating or recording?
8 A. We are now talking about early 1992. He by that stage
9 had been elected, I think is the right word, the
10 coordinator of the UK ACTA scheme for evaluating cardiac
11 anaesthesia and cardiac surgery across the UK and
12 I believe that he had comparable data from one or two
13 other centres -- and I cannot remember whether one was
14 Glasgow and one was Southampton at the time -- but
15 I knew he had been in touch with people in Southampton
16 and it may be that those are the data he was making
17 comparison with.
18 The point he was making then was "Look, these
19 figures are suggesting to me that our mortality is much
20 higher than it ought to be" and he was becoming more and
21 more concerned about this.
22 Q. Can you remember roughly how many children had been
23 operated upon according to --
24 A. I cannot remember the numbers.
25 Q. Again, just going back to the evidence at the GMC, you
0017
1 there suggested there was a list of something
2 approaching in the region of 200 patients with about 40
3 deaths?
4 A. That may well have been true, I cannot recall that.
5 Q. You have just told us that Dr Bolsin was telling you the
6 mortality was much higher than in other centres?
7 A. Yes.
8 Q. Did he put a percentage on the comparison between the
9 two?
10 A. Yes, I am sure he put a percentage on them, but I cannot
11 recall the numbers now, I mean this is going back seven
12 years or so and I was not anticipating that this was the
13 sort of number that I needed to keep in my head at that
14 time. No, I cannot remember the exact numbers.
15 Q. Again if we go back to GMCT 11/101, we can see there and
16 look now to the answer "Concern, can I be blunt, that
17 there might be unnecessary deaths of children taking
18 place". You said in response to that question that your
19 concern was "being shown the data and being told that
20 the mortality was approximately double that in other
21 major cardiac centres."
22 That was evidence you gave in 1997; is that
23 a memory you would now confirm or not?
24 A. Using the word "approximately", yes, I think that is
25 approximately. It certainly was not five times; it
0018
1 certainly was not so close to other centres that one
2 would not have said that there was a difference. So
3 mortality of double would have been a value. As I say
4 there, "approximately double" because even at that stage
5 I could not remember precisely what I had seen five
6 years earlier.
7 Q. You had some discussion with Dr Bolsin about
8 comparators.
9 A. About?
10 Q. About comparators, about national figures that might be
11 used to make comparisons with Bristol figures.
12 A comparison between a national figure and the figures
13 for Bristol might only be meaningful if there was some
14 sense of the range that was exhibited by centres other
15 than Bristol?
16 A. Yes, even if one was making a direct comparison with one
17 other centre, the other centre would have a mortality
18 and one would not wish to put too much inference on one
19 year's data so you would look at a number of years and
20 then have a mean value with a dispersion around that
21 mean.
22 Q. It follows, does it, whatever you had been shown by
23 Dr Bolsin was only the most preliminary (if that) stage
24 of assessing the performance of Bristol as opposed to
25 that of other centres?
0019
1 A. Yes.
2 Q. Was it genuinely, do you think, at a stage at which you
3 could say that the data he was giving you was such as to
4 raise a concern about mortality in Bristol?
5 A. It raised a concern with me personally because I could
6 see from the data at that time that things were clearly
7 not as one would have liked them to be. On the previous
8 occasion, 1989 when he first came to me, he had no
9 data. Now he had some data, but the data, as I say they
10 were not properly statistically analysed and so on, but
11 one can look at a set of data and say "There is
12 something there, we have to look at this" and my concern
13 at that stage was simply to alert Dr Roylance to the
14 fact there was something that really did need looking at
15 rather than simply dismissing it.
16 Q. But handwritten data of the sort you have just described
17 with only tentative or preliminary conclusions and
18 limited national figures available for comparison might
19 be the sort of information that Dr Roylance would be
20 justified in saying did not raise any concern?
21 A. The fact that they are handwritten is neither here nor
22 there. You can put the same data on a typewriter and
23 make it handwritten, it does not alter the nature of the
24 data, it is the data, the way it is presented in tabular
25 form and (if necessary) in detail.
0020
1 No, it certainly would not be the sort of
2 information at that time that one would have said "This
3 is hard evidence that Bristol is doing far less well".
4 What I was seeing was soft evidence that gave me concern
5 and my concern supported Dr Bolsin at that stage, and
6 I was very keen that he was not being pushed into
7 a corner persistently by people who not listen to him
8 and so I volunteered that I would speak to Dr Roylance
9 about it.
10 THE CHAIRMAN: Can I be clear on what exactly was your state
11 of mind at the moment, Professor? You say in answer to
12 Miss Grey -- and I am reading from the transcript:
13 "I could see from the data at that time that things
14 were clearly not as one would have liked them to be".
15 But you then say a little later on "My concern at that
16 stage was simply to alert Dr Roylance to the fact there
17 was something that did need looking at".
18 Those are quite different propositions: one is
19 there is a question; the other is there is a real need,
20 real cause for concern. What is your evidence on that
21 particular point?
22 A. I think I would say there was real concern in my mind at
23 that stage.
24 THE CHAIRMAN: Even though you have described the data as
25 "preliminary"?
0021
1 A. Yes.
2 MISS GREY: If we can go back to the data itself that
3 I showed you a moment ago, the perfusionists' data,
4 WIT 80/423, we can see there are some 15 operations
5 listed in 1990 and then scrolling on, please, there are
6 50 on the first page in total. If we turn over the page
7 you can see that the series goes as far as 99 before the
8 numbering resumes again and stops at 16.
9 So the total number of operations shown in this
10 data is 115?
11 A. Yes.
12 Q. If one goes through the exercise of counting up the
13 number of deaths that appear to be recorded; that is an
14 exercise in counting up the black bars and also the
15 crosses, there would appear to be 21 deaths recorded in
16 this table.
17 Again referring back to what you were reminded of
18 as your evidence to the GMC, data of approximately 200
19 patients with about 40 deaths; can you comment on the
20 discrepancy between what you were apparently being shown
21 and this data?
22 A. This data here are from the perfusionists' log I presume
23 from what you have said earlier on. I do not know
24 whether the perfusionists' log is total. My
25 recollection at the time, and as I say I have not seen
0022
1 this data before, was that the number was around 200 and
2 that the number of deaths was 40 roughly.
3 Q. It may assist for the sake of the wider audience, if
4 I say that if one compares -- which you obviously would
5 not have been able to do at the time, either because you
6 did not see this document or the information would not
7 have been available to you -- the returns or the
8 operations listed in this document for 1991 which
9 appears to be complete with the figures in the Bristol
10 returns to the UK Cardiac Surgical Register which is at
11 UBHT 55/211. I do not think we need to turn it up, but
12 I make this point for the sake of the wider audience: we
13 can see there that 139 operations in total were
14 performed according to that source that year, whereas
15 here we are told that for 1991 some 83 operations were
16 performed.
17 So it would follow from that, if I am right in the
18 summary that I have just made, that whatever this data
19 is, it is incomplete?
20 A. It could be incomplete because not all cardiac
21 operations involve cardiopulmonary perfusion and the
22 perfusionists' data would only apply, I presume, to the
23 occasions or the operations in which they as the
24 perfusionists were providing cardiopulmonary bypass.
25 But there would have been operations which may be
0023
1 preliminary, may be certainly on children, operations
2 for patent ductus and so on which does not need
3 cardiopulmonary bypass. The fact the two numbers do not
4 add up is not totally inconsistent.
5 Q. How sure are you though of your recollection that
6 whatever Dr Bolsin had collected, it included figures
7 for approximately 200 operations?
8 A. I cannot be absolutely sure because, as I say, I am
9 recollecting something that occurred 7 or more years ago
10 and which I had a fleeting glance at.
11 Q. Professor, you spoke earlier in response to a question
12 from the Chairman about the distinction between an issue
13 deserving further investigation and raising concern; was
14 there anything else that by the time you had gone to see
15 Dr Roylance had raised this issue in your mind quite
16 independently of conversations with Dr Bolsin?
17 A. I cannot think of anything other than the conversation
18 with Dr Bolsin.
19 Q. Again picking up evidence at the GMC, you spoke there
20 about a letter from anaesthetists in another city and
21 another university centre. If I bring up on the screen,
22 please, WIT 382/6, does this help to explain what it is
23 you were referring to at that passage.
24 A. Yes, it would certainly help to explain it --
25 THE CHAIRMAN: One moment, Professor, there is an
0024
1 address there which I think I would want taken out
2 before I would put it on the screen. Thank you.
3 MISS GREY: Can we scroll up? First of all we can note
4 that the letter is from the University of Southampton
5 and from Professor Norman.
6 A. That is correct.
7 Q. If you could explain firstly: who was Professor Norman?
8 A. Professor Norman was a Professor of Anaesthesia in
9 Southampton who was a close colleague of mine in the
10 sense we have worked together in the Royal College of
11 Anaesthetists a great deal and he was expressing here
12 a view that had concerned him because -- I do not know
13 who the three younger cardiac anaesthetists would have
14 been and he did not tell me, but he was simply trying to
15 be helpful and suggesting that if there was anybody --
16 Q. Can I stop you there whilst we come back to the body of
17 the letter in a moment. First of all can I say, it is
18 right, is it, that this letter has been produced by you
19 in response to a request from the Inquiry today?
20 A. That is correct, yes.
21 Q. If we can scroll down to the bottom of the page we can
22 see there the date of the letter, 11th October 1991.
23 I stopped you, Professor, you were telling me of
24 the concerns expressed in this letter that were being
25 drawn to your attention.
0025
1 A. Yes, John Norman, as you can see in the letter,
2 expressed the concern and offered the help of Tom Abbott
3 who was a senior consultant involved in cardiac
4 anaesthesia in Southampton which was one of the centres
5 which was reputed at that stage to have very good
6 results especially in paediatric cardiac surgery and
7 I did not show the letter, but I discussed the contents
8 of the letter with Dr Peter Baskett --
9 Q. Can I stop you there, we will come to that in a moment.
10 First of all can I ask you -- it is apparent from the
11 text of the letter -- that the "three younger cardiac
12 anaesthetists" at Bristol are not named?
13 A. Yes.
14 Q. Did you have a conversation with Professor Norman as
15 a result of this letter being sent to you about its
16 contents?
17 A. I had a discussion with John, an informal discussion
18 about it and he said he did not know who the three
19 specific people were, but that Tom Abbott had approached
20 him.
21 Q. You did not yourself speak to Dr Abbott?
22 A. No.
23 Q. What action did you take as a result of the letter being
24 received by you, then?
25 A. I spoke to Dr Peter Baskett who is one of the senior
0026
1 cardiac anaesthetists and said I had this letter from
2 John Norman and that Tom Abbott, who Peter Baskett knew
3 perfectly well, had offered to be of assistance if
4 assistance was needed and Peter said, yes, he would
5 contact Tom Abbott and that is the last I heard of it.
6 Q. Did you ever ask Dr Baskett what he had done in response
7 to this?
8 A. Not specifically, no.
9 Q. If any further follow-up needs to be made it must be
10 done through Dr Baskett; is that correct?
11 A. I would guess so, yes.
12 Q. What was your reaction to receiving this letter in terms
13 of your perception of the service at Bristol?
14 A. It simply made me more aware of things that I knew were
15 concerning Dr Bolsin and I was not sure -- when it said
16 "three of your young cardiac anaesthetists" I was not
17 sure whether that was people who were existing in
18 Bristol at that time or people who had been in Bristol
19 and moved to Southampton. It was simply another
20 expression of concern.
21 Q. What did you understand to be the nature of the problem
22 at Bristol, if there was one, because problems about
23 high mortality can have a number of causes and in
24 particular, if I may split them down, they may be
25 surgical causes or anaesthetic causes?
0027
1 A. I had spoken to Steve Bolsin, I had spoken with the
2 other cardiac anaesthetists off-the-cuff in the corridor
3 and said "There is a growing perception of a problem; do
4 you think there is any aspect of this which is directly
5 related either to the anaesthesia which is being given
6 or to the intensive care of the patients afterwards?"
7 and the answer was a resounding "No" from all of them.
8 My perception was there was a problem which was manifest
9 in, not only a death rate but a complication rate within
10 the unit which was causing concern to the people in the
11 unit.
12 As I was not a cardiac anaesthetist and not
13 involved in the clinical service, they were not asking
14 me to become involved other than simply to keep
15 Steve Bolsin advised as to how to go about things.
16 THE CHAIRMAN: Professor Prys Roberts, you will forgive me
17 if I ask you whether "off-the-cuff conversations in the
18 corridor" with colleagues had a status sufficient to
19 allow you to draw any meaningful conclusions about
20 preoperative or postoperative involvement rather than
21 surgical involvement? You seem to be prepared to draw
22 the conclusion about surgical involvement, but
23 disregarded any possible other involvement apparently
24 without any evidence?
25 A. No, I would not want to give that impression that I was
0028
1 saying there was not any other involvement, I simply
2 asked my colleagues "Do you believe that there is any
3 reason why this should be an anaesthetic problem?" In
4 that event if they had said "Yes", one of my first
5 reactions, I would say we ought to have a meeting about
6 it and set up a research programme to try and find out
7 what mechanisms relating to either anaesthesia or
8 intensive care might be responsible for such events.
9 THE CHAIRMAN: That is an intriguing response because,
10 as regards the involvement of the surgeons, it did not
11 seem to be your response to suggest "Let us have
12 a meeting with Mr Wisheart"?
13 A. The reason I did not suggest having a meeting with
14 Mr Wisheart was that at that stage I was largely
15 concerned with helping Steve Bolsin to get his own act
16 together, find data which you could then take either
17 through -- I mean I was aware (I cannot be specific
18 about it) that the cardiac anaesthetists in general had
19 expressed concerns and that those concerns had not been
20 fully appreciated, irrespective of the concerns
21 Steve Bolsin was expressing to me.
22 MISS GREY: You said just a second ago that the cardiac
23 anaesthetists in general had expressed concerns; can you
24 help us, firstly, whom are you referring to when you
25 speak of the cardiac anaesthetists there?
0029
1 A. The cardiac anaesthetists at that time would have been
2 Dr Geoffrey Burton who was certainly doing paediatric
3 anaesthesia, Dr Baskett to my recollection was not, he
4 was mainly doing adult stuff. Dr Sally Masey had
5 recently arrived, Dr Bose, Dr Short -- they were not
6 involved in the paediatric side. There was a cardiac
7 team.
8 Q. Who had been expressing concerns from that team?
9 A. I think all of them had expressed concerns at some
10 stage. You know one meets over coffee or after
11 a departmental meeting and somebody would say "Steve is
12 going on about this process, what do you think about
13 it?" and so on. It is very difficult --
14 Q. That is merely repeating concerns that Dr Bolsin was
15 raising rather than expressing concerns of their own;
16 which was it?
17 A. I cannot be certain they were not expressing their own
18 concerns as well. Geoffrey Burton I knew rather better
19 than the others in the sense being a paediatric
20 anaesthetist myself I would see him and I was sharing
21 some lists with him on previous occasions so that
22 I would have discussed it with him. But I cannot recall
23 precisely the details that you are trying to find out at
24 this stage.
25 Q. When you say that "the concerns had not been
0030
1 appreciated"; what do you mean by that?
2 A. My recollection is that -- I cannot remember who it was
3 but somebody had -- there had been a letter from
4 Steve Bolsin to the Trust at some stage, I cannot
5 remember the details of it. I mean it has been
6 presented in the evidence at this Inquiry and I was
7 aware that that had occurred.
8 Q. So when you are talking of either rebuffs or things not
9 being appreciated, you are coming back to the reaction
10 that you understood had been received to that letter?
11 A. Yes.
12 Q. If we turn back then to the point at which you spoke to
13 Dr Roylance, can I ask you firstly: the meeting took
14 place after you had already had a meeting with others,
15 with Dr Roylance either on the subject of the relocation
16 of the University department or on the subject of
17 special increments for teaching and research.
18 We have had two dates, 14th February and 5th March
19 and I think both you and Dr Roylance agree that of those
20 two dates the latter is the more probable?
21 A. I think the latter is the more probable, yes.
22 Q. By the time the second took place the Trust had failed
23 to persuade Dr Elliott to apply for the post of
24 Professor of Cardiac Surgeon and he had instead decided
25 to appoint Professor Angelini. What did you know of
0031
1 that at that time?
2 A. I knew it had occurred. I do not recollect making that
3 a specific aspect of my discussion with Dr Roylance on
4 either of those two occasions, although I may well have
5 done so simply as a sort of passing thing, "I am very
6 sorry that a paediatric cardiac surgeon was not
7 appointed into the Chair" because it was seen at that
8 stage -- how can I put it, it was a belief that there
9 was a solution to what people already saw as a problem
10 by appointing another paediatric cardiac surgeon who
11 would be an academic and the resolution of both those
12 events would improve paediatric cardiac surgery and some
13 of the problems related to it like the moving from the
14 BRI up to the Children's Hospital and so on.
15 Q. You say you may have mentioned it on either of those two
16 occasions. As I understood your evidence it was that
17 a discussion about paediatric cardiac surgery took place
18 on one occasion but not two; is that correct?
19 A. Yes.
20 Q. On the occasion you did speak to Dr Roylance, what did
21 you say to him?
22 A. I believe I used the term "I am concerned about the way
23 Steve Bolsin is trying to make the information known
24 within the Trust and within the hospital that the
25 paediatric cardiac mortality is higher than it should
0032
1 be. I am aware that you have prior knowledge of this
2 and I am simply expressing a concern that I have seen
3 data that Steve Bolsin has presented to me, I do not
4 have the data with me, but Steve has told me that he
5 would have been willing to show you, Dr Roylance, the
6 data" and I believe I used the term which I tend to use
7 as a sort of throwaway phrase, "this is not something
8 that we should sweep under the carpet".
9 Q. Dr Roylance for his part says that that is a phrase that
10 he would have found offensive.
11 A. Yes, I have read that.
12 Q. What was his reaction to the phrase if you used it to
13 him?
14 A. I do not recollect him appearing to be offended or
15 appearing to be disturbed by what I said. He was
16 a fairly taciturn person and he simply said to me
17 "I note your concerns and I will deal with them".
18 Q. What was the general tone of the conversation, then?
19 A. Friendly.
20 Q. Does the fact that Dr Roylance would find the use of
21 such a term, he says, offensive but that the
22 conversation apparently remained friendly not lead you
23 to reflect a little on whether or not you in fact did
24 use that term?
25 A. I cannot be certain that I would use the term, but
0033
1 I think I did use the term.
2 Q. Can you be confident that you would have mentioned
3 figures or data to Dr Roylance?
4 A. No, I would certainly not have mentioned specific
5 numbers to him. What I said to him is I had seen
6 a collection of data which seemed to me to support
7 Dr Bolsin's contention that "there is a higher mortality
8 than we should be happy to have in the BRI cardiac unit
9 and I feel that you as the Chief Executive should know
10 about it and maybe deal with it".
11 Q. What was Dr Roylance's reaction to the suggestion that
12 he should deal with data or figures on higher mortality?
13 A. My recollection was that he said "yes" he would deal
14 with it and I did not pursue as to how he would deal
15 with it. I knew John Roylance very well as an
16 individual and I expected him to do that.
17 Q. Did he not seek to explore with you exactly what sort of
18 figures had been collected?
19 A. Not in detail because I had said that Steve Bolsin had
20 the data; that he would be perfectly happy to share the
21 data with Dr Roylance. One of the problems was that
22 this meeting was relatively brief because Dr Roylance
23 had another meeting to go on to but he had agreed to see
24 me briefly after the end of the other meeting we had.
25 This was an opportunistic way of talking to him about
0034
1 this concern of Steve Bolsin's.
2 Q. Again Dr Roylance's suggestion is that if anyone had
3 suggested to him that there was data or figures that had
4 been gathered on performance of the unit, that he would
5 have regarded that as being a matter for the Trust Audit
6 Committee or Dr Thomas and that he would want to pass
7 that on as a "political hot potato" as rapidly as
8 possible. Was there no discussion of such a course of
9 action?
10 A. I have no recollection of any discussion of that nature
11 at all.
12 Q. Why mention Dr Bolsin?
13 A. Because it was Dr Bolsin who had asked me to present the
14 concern to Dr Roylance.
15 Q. Here Dr Bolsin had been rebuffed you understood in the
16 past. Why bring his name to the attention of the person
17 who at least (presumably) played some part, you might
18 have thought, in that previous incident?
19 A. I am not sure I knew what John Roylance's part in the
20 previous rebuff had been. I believe (again this is
21 simply my own personal opinion) that Bolsin had written
22 to the Trust, Roylance had dealt with it and passed the
23 information back to Mr Wisheart who had then spoken to
24 Dr Bolsin; I was not part of that process at all, so
25 I cannot give you any more detail than that. But I was
0035
1 not under the impression that it was Dr Roylance who had
2 rebuffed Dr Bolsin in the first place.
3 Q. Was there any discussion that you can recollect, then,
4 of the appointment of a paediatric cardiac surgeon and
5 the need for that?
6 A. There had been a lot of discussion in that sort of
7 period during 1991. I was not involved in it. There
8 were discussions about appointing a Professor --
9 Q. I was asking you specifically for your evidence in
10 relation to the meeting with Dr Roylance, whether you
11 recollect that subject being raised at that time?
12 A. I do not recollect saying on that occasion that I was
13 disappointed, but I may well have done, I simply do not
14 recollect that.
15 Q. Because you will appreciate that Dr Roylance's
16 recollection is of a conversation about the need, indeed
17 the urgency of appointing a paediatric cardiac surgeon.
18 Is it possible that the two of you did discuss that and
19 that the explanation for this lack of agreement as to
20 what took place was that both of you assumed it was
21 necessary that that appointment should be made but from
22 different perceptions of the reason why it was
23 important?
24 A. I would certainly agree with that last statement, but
25 I do not recollect discussing that particular problem
0036
1 with John Roylance on that occasion because that was not
2 my prime purpose in asking to see him after the other
3 meeting. My prime purpose was to draw his attention to
4 the fact that Steve Bolsin now had a set of data which
5 I considered ought to be causing concern.
6 Q. If there was a problem with the cardiac surgery going on
7 and its competence or quality, would that be a matter
8 for the Royal College of Surgeons to investigate?
9 A. I think you are asking me for an opinion and I am not
10 sure that I am the right person to give that opinion,
11 no.
12 Q. Let me put it in terms of what you would have perceived
13 in early 1992; if there was a problem about the proper
14 performance of a discipline within the BRI, that of
15 cardiac surgery, what was the proper way of addressing
16 that deficiency?
17 A. I think the proper way that was perceived at that time
18 was a process using the senior doctors involved in
19 hospital management at that time of whom James Wisheart
20 was one and he was becoming much more involved in the
21 management process.
22 I do not think the Royal Colleges would become
23 involved unless there was a perception of inadequacies
24 of training, inadequacies of conduct and so on which
25 would have been a GMC matter in any case.
0037
1 Q. What you are referring to there is the "three wise men"
2 procedure; is that right?
3 A. Yes, that is what it is commonly known as.
4 Q. That is a procedure under which professional clinicians
5 at least initially investigate the performance of their
6 peers and form a view upon that, to describe it very
7 loosely?
8 A. Yes, that is correct.
9 Q. The "three wise men" at that time would have been the
10 past, present and chairman-elect of the Hospital Medical
11 Committee?
12 A. Medical Committee, yes.
13 Q. It is not therefore what one might describe as
14 a management structure, is it?
15 A. The "three wise men" process is certainly not
16 a management process, no.
17 Q. Why go to Dr Roylance if what you have identified is
18 a process that is quite apart from his control?
19 A. Because at that stage I did not perceive that the
20 problem was a personal problem of an individual surgeon,
21 I was perceiving that there were data which were, to my
22 mind, sufficiently worthy of concern that I should draw
23 them to the attention -- you see, I did not regard
24 John Roylance as a manager because he had been
25 a radiologist, he was still a radiologist, he was still
0038
1 "one of us" if you like. In those days the concept of
2 management and the doctors being separate was far less
3 precise than it is nowadays.
4 Q. You have on the one hand told us the "three wise men"
5 was the appropriate procedure to look into matters
6 regarding the performance of a paediatric cardiac
7 surgery service and on the other hand you have told us
8 it is not because one individual's competence might not
9 be at issue?
10 A. If there was a specific concern that the performance of
11 an individual was the prime concern, yes, I think it
12 would have been appropriate in the context and the
13 culture in those days to have evoked the "three wise
14 men" procedure. For instance, if a surgeon or physician
15 kept on coming into the hospital smelling strongly of
16 drink or something like that, one would have said that
17 is a "three wise men" process.
18 I was being concerned that Steve wanted to
19 publicly express the problem that he perceived and
20 I felt what I was being asked to do at that stage was to
21 explore the Hospital Authority -- I cannot remember
22 whether it was a Trust or an Authority at that
23 particular time -- and it was simply an opportunistic
24 thing, I knew I was going to meet with John Roylance at
25 that stage and I wanted to express that view to him.
0039
1 Q. What did you expect him to do?
2 A. I think I had expected him at that stage, because this
3 was a problem of a service rather than an individual, to
4 look at the service because there were concerns for
5 instance about the appropriateness of Bristol being
6 a designated supra-regional paediatric cardiac service
7 and this was part of the argument for having another
8 paediatric cardiac surgeon and an academic to head up
9 the unit and so on. So I felt this was part of that
10 process. I do not think it was inappropriate to speak
11 to --
12 Q. You had worked with Dr Roylance over a number of years?
13 A. Sorry?
14 Q. You had worked -- I am thinking still by 1992 -- with
15 Dr Roylance --
16 A. I had been in the same hospital. I have never actually
17 worked with him in the sense that one does with
18 surgeons.
19 Q. How often did you come into contact with Dr Roylance?
20 A. Maybe once every six months.
21 Q. Were you aware of his views on the importance of
22 managers remaining within their managerial role and
23 professionals dealing with matters of professional
24 performance?
25 A. Not at that time, no, I was not. I think with
0040
1 hindsight, yes, I mean that has become a hallmark of
2 this new development of the managerial and the doctor
3 process, but I do not think at that time that was
4 anything like as well described and as well identified,
5 and I certainly did not know of John Roylance's specific
6 views in relation to his role as a manager.
7 THE CHAIRMAN: Again, Professor Prys Roberts, just for
8 my own understanding, we had a conversation a moment ago
9 about what was the cause of concern and you said it was
10 in your view the surgeons. You said in response to
11 Miss Grey a moment ago, "I think I expected him
12 [Dr Roylance] at that stage to look because there was
13 a problem of a service rather than individual". There
14 were only two surgeons; what is it that is the "service"
15 as distinct from the two surgeons?
16 A. I think that is a very difficult question to answer,
17 sir. As I was not involved --
18 THE CHAIRMAN: It was your answer.
19 A. Yes, I appreciate that. I was not involved in the
20 direct clinical management of patients involving cardiac
21 surgery and therefore I regarded cardiac anaesthesia,
22 cardiac surgery as a service unit which was an entity in
23 itself, that I was not directly involved with and yet
24 one of my younger colleagues was asking for advice and
25 help in drawing attention to problems that he perceived
0041
1 were within that service.
2 Whether he perceived that the problems related
3 directly to one or other of the surgeons or both was not
4 my intention to draw to John Roylance's attention at
5 that particular time.
6 MISS GREY: Let me see if I have understood this: you
7 regarded Dr Roylance as being an appropriate channel of
8 communication because the service as a whole might
9 require further investigation; is that correct?
10 A. I would say that was correct, yes.
11 Q. You did not on the other hand regard the "three wise
12 men" as being appropriate because the conduct -- please,
13 if you would wish to answer the question --
14 A. I did not think the "three wise men" process was
15 appropriate at that stage because we did not have
16 evidence of any sort that either one or other or both
17 surgeons were either competent or incompetent for
18 whatever reason, we did not have that evidence.
19 All we had was evidence from Steve Bolsin's data
20 collection that the mortality of children undergoing
21 cardiac surgery was higher than was perceived to be
22 appropriate and higher than national averages and so
23 on. That does not imply within that data that the fault
24 lies with any specific individual. If the fault could
25 clearly be identified with a specific individual, then
0042
1 I think the "three wise men" procedure would have been
2 entirely appropriate.
3 Q. If we can go back to your statement, please, at page 4
4 you talk, at the top of the page, about the role of the
5 Royal College of Anaesthetists. A few minutes ago
6 I think you suggested that unless training issues were
7 in issue, the Royal Colleges would not be an appropriate
8 channel of advice or assistance; is that consistent with
9 what you were suggesting here at the top of page 4?
10 A. The Colleges are involved in more than training, they
11 are involved in standards, the setting of standards, the
12 overall evaluation of standards and the matching of
13 standards to training, ensuring that where people are
14 trained, the overall standards of the consultants who
15 were doing the training is up to scratch and so on.
16 Q. They accept a role, did they not, on occasion for
17 convening informal inquiries or investigations by
18 assisting in advising who might act as an independent
19 investigator into services in hospitals which have
20 developed problems?
21 A. Yes, that is certainly true. Yes, the Colleges and the
22 craft unions, the Associations of Anaesthetists and of
23 Surgeons would both be involved in helping people to
24 find "three wise men" on a national standard because
25 there was a process also within anaesthesia for doing
0043
1 that.
2 Q. If the Royal Colleges were generally involved in
3 maintaining appropriate standards and investigating
4 allegations that those might not be being met, why not
5 take concerns to either the Royal College of Surgeons or
6 the Royal College of Anaesthetists?
7 A. To the surgeons at that stage, because the evidence,
8 such as it was, was not strong enough to warrant going
9 to -- I think at that stage it was a local matter rather
10 than a national matter. Certainly as far as anaesthesia
11 was concerned, I had no evidence either from my
12 colleagues or from things that other people might have
13 said which led me to believe that the Royal College of
14 Anaesthetists should in any way become involved in the
15 process. Steve Bolsin certainly did not ask me to take
16 the matter to the College in an official way and there
17 was certainly no correspondence on that.
18 Q. If we can go on, please, in your statement in terms of
19 time, go on please to page 2, scroll down towards the
20 bottom. You talk there about Dr Bolsin again expressing
21 to you his continuing concern about the results and then
22 you describe the meeting with Dr Roylance that we have
23 just covered. If we go over the page, please, we can
24 see that Dr Bolsin was informally discussing his
25 concerns about the continuing paediatric cardiac surgeon
0044
1 problem with you and Dr Williams on 22nd July 1992.
2 Firstly, can I ask where in this story does the
3 decision that Dr Bolsin took to apply for a post at
4 Oxford fit?
5 A. I cannot remember precisely when he decided to apply for
6 a post at Oxford. My recollection was that it was
7 mid 1992 because he came to me and asked if I would give
8 him a reference and I said "Why do you want to go to
9 Oxford?" and he said "I am not happy doing cardiac
10 anaesthesia, I want to be a cardiac anaesthetist, I want
11 to be a paediatric cardiac anaesthetist, I cannot work
12 in this setting" and therefore that taken with the
13 rebuff he had had previously, he expressed a view one
14 solution would be to apply for a job elsewhere and the
15 Oxford job had become available at that time and
16 I agreed to provide him with a reference, not about his
17 cardiac anaesthesia because I could not do that but
18 about his research and general characteristics.
19 Q. Dr Bolsin for his part has given evidence really of only
20 one substantive conversation with you which arose out of
21 the application for a job in Oxford in which he came
22 back disappointed -- when he raised the question of the
23 reference with you at that point he describes
24 a "gentleman's agreement" or a bargain involving the
25 collection of data. We will come to that in more detail
0045
1 in a moment.
2 The point I am putting to you is that that appears
3 to truncate the conversations between you into that one
4 incident rather than a series of conversations that you
5 are describing?
6 A. He describes them as a truncated set of incidents,
7 I would not regard them as a truncated set of incidents
8 because in between these specific items we were
9 discussing research procedures, funding of a big study
10 he was trying to do in patients in cardiac anaesthesia
11 which I was supporting him from --
12 Q. In adult patients?
13 A. In adult patients, yes. Yes, there may well have been
14 brief conversations about how things were going on at
15 other times. When Dr Bolsin identifies a specific date,
16 that does not imply that those are the only times we met
17 or discussed things.
18 Q. You are able to date this particular conversation
19 precisely to 22nd July; why is that?
20 A. Because there is a date in my personal diary which says
21 I met and discussed his concerns with Steve and
22 Brian Williams who was the Department Chairman at that
23 time.
24 Q. What was Dr Williams's involvement, why bring him into
25 that conversation?
0046
1 A. We were concerned that Steve, as he frequently did,
2 would express his frustration about things and he wanted
3 to go public. Our view was that he did not yet have
4 enough good evidence to go public on it or to make
5 further representations to some other body and my
6 recollection of that particular meeting was simply we
7 were trying to sort of quieten him down and get him to
8 relax and carry on with the evaluation of the data that
9 he had.
10 Q. What did he mean by "going public"?
11 A. I do not know what he meant by "going public". I think
12 there had been a public perception and there were media
13 reporters of one sort or another who wanted him to make
14 statements and he on one or two occasions came and said
15 to me "Do you think I ought to say something?" and
16 I would say "Whatever you do making a public statement,
17 do not do it without having first consulted the Medical
18 Defence Union and/or your own personal solicitor"
19 because I felt at that stage he was likely just to have
20 a sudden explosion of outpouring of his quite intense
21 frustration.
22 Q. Did he say specifically who he wanted to speak to?
23 A. No, I do not recollect him saying that at all.
24 Q. Why did you think it was inappropriate to go public or
25 talk to further people at that stage?
0047
1 A. Because the data he had shown me earlier in the year, in
2 February or whenever it was, was simply convincing me
3 that there was something to be concerned about and he
4 had then decided to gather more data and I had offered
5 the services of my senior lecturer Andy Black for him to
6 try and put that data into a way in which the
7 statistical elements could be retrieved.
8 Dr Black was particularly interested at that time
9 in various statistical exercises of multivariate
10 analysis where you could pick out from a series of
11 stratified data and identify the weight you could give
12 to each particular part of it, it is a statistical
13 exercise that he has become very adept at and from there
14 on they went along their own way and I am aware they
15 were gathering other data, but I was not involved in
16 that particular part of it.
17 Q. It was 1989 when Dr Bolsin first approached you?
18 A. Yes.
19 Q. Now some 3 years on he is expressing the same concerns;
20 did that lapse of time not concern you?
21 A. Only in as much that within that time period he had only
22 gathered a certain amount of data that could be analysed
23 to sustain his concern, yes, but it takes him to
24 develop, you cannot simply take one year at a time. If
25 you are going to look at a series of mortality studies,
0048
1 you have to look at more than one year. So the fact it
2 had taken three or four years, and in between times
3 Steve would be perfectly happy getting on with
4 everything else and getting on with research.
5 Q. You say you had raised this matter with Dr Roylance,
6 when you saw Steve in July 1992 did you have any further
7 assurance to give him that the matter was being looked
8 into or developed, investigated by the Trust?
9 A. No.
10 Q. Had you been back to Dr Roylance to check what was
11 happening as a result of your conversation?
12 A. No.
13 Q. Did you ever at any time go back to Dr Roylance to
14 follow that conversation up?
15 A. I do not think I did. It has been suggested, I think it
16 was Dr Bolsin who thought that I had telephoned
17 Dr Roylance after seeing him and Dr Black on one
18 occasion. I do not recollect doing that and Dr Black
19 supports me in that recollection.
20 Q. Why not go back to Dr Roylance, then?
21 A. Because at that stage I did not think there was enough
22 further evidence before they had done the full
23 statistical analysis of their data and at that time
24 I was deeply involved in things elsewhere, specifically
25 I was on the GMC and their education committee and in
0049
1 SCOTMI, and I was involved in a whole host of other
2 things which kept me away from Bristol a great deal and
3 Steve did not keep coming back to me at that stage.
4 Q. Time constraints, put those on one side, I think one
5 understands those. But the first part of your answer
6 was that there was no further data to present to
7 Dr Roylance. Surely the point of going to Dr Roylance
8 had been to require him or to ask him to initiate some
9 sort of investigation rather than leaving the whole
10 matter on the shoulders of Dr Bolsin?
11 A. Yes, I do not know now why I did not go back and talk to
12 Dr Roylance further, I mean the opportunities did not
13 raise themselves easily.
14 Q. If we go back, looking again still at your statement,
15 you put there an account of being informed about
16 a continuing process of data collection and analysis
17 that was already in hand on the part of Dr Bolsin; is
18 that a fair summary?
19 A. Are we now talking about the --
20 Q. We are looking now in July 1992, the summer of 1992?
21 A. I was aware from the things Dr Black told me that they
22 were not only addressing the issues of analysis of data
23 that he already had, but they were beginning to collect
24 prospective data, but this was something they had
25 undertaken on their own account, it was not something
0050
1 I had either commissioned or sanctioned or in any way
2 made an official process because I had no authority to
3 do that.
4 Q. If we look at Dr Bolsin's statement, WIT 80/111, he says
5 there that he applied for a post at the John Radcliffe
6 in Oxford and he explained why he wanted to leave to you
7 and that you said, yes, you would provide him with
8 a reference and what you said was:
9 "He asked me if I would exchange favours with him
10 if I was unsuccessful in my application to Oxford."
11 The favour you requested in return for the
12 reference for the Oxford job was that Dr Bolsin should
13 collect the data in Bristol with Andy Black and show the
14 data to Professor Prys Roberts -- turn over the page,
15 please -- and if there was a problem you would help to
16 deal with it. "If there was no problem, then he should
17 [as you apparently put it] 'shut up and put up'".
18 Can I ask you to comment on that account of
19 events, firstly the comment from Dr Bolsin -- turning
20 back, please -- that the reference and data collection
21 were a process of exchange of favours?
22 A. I think that is an entirely inappropriate statement for
23 him to make. He asked me to give him a reference for
24 a job in Oxford. I would normally give references for
25 any trainee that I knew and it was a very unusual thing
0051
1 to be asked to give a reference for a fellow consultant
2 because by and large fellow consultants did not move
3 around, so once you got your consultant job you stayed
4 there, so this was an unusual thing. I do not like the
5 comment he makes in terms of "exchanging favours".
6 There was no favour done. I gave him a reference
7 because that is an entirely proper thing for an academic
8 Professor to do for a fellow consultant or for
9 a trainee.
10 Q. He also suggests this is a request from you to start
11 collecting the data as of that time, that is the
12 beginning of this particular process; how does that --
13 A. I do not recollect specifically asking him to collect
14 data from that time. I think probably what I would have
15 said to him was "if you do not get the Oxford job, what
16 are you going to do? You are going to be back here in
17 Bristol I think you should then concentrate more on
18 collecting more data."
19 Q. "A gentleman's agreement" was what Dr Bolsin described
20 it in evidence to us, do you think that is appropriate?
21 A. I do not know what he means by "a gentleman's
22 agreement", there was certainly not an official
23 involvement, we did not set up an official research
24 study, it was not an official involvement of the
25 University Department with what he was doing, I was
0052
1 simply offering him Andy Black's services as a relative
2 expert in statistics so --
3 Q. What do you mean, if I may stop you: "by offering
4 Dr Black's services"?
5 A. I suggested to Steve Bolsin: "the analysis of these data
6 require a statistical process. You may want to start by
7 asking Andy Black about it because this looks to me like
8 the sort of data collection which requires multivariate
9 analysis in order to pick out the details. He is an
10 expert in that. He may say 'go elsewhere'." He did
11 not.
12 Q. Is that a recommendation that you made to Dr Bolsin at
13 the time at which the Oxford job was under discussion?
14 A. I cannot remember whether it was at the time, before or
15 immediately after the Oxford job because I cannot
16 remember the exact dates on which he asked for
17 a reference.
18 Q. If we turn back over the page, please, we can see there
19 the phrase Dr Bolsin remembers you using, he says: "if
20 there was no problem then he should 'shut up and put
21 up'"; is that a phrase you can recollect using?
22 A. No, it is not a phrase I recollect using, it is not
23 a phrase which I would normally use, in fact I do not
24 ever recollect saying anything of that sort before.
25 I have frequently suggested that evidence is much
0053
1 more important than opinion and I would maybe have said
2 something like that. But the precise phrase, as he puts
3 it in parenthesis, is not something that I would
4 normally use, so I do not know where he got it from.
5 Q. If we go to an interview which you gave to Despatches,
6 this is PAR 1 (5) 212:213: your involvement again in this
7 audit process. You said to Despatches that you:
8 "Suggested to run an audit of the cases that was
9 being done, the way they were being anaesthetised, the
10 way they were surviving after the operation and if after
11 a certain time the results were still as surprising and
12 he felt he needed to do something about it, then he
13 would have more facts at his disposal."
14 Firstly do you think that is an accurate recording
15 of what you said to the programme?
16 A. I have no doubt it is an accurate because if this is
17 a transcript of the programme then it must be reasonably
18 accurate. The only thing I would question, not so much
19 the use of the word "audit" but the implication of the
20 word audit because at that stage in the late 1980s/early
21 1990s audit was a more loosely used phrase than it is
22 now. We now have specific types of audit and the
23 overall process of audit as a circular process -- what
24 I meant by "audit" as far as Steve was concerned was not
25 only the collection of the data but the analysis of the
0054
1 data and that is what I had suggested that he and
2 Dr Black should do.
3 Q. Can we turn back to page 212? One of the things that
4 was suggested there that might be investigated was the
5 way they were being anaesthetised?
6 A. Yes.
7 Q. Can you recollect a discussion of that item?
8 A. What, with Dr Bolsin?
9 Q. Yes.
10 A. That would be a perfectly normal part of any audit
11 process. If you were auditing or collecting data on
12 operations that had been anaesthetised, the technique
13 that had been used, the appropriateness of it and the
14 effects of that technique would be part of a normal
15 process of just maintaining a logbook and subsequently
16 auditing the result of it.
17 Q. Can you remember suggesting that to Dr Bolsin?
18 A. Not specifically, no.
19 Q. If it was being discussed at all did that reflect any
20 continuing questioning of the anaesthetic role in
21 possible mortality or outcomes?
22 A. I do not think the question was being raised, it would
23 be very difficult to identify a specific part of the
24 anaesthesia process as being contributory to the deaths
25 of children either in the operating theatre, in other
0055
1 words not getting them off bypass.
2 On the other hand one would look for evidence, for
3 instance, in cardiac surgery that the anaesthetic
4 technique that had been used might influence the time it
5 took to come off bypass. I mean there are plenty of
6 evidences in the literature of that nature. Those are
7 the sort of things that would have come out of the
8 woodwork so to speak by looking and simply documenting
9 the nature of the anaesthesia and the intensive care
10 procedures that these children (and subsequently adults)
11 would have been subjected to.
12 Q. We have discussed the summer of 1992. In October 1992
13 Professor Angelini took up his post as Professor of
14 Cardiac Surgery. Did he ever consult you about the
15 concerns of Dr Bolsin or generally concerns about
16 outcomes or results in paediatric --
17 A. Not at that time. Not at that time at all. I did have
18 a meeting with Gianni Angelini and with John Farndon,
19 but my recollection is that that meeting was much much
20 later after the episode of the Joshua Loveday surgery
21 and so on and it was a meeting largely to discuss damage
22 limitation as far as the effect on the way that our
23 individual academic departments were involved.
24 Q. So you do not recollect any discussion prior to
25 Joshua Loveday's case?
0056
1 A. No.
2 Q. If we go back to Dr Bolsin's statement, WIT 80/113 we
3 can see there the account of the: "Results of the data
4 analysis". This was available, he says, in early 1993
5 and the bulk of those who have given evidence to the
6 Inquiry have spoken of receiving or hearing of its
7 results (if they heard of it at all) in
8 September/October 1993.
9 Do you recollect having any further information
10 from Dr Bolsin or Dr Black about the process they had
11 been engaged in since the summer 1992?
12 A. I recollect having a meeting with them during which
13 Steve had to leave and go off and left me to look at the
14 data with Dr Black. I cannot recall the date. I know
15 it would have been mid 1993 but probably not earlier and
16 Dr Black showed me the results in tabulated form from
17 a minute-type analysis that he had done. I do not
18 recall doing anything about it at that stage because my
19 recollection is that Andy Black went away and discussed
20 it subsequently with Dr Bolsin, but they did not ask me
21 to take any specific action at that stage.
22 Q. If we go down the page, I think you have already
23 referred to this, we can see that Dr Bolsin there
24 informs us (the Inquiry) of something Dr Black is said
25 to have told him, that you immediately telephoned
0057
1 Dr Roylance; that is not something, I think you have
2 already told us, that you remember doing?
3 A. I do not remember doing it. I have discussed it with
4 Dr Black and he does not remember me doing it in his
5 presence.
6 Q. You say that Dr Black and Dr Bolsin did not ask you to
7 do anything specific?
8 A. No.
9 Q. What was your reaction to the data they had given to
10 you?
11 A. My reaction was that the data -- which were still not
12 what I would call finalised figures, but they were
13 figures which were much more reasonable, I did not look
14 at them in real detail at the time -- that these were
15 simply confirming the conclusion we had come to before,
16 that there was a serious cause for concern.
17 Q. If there was a serious cause for concern why not ring
18 either Dr Roylance or possibly Mr Wisheart?
19 A. With hindsight I do not know why not. As I have said,
20 at that stage I was not spending a great deal of time in
21 Bristol, I was not involved in the overall process,
22 I knew that others were involved and becoming more
23 involved certainly on the cardiac anaesthesia side and
24 that they were concerned with Dr Roylance.
25 I cannot recollect why at that particular stage
0058
1 I did not take it any further.
2 Q. Turning back to look also at the incident in
3 February/March 1992 when you spoke to Dr Roylance,
4 Dr Roylance made the point to the General Medical
5 Council, firstly that you were not a reticent man, that
6 if you had problems you let people know about them;
7 would you agree with that?
8 A. I would agree with that.
9 Q. He went on to say, therefore, that if you had been
10 genuinely concerned about problems of mortality in
11 paediatric cardiac surgery you would have made that
12 plain to him in any meeting?
13 A. Had we had a meeting, yes, but I did not specifically
14 ask for a meeting with him and I think the reason I did
15 not was simply that Dr Black and Dr Bolsin were still in
16 the process of evaluating their data and I was
17 anticipating that they would come back with more.
18 Q. When you say that what are you talking of, now are we
19 back looking at the presentation of the data in mid
20 1993?
21 A. 1993, yes.
22 Q. Because you say you did not have a meeting with
23 Dr Roylance but you had one of course in March/February
24 1992?
25 A. Yes, that is correct.
0059
1 Q. At that meeting, and going back to focus on that
2 meeting?
3 A. 1992 or 1993?
4 Q. February or March of 1992. You have agreed, I think,
5 that you are generally the sort of person who makes
6 plain concerns to people such as Dr Roylance.
7 Dr Roylance I think for his part would suggest that the
8 reason why he does not appear to have picked up those
9 concerns from you at that meeting was that in truth you
10 were not concerned at that stage by the data that had
11 been presented to you to such a point as you felt it
12 appropriate to tell him that there was a problem about
13 excessive mortality in the cardiac surgery unit?
14 A. I am afraid I think the Inquiry will have to regard that
15 as a difference of opinion between Dr Roylance and
16 myself. I have no doubt of my concern in 1992, which
17 was the reason that I asked to see him at that stage.
18 Yes, I was concerned subsequently but I did not regard
19 my position as the Professor of Anaesthesia not involved
20 with the cardiac surgery but knowing that things were
21 going on, I did not regard it at that stage, in 1993
22 when I had had a look at the preliminary tabulations
23 which I believe is what was shown at the GMC or shown to
24 me at the GMC, those were still not in a finalised form
25 that I would regard as something that one ought to
0060
1 present in a wider forum within the hospital setting let
2 alone in any other setting.
3 Q. You did not, therefore, go back to Dr Roylance --
4 A. No.
5 Q. -- as a result of the data given to you in 1993? What
6 sort of contact did you have with Mr Wisheart at that
7 time?
8 A. I had very little direct contact with Mr Wisheart
9 because although there were people working in my
10 department who were doing research in the cardiac unit,
11 they were primarily linked to Dr Bolsin or with other
12 people and the only contact that I might have had with
13 Mr Wisheart, again, would have been passage in the
14 corridors because the cardiac surgery was done in
15 a totally different theatre area, I would not normally
16 see him on a day-to-day basis.
17 Q. Were you not involved in audit of adult cardiac surgery
18 that involved Mr Wisheart's patients?
19 A. I was not personally involved in it, no.
20 Q. What was your involvement with that audit process?
21 A. I am not quite sure which audit process you are
22 referring to now.
23 Q. I think, again before the GMC, you referred to the fact
24 that you were collaborating with Mr Wisheart in an audit
25 of his adult patients as being a reason why you might
0061
1 not have wished to have approached him with the concerns
2 that Dr Bolsin was raising with you?
3 A. Without seeing the transcript of that particular
4 statement that strikes me as rather strange. I was
5 certainly not involved with Mr Wisheart in any form of
6 audit; I do not know how that came across, if it came
7 across in the GMC transcript, and I do not recollect the
8 nature of the wording that took place then.
9 Q. Can we go back please to GMCT 11/93? You are asked
10 there to look at your statement and look at page 2 of it
11 and the last four lines:
12 "I did not speak to Mr Wisheart about the matter
13 as I was setting up a research study on his adult
14 patients with Dr Bolsin, and I had every anticipation
15 that Dr Roylance would investigate the matter more fully
16 and deal with it."
17 That was talking of events back in early 1992.
18 A. My concern there was -- on the first occasion when you
19 asked me the question you used the word "I was setting
20 up an audit with Mr Wisheart". I was doing a research
21 study, that is totally different.
22 I was not directly involved with Mr Wisheart,
23 I was directly involved with Dr Bolsin and with
24 a visiting Professor from Brazil who worked with
25 Dr Bolsin looking at Mr Wisheart and other patients who
0062
1 were recovering from cardiac surgery and they were
2 looking at renal function in the cardiac intensive care
3 unit. I was simply acting as an advisor to the two
4 people, Dr Vianna and Dr Bolsin, about the research
5 aspects.
6 Q. How often did you see Mr Wisheart?
7 A. I very rarely saw Mr Wisheart. I had no reason to see
8 Mr Wisheart directly because the research side was
9 conducted by the cardiac anaesthetists themselves and
10 they would be doing that largely -- I mean they
11 certainly had the approval of Mr Wisheart and
12 Mr Dhasmana and Mr Hutter I believe at that time.
13 Q. If we continue reading through the transcript, you went
14 on to make the same points about Dr Bolsin setting up
15 the research study and your assistance that we have just
16 heard from you directly. Then over the page at page 94,
17 we see there:
18 "Question: I do not understand why that
19 precludes you from speaking to Mr Wisheart?
20 "Answer: I cannot really comment on that."
21 Is there anything else you would wish to add,
22 about the reasons why you did not speak to Mr Wisheart,
23 to that exchange?
24 A. No, I do not think there is because the questions that
25 were being raised by Steve Bolsin and which he had
0063
1 discussed with me were to do with paediatric cardiac
2 surgery, the research study, which I was only very
3 peripherally involved with, and in terms of advising
4 them on the design of a study and so on, they were
5 actually doing the study themselves. So I had no reason
6 to see James Wisheart about that particular study unless
7 something was going awry, and nothing was doing that.
8 The other matter was nothing to do with the adult
9 series, it was to do with the paediatric.
10 Q. Thank you Professor. Professor, I have asked a number
11 of questions, is there anything else you would wish to
12 add, to add to your statement or to raise any further
13 matter for the attention of the panel?
14 May I say that there is no necessity for you to do
15 so here and now. We are still here, you may of course
16 read the transcript and if there is anything further you
17 would wish to add, put that in writing rather than do so
18 here and now. It is merely an opportunity now, if you
19 wish to do so, to add anything further?
20 A. No, I do not wish to make any statement now, thank you.
21 MISS GREY: Are there any questions from the Panel.
22 THE CHAIRMAN: There are no questions from the Panel.
23 I think it only remains for me to say thank you very
24 much for coming to spend some time with us this morning,
25 Professor Prys Roberts.
0064
1 MISS GREY: Sir, I wonder if we might take a quarter of an
2 hour break and resume at 11.10?
3 THE CHAIRMAN: Would it be of assistance from I said 11.15?
4 MISS GREY: 11.15 will be fine.
5 (10.55 am)
6 (A short break)
7 (11.25 am)
8 MR JAMES WISHEART (RECALLED):
9 EXAMINED BY MR LANGSTAFF (CONTINUED):
10 THE CHAIRMAN: Good morning again, everyone.
11 I apologise for keeping you waiting. I apologise also
12 to you, Mr Wisheart, for keeping you waiting a little
13 longer than we had expected, but there were other things
14 to discuss elsewhere.
15 Mr Langstaff?
16 MR LANGSTAFF: Mr Wisheart, we are returning today to the
17 matters that we were discussing on Monday of this week.
18 May we have on the screen, please, UBHT 61/284?
19 This is a letter written after the Joshua Loveday
20 operation, dated 26th January 1995, and it is from
21 Dr Roylance, but he tells us that when he use the
22 initials JR/JDW/[whatever] that the letter is one which
23 is drafted by you, even though he may make the odd
24 alteration?
25 A. That is correct.
0065
1 Q. So this is your text which goes out in his name?
2 A. Well, certainly largely. I would not be able to speak
3 to every phrase and dot and so forth.
4 Q. Let us see what we can make of the next page,
5 UBHT 61/285. This describes a complaint about "the
6 manner in which this matter has developed, apparently on
7 the basis of views or whispers by staff of the BRI and
8 outside cardiac surgeons. We do not know whether any
9 facts are on your table. We have had no opportunity to
10 inform you of the results of our work, which we are
11 always ready to do, and which was done annually in the
12 context of being a supra-regional centre between 1984
13 and 1993. Yet we now find ourselves with no practical
14 alternative to a temporary stoppage of infant work
15 following your letter.
16 "The bold steps which were taken last year in
17 appointing a new paediatric cardiac surgeon and deciding
18 to move children's work to the Children's Hospital was
19 primarily in relation to a specific problem of
20 a particular operation, a problem which we fully
21 acknowledge, and no neonatal switch operation has been
22 carried out since. The issue appears to have widened to
23 all complex neonatal and infant surgery for reasons
24 which are far from clear."
25 That is what is said. Are those your words?
0066
1 A. I think they probably are.
2 Q. Is it accurate?
3 A. I think it is historically accurate.
4 Q. So if it is historically accurate, you are saying here
5 that the appointment of a paediatric cardiac surgeon was
6 primarily an answer to a specific problem in relation to
7 the neonatal switch operation?
8 A. Yes.
9 Q. But the decision to move the children's work to the
10 Children's Hospital was primarily in relation to the
11 neonatal switch operation?
12 A. Yes. That is what sparked off the whole process.
13 Q. So until the perceived failure of the neonatal switch
14 operation, there was no primary need to appoint
15 a paediatric cardiac surgeon or to move to the
16 Children's Hospital?
17 A. Both of those objectives, as you know, had been the
18 goals for which we had been working for some time, since
19 1989, certainly since 1990, not in response to
20 a particular problem but because we thought it was the
21 right thing to do for the future.
22 When the neonatal switch operations stopped in
23 October 1993, then there was, for the first time,
24 a deficiency, a gap, if you like, in the service which
25 we provided.
0067
1 The discussions which led to these decisions were
2 instituted shortly after that, and the reason why they
3 were instituted was really -- well, I suppose there were
4 a number of reasons, but the immediate reason was the
5 response to stopping the neonatal switches. Clearly
6 there were also the background reasons which had existed
7 for the previous five years, approximately.
8 Q. So are you, then, saying -- I think you are, but I want
9 to get it right -- that without the failure of the
10 neonatal switch operation, without the stopping of that
11 because of Mr Dhasmana's feeling that he had failed in
12 his attempt to do it satisfactorily, there would have
13 been no appointment of a paediatric cardiac surgeon, nor
14 move of the Children's Hospital, at least when they took
15 place?
16 A. I mean, that is partly correct, I think, and partly not
17 correct. It arises out of what I said a moment ago.
18 The immediate development which led to the discussions
19 which led to these appointments was the cessation of the
20 neonatal switch operations, but that was against
21 a background of our desire to do each of these things,
22 and we were continuing to seek to do so.
23 Had there not been this particular initiating
24 development, if you like, then our persistence in
25 pursuing these goals, I hope, would have led to these
0068
1 developments perhaps a little later, but they would
2 still have been our goals; they had always been our
3 goals.
4 Q. I will come back to that because I want to examine that
5 with you. Can we focus on the words "no neonatal switch
6 operation has been carried out since."
7 On a literal reading of the letter, it would
8 appear to suggest that the neonatal switch operation had
9 stopped in 1994, which was not the case.
10 A. May I look at it to see why you say that, because I have
11 not read it that way.
12 Q. Yes, please.
13 (Pause)
14 A. If I might say so, I think, yes, that is a possible
15 conclusion one might draw, but I think it would be
16 a slightly superficial one. What we are actually saying
17 is that the process led to the development in 1994.
18 Anyone who knows how slowly the wheels turn in the NHS
19 will realise that that process would have taken some
20 time. In fact, as I say, the process began at the end
21 of 1993, and led eventually to decisions in June and in
22 August of 1994.
23 Q. Did the concerns which you actually had, even although
24 you frankly acknowledged on Monday that you had not
25 always expressed them, but the concerns you actually had
0069
1 about your own AVSD series play any part in the decision
2 to appoint a new paediatric cardiac surgeon and to move
3 the children's work to the Children's Hospital?
4 A. I find that difficult, not because the anxiety was not
5 there. We are speaking of the time when it was coming
6 more clearly into focus, but it was not in focus in my
7 mind; others had not spoken to me about it. There is no
8 doubt in my mind that the actual process here was in
9 response to the historic events that I have described.
10 I am very clear about that, and I am quite certain.
11 As far as I am concerned, at any rate, that is
12 where this process was coming from.
13 Q. Help me, then, with the words that "the issue appears to
14 have widened to all complex neonatal and infant surgery
15 for reasons which are far from clear".
16 The position in that last sentence might suggest
17 that this paragraph is saying, in other words, "We just
18 have a problem with the one operation, and that is the
19 neonatal switch". That might be the message, might it
20 not, that the reader would be expected to derive from
21 it?
22 A. I agree it could be a possible interpretation, but I do
23 not think it is the only one.
24 Q. Is it not the probable interpretation?
25 A. If we are describing what was the development which
0070
1 initiated the discussions which led to the decisions,
2 then --
3 Q. No, I think the focus of this question, actually, is
4 slightly different. It is focusing upon the impact
5 which this paragraph has upon the eyes and mind of the
6 reader. Reading it, he says to himself, "Well, Bristol
7 are saying they had a particular problem with
8 a particular operation. That is the only problem they
9 really had and they are querying why on earth we need to
10 have an investigation into the whole of paediatric
11 cardiac surgery".
12 That is the message, is it not, that comes
13 through -- I say "is it not?"; is it?
14 A. I think the paragraph gives a message which is, in the
15 penultimate sentence, describing a process and what
16 initiated it, and, in the final sentence, describing the
17 position that seemed to exist on 26th January 1995.
18 I do not know that it is actually seeking to make
19 a statement about what happened in-between, or to make
20 a comprehensive statement. It was a response to
21 a letter. It certainly had no intention to mislead.
22 The intent in writing is what I have described, and
23 I still feel that intent is what it says. I think that
24 it is not addressing comprehensively the question of
25 surgery, other than to say, "How is it that we have got
0071
1 to the place where we now seem to be, where everything
2 appears to be in question?"
3 Q. Let me leave it there, and leave others to judge whether
4 the content, if not the intention, was misleading, or
5 may have been and ask you two more questions which arise
6 from it: why should the mortality in a particular
7 operation give rise to the need, first of all, to
8 appoint a new paediatric cardiac surgeon and secondly to
9 move surgery from the BRI to the BCH?
10 A. With regard to the first question, the operation was
11 being undertaken by Mr Dhasmana only, not by myself.
12 Therefore, that operation was no longer being carried
13 out. In as much as Mr Dhasmana was not at that time in
14 a position to resume doing it, then if we were to
15 maintain a full service, we needed to have a new
16 surgeon.
17 So that was the thinking at that time. But again,
18 of course, that thinking is against the background of
19 the fact that we had been seeking to make that step for
20 five years or so.
21 Please remind me of the second one, I am sorry,
22 I apologise.
23 Q. The second one was why that should involve a move from
24 the BRI to the BCH.
25 A. Again, I do not think that it would be right to say that
0072
1 the decision to move the Children's Hospital rested
2 entirely upon this development. After all, the case had
3 been made --
4 Q. The word used is "primarily", you are absolutely right.
5 A. I would not even -- are you using my word "primarily"?
6 Q. It is your word.
7 A. Well, that is difficult. Perhaps primarily, it is
8 a poorly chosen word. My view is that the case to make
9 the move was already made and accepted by everybody; the
10 case in principle was not in dispute; there were no
11 dissenting voices; it was purely a matter of finding the
12 resources to do it, so in a sense, this development was
13 the factor that tipped the balance so maybe the word
14 "primarily" in that context is not well chosen, but in
15 response to your question, that is how I would describe
16 the decision.
17 Q. The development is, is it, the perception that there was
18 a link between mortality or increased mortality, and the
19 performance of surgery upon the split site rather than
20 on a unified site?
21 A. I think it was a mixture of principle and pragmatism.
22 I think the principle really refers to the argument that
23 had already been made and was accepted, and that
24 principle continued to be true, so the case was still
25 there. Whether that case involves an acceptance that
0073
1 mortality would fall because of resolving the split
2 site, or whether it was a response to the fact that the
3 split site was not ideal and that for the future it had
4 to be different, I would not be quite clear.
5 I have lost the ...
6 Q. Let me rephrase the question and perhaps refocus it.
7 Why should the move to the Children's Hospital be
8 a response to a failure of this particular series of
9 operations?
10 A. I think the second part of my answer, if I may give it,
11 was the pragmatic heading. You will recall, we had had
12 an experience in 1991/92 when Mr Elliott declined to
13 come. This was one of the reasons. So the pragmatic
14 reason is that if we want to attract a paediatric
15 surgeon who is to be a whole-time paediatric surgeon as
16 opposed to someone doing adult and paediatric work as we
17 were, and if we were to attract one of adequate quality,
18 which we wanted to do, then we would have to have our
19 own infrastructure sorted out. So that is the pragmatic
20 reason.
21 Q. So that logic is really saying, "Well, we need a new
22 surgeon in order to provide a full service. In order to
23 get the new surgeon, we need to have a unified site"?
24 A. Yes, but I would not want the two reasons to be put as
25 against each other. They were complementing each other.
0074
1 Q. Twice in your statements to us, you talk about the full
2 "repertoire" of the cardiac surgeon. "Repertoire" is
3 the word you used twice. You have spoken in your last
4 answers of a full service: "so that we, in Bristol, can
5 provide a full service". You never did, in Bristol, do
6 the Norwood type of operation, did you?
7 A. No, but that was not part of the conventional
8 repertoire, to use the word.
9 Q. That is what I was going to ask. You never did heart
10 transplantation in neonates?
11 A. No, that was only done in centres designated for
12 transplantation.
13 Q. So again, it is not part of the "repertoire".
14 A. That is not within the normal "repertoire", the
15 conventional "repertoire"; that is extra.
16 Q. What convention defines the "repertoire"?
17 A. Broadly speaking, pretty well everything except
18 transplantation. Say we place ourselves in the 1980s,
19 and ask your question. Then everything except
20 transplantation would be within the normal repertoire.
21 But as we have noted frequently, the scene changed in
22 all sorts of ways.
23 There was a rapidly changing scene in paediatric
24 cardiac surgery, and one of the new elements was the
25 so-called Norwood approach to a particular and very
0075
1 difficult problem. That was a very controversial
2 approach. It was an approach with a very high risk; it
3 was an approach which certainly in the 1980s and into
4 the 1990s very few people worldwide achieved anything
5 approaching acceptable results, so it remained very much
6 on the fringes of normal practice.
7 In that sense, it was a new development; it was
8 still controversial; very few people did it and even
9 fewer people did it successfully, so I would not have
10 regarded that as part of the normal repertoire. Indeed,
11 very few people in this country undertook it.
12 Q. Was it part of your concept of the normal repertoire of
13 a paediatric cardiac surgeon that there are some
14 operations which any surgeon who wishes with
15 self-respect to call himself a paediatric cardiac
16 surgeon simply has to be able to do?
17 A. Yes. Definitely. There would be a range of operations
18 that would fall under that heading.
19 Q. Would it then be the case that deciding, in
20 Mr Dhasmana's case, that he would not offer the neonatal
21 switch operation would mean that he not having the full
22 conventional repertoire of the paediatric cardiac
23 surgeon, was to that extent not providing what you and
24 others would expect of a paediatric cardiac surgeon?
25 A. I would not look at it as narrowly as focusing on
0076
1 Mr Dhasmana not doing an operation. I would look at it
2 as the service provided by the unit. Without naming
3 names, I could describe to you how in other well-known
4 places where there are a group of surgeons doing
5 paediatric cardiac surgery, some do one thing, some do
6 another.
7 Q. Let me take the position that you were in at the end of
8 1993, no longer providing as a unit the full repertoire,
9 conventional repertoire of paediatric cardiac surgery,
10 because Mr Dhasmana has, for his particular problems,
11 given up the attempt to persevere with the neonatal
12 arterial switch.
13 You were the other paediatric cardiac surgeon.
14 Why did you not do it?
15 A. Because I had not been doing switches and at my advanced
16 stage in life I did not think it was appropriate that
17 I should, in a sense, make a fresh start in that
18 operation. I think that is a judgment my colleagues
19 would have agreed with. I do not know that we ever
20 explicitly discussed it.
21 Q. On the face of it, it might seem to be a much simpler
22 solution than recruiting a new paediatric cardiac
23 surgeon and moving the whole operation from the BRI to
24 the Children's Hospital, even though they may have been
25 desirable for other reasons, yet there was no discussion
0077
1 about it, as you have said.
2 For what reasons, pushing a little, did you think
3 it would be inappropriate for you to begin to learn to
4 do the operation?
5 A. I think essentially the reasons of looking to the
6 future, and after all, that was the consideration that
7 had been predominantly if not solely in our minds back
8 in 1989/90/91 when we were trying to recruit a surgeon.
9 At that point, I was, as part of that proposal, prepared
10 to step down from paediatric surgery if we had been
11 successful. That was really entirely because: (1) there
12 was an opportunity; (2) because we felt it would be to
13 the benefit of the unit for the future, a long-term
14 decision. In the event, that did not happen, but the
15 principle of looking to the future did not change.
16 Q. You have anticipated the next question I was going to
17 ask you, which was about the events in the 1990s when
18 you had expressed the willingness to cease doing
19 paediatric work yourself, and concentrate on adults.
20 Is it the case that -- for perhaps entirely
21 understandable and proper professional reasons, let it
22 be said -- you preferred to operate on adults?
23 A. No, that was not the case at all.
24 Q. But you were happy, nonetheless, that Mr Dhasmana would
25 continue as a part-time paediatric cardiac surgeon, and
0078
1 another, who had a track record in the field, would take
2 over and do full-time paediatric work?
3 A. The actual proposal would have been full-time in the
4 sense that he was only doing paediatric work, but in the
5 sense that he would have been an academic, half of his
6 time would have been academic and half of his time would
7 have been clinical.
8 So with that caveat, yes, I was happy because it
9 seemed to be a good thing for the unit, but I personally
10 would have missed doing the paediatric work.
11 Q. Would you then have described him as a full-time
12 paediatric cardiac surgeon?
13 A. In the sense that I have just described to you.
14 Q. You have told us, and this letter reflects, the reasons,
15 as you see it, that led to the appointment and to the
16 move. Had the split site been recognised at an earlier
17 stage as having a potential or probable impact on
18 mortality?
19 A. I think there are two things to say, one a general one:
20 I think that we had all come to recognise that with the
21 development of paediatric care generally and paediatric
22 intensive care in particular, in the late 1980s and
23 early 1990s, our arrangements were no longer ideal.
24 It may be that saying they are not ideal is also
25 saying that there is the possibility that they do not
0079
1 deliver the absolutely best results. I am not able to
2 resolve any debate about that because I do not know, but
3 we recognised they were not ideal and that is why we
4 wanted to change them.
5 The second point, the specific one which I would
6 refer to, is of course that Mr Elliott in his letter to
7 us, I think in January 1992 --
8 Q. 3rd January, JDW 3/107 I think is probably the part you
9 want. It could be 106.
10 A. He made the comment that he regarded the split site as
11 "potentially dangerous". We understood that term in
12 the sense that I have described to you under my first
13 point, namely, that it meant it was not ideal.
14 Therefore, we persevered in our attempts to change it.
15 Q. That is 3rd January 1992. There followed, on 25th March
16 1992, UBHT 61/161. If we scroll down, item (3), the
17 action taken, clinical changes instituted:
18 "Problem of split site identified as important in
19 mortality of sick neonates and infants. Press for full
20 integration of service."
21 So we can see who was there, let us go back up to
22 the top of the page. You were Chairman. This is the
23 "paediatric cardiology" it is called, the
24 cardiologists, the surgeons and some junior doctors,
25 I think. Apparently, in this note identifying, if we go
0080
1 back down to the bottom of the page, that the split site
2 was "important in mortality".
3 What did that mean? What discussion does that
4 reflect?
5 A. This particular audit meeting was in the programme of
6 paediatric cardiological audit meetings and the
7 privilege of occupying the Chair meant that you
8 presented the data and the audit to that meeting. So
9 I think the title says that we had been reviewing the
10 results in children under 1 year of age over some
11 previous period. I did not pick up all the details of
12 that.
13 Q. I think we can see there is a review at the top of the
14 screen, as it stands at the moment.
15 A. I think then, in attempting to draw some general
16 conclusions from that, Dr Martin, in making this note,
17 has made the points that you have drawn our attention
18 to, and in particular point 3. I do not recollect
19 whether that was explicitly discussed, but I think it
20 should be understood as a general point. I do not think
21 that any data that specifically demonstrated that as
22 a phenomenon was offered or discussed. I think this is
23 a general point and simply reflects our continuing
24 feeling that this was a situation which we should
25 continue to work to change.
0081
1 Q. Yes, but the words, albeit on the basis of no data, no
2 statistical study, appear to suggest that all those
3 present agreed in the event that the presence of the
4 split site had an impact on mortality in some way, and
5 it is tempting to read "important in mortality" to mean
6 affecting mortality adversely.
7 Do you think that is a fair or unfair reflection
8 of the feeling, at any rate, of the clinicians at the
9 time?
10 A. I do not think that it reflected a feeling that there
11 was either an individual instance of mortality which
12 might have been prevented or that overall, on a more
13 statistical type of basis, there was a general
14 systematic evidence of mortality for that reason.
15 I think that this is an example of doctors drafting, and
16 I think that the word "potential" would more accurately
17 reflect what we felt, but there we are.
18 Q. I need to press you just a little on this, because what
19 you have described is saying, "We could not point to any
20 particular case in which we could say hand on heart that
21 the presence of the split site had contributed in an
22 observable and demonstrable way to mortality. There was
23 no data, there was no survey".
24 That leaves the third proposition which I think
25 I was putting to you, the feeling, if you like, the
0082
1 equivalent of someone saying, "Well, I cannot think of
2 any specific instance, but this is what was happening;
3 this was the process; this is what was understood, this
4 is how we saw it".
5 That is what I am asking you about.
6 A. I think that feeling is very close to what I was saying
7 about everybody agreeing that it was not an ideal
8 situation. In as much as they are very close together,
9 I agree with you, but I would put it my way, that it is
10 not ideal. I think the implication of that is that
11 there is, in Martin Elliott's words, "potential danger",
12 but I do not actually recall any instance where anybody
13 ever said -- I mean, these matters have been considered
14 over very long periods now in different places, and I do
15 not remember ever hearing anybody say that they could
16 identify an instance where they thought that the split
17 site made the difference between a patient surviving or
18 not surviving, or even suffering serious complication or
19 not suffering serious complication.
20 So I feel we were trying to address a situation
21 that we believed was not ideal.
22 Q. In 1992 Dr Elliot Shinebourne came to look at the unit
23 with a view to seeing whether the appointment of
24 a Senior Registrar in cardiology was justified. You
25 knew of that?
0083
1 A. I was aware of that, yes.
2 Q. Shortly before this time, there had been a Working Party
3 into designation and indeed, in the middle of 1992,
4 a further Working Party in respect of the issue of
5 designation as a neonatal and infant cardiac centre, in
6 each of which consideration was given to the identities
7 of those units which carried out that particular work.
8 In those reports, speaking generally -- we can go
9 to them if need be -- reference is made to the fact that
10 there was a split site in Bristol, as by the beginning
11 of the 1990s there was nowhere else except, it would
12 appear in Edinburgh, which the text suggests was
13 remedying in the position.
14 Let me ask in respect of those, first of all, did
15 you know about the visit of Dr Shinebourne?
16 A. Yes, I knew about the visit of Dr Shinebourne. I was
17 unable to meet him, but I knew about the visit.
18 Q. You knew why it was that his report, initially at any
19 rate, turned down the request to agree to recommend the
20 appoint of a Senior Registrar in cardiology?
21 A. Yes, I think I must have done, because I think I have
22 written a letter, have I not? I do not have a clear
23 recollection of it all, but the answer is yes, I must
24 have known, so I did know.
25 Q. You wrote a letter about it on 3rd April 1992 which if
0084
1 necessary we can put on the screen, but I shall not
2 otherwise trouble you with it. For the reference for
3 the transcript, it is UBHT 195/2, and that was to the
4 Post-graduate Dean?
5 A. Yes.
6 Q. Did you know about the comments that had been made to
7 the Supra Regional Services Advisory Group in the report
8 of the working parties?
9 A. I have more difficulty with my recollections there
10 because I certainly saw some reports but I have since
11 seen other documents, through this Inquiry chiefly,
12 which I had never seen before.
13 I think the summary of my position on this would
14 be that I knew that they knew about the split site and
15 they never indicated in any way to us that the split
16 site was either a particular problem in their minds or
17 that it was something that really meant we should not be
18 a designated centre. I mean, they never came to us with
19 anything on that particular front. Indeed, when we
20 sought capital monies from them that would have helped
21 us to deal with it, it was not forthcoming, either in
22 1987 or in the early 1990s.
23 So I can only assume that they did not regard it
24 as unacceptable.
25 Q. I will tie these threads up together, I hope, in
0085
1 a moment or two, but in 1991 there was a meeting of the
2 unit which is recorded at UBHT 61/146. Can we scroll
3 down? This is the minute which Dr Bolsin made of
4 a meeting which took place in July 1991, so it is
5 slightly before the matters in 1992 that I have just
6 been talking about with you.
7 You provide tables of the open and closed cardiac
8 surgery results, comparison made with mortality in 1990,
9 which we looked at on Monday. That was where I showed
10 you that the results as recorded for Bristol in the
11 under 1s were good, indeed, better than the United
12 Kingdom average presented as a comparison. The results
13 for the over 1s had gone the other way in that
14 particular year.
15 It is what follows:
16 "Mr Wisheart said that he thought the tables
17 demonstrated that the problem which was thought to have
18 been reaching crisis proportions in the Bristol unit
19 when put in context was actually not as serious as had
20 been thought."
21 First of all, did you use words to that effect?
22 A. The quick answer is that I cannot remember, but I think
23 it is probably unlikely. I think that this is probably
24 an interpretation of what I said. But I mean, I cannot
25 recall, so I cannot be sure.
0086
1 Q. Had you, then, allowing for an element of hyperbole,
2 been suggesting that the results had been grim but now
3 looked as though they were better?
4 A. I think what is reflected by this phrase, whether I used
5 the words or not, is the fact that in 1988 and in 1989
6 the results in the under 1s had been disappointing,
7 previous years having been as we discussed, I believed,
8 acceptable.
9 So we had been recognising and discussing those
10 particular problems and that is what is reflected here.
11 Whether the words are accurate or not I do not think is
12 particularly important, but that is what we had been
13 dealing with.
14 Q. So let me then, having shown you that, take you on to
15 a letter which was written in November 1991. So we have
16 looked at events in early 1992 discussing mortality and
17 its potential link with the split site; the Elliott
18 rejection; the events surrounding Dr Shinebourne's
19 visit; and your awareness, which I do not think adds
20 very much from what you say, of the way in which the
21 Royal Colleges, the working parties, looked at the
22 question of the split site.
23 In 1991 there is a meeting which has discussed the
24 apparent performance of the unit in 1988, 1989 and 1990
25 in the way that you have discussed.
0087
1 Now can we look at UBHT 38/430: a letter from
2 Catherine Hawkins to Dr Roylance. If we just have
3 a look, please:
4 "We heard how poorly the Bristol Trust is now
5 performing on cardiac surgery contracting and as
6 a consequence, some are shifting their contracts this
7 coming year ... without exception the business managers
8 were identified as problems ... as currently we at the
9 Region of reviewing cardiac units and our needs, and the
10 fact that we have invested in Bristol to serve the
11 Region and not just Avon, I would more than welcome your
12 comments and action if you feel you are not in sympathy
13 with the current rate and quality of performance of the
14 cardiac unit."
15 Dr Roylance tells us he got this letter, and
16 indeed we can see the stamp, if we scroll down a little
17 bit, please, which he puts on it, and that he sent it to
18 you to consider potential replies. "JDW" is an
19 indication he has done that. That was his habit and
20 pattern, was it?
21 A. It was.
22 Q. If letters like this came in in respect of the Cardiac
23 Unit, do I take it that he generally came to you to help
24 him with a reply, or to draft a reply for him?
25 A. This is the first instance that I can recall.
0088
1 Q. Did it happen regularly thereafter?
2 A. Not regularly.
3 Q. Beforehand, if any issue had arisen relating to the
4 unit, would he, do you think, have discussed that matter
5 with you?
6 A. Probably, but it was only after this that I really
7 became part of the Trust management group, so I was
8 really just a person out there doing the work. I do not
9 recall any previous -- well, that would be wrong.
10 I mean, clearly there was an involvement with
11 Dr Roylance over all the major steps in the 1980s, the
12 development of the unit, the proposal to establish
13 a University Chair, and so forth, because he was the
14 General Manager in those days. So clearly, any major
15 proposal was in discussion with him, but I was not
16 acting in the sort of way where he would ask me to draft
17 or reply to a letter.
18 Q. Your draft responses -- can we look at UBHT 38/432? Can
19 we scroll down? This is the first of the proposed
20 replies. There were three of them, I think, which you
21 proposed as potential replies, leaving Dr Roylance to
22 choose which met his aims best?
23 A. As I said, I had not worked with him in this way before,
24 and I did not have a good idea of what style of reply he
25 would wish to have, so I did, as you say, offer him
0089
1 three different possibilities.
2 Q. Can we turn over the page? The only difference is the
3 manuscript addition to the first one. Go over the page,
4 please.
5 "Quality of care ..."
6 You deal with waiting times there. Can we go back
7 to the foot of page 433?
8 "Quality of outcome" is the first matter you raise
9 under "quality".
10 You are dealing here of course with cardiac
11 surgery generally, not just paediatric surgery but adult
12 as well, indeed, the adult volume much greater, but you
13 are dealing with both, are you not?
14 A. We believed this letter, and I think earlier on it may
15 say so, to be dealing essentially with the adult work.
16 Strictly, it could also have dealt with the work in
17 children over 1 year of age because that is what the
18 Region and the various purchasers in the Region made
19 agreements with us to do. But it was predominantly to
20 do with adult surgery.
21 At least, that is how we understood the letter.
22 I think in our response we invited her to come back to
23 us if we had misunderstood her intention. I think that
24 is quite important, because the letter does not actually
25 make it clear. So to an extent, we were interpreting
0090
1 the letter, but our understanding was that it was
2 predominantly about adults.
3 Q. Two matters arise out of the letter. You saw the letter
4 from Catherine Hawkins as referring to quality in both
5 senses: the quality of outcome and the quality in terms
6 of waiting lists and what might be described as other
7 indicators of performance?
8 A. Well, again, her letter, which you showed us, does not
9 make clear what it is that she is referring to, but in
10 as much as she does develop the theme, it appears to be
11 relating to contracting matters and business matters
12 rather than about the quality of clinical outcomes.
13 That is an interpretation and we specifically invited
14 her to come back to us if that interpretation was
15 incorrect, but she did not.
16 Q. But you respond in your draft in respect of outcomes?
17 A. Well, I was trying to cover the possibilities.
18 Q. So you thought her letter might very well mean --
19 A. No, I thought it was possible. And I was not trying to
20 evade any issues that might be there which she intended
21 to be there, so I have referred to it. But I did not
22 actually think she was asking about that.
23 Q. The second issue which arises out of the correspondence
24 is not from your draft in particular, but from the reply
25 which is actually sent, UBHT 38/426. This is a letter
0091
1 which you may have seen since. I do not know, did you
2 see it at the time?
3 A. I honestly do not remember whether I did or not.
4 I think I probably did. Was it copied to me?
5 Q. Shall we look at the next page?
6 A. I mean, I have seen it many times since.
7 Q. Go down to the bottom of the letter, the next page.
8 A. I think on balance it is likely that I was aware of it.
9 But I have seen it so many times since, I am really not
10 sure.
11 Q. Because although you are not described as a copyee, it
12 is the sort of letter Dr Roylance would have passed on
13 to you?
14 A. I think it is likely, yes.
15 Q. The second matter I want to ask you about is the full
16 paragraph on that page:
17 "I am satisfied that the true quality of the
18 service is, under the current stress, of a very high
19 order ..."
20 It then talks about improving waiting times.
21 Those are his words; they do not come from you,
22 let it be said at once, but if you were a copyee of the
23 letter, if the words had not been appropriate, no doubt
24 you would have picked them up with Dr Roylance? Would
25 you, do you think?
0092
1 A. I think that is quite hard to answer. I mean, I was not
2 invited to comment on the draft before he sent it. So
3 if he had sent it and expressed an opinion that
4 I disagreed with, would I have drawn it to his
5 attention? I think if he had stated a fact that was
6 clearly incorrect, I probably would, but if I had
7 presented him with my advice and he offered his opinion,
8 which might have been at variance with my advice, I am
9 not sure what I would have done. I mean, I might well
10 have said, he is the Chief Executive and he is writing
11 the letter. I am not sure. I am really not sure.
12 I think it would have depended on the degree and
13 importance of the point.
14 Q. At this stage, you are beginning to see him quite
15 regularly, are you?
16 A. This is in November 1991, or thereabouts?
17 Q. Yes.
18 A. Well, no, I would not have been, really, until into the
19 following year.
20 Q. The words "under the current stress" might suggest that
21 he had a view of those providing cardiac surgery that
22 the service was under some degree of stress.
23 What do you know of the time or of the
24 observations which you or others may have made to him
25 that would have given that impression?
0093
1 A. The continuing stress in the department which had short
2 periods of relief were essentially because of the
3 limited facility and resource which we had and
4 therefore, in relation to the demands that were placed
5 upon us, we were always under pressure.
6 Now there was relief for six months or so after
7 the developments in 1988, but the demand outside was
8 such that once people became aware of the fact that the
9 resource had increased, then referrals quickly increased
10 and we were really back to where we were.
11 In other words, what was reflected was the
12 position that, although we were developing, we were
13 still continuing to be seriously behind the demand and
14 the need in the region as a whole.
15 So that is the most important element. Whether
16 that is properly called "stress" or what, I would not
17 like to debate, but I think that would be the most
18 important element of Dr Roylance's meaning, and of
19 course, that then has a variety of consequences.
20 Q. Because waiting lists had already been referred to in
21 the letter?
22 A. Indeed.
23 Q. In essence, I think you are interpreting the "current
24 stress" as probably relating to the pressures upon the
25 unit in terms of those needing to be operated upon, and
0094
1 the best desires of those in the unit to service that
2 need?
3 A. Indeed.
4 Q. In that sort of situation, is it in fact a position
5 which does cause a degree of, leaving aside the word
6 "stress" which may have connotations, but strain,
7 certainly, upon those in the unit?
8 A. That is why I just put a little question mark on the use
9 of the word "stress". I think that the consequences of
10 the pressure that you have described, namely, the
11 numbers on the waiting list and the length of time they
12 were waiting, have two consequences: the stress
13 consequence is when you sit down at your desk and you
14 have to decide what names should be on the operating
15 programme next week or next month, because you have to
16 choose. But having made your choice, you then do your
17 work. So I think that the stress element is essentially
18 to do with that process of choice.
19 The second consequence of the situation, of
20 course -- and I think it has been referred to by others,
21 in particular the cardiologists -- is that the sicker
22 patients who either needed surgery more urgently or
23 could not travel formed a greater proportion of the
24 people we operated on than if we had had a resource that
25 was in balance with the demand, because those who were
0095
1 less sick, in other words, were in a more stable state,
2 could be sent to London or wherever.
3 So those would be the two consequences of the
4 waiting list pressure.
5 Q. Would it be part of the relief of some of the waiting
6 list pressure, perhaps, stress or strain, whatever word
7 is appropriate, at this time, if, let us suppose, there
8 had been the appointment of a paediatric cardiac
9 surgeon, and the increase in facilities in the sense of
10 providing an operating theatre in the Children's
11 Hospital, in addition to the adult facilities that there
12 were at the Royal Infirmary?
13 A. Essentially if the facilities had been increased, that
14 would have relieved that pressure. But again, it would
15 have been a step rather than a complete answer to the
16 problem.
17 Q. I began this line of questioning by showing you what had
18 happened in the beginning of 1992. There is one further
19 matter which I want to take you back to in 1992, between
20 the events that we have spoken about, between the letter
21 from Martin Elliott to you and the audit meeting of
22 paediatric cardiology in March which reviewed the
23 disappointing results, as they had been, for 1991.
24 That was the visit that was paid by Mr Owen,
25 Steve Owen, as the Administrative Secretary of the
0096
1 Supra Regional Services Advisory Group. Can we pick it
2 up at DOH 4/45? Can we scroll down?
3 "Review of the 1991-92 contract".
4 They had moved over to a contract system, in line
5 with the rest of the Health Service. You are
6 misdescribed, but I think it must be you at the start of
7 the second paragraph?
8 A. Undoubtedly.
9 Q. " ... presented the surgical results to date. Both open
10 and closed heart operations had increased from 1990 to
11 1991."
12 Were they constantly looking for evidence of an
13 increase of throughput?
14 A. Yes, I think they were, but it never -- I mean, it was
15 a goal, but I never had the impression that it was an
16 enormously important factor, by which I mean if we
17 failed to achieve a certain increase, our position would
18 be in jeopardy for that reason as a designated centre.
19 We too wanted to increase the numbers. There was no
20 difference between us on that. We wanted to, in as much
21 as it could be done in a clinically appropriate way. So
22 that is what we sought to do.
23 Q. "The 30-day mortality for open-heart operations was
24 30 per cent, compared to a UK average of 20 per cent.
25 This was mainly due to a number of particularly
0097
1 difficult cases."
2 So however one reads the minute of July 1991, the
3 encouragement that one might have drawn from the 1990
4 results was recognised at this stage, it would appear,
5 to have evaporated a bit, because there was again an
6 apparent difference which had to have, or was given, an
7 explanation as between the results in Bristol and the
8 results in the United Kingdom as a whole. So it appears
9 from the text.
10 Is it right, do you think, that you recognised to
11 Mr Owen that there was a broad difference between
12 Bristol, 30 per cent and the UK at 20 per cent, and gave
13 the reason attributed to you in the text for that?
14 A. Yes, I believe that is probably quite correct, namely,
15 that I said it.
16 Q. So in 1992, were you aware that at about this time, the
17 Supra Regional Services Advisory Group were looking at
18 the whole question of de-designation and were
19 considering actively whether the service ought to be
20 de-designated?
21 A. I think my awareness at that time of that issue was not
22 as clear as it is now, because I have seen many papers
23 since. I think my awareness at that time was that there
24 were more centres than they wished to have practising
25 paediatric cardiac surgery, because in addition to the
0098
1 designated ones, there were either two or three others.
2 How they would resolve that issue, what they would
3 do if they would do anything, I had no knowledge
4 whatsoever, and was not party to any discussions,
5 debates, conversations, on that topic.
6 Q. At this stage, the number of particularly difficult
7 cases that you have referred to would not have included
8 the neonatal switch.
9 A. That is correct. This is 1991.
10 Q. Could I put the various strands together that we have
11 been talking about over the last hour or so? We began
12 by looking at the reasons why it was that, in 1994, as
13 you recall it, the letter which was drafted for
14 Dr Roylance after the Joshua Loveday operation to the
15 Department of Health, the reasons why it was that there
16 was then an appointment of a paediatric cardiac surgeon
17 and the move to the Children's Hospital.
18 The incidents, the letters, the materials I have
19 been focusing on for the last half an hour, have been
20 essentially at the end of 1991 and the beginning of
21 1992, which all appear to reflect a degree of concern
22 about the position, viewing it from one way or the other
23 and whatever the explanation might be in Bristol.
24 Coming back again to the question of the split
25 site and the possible appointment of a new paediatric
0099
1 cardiac surgeon, may I ask, why did it take so long,
2 given that there are all these pressures in early 1992,
3 to at least have a decision, a binding decision in
4 principle to do it?
5 A. I do not know that I can answer that question. I mean,
6 all I can say is that the clinicians, of whom I was one,
7 were united and unanimous in the desire in principle.
8 We believed that the management -- I mean, in this
9 period, 1990/91, early 1992, I was outside of that. The
10 management of the hospital, we understood, accepted the
11 principle, but could not find the means to implement
12 it. We continued in 1992 to try to find ways -- and
13 there is evidence for that.
14 We could not identify avenues to explore in 1993,
15 but we returned to it at the end of 1993/94, so we did
16 persist, as one always had to do in the NHS.
17 Q. There is evidence we have had that Dr Joffe put in an
18 application for funding from the Supra Regional Services
19 Advisory Group, unfortunately in the last year that
20 there was going to be any money available for capital
21 funding, which would have been, we have been told,
22 a potential source of income from the mid-1980s?
23 A. Yes.
24 Q. Can you help as to why that was not considered earlier?
25 A. Well, it was considered earlier, was it not?
0100
1 Q. Why was it not done earlier?
2 A. First of all, capital money became available in 1987, or
3 1988, not in the mid-1980s, and I think that is clearly
4 set out in documentation.
5 In 1987 or 1988 -- I cannot state clearly which
6 year, I think it was 1987 -- an application certainly
7 went from the Trust to the Region, because there was
8 a circuitous path. It was not a Trust, then, I beg your
9 pardon, it went from the Health Authority to the Region,
10 to go to the supra-regional services people in the
11 Department of Health, requesting capital money to help
12 with the development of the catheter lab in the
13 Children's Hospital. That was unsuccessful, for reasons
14 that I do not know.
15 I have seen, in the documents that you have
16 provided me with, but I could not at this instant
17 identify the document, that I think in 1989 there was
18 a discussion between Mr Nix and some of his financial
19 colleagues about applying for some capital money to the
20 supra-regional services people. I think it is correct
21 that in the context of our campaign, application,
22 whatever, to resolve the split site in 1991/92, I do not
23 think any application was made until after this meeting,
24 when Mr Owen suggested that it should be made and
25 Dr Joffe responded.
0101
1 Q. There was actually a capital bid which we have a note of
2 for 1988 to 1989. We can pick this up at UBHT 62/370.
3 If we go scroll that down, what is asked for is
4 equipment for extended ward and theatre areas at the
5 Royal Infirmary, not the Children's Hospital, so it
6 would appear.
7 Can you help with that?
8 A. Although the heading says "Financial year 1988/89",
9 could I ask you what the date of that letter is,
10 please?
11 Q. Certainly, up the top: November 1987.
12 A. So this was an application which was made in the
13 preceding year for the financial year to follow.
14 I think that this was an application by the Health
15 Authority or the Region, whoever, seeking to recoup
16 money that they had already committed to the development
17 of 1987/88. I think that is my understanding of this
18 one.
19 Q. So it does not represent the clinicians in the Royal
20 Infirmary saying, "We want to extend the facilities, but
21 let us do it here rather than by --
22 A. I doubt if the clinicians had any awareness of this
23 financial pathway at that time.
24 Q. And the second matter which I need to ask you about in
25 this context, is when the application was made, when the
0102
1 invitation was made in 1991 for applicants to seek
2 appointment to the post of Professor of Cardiac Surgery,
3 there was nothing in the advertisement as such to tie it
4 to paediatric cardiac surgery?
5 A. No. That is correct. The agreement, if you like, or
6 the understanding, whatever, between the British Heart
7 Foundation, who were providing the additional finance to
8 make this possible, and ourselves, was simply a broad
9 one in terms of cardiac surgery, and it was our own
10 desire as a group to use that opportunity to attract
11 a paediatric cardiac surgeon.
12 Q. When Mr Martin Elliott, who was one of the applicants --
13 I think the other principal applicant was Professor
14 [now] Angelini.
15 When he withdrew, for the reasons that he gave,
16 Professor Angelini was left in the running, if I can
17 call it that. He was obviously not a paediatric cardiac
18 surgeon, but the documents that we have indicate that
19 you, nonetheless, wished to proceed with his appointment
20 even although the funding from the British Heart
21 Foundation might not be forthcoming?
22 A. I think there are a couple of points I would wish to
23 make in response to that. The question of seeking to
24 recruit someone to the Chair had probably been going on
25 certainly for 12 months, probably 18 months, prior to
0103
1 Martin Elliott's letter. During that time we had not
2 only seen, heard or thought about, potential applicants
3 from the United Kingdom, but really, worldwide.
4 First of all, there were very, very few, if any,
5 candidates, apart from Martin Elliott, who were
6 paediatric cardiac surgeons. I think there were one or
7 two, but unlike Martin from an academic standpoint, they
8 were not strong, possibly not even viable candidates.
9 So it was for that reason that we did not feel we could
10 pursue our primary goal once Martin Elliott had said he
11 withdrew.
12 That is the first point.
13 The second point is that you said we proceeded
14 with it even though we did not know that money would be
15 coming from the Heart Foundation.
16 Q. You indicated the wish to do so, even if the money might
17 not be forthcoming from the British Heart Foundation,
18 did you not?
19 A. I think what needs to be understood is what was the
20 agreement between the Heart Foundation, the University
21 and what was then the Trust. The agreement was that
22 they would provide money for a personal Chair and that
23 the mechanism should be as follows: that the University
24 would make the appointment, perhaps better called
25 a provisional appointment; that the Heart Foundation
0104
1 would have a representative on the Appointments
2 Committee; and that that provisional appointee, together
3 with his or her proposals for research would be
4 submitted to the Heart Foundation, who hopefully would
5 then approve them and then the appointment would be
6 complete. That was always the understanding. But, of
7 course, as you will imagine, there were checks in
8 place. The University was not going to make
9 a provisional appointment that the Heart Foundation
10 would not then proceed with. So there were good
11 communications between all parties concerned at all
12 stages.
13 In the event, they took a little while to make up
14 their minds. So I mean, we were not just taking chances
15 in what we were doing; it was carefully managed and
16 thought through.
17 Q. What I had in mind arises from a note from Professor
18 Stirrat, which we find at JDW 2/220: 3rd March 1992. It
19 is recording a conversation which you, Professor Farndon
20 and Professor Stirrat had about what is described as the
21 "unsatisfactory situation". This is when the British
22 Heart Foundation were threatening, I think, not to
23 provide funding?
24 A. Well, they were delaying their decision.
25 Q. If we go down to the very bottom:
0105
1 "In discussions about contingency plans, JW and
2 Professor Farndon felt it important that we try to put
3 together a package which would allow Angelini to come to
4 Bristol without the [British Heart Foundation] support
5 on offer."
6 Professor Stirrat agreed, and it appears you
7 pressed the point that you would speak to John Roylance
8 and raise the possibility of an approach to the special
9 trustees on the basis that the post would be in the
10 medium and long-term interests of the Trust.
11 The report is accurate, is it?
12 A. This note?
13 Q. Yes.
14 A. I think that is what we discussed, and, yes, I think
15 that is an accurate reflection of the conversation.
16 Q. So although you had every hope and expectation that
17 there would be funding from the Heart Foundation in the
18 way that you have described, you were looking, if there
19 was not such funding, to go it alone, as it were, as
20 a Trust, with the appointment of a non-paediatric
21 cardiac surgeon, anyway?
22 A. We were certainly exploring that possibility. I do not
23 actually think the exploration of this alternative
24 source of funding got anywhere, but eventually the
25 British Heart Foundation made a decision, so that ceased
0106
1 to be an issue.
2 Q. The thrust of this is not simply exploring it, but the
3 question of your desire at the time to go ahead. You
4 are described, you say it is an accurate reflection of
5 the conversation, as feeling it important to try to put
6 together a package?
7 A. It had been my desire since going back to 1988 or so,
8 and it had taken me that length of time to get to where
9 we were, because I felt that it was right and important
10 that this development should be achieved.
11 MR LANGSTAFF: Let me leave that there and shall I return to
12 ask you some questions after we have had the opportunity
13 of a lunch break.
14 THE CHAIRMAN: Yes. May I, before we break, just share an
15 impression with Mr Wisheart to see his comment: that
16 during all of the time that you were seeking to bring
17 about the various developments, not least the
18 appointment of another surgeon and the movement to
19 another place, you were, were you not, chasing almost
20 mutually incompatible goals, namely, making sure you had
21 enough children treated through and looking at them,
22 whilst at the same time meeting increasing adult waiting
23 lists, always with the same, not only people, but
24 physical resources, numbers of theatres.
25 I imagine that is not atypical in the Health
0107
1 Service, but at some point, did it occur to you to ask
2 whether, if I may use a colloquialism, some wheel is
3 going to come off this particular car?
4 A. I think you are correct to say it is not atypical.
5 I think it was very typical. I am not sure that I ever
6 had any other experience as a junior doctor or senior
7 doctor in the Health Service.
8 I think, yes, that is a very important question,
9 because the discussions could create that impression.
10 In terms of patient care, I think it would be
11 a misleading impression because I think that there is
12 a distinction between the work and the efforts that one
13 is making to develop the unit, the committee meetings
14 you have to go to, the perseverance you have to exhibit,
15 the disappointment you have to cope with on the one hand
16 and the actual work for patients that you are doing on
17 another hand, because at any given time you have, if
18 I may put it this way, a "package" of facilities,
19 meaning physical facilities, human facilities, money,
20 and so forth. The patients you are caring for are
21 within that package which you actually have.
22 Apart from the inevitable question of people being
23 ill or such like, wheels are not falling off that. That
24 is something that is there and is happening, with its
25 strengths and its weaknesses, but it is basic and it is
0108
1 happening.
2 So far as patients are concerned, I do not believe
3 that the wheel was in danger of coming off.
4 Q. Just pressing a little on that, you spoke of identifying
5 the stress referred to in Dr Roylance's letter, and he
6 might also have been talking about the general stress of
7 becoming a Trust, with all that that involved during
8 that period, 1989 to 1991?
9 A. Yes.
10 Q. Putting that aside, you identified the stress as "having
11 to make the hard choice of whom to treat". That is
12 where I wonder whether -- I am obviously not taking
13 a view but seeking your observation -- it may be in that
14 need to make those choices, conscious of the fact that
15 you have these two almost incompatible goals to meet,
16 the adults and the children, that one might keep this
17 child waiting a little longer than one ought to, or make
18 that person wait, albeit in a situation where you are
19 treating very sick children? I just wanted your view on
20 that.
21 A. Thank you. Can I make clear, first, that the choice was
22 not whether to treat or not to treat, just to make that
23 clear.
24 I think the best way to look at this is to say
25 that, within the package that I mentioned a moment ago,
0109
1 there were in a sense two packages: one was adult and
2 one was paediatric. I do not want to give the
3 impression that they were completely isolated one from
4 the other, because that would be misleading; they did
5 interact. Fundamentally, in the ongoing planning of the
6 work there were two packages. So, for example,
7 Mr Dhasmana and I, in terms of our paediatric work,
8 would have specific days when we operated on children,
9 because the paediatric anaesthetists were on the rota to
10 provide the service that day and in any given week there
11 would be so many operations that were paediatric. The
12 intensive care ward, with its facilities and resources,
13 was, if you like, prepared to provide services for that
14 number of children week-by-week.
15 Then, on the other sessions and the other days,
16 I or others would operate on adults.
17 So in terms of the elective work and the planning
18 of the work, one had that basic framework, which
19 I think, certainly minimised, if not totally eradicated,
20 any competition on a day-to-day basis between adult
21 patients and paediatric patients. The point, of course,
22 that is not provided for by that is when emergencies of
23 one sort or another came, but emergencies were
24 a relatively small proportion of the total work.
25 Q. And intensive care, of course; length of stay in
0110
1 intensive care for a child might be longer?
2 A. Yes, but I think that was built into my earlier comment
3 about ITU being in a position to provide for that number
4 of children.
5 THE CHAIRMAN: Thank you. Why don't we then take a lunch
6 break now until 1.30?
7 (12.50 pm)
8 (Adjourned until 1.30 pm)
9 (1.45 pm)
10 MR LANGSTAFF: Mr Wisheart, am I right in thinking that in
11 1984, as early as that in the terms of reference that
12 the Inquiry has, you had recognised and said so, the
13 desirability of unifying the paediatric cardiac surgery
14 on one site at either the Royal Infirmary or the
15 Children's Hospital?
16 A. I had recognised the possibility, I think that was the
17 term you used.
18 Q. I think I said "desirability".
19 A. Desirability, I apologise. I think we recognised it as
20 a goal in principle. I think at that stage when the
21 whole unit was still a very small unit there was
22 a question in many minds and there was a question in my
23 mind as to what would be the right time to do it because
24 to divide our small unit into two would have possibly
25 created two very small units.
0111
1 Q. If one goes back before 1984 to 1981, we saw when
2 Dr Joffe gave his evidence that in 1981 there had been
3 a paper produced by the cardiologists urging the same
4 ultimate result, although I think expressing the same
5 fear.
6 A. I think it was common ground amongst us. I think
7 I wrote something after designation that alluded to this
8 school also. That was common ground. There might have
9 been some debate about timing, but no serious
10 differences.
11 Q. Can we have a look at ES 2/8? Just identify the
12 document perhaps by going back a couple of pages.
13 THE CHAIRMAN: Mr Wisheart, did you want to come in and
14 comment before? Please do if you wish.
15 A. I apologise. There was something I wanted to say,
16 please, arising out of the very end of the morning, very
17 briefly.
18 I realised as I departed that there was something
19 I had omitted to say to you, sir, in my answer, very
20 briefly, very simple: when I had referred to the two
21 packages, the paediatric and adult package, within the
22 larger package and I was trying to make the point there
23 was not day-to-day competition between the adults and
24 children, what I omitted to proceed to say was there was
25 of course continuing competition within each package,
0112
1 adult and child, because that was the nature of the
2 situation we were in, I apologise.
3 MR LANGSTAFF: What you are looking at is a document,
4 Meeting of Representatives of the Designated
5 Supra-regional Centres on Wednesday 5th December 1984 at
6 the Elephant & Castle.
7 If we go to page 8, scroll down. We deal with
8 each of the individual units. Can we turn over the
9 page? We come to Bristol at h.
10 "The Children's Hospital dealt with
11 supra-regional specialities of various kinds. The
12 surgical work was carried out at the Bristol Royal
13 Infirmary which treated only adults ... additional staff
14 were needed since there was only one fully dedicated
15 paediatric cardiac surgeon and there was a shortage of
16 nursing staff."
17 In 1984, am I right in thinking from the questions
18 I have just been asking you that it was recognised that
19 the split site was a disadvantage which it would be
20 desirable to overcome in the interests of child patients
21 generally, if it could be done?
22 A. That was accepted, as I say, as a principle without
23 there being a commitment to timing as just yet.
24 Q. Is it the case that there was a shortage of appropriate
25 nursing staff?
0113
1 A. I am sorry, I am not quite sure what nursing staff you
2 mean.
3 Q. These are the words which come from the presentation
4 made by Bristol because --
5 A. May I ask if I was present at this meeting?
6 Q. Yes, you were.
7 A. This was the one I was at?
8 Q. Yes. Let us go back to page 6.
9 A. Yes, thank you, I have seen that. I knew I was present
10 at one, but there was another meeting I was not at.
11 Q. Dr Joffe was there too. Can we go back, then, to
12 page 9? Each of the units were asked to make
13 a presentation about their position, so these words
14 would have come from you or Dr Joffe or both.
15 You are recorded as having said "We need
16 additional staff since there was only one fully
17 dedicated paediatric cardiac surgeon, there was
18 a shortage of nursing staff."
19 Was there in fact a shortage of nursing staff?
20 I think one may need to put the word "appropriate"
21 before the word "nursing staff" because I think that is
22 the sense; you may like to comment?
23 A. I must confess, I see one glaring error in the second
24 sentence -- that is just by the way -- I honestly cannot
25 remember the exact position with nursing staff in 1984
0114
1 but I suspect that what is being said here is that with
2 an increasing amount of surgery being done, and
3 hopefully that is both children and adults, that there
4 is a need to recruit nursing staff and it is not always
5 easy to get them.
6 I think the second component would be the one that
7 has been recognised, that there were a relatively small
8 number of paediatric trained nurses in Ward 5 in the
9 infirmary at any particular time through the period.
10 So I think it could reflect either or both of
11 those two things.
12 Q. What you say about the record of the presentation made,
13 that there was "a fully dedicated paediatric cardiac
14 surgeon"?
15 A. Clearly there was not -- if that is taken to mean there
16 is somebody who was doing only paediatric cardiac
17 surgery then that is incorrect because the reference is
18 clearly to me rather than to my colleague who did adult
19 work and of course everybody knows that I did
20 approximately 50 per cent of my time with children and
21 50 per cent of my time with adults throughout the whole
22 period.
23 Q. The impression at any rate that was given at this stage,
24 just after designation, to the supra-regional group, if
25 this is an accurate reflection -- I appreciate you did
0115
1 not draft the minutes or the note -- would have been one
2 fully dedicated paediatric cardiac surgeon and that is
3 in the context of needing additional staff, the
4 suggestion appears to be "We need two paediatric
5 surgeons for a unit"; that was a general feeling, was it
6 not, that one needs two surgeons for a unit in order to
7 provide cover for each other and so on?
8 A. Absolutely, a most important principle, it had been set
9 out in the joint Colleges' report a few years earlier
10 and in fact we were able to move to that quite quickly,
11 as you know.
12 Q. With the appointment of Mr Dhasmana?
13 A. Yes.
14 Q. What this then means is, is it, that in 1984 when
15 Bristol was first designated there were recognised
16 problems as the unit saw it with the split site, there
17 was an absence of two paediatric cardiac surgeons, there
18 was a shortage of nursing staff, the numbers we looked
19 at I think the last time you were giving evidence to us,
20 the throughput was low. Can I simply ask for your
21 comments: looking back on it, should Bristol really ever
22 have been designated, do you think?
23 A. Of course when one looks back, one looks back with
24 different eyes and with different thoughts, particularly
25 over such a long period, but I think the idea underlying
0116
1 your question is that Bristol did not meet the ideal set
2 of criteria at that moment in 1984, but I must say
3 I never saw designation in that light. I saw
4 designation as a means of facilitating and encouraging
5 the development of units to meet what were recognised as
6 being the ideals and the goals. So I would have seen it
7 much more in that dynamic context.
8 Q. Did the feeling at the time, in the 1980s, that it was
9 part of the repertoire of a cardiac unit to offer
10 paediatric cardiac surgery as well as adult surgery play
11 a role?
12 A. Absolutely, because I think that was the thinking that
13 had previously existed and the whole concept of
14 designation was an attempt to move away from that and to
15 concentrate the work on children in a smaller number of
16 units.
17 Q. Going back to the question which caused you to hesitate
18 and think when you said "Well, you may see things very
19 differently from the eyes of 1999 that you saw at the
20 time" and then you went on to explain how in 1984 you
21 saw the potential for development.
22 You have not I think answered the question from
23 your present perspective: do I get the implication that
24 the answer is "Perhaps not, but one has to look at it
25 with the eyes of 1984 and not the eyes of 1999"?
0117
1 A. I would have no doubt that looking at it with the eyes
2 of 1984 I do not have a problem with it. As regard the
3 eyes of 1999, it has been my view (and this is a general
4 view and it is not specific as to whether Bristol should
5 or should not be designated) but it has certainly been
6 my view that a smaller number of centres was the ideal
7 and in many ways I think looking at the national
8 interest I would have hoped that is what the
9 supra-regional people would have done in the early
10 1990s. They would have then had to make choices and
11 I would not care to suggest what choices they should
12 have made. That is I think a sound principle with
13 today's knowledge and insights.
14 Q. It is tempting for me to ask you in the light of that
15 last answer whether you would have considered there
16 being at least some justification for a view at the
17 beginning of the 1990s when the number of units came
18 under consideration, there would have been at least some
19 justification for a view that it might be restricted to
20 units excluding Bristol?
21 A. As I say, I think had there been a smaller number of
22 units I would have had much sympathy with that and would
23 have been happy to enter into a dialogue about that, but
24 in fact one had no opportunity, one was completely
25 outside whatever processes were happening.
0118
1 Q. When the Royal College of Surgeons were asked to say
2 "We have 13 units who want to do the work in this
3 particular field, we think that is too many", reflecting
4 a general view of surgeons and clinicians which has
5 remained, as we heard the evidence, throughout 1984
6 until now, they never actually asked you for your views?
7 A. Never.
8 Q. Never asked who would be prepared to be, if I could
9 describe it as a "sacrificial lamb" you understand the
10 point?
11 A. No, no, neither the College nor the Department.
12 Q. It is very difficult with the benefit of hindsight, but
13 a hypothetical question, if they had, do you think
14 Bristol would have fought its corner with the greatest
15 of strength or not?
16 A. As you say, it is hypothetical and it is very difficult
17 and one can only speculate, one cannot say what one
18 would have done. I do not think that any centre would
19 have been keen to stop doing the work, but I do have to
20 say that we did not have the opportunity. Had there
21 been a discussion openly and freely and had it been put
22 in the framework that the national interest -- it is
23 a very small bit of the national -- you know what
24 I mean, would have been better served by a smaller
25 number of units, then I think that all things are
0119
1 possible and I could say no more than that, but the
2 opportunity did not happen.
3 Q. Can I change the topic of questions --
4 THE CHAIRMAN: Before you do, forgive me, Mr Langstaff:
5 Mr Wisheart, you say you do not think any centre would
6 have been keen to stop doing the work; why?
7 A. Because I think the clinicians concerned were all
8 committed and enthusiastic to do it, you know, as
9 individuals. But I have held against that the larger
10 issues which I believe people would have entered into
11 constructive discussion about, had it been put to them
12 and had they had an opportunity.
13 Q. We have heard evidence from some quarter that one of the
14 reasons why in this hypothetical situation people might
15 not have been keen was because of the financial benefit
16 that accrued to the Health Authority and later the Trust
17 through that process of designation because it was a sum
18 based upon calculations of throughput and if one did not
19 ever meet the numbers there was, as it were, added cash
20 that could go elsewhere. I just put that to you to get
21 your observation.
22 A. I cannot speak for other centres, but I can speak for
23 Bristol and I can say quite clearly I think that -- it
24 goes back to this morning -- we were under such pressure
25 that had one section of the work ceased to come our way
0120
1 for whatever reason, we would have been able to use our
2 established facilities and resources by increasing our
3 service agreements in other areas, so I do not believe
4 it would have created a problem for the institution or
5 for individuals.
6 PROFESSOR JARMAN: I wondered if it would give you a bit of
7 kudos, being identified as a supra-regional service,
8 a feather in your cap, as it were?
9 A. I suppose there was an element of that but there was
10 also kudos in doing the adult work well, I think cardiac
11 surgery brings its own satisfactions and rewards as well
12 as its disappointments at times.
13 Q. I wonder also whether there had been any thought at that
14 time of becoming a heart transplant centre?
15 A. We had done in approximately 1990, it was either 1990 or
16 1991 when we appointed a new consultant, Mr Hutter in
17 fact, who had as part of his training a time with
18 Sir Terence English at Papworth and he himself therefore
19 was trained and skilled and competent in this area. As
20 you know, that work was also subject to designation and
21 the designation did not come our way.
22 Q. I wonder if it was a twinkle in your eye, so to speak?
23 A. Had it come our way we would have been happy and with
24 Mr Hutter we believed we had the competent person to
25 lead that work and the Trust had made a very
0121
1 thoroughly-worked proposal as to how it would be
2 provided had the application been successful.
3 Q. You had actually discussed the possibility of becoming a
4 cardiac transplant centre?
5 A. We made an application.
6 MR LANGSTAFF: The same theme: in answer to the Chairman you
7 said "Well, the individuals were keen to do the work"?
8 A. Yes.
9 Q. As it happens, if we take 1991/1992 you personally were
10 not so keen because you contemplated the possibility,
11 the desirability of bringing in a paediatric surgeon who
12 would actually take over that part of the work for you,
13 so in your own perspective, was it the unit that was
14 keen to do the work or the individuals?
15 A. It is an incorrect interpretation of my actions to say
16 that I was not keen, I was keen but I was prepared to
17 step down in what seemed to be a worthwhile step if that
18 had happened.
19 Q. The thrust of the question I am asking is really whether
20 this was seen as something for individuals to fulfil
21 themselves or the unit to fulfil itself?
22 A. None of this is something for individuals to fulfil
23 themselves, that may be an element of it, but that is
24 not the object of the exercise. Sorry, I clearly failed
25 to pick that up.
0122
1 The object of the exercise is what is best for the
2 service, for the patients and for the community and then
3 the individuals who are providing it must organise
4 themselves appropriately in the light of that.
5 Q. I will turn now to the other matter I was going to come
6 on to: can we have a look at UBHT 52/290? The bit that
7 is marked at the side with an X. It is Dr Bolsin's
8 letter as you now recognise it to Dr Roylance where he
9 talks about the unfortunate position of the South West
10 Regional Cardiac Centre's mortality for open heart
11 surgery on patients under 1 year of age:
12 "This, as you may or may not know, is one of the
13 highest in the country and the problem should be
14 addressed."
15 At the date of this letter in 1990, who was the
16 Associate Clinical Director of Cardiac Surgery?
17 A. I think the directorate system was established in 1990
18 and I think that I became the Associate Clinical
19 Director in October of that year; that is subject to
20 confirmation, but that is my recollection at this
21 moment.
22 Q. If the District General Manager, Chief Executive
23 designate perhaps or prospective Chief Executive had
24 wanted to get information about the performance of
25 paediatric cardiac surgery, is it likely that he would
0123
1 have turned to you rather than to others?
2 A. That would seem to be likely.
3 Q. Mr Dean Hart was Chairman of the Hospital Management
4 Committee?
5 A. No, the Hospital Medical Committee.
6 Q. That is what I meant, you are quite right to correct
7 me.
8 What was his specialty?
9 A. He was an eye surgeon, ophthalmologist.
10 Q. Dr Williams, the anaesthetist, did you see him
11 regularly?
12 A. Not regularly, from time to time. We did not do any
13 work together.
14 Q. And anaesthetists, every day upon which you operated you
15 saw day by day?
16 A. I am sorry, I missed the beginning of that.
17 Q. When you operated, each time you operated you would have
18 seen one or other of the anaesthetists?
19 A. One or other of the cardiac anaesthetists, yes.
20 Q. When do you say you first saw this letter?
21 A. My first recollection of seeing this letter is I think
22 on television in I think 1995.
23 Q. You put that carefully: your "first recollection" of
24 seeing the letter?
25 A. Yes.
0124
1 Q. Does that mean you might have seen it beforehand but not
2 now recollect the fact?
3 A. I think the answer to that question is "Yes", and if
4 I may explain: since 1995 I have thought very frequently
5 about this letter and I have been unable to recollect
6 ever having seen it before; that is all I can say.
7 Q. The second question which perhaps needs to be asked is:
8 when did you first know about this letter even though
9 you may not have seen it?
10 A. At the same time, in 1995.
11 Q. If we scroll down to the bottom. We know Dr Roylance
12 saw the letter because it was addressed to him, and he
13 has dealt with it. We know he telephoned Dr Bolsin in
14 response to it. It would follow that he did not
15 telephone you?
16 A. That is correct.
17 Q. Mr Mortimer, the Chairman of the Health Authority,
18 perhaps not the Chairman for much longer after this
19 date, but was he someone that you knew?
20 A. Not in particular.
21 Q. Mr Dean Hart, does it follow from your earlier answers
22 that he never spoke to you about this letter?
23 A. He did not speak to me about this letter.
24 Q. Dr Williams, does it follow he never spoke to you about
25 this letter?
0125
1 A. He did not speak to me about this letter.
2 Q. We have heard from more than one source -- Dr Bolsin
3 being one, Dr Monk being another -- that there was
4 a meeting of anaesthetists in 1991 following this letter
5 at which we are told Dr Bolsin was advised to keep his
6 head down and Dr Williams and Dr Monk would take matters
7 forward.
8 The reason we are told Dr Bolsin was giving that
9 advice or something along those lines was that there had
10 been some concern, some criticism expressed of him in
11 respect of sending this letter to the Chief Executive
12 designate as he had done rather than raising the issues
13 which it relates to in other ways.
14 Two questions: first of all, do you think, if he
15 had the anxieties expressed in that paragraph, that he
16 chose an inappropriate route at the time to express them
17 or not?
18 A. Dr Bolsin?
19 Q. Dr Bolsin.
20 A. It was certainly a route. I would have thought it would
21 have been appropriate also for him to raise it with his
22 more immediate colleagues. I certainly would not dream
23 of saying he should not have drawn it to the attention
24 of Dr Roylance. I think what I would say is, I would
25 have been surprised that he would have done that without
0126
1 drawing it to the attention of his more immediate
2 colleagues, I think that would be the right way to put
3 it.
4 Q. Without drawing it to your attention?
5 A. Without drawing it to my attention.
6 Q. The second question: if indeed the reflection of that
7 meeting of the anaesthetists is rightly reported to us
8 that they felt there was some degree of criticism as to
9 the approach Dr Bolsin had taken in addressing this
10 anxiety direct to Dr Roylance without first discussing
11 it with others, none of that ever reached you at the
12 time? None of the fact that there was some criticism,
13 some complaint about his approach, ever reached you at
14 the time?
15 A. I have absolutely no recollection of seeing this letter
16 or any of the consequences that I have since become
17 aware of that are stated to have followed it, and I have
18 thought very hard and very long.
19 Q. No anaesthetist with whom you worked ever raised the
20 matter with you?
21 A. The matter in this letter?
22 Q. Yes.
23 A. I do not believe they did.
24 Q. You appreciate I asked you those questions because the
25 upshot is they, it appears, all knew of this letter and
0127
1 you did not.
2 A. Yes.
3 Q. It is suggested by Dr Bolsin that indeed he did speak to
4 you some time in the autumn after this letter was
5 written and you were hostile to him with a copy of the
6 letter on your desk, in effect telling him off for
7 approaching matters in this particular way. That is his
8 recollection; did it happen?
9 A. I do not believe it did.
10 Q. He has suggested that during that meeting you were
11 angry, that you demonstrated this by in part being
12 red-faced. May I ask you to have a look at what
13 Rachel Ferris says at WIT 89/100. Can we scroll down to
14 paragraph 27? She is dealing with a period long after
15 the event but the context in one sense is similar, she
16 says here figures are in issue. You have asked her to
17 come to the office, Dr Bolsin says you asked him to come
18 to the office back in 1990; she says "Mr Wisheart gave
19 the impression that he had heard I had been asking
20 questions and wanted to put me right".
21 So far as Mrs Ferris is concerned, did this
22 meeting happen? Did a meeting to that effect happen?
23 A. It may have done, I do not have a precise recollection
24 of the details of such a meeting; I have a vague
25 recollection that we had such a conversation, that is
0128
1 all.
2 Q. Mrs Ferris gives a description here of you wanting to
3 put her right and her description of your being angry
4 because you were quiet and controlled and feeling that
5 she had been warned off; do you recognise yourself in
6 that?
7 A. I was quite confused by that sentence, I was not really
8 sure how much was fact, how much was interpretation and
9 how much was accurate.
10 Q. Can we have page 103? She goes on to -- this is
11 a conversation she has with somebody else, not in your
12 presence -- report that Hugh Ross said to her that he
13 was worried about the way in which her actions were
14 perceived by you, and his indication. I ask you to read
15 it through. You have read it, I think?
16 A. I have.
17 Q. Would you like to respond to that?
18 A. Yes. It is correct that at some stage I drew
19 Hugh Ross's attention to the fact that I had some
20 uneasiness about the way Rachel Ferris was carrying out
21 her duties. I drew it to Hugh Ross's attention I think
22 for two reasons: one because she was a director,
23 a General Manager and therefore he was her boss, so to
24 speak and, secondly, of course because I was frequently
25 in contact with him and therefore it was easy for me to
0129
1 have the opportunity.
2 Where I disagree entirely with Mrs Ferris or with
3 what is said here is the remark that if I continue to
4 involve myself in paediatric cardiac surgery, my career
5 in the NHS would be severely compromised. No such
6 remarks were ever made by me to Hugh Ross. I shared
7 with him an uneasiness which I had which he chose in
8 turn to share with her, which is fine, but nothing of
9 that sort was ever discussed between Hugh Ross and
10 myself.
11 Q. What did the uneasiness relate to?
12 A. I think two considerations that I can recall, there may
13 have been others, but there are two I am able to
14 recall. The first one is -- I need to remind you that
15 Mrs Ferris took up her duties either right at the end of
16 1994 or the beginning of 1995 and at that time
17 Mr Dhasmana was the Associate Clinical Director.
18 You will appreciate that 1995 was a very difficult
19 year for all of us, but for Mr Dhasmana in particular.
20 So he was under a whole series of pressures and
21 difficulties and, in short, I felt Mrs Ferris was not
22 giving him the understanding and support that he needed
23 in those circumstances, indeed, I had on more than one
24 occasion heard her criticising him in his absence. So
25 I was not comfortable with the understanding and support
0130
1 she was bringing to him in the circumstances of that
2 year.
3 The second factor which I think exercised me was
4 that, as I said, 1995 was a difficult year and it is
5 public knowledge that within the unit there was of
6 course some polarisation and difference of opinions.
7 I felt it was appropriate for the manager to, in
8 a sense, distance herself from those disagreements and
9 to just to stand apart from them. But in the event, as
10 I perceived it, she very much allied herself with one
11 particular viewpoint and those were the two reasons why
12 I spoke to Mr Ross.
13 Q. Is another way of putting the last of those two points
14 that she had allied herself to a viewpoint which you saw
15 as critical, amongst others, of yourself?
16 A. I think that was my perception. But let me be clear:
17 I do not expect people to agree with me but I expected
18 her as a manager to in a sense stand apart from this
19 particular debate in her managerial capacity.
20 Q. Can I come back from 1995 because it may be thought
21 there is a possible parallel to 1990 and to the
22 statement of Dr Williams which we have at WIT 352/27.
23 Can we scroll down please? He says, bottom of paragraph
24 164, that he stated he would meet directly with you to
25 discuss the contents of Dr Bolsin's letter to
0131
1 Dr Roylance and he goes on that when he met with you,
2 you expressed annoyance at the content, style and
3 distribution of Dr Bolsin's letter; then he goes on to
4 talk about discussions with other cardiac anaesthetic
5 colleagues.
6 His recollection is that he both promised
7 Dr Bolsin he would discuss the matter with you and did
8 so. If he is right in his recollection, his evidence is
9 consistent only with the fact you had actually seen the
10 letter at the time or at least knew sufficient of the
11 contents, style and distribution to make a comment about
12 it?
13 A. I have to confess that in my preparation I have omitted
14 to read Dr Williams's statement. I have a high regard
15 for Dr Williams and would not lightly dismiss anything
16 he has said. It does not alter the fact that I have --
17 I have really tried to dredge this one out of my
18 recollections for now nearly five years. I do not
19 recollect what Dr Williams is describing and really
20 I can say no more, I am unable to recollect it.
21 Q. We have dealt with the correspondence in 1991 between
22 Catherine Hawkins and yourself. Let me take the period
23 now from 1990 fairly quickly through to what happened
24 later on in the 1990s: did you at any time see any data
25 or figures or analyses, however one describes them,
0132
1 which were produced by Dr Bolsin in respect of
2 paediatric cardiac surgery at any rate before April
3 1995?
4 A. Not before April 1995.
5 Q. Does it follow that even at the time of the
6 Hunter/de Leval investigation you did not see the data
7 then?
8 A. I did not see the data. I first became aware of its
9 existence at the final meeting of the Hunter/de Leval
10 investigation.
11 Q. When you did become aware of the data you told us
12 yesterday that there was one glaring error in it in
13 respect of VSDs; was there another?
14 A. I am aware of at least one other important error.
15 Q. What is that?
16 A. It is the stated cross-clamp time for correction of
17 Fallot's tetralogy which in Dr Bolsin's audit table is
18 stated to be an average, a mean of 140 minutes.
19 I thought that was a very unlikely figure so I extracted
20 an operation note for each patient that I had operated
21 on during the period of Dr Bolsin's audit for Fallot's
22 tetralogy and made a note of the cross-clamp time.
23 I think there were 13 patients but that is from memory,
24 but what the calculation resulted in was that the
25 average cross-clamp time in my hands was 79 minutes.
0133
1 Now of course there was also the work which
2 Mr Dhasmana had done which would have contributed to the
3 overall mean but it is inconceivable that Mr Dhasmana
4 would have taken such a long time as to result in 140
5 minutes. The probability is that he took a marginally
6 shorter time than I had taken.
7 Q. If you had had sight of the figures and data at an
8 earlier stage when they were in the process of
9 collection or in the process of analysis, would you have
10 been able to correct either or both of those errors?
11 A. Oh, I believe so.
12 Q. When ultimately were those errors corrected so that
13 others knew they were in fact errors?
14 A. The first one, the one regarding ventricular septal
15 defect correction was eventually corrected, in the sense
16 that it was agreed by Dr Bolsin and Dr Black that there
17 was an error, in the second half of September 1995 and
18 there was a letter from Dr Bolsin to Dr Roylance
19 following that meeting in which he acknowledges the
20 error.
21 Q. We have had that letter in the Inquiry.
22 A. Unfortunately, although he had placed the information in
23 the public arena he had never placed the correction in
24 the public arena prior to the GMC findings.
25 The second error is one which I identified in my
0134
1 preparation for the GMC hearings and has not really been
2 a matter of much public or other debate.
3 Q. Although you did not see the actual figures, there was
4 a meeting I think between Professor Farndon and yourself
5 on 17th November 1994. In another context we have
6 looked at the notes briefly, but perhaps we can go and
7 see the typed version of it at WIT 87/25. Scroll down
8 to the bottom of the page. The subject of the
9 acceptability of performance figures was first broached
10 by you. We have been through some of the rest of this
11 sheet on Monday. If I focus upon the paragraph fourth
12 down, under the heading "JW", that you had been aware of
13 problems and have kept John Roylance informed. Do you
14 see that?
15 A. I do.
16 Q. You had been aware of the neonatal switch as a problem;
17 you had been aware of your own AVSD series as a problem;
18 was there any other problem?
19 A. In terms of paediatric cardiac surgery those were the
20 two problems and a knowledge and awareness of those two
21 problems went back a year or more, depending on which
22 one we are talking about, and those two problems in
23 November 1994 Dr Roylance knew about.
24 What arose at very close to the same time as this
25 meeting was a question about my results for adult
0135
1 cardiac surgery. I would be pretty certain that I would
2 not have informed Dr Roylance about that at that time
3 because we are really talking of within a few days. So
4 in terms of my recollections that would be my
5 recollection.
6 Q. You are recorded as saying, a few sentences above that
7 one, that you had not been approached by anyone, and
8 then word "directly" is underlined, over doubts over
9 performance figures.
10 A. Yes, that is interesting. I mean I am uncertain when
11 Professor Angelini first raised the question of the
12 adults. I know it was very close to this time and
13 I know that we subsequently -- that is the cardiac
14 surgeons -- met to discuss it some 12 days after this,
15 but whether it was immediately before it or immediately
16 after it, I do not have a record, I do not have a clear
17 recollection.
18 Q. The indirect approach you had had in respect of doubts
19 over performance figures: to which branch of your
20 surgery did that relate?
21 A. That would have been the matter of Professor Dieppe
22 talking with me, which we have discussed, the subsequent
23 discussion which I initiated with Professor Vann Jones,
24 and those of course were the main issues that led up to
25 the Bistro 21 dinner when I made inquiries. So those
0136
1 were the approaches which were indirect and in
2 retrospect quite incomplete approaches, yes.
3 Q. Is it right that you had kept Dr Roylance informed?
4 A. Dr Roylance knew about the neonatal switches, if not
5 before the end of 1993, then sometime early in 1994
6 because as I said to you this morning, that was really
7 the sparking off and initiating factor for those serious
8 discussions.
9 Exactly at what time I told him about my AVSDs,
10 the questions in my mind and the eventual decision
11 September/October time to stop doing them, I do not know
12 -- I mean I do not know exactly -- but I know that it
13 was prior to this.
14 Q. Using this -- this is November 1994 -- we can go back
15 a year or so to your awareness that people were
16 expressing doubts over performance figures; not directly
17 to you, but you were getting word of it?
18 A. I was getting word that comments were being made.
19 Q. Can we go back further than a year before, further back
20 than the end of 1993?
21 A. You could say that the Private Eye incidents perhaps
22 raised those issues.
23 Q. At the time of Private Eye or shortly afterwards you
24 indicated in your statement that you had gone so far as
25 to associate Dr Bolsin as a potential source of those
0137
1 comments because you actually asked him had he done so
2 and he said "No, I have not" and you accepted his
3 denial?
4 A. I did not personally ask him.
5 Q. You heard he had been asked and denied it?
6 A. Yes.
7 Q. Some time in late 1992, is it right that you had the
8 idea that comments were being made about performance
9 figures and that Dr Bolsin might be involved in making
10 such comments?
11 A. You may need to remind me, but I do not recall specific
12 events in late 1992.
13 Q. Late 1992 is Private Eye.
14 A. Yes, that is sort of in the middle of 1992.
15 Q. The last one is October, I think. We can show you -- we
16 may as well have it on the screen, SLD 2/6. This is
17 October 1992. If we can scroll down. The reason why
18 you may remember this one is because it mentions you by
19 name. "The sorry state of paediatric cardiac
20 surgery ..." and then it goes on to mention your name in
21 the second paragraph there.
22 A. Yes.
23 Q. Would I be right in thinking it was some time round
24 about then you were obviously concerned about what had
25 been written in Private Eye, that you had heard from
0138
1 what you had been saying some comments were being made,
2 even though they were not being made directly to you and
3 you had -- this was the rolled-up question I put to you
4 for an answer -- some idea Dr Bolsin might be associated
5 with those comments?
6 A. That question had arisen, but I must say that following
7 the answer he gave to whoever -- I think we know of two
8 people who asked him the question -- I think I can
9 honestly say that I dismissed that from my mind for two
10 reasons: one because he denied it and I had no reason to
11 think other than that was correct. Secondly, because as
12 Dr Roylance pointed out to me, but I think to a much
13 wider circle also, that it was really an irrelevance who
14 was the source of the information because we would not
15 do anything about it anyway because if that was within
16 their rights to do and so forth and we would not be
17 taking any action as a consequence of that. So there
18 was therefore no further reason to think about that and
19 I think I had put it, if not out of my mind, at least to
20 the back of my mind.
21 Q. Again so I understand what was happening: at this stage
22 you were the Medical Director, you were also, were you,
23 Chairman of the Hospital Medical Committee?
24 A. Yes, I had begun in April 1992.
25 Q. You saw Dr Roylance regularly?
0139
1 A. Indeed.
2 Q. You got on well with him and talked to him about
3 a number of issues?
4 A. Yes.
5 Q. You recollect saying to him something along the lines
6 of: "I am concerned about how this got into Private Eye"
7 and his saying "that is not a proper concern"; did you,
8 do you think, mention to him any suggestion in your mind
9 that it might have been Dr Bolsin, even if later on you
10 were disabused of that?
11 A. I think it is likely that he knew both of the
12 speculation and the fact that Dr Bolsin had denied it,
13 so to speak.
14 Q. Never once in his conversations did he mention to you
15 "I got a letter in 1990 from Dr Bolsin making some
16 suggestions"?
17 A. Definitely not.
18 Q. From the beginning of 1993 onwards you were no longer
19 Associate Clinical Director of cardiac surgery,
20 Mr Dhasmana was?
21 A. That is correct.
22 Q. Did he have any responsibility, as you would see it, to
23 provide returns in terms of figures to the Central Audit
24 Committee of the Trust?
25 A. Mr Dhasmana?
0140
1 Q. Mr Dhasmana.
2 A. Theoretically he did in as much as he was the Clinical
3 Director but the responsibility was delegated to the
4 person who was the Audit Coordinator for cardiac surgery
5 at the time.
6 Q. That was Mr Bryan, was it; he came later, did he?
7 A. Shortly after he came Mr Bryan took that up, it had
8 previously been Mr Hutter's responsibility.
9 Q. Can you help at all as to why, in chronological terms
10 after the Private Eye article, although figures went on
11 being returned to the register from the Trust,
12 Dr Thomas, the Chairman of the Trust Audit Committee was
13 to complain that no such figures were received in
14 respect of cardiac surgery by the Trust Audit Committee?
15 A. Yes, I was aware of and embarrassed by that fact because
16 I too was a member of the Audit Committee at the time.
17 Q. So as a member of the Audit Committee you would have
18 wanted to see the figures put forward in a public arena,
19 would you not?
20 A. There may be a slight misunderstanding here: the answer
21 to your question is I would have wanted the reports of
22 the audit meetings of cardiac surgery to have been made
23 to the Audit Committee. The actual figures that went to
24 the register were never submitted to the Audit
25 Committee, that was not part of the process as it
0141
1 existed.
2 Q. I accept that.
3 A. So what I would have wanted to see, as I say, were the
4 appropriate reports that the meetings had taken place,
5 which they had, and of course I knew they had taken
6 place but the reports never reached the committee for
7 those two years.
8 Q. When Messrs Hunter and de Leval produced their report,
9 they criticised -- I will find the reference for you, it
10 is UBHT 61/382. Scroll down to item number 2 under
11 "Perceptions Collected During The Visit":
12 "The surgeons reticence to produce and analyse
13 their own results has obviously contributed to tension
14 and eventually conflict between the Department of
15 Cardiac Surgery and the Department of Anaesthetics."
16 Is that a justified statement?
17 A. I did not think so.
18 Q. You then did not give them that perception, and others
19 to whom they spoke must have done?
20 A. No, I did not give them that perception.
21 Q. You may recollect the letter in response to
22 Catherine Hawkins which Dr Roylance wrote and which we
23 looked at earlier. You may recollect the response he
24 gave to Ms Binding, the NHS Management Executive to the
25 Private Eye articles. A suggestion was made that
0142
1 paediatricians in the south western region would be
2 given, or it was likely they would be given, copies of
3 the results of the unit so far as cardiac surgery was
4 concerned?
5 A. Was that in Dr Roylance's letter to Ms Binding?
6 Q. I think that is so. We will find the last page of that
7 letter for you, I think it is JDW 3/158. It is the last
8 full paragraph:
9 "On the suggestion of the Chairman of the Trust,
10 it is likely that we should circulate to the
11 paediatricians whose children we serve a regular report
12 on the results of our work."
13 Do you know whether that happened?
14 A. I am not aware that it did happen.
15 Q. Given those answers why -- if you can put it briefly
16 because there may be much to say -- do you not think
17 that the comment made in the Hunter/de Leval report was
18 justified or had some justification to it?
19 A. Because the surgeons produced their figures each year
20 and I believe you have the documents that show that.
21 I was personally responsible for it within the period of
22 the review from 1984 up to and including 1992 and you
23 will find summaries for each year, you will find them
24 broken down, you will find comparisons to the most
25 recent UK figures and you will also find information
0143
1 from previous years so that the small numbers are at
2 least a little bit more meaningful.
3 Those figures were first of all put together and,
4 secondly, they were made available and discussed and
5 that was our approach and that was what we did.
6 Q. Can I, as the last topic to which I shall turn before
7 the break, ask this: you were aware of comments being
8 made from some time after the Private Eye articles,
9 comments about the nature of the performance of the
10 unit. You were not aware who was making the comments;
11 who did you ask to find out because obviously there may
12 have been someone making comments who could quite easily
13 have been disabused on showing them the true figures of
14 the unit?
15 A. I did have some knowledge because when Professor Dieppe
16 came to see me, he said Dr Bolsin had spoken to him.
17 When I then subsequently went to Professor Vann Jones,
18 he said to me that Dr Bolsin had in fact, as it
19 happened, spoken to him just a few days earlier. So to
20 that extent at any rate I knew Dr Bolsin at that stage
21 -- but we are now towards the end of 1993.
22 Q. It is the period in between that I am particularly
23 interested in.
24 A. Between?
25 Q. The end of 1992 and the time that Professor Dieppe
0144
1 raised the matter with you in late 1993.
2 A. I am not sure -- you may be able to help me, but at this
3 instant I cannot just pick up in my mind much relating
4 to that period but I am not sure.
5 Q. The reason why I am asking is your own recollection,
6 difficult as it is looking back -- that at some stage
7 after, and perhaps in response to the Private Eye
8 episode, if I can call it that, you were aware comments
9 were being made about the performance of paediatric
10 cardiac surgery. That was your general perception.
11 What I was asking you was whether, given that
12 general perception, you can recollect doing anything to
13 find out the nature of the comments or the source of
14 them?
15 A. No, stemming from the conversations I have told you
16 about with Dr Roylance, I made no effort whatsoever to
17 pursue the question of the source of the information to
18 Private Eye for the reasons that I told you.
19 Q. As to the nature of the comments?
20 A. Do you mean their accuracy/inaccuracy?
21 Q. Yes: "What were they saying about our unit?"
22 A. Well, as I think you know from that letter to Ms Binding
23 -- no, that letter reported some information I had
24 given to some parents. Prior to that -- sorry, this is
25 incoherent...
0145
1 Following the first article in Private Eye which
2 raised questions about Fallot's tetralogy I did of
3 course discuss that with Dr Roylance and I provided him
4 with figures for Fallot's tetralogy which would have
5 been I think the same figures as is in the Binding or
6 was attached to the Binding letter, indicating
7 essentially two things: that there had been a period of
8 very acceptable results for that operation in the late
9 1980s and that in 1990 and 1991 there had been a period
10 of less good results, it would have been too early to
11 make any comment subsequent to that. So that
12 information was shared with Dr Roylance.
13 Q. But you think nothing further in response to what you
14 understood to be adverse comments; no further knowledge
15 of them until Professor Dieppe comes to talk to you in
16 1993?
17 A. I think in terms of adverse comments that is correct.
18 Yes, I think that is correct.
19 Q. Let me leave the chronology, if I may at the end of 1993
20 and come back to it in about 10 minutes time.
21 THE CHAIRMAN: Shall we take a break for 10 minutes until
22 just before 3.05?
23 (2.50 pm)
24 (A short break)
25 (3.23 pm)
0146
1 THE CHAIRMAN: Mr Langstaff, before we begin, would you mind
2 if I intrude by making an announcement -- in fact, two
3 announcements.
4 PANEL'S DECISION ON MR LISSACK'S
5 APPLICATION TO RECALL WITNESSES:
6 THE CHAIRMAN: The first relates to the application made by
7 Mr Lissack on Day 61, which was 12th October, that three
8 witnesses be recalled and one called for the first time
9 to give oral evidence.
10 I have responded twice since on progress, on
11 Day 65 and on Day 84.
12 As I have said, the Panel took the view that there
13 was no need for further examination of the various
14 witnesses, subject to hearing further from Professor
15 Berry.
16 We have now heard from Professor Berry and from
17 Ian Barrington, General Manager of the Bristol Royal
18 Hospital for Sick Children. Their statements have been
19 made available to legal representatives and will be
20 published on the Inquiry's website this week.
21 We remain of the view that it would not assist the
22 Panel to hear from Professor Berry further. That said,
23 we draw attention to paragraph 3 of his supplementary
24 statement as demonstrating the difficulties which
25 surrounded, and still surround, the law and practice
0147
1 relating to the retention and use of tissue, for, in
2 paragraph 3, Professor Berry talks of "subsequent use"
3 of archive material for research and teaching purposes.
4 Although laudable purposes, it is by no means
5 clear that at least in the case of a Coroner's
6 postmortem, the pathologist has legal authority to use
7 the tissue in this way. The legal opinion commissioned
8 from our experts suggests that such authority does
9 exist. However, the well-argued submission of the legal
10 team representing the BHCAG suggests that the law is
11 otherwise. Certainly, to describe such use as "best
12 practice" as does Professor Berry is perhaps to endow
13 the custom with more propriety than it deserves. The
14 best that can be said is that it was and to a degree is,
15 common practice.
16 In formal terms, we do not accede to Mr Lissack's
17 application, but let me go on immediately to say the
18 following: it is the lack of clarity in the law
19 demonstrated by Professor Berry's statement, by
20 Mr Lissack's team and by the independent legal opinion
21 commissioned by the Inquiry, that has persuaded us of
22 the pressing need for clarification of what is proper
23 from both an ethical and a legal perspective.
24 I am pleased to say that I have heard today from
25 the Chief Medical Officer. I wrote to him in October,
0148
1 offering the services of the Inquiry if it was thought
2 that we could help. Specifically, I offered to produce
3 what would in effect be an interim report dealing with
4 the retention and use of tissue. I would envisage
5 reporting on all the evidence the Inquiry has heard on
6 this matter, addressing issues such as the complexity of
7 the law and what may be proper or good practice, and
8 making recommendations for the future.
9 Today I was informed that the Chief Medical
10 Officer would, indeed, be assisted by our producing an
11 interim report. This would enable him to consider it
12 and advice from other quarters so as to propose changes
13 as soon as possible.
14 For our part, we will aim to produce our interim
15 report in the Spring. As befits the way in which we
16 have always worked, we will, of course, keep all those
17 interested informed of progress as we proceed, and the
18 interim report itself will be published.
19 Mr Langstaff?
20 MR LANGSTAFF: Mr Wisheart, before I return to the themes
21 that we have largely been exploring this afternoon, can
22 I raise a matter which we were invited to clarify,
23 arising out of the Clinical Case Note Review, and which
24 in fairness to you needs to be said publicly, although
25 it will form part of the written further evidence of
0149
1 Professor Steven Evans to the Inquiry in respect of the
2 Clinical Case Note Review.
3 It is this: that in the report on the Clinical
4 Case Note Review, 10 per cent of the procedures had
5 surgical care graded below 3, 90 per cent above grade 3,
6 adequate or less than adequate or making no difference
7 to outcome, and 21 per cent below grade 4, that is
8 79 per cent were grade 4 adequate care.
9 Those figures, he says to us, must be taken in
10 context. The assessment of adequacy or inadequacy of
11 surgical procedures in particular based only on the
12 notes has limitations: absence of evidence of a problem
13 is not evidence of absence. The way the sample of notes
14 was taken to reflect concern about higher risk
15 operations and those who died must also be considered.
16 The adjusted percentages are estimated to be for those
17 graded 4, 93 per cent, with a confidence interval of
18 95 per cent from 88 to 96 per cent; for those grade 3 or
19 4, 97 per cent, that is a confidence interval of 94 per
20 cent to 99 per cent, and in layman's terms, my
21 understanding -- these are my words, not his -- that
22 means that 3 per cent of surgical procedures taken
23 across the whole 2,800 odd cases that were looked at in
24 order to produce the Clinical Case Note Review would
25 have a grading extrapolated from that which the team has
0150
1 found of 1 or 2, that is, 3 per cent of the total
2 procedures.
3 This bears out what I have said by way of caution
4 when we began looking at four cases yesterday, that of
5 course they are selected because one can learn perhaps
6 more from failures than successes and in fairness to
7 you, I was asked to, and do, indicate the percentage of
8 adequate care compared to less than adequate care.
9 MR WISHEART: Thank you.
10 MR LANGSTAFF: Can I then return to what we were talking
11 about? I was asking you about your knowledge of
12 concerns and how they developed. One particular matter
13 that we have not yet dealt with is the letter which
14 anaesthetists wrote in the middle of 1994 -- let us look
15 at it, UBHT 61/6. Can we scroll down? This was
16 a letter about which there has been much evidence, and
17 of which you may have read something in the transcripts.
18 A. Yes.
19 Q. You have seen this letter before. When did you first
20 see it?
21 A. I first saw it on television, in, I think, 1995.
22 Q. You then were not told of this letter by Dr Monk, or
23 were you told of the letter by Dr Monk?
24 A. I was not told of that letter by Dr Monk.
25 Q. Were you told of it by any anaesthetist?
0151
1 A. No.
2 Q. Even although, as we have seen from different versions,
3 all six signed a copy?
4 A. Yes, I understand that.
5 Q. Were you ever told of it by Dr Roylance?
6 A. No, definitely not.
7 Q. Did you understand, in the middle of 1994, that the
8 anaesthetists had a concern about the switch series?
9 A. I understood that there was some measure of unease
10 amongst them. I was unclear what it was based on,
11 whether it related to the neonatal switches of the past,
12 or what. It was as vague as that. It did not go beyond
13 that.
14 Q. Did Dr Monk talk to you about that concern, even though
15 he may not have mentioned the letter?
16 A. I think that Dr Monk and I had a number of conversations
17 that would have touched on that. There were certainly
18 some before the letter. Whether there were any
19 afterwards, I really do not recall specifically.
20 Q. And ones before the letter?
21 A. As I say, they would have touched on it, but there was
22 no precise content, there was no precise proposal or
23 precise concern.
24 Q. If there is no precise content, what was the general
25 content?
0152
1 A. That there was a discussion that there seemed to be some
2 unease amongst some of the anaesthetists on the subject
3 of the switch operation.
4 Q. What, as you recollect it, albeit in general terms, was
5 your response to that?
6 A. We discussed it and as far as I understood things, the
7 neonatal switch had stopped the previous autumn. The
8 facts and figures about that were, as I understood it,
9 not in dispute; they were there and were not disputed.
10 At this stage, the non-neonatal switch operation,
11 I thought was not the subject of controversy.
12 I hesitate there, because I hesitate to say whether
13 I actually knew, let us say in May 1994, that there had
14 been 13 in the 1990s with one death. I knew that
15 subsequently. I hesitate just to say whether I had the
16 clarity of that knowledge, say, in May, because I am not
17 sure, but I was aware that a significant number had been
18 done with good results.
19 Q. Were you aware of any formal or informal decision not to
20 continue with the non-neonatal switch without a review
21 by the surgeons and the anaesthetists together?
22 A. A decision not to continue with the non-neonatal
23 switch?
24 Q. Non-neonatal switch operations, without the agreement of
25 the anaesthetists as a body?
0153
1 A. I do not believe that I was aware of that.
2 Q. So you were not conscious of there being any informal
3 decision to stop operating on the non-neonatal switch?
4 A. You mean by the surgeon? By Mr Dhasmana?
5 Q. Yes.
6 A. No, I was not aware of that.
7 Q. Can you help as to why it might be that a letter like
8 this is drafted? There are a number of parts to this
9 question, so you need not answer just yet: why a letter
10 like this should be drafted but not come to your eyes;
11 why it should be that we have been told by Mr Dhasmana
12 that there was an agreement not to continue with the
13 non-neonatal switch without first discussing it with the
14 anaesthetists; why it should be necessary or thought
15 necessary on 8th December 1994 to convene a special
16 meeting to discuss, amongst other things, the switch
17 results and then be thought necessary to produce further
18 information after that meeting which came to light in
19 the meeting which we have dealt with already, the night
20 before the operation on Joshua Loveday; all of which
21 might suggest that there was an absence of exchange of
22 information and communication within the unit.
23 That is a long question. The focus is
24 communication. Was there, do you think, an absence of
25 communication between the various members of what should
0154
1 have been a team?
2 A. I think it is clear that there was an absence of
3 communication.
4 Q. To what do you ascribe the absence?
5 A. I find that very difficult, because, as you have set it
6 out, I find that a very difficult situation to
7 understand. I can only tell you what my perceptions
8 were at that time, but that is not an answer to your
9 question.
10 Q. Your perception at the time of the degree of
11 communication was what?
12 A. I mean the second half of 1994.
13 Q. What then?
14 A. Following what I now know to be the 13 operations, but
15 I may not have known the number at the time, with just
16 one death, there were of course two further operations
17 in June, or June/July 1994, with two deaths. I know
18 that there was considerable disappointment about that,
19 and coming so soon after stopping the neonatal switches,
20 I was conscious that Mr Dhasmana was, as you would
21 expect, very disappointed about that.
22 Following that, my perception was that it happened
23 that there were no referrals of patients for a number of
24 months and so when we came up to have our evening
25 meeting in December, it did not seem at all out of order
0155
1 to me that we should actually be reviewing that
2 situation, which we did.
3 Q. Returning to the question of communication, can I just
4 explore one possible thesis with you? For this one
5 needs, again, to go after the events of the Loveday
6 operation and explore three things, although briefly.
7 First of all, can I ask you, after the operation
8 on Joshua Loveday on 7th April 1995, was there an
9 extraordinary meeting of the Hospital Medical Committee,
10 at which you made a personal statement?
11 A. Yes, there was.
12 Q. We see, amongst other things, we have on record --
13 I need not go to it -- that personal statement.
14 A year later, in May 1996, was there a letter from
15 Dr Coates to Mr Baird concerning your credibility as
16 a Medical Director?
17 A. Yes, there was.
18 Q. We have that, please, at UBHT 52/65. The opening
19 paragraph:
20 "You should be aware of the views of the majority
21 of consultant anaesthetists regarding the continuation
22 of Mr James Wisheart as Medical Director ..."
23 He says it has been considered at three
24 Directorate meetings each attended by 15 consultants,
25 concern about your position:
0156
1 "The Trust needs clear and careful direction by an
2 individual who commands the confidence and respect of
3 all consultants ... It is important to stress that
4 concerns are based on managerial rather than clinical
5 credibility. I have informed James directly of the
6 concerns this morning."
7 Had he done that, told you of the concerns?
8 A. I believe he did, yes.
9 Q. If we scroll down, the four points which he raises to
10 the then Chairman of the Hospital Management Committee
11 are that, as he puts it:
12 "Verified outcome data ... were available, but
13 remedial action was not taken. Repeated requests from
14 senior clinicians, concerns not addressed in open forum"
15 and he suggests that reflects a lack of insight.
16 Secondly, "...refusal to accept these outcome data
17 has resulted in the withholding of proper information
18 from parents who were asked to give consent to
19 surgery ...".
20 The next point relates to the operation on Joshua
21 Loveday. The fourth, I think, is perhaps in the same
22 vein.
23 Was that letter discussed by the consultants on
24 the Hospital Medical Committee?
25 A. Yes, it was debated at two meetings.
0157
1 Q. Is it right that 13 out of 14 of the consultants
2 supported you?
3 A. That was at a different meeting. That was at the
4 meeting of Clinical Directors which preceded the meeting
5 of the Hospital Medical Committee.
6 Q. So 13 out of 14 of the Clinical Directors: was the
7 exception Dr Coates?
8 A. Yes.
9 Q. So after the operation on Joshua Loveday, the events we
10 have spoken of in 1995, until the middle of 1996, those
11 with whom you worked as Clinical Directors were prepared
12 openly to express their support for your position and
13 view, as a manager?
14 A. That is correct.
15 Q. The Clinical Directors, between them, the 14 Clinical
16 Directors, would be, would they, the most powerful
17 clinicians in the hospital?
18 A. Not necessarily.
19 Q. Probably?
20 A. Many of them, probably, yes.
21 Q. And no doubt the perception would be, amongst others,
22 more junior consultants and perhaps consultant
23 anaesthetists, that you would have had this support,
24 because you had enjoyed support throughout your time as
25 Medical Director and as Chairman of the Hospital Medical
0158
1 Committee when you were?
2 A. That is what I understood, yes.
3 Q. Speaking first in general terms, and then I shall ask
4 you more closely about this as it relates to you, is
5 there, in general terms, perhaps a natural inhibition on
6 the part of someone in a hospital setting who is more
7 junior to feel that he is criticising someone who not
8 only is senior, but is known to have the support of the
9 vast majority of senior and powerful clinical
10 colleagues?
11 That is a general question.
12 A. I do not think that is correct.
13 Q. You do not think it is correct?
14 A. No.
15 Q. I need not then ask you the second question, which would
16 have been -- perhaps I am asking it, therefore, am
17 I not: if there were that possibility, did you take any
18 steps to guard against it reflecting against you as an
19 individual?
20 A. I am glad you asked the second question, because there
21 is something I would like to draw your attention to.
22 This is May, I think, of 1996, and in the early part of
23 that year, Mr Ross had asked me to extend my term as
24 Medical Director, and as part of my own thinking before
25 I responded to that invitation, I took advice from my
0159
1 colleagues, and I specifically took advice from Dr Monk,
2 who, until weeks prior, had been the Clinical Director
3 of Anaesthesia, but who clearly knew me well and was
4 able to give good advice.
5 I sought the advice of Professor Vann Jones, for
6 obvious reasons, and I sought the advice of Mr Hutter,
7 who by then was the Associate Clinical Director of
8 Cardiac Surgery and therefore any decision of that sort
9 on my part would impinge on the clinical service.
10 I really invited them to say to me that this was
11 not appropriate. Each of the three, individually -- not
12 together, individually -- encouraged me to proceed. So
13 I was not just going off on my own in responding to
14 Mr Ross.
15 Q. The focus of my exploration was the obvious and vocal
16 support that you had from the vast majority of your
17 clinical colleagues, the exception being the
18 anaesthetists.
19 Can we look at JDW 7/95?
20 A. May I comment on the suggestion that the anaesthetists
21 as a group did not support me?
22 Q. I was reflecting Dr David Coates' letter. Please, if it
23 is not a proper reflection, tell us.
24 A. I think it would be correct to say that opinion was
25 divided. Following the meeting of the Clinical
0160
1 Directors, there was a meeting of Chairmen of Division,
2 which Dr Coates would have attended had he been able to
3 do so, but he was unable to do so. Dr Monk attended in
4 his stead. I had unanimous support at that meeting, so
5 I think that does indicate that -- and the anaesthetists
6 as a group were not critical of my -- at least, did not
7 wish me to step down from my position.
8 Q. The letter we are now looking at on the screen is very
9 much earlier, very much closer in time to the operation
10 on Joshua Loveday.
11 A. Yes.
12 Q. It is a letter from Professor Vann Jones to you. The
13 opening words:
14 "I was dismayed at the meeting of the Cardiac
15 Surgery Associate Directorate last Tuesday to find out
16 how divided and acrimonious the atmosphere is in cardiac
17 surgery. I was also sorry to hear and indeed to see how
18 our colleagues in less favoured positions in the
19 Directorate are being abused. I do not think we should
20 be bandying terms like 'disloyalty' or 'lack of
21 co-operation' about. I also thought it was distressing
22 to see the perfusionist so interrupted that he could not
23 get a word in edgeways particularly as the person
24 berating him did not even turn round to face him."
25 First of all, were you at the meeting he was
0161
1 writing about?
2 A. No, I was not.
3 Q. Were you at meetings which were similar in style?
4 A. I think this one must have been exceptional.
5 Q. Was there, as you saw, it following the operation on
6 Joshua Loveday, a "divided and acrimonious atmosphere"?
7 A. There were definitely tensions within the department.
8 Whether I would have used the word "acrimonious", I do
9 not know, but there were certainly tensions within the
10 department. I have already referred to them.
11 Q. It is a rather blander word, "tensions".
12 A. It is.
13 Q. How far were terms like "disloyal" or "lack of
14 co-operation", as Professor Jones put it, being bandied
15 about?
16 A. I really do not know, I was not clearly conscious of
17 them being bandied about, but clearly they arose at that
18 meeting.
19 Q. Were there accusations being levelled against an
20 anaesthetist or a perfusionist, or what?
21 A. I do not think there was any question of anything being
22 levelled against the perfusionist. I think he just got
23 caught up in it, so to speak. Nor am I -- I mean,
24 accusations; there were tensions between certain people
25 who saw -- I mean, let us take the Loveday issue that
0162
1 has been quite widely discussed. There were clearly
2 people who saw that issue from one standpoint and there
3 were people who saw it from another standpoint. That
4 probably fairly represents the tensions and the people
5 who saw things from different standpoints.
6 Q. We have been told that, not long after this, there was
7 an occasion when you and Dr Bolsin were together and
8 observed. I think it was during the Hunter/de Leval
9 inquiry. It was thought that there was an atmosphere
10 between the two of you. Was there?
11 A. I have seen the reference to which you refer. The only
12 comment I can make is that that was the meeting at which
13 it emerged for the first time, to me, that Dr Bolsin had
14 undertaken an audit, and that he had given it to
15 Dr Hunter and Mr de Leval, and I am not always good at
16 concealing my feelings, and it is quite possible that my
17 body language was visible on that occasion. I mean,
18 I was absolutely shocked; profoundly shocked.
19 Q. Just shocked?
20 A. Yes.
21 Q. Angry?
22 A. Well, I expect so.
23 Q. You refused either then or shortly thereafter to work
24 with Dr Bolsin for a while, did you?
25 A. It is important that it was not then; it was later,
0163
1 after further developments. It was not because he had
2 levelled a criticism; it was after he had, whatever the
3 mechanics of it were I cannot say, but it appeared that
4 in a well-known national broadsheet his criticisms were
5 printed. After that, or in the light of that, I did not
6 see how he and I could work together in the interests of
7 a patient because the trust that is necessary to deliver
8 a safe service or the safest possible service to
9 a patient simply does not exist.
10 Q. His explanation of that is that the reporter from the
11 broadsheet having got the details from elsewhere, phones
12 him, relates the details and says "What do you think
13 about that?" and gets an answer to the effect of, "You
14 have got most of the facts about right", or have got
15 "most of the facts". That is my paraphrase of what he
16 tells us he said.
17 Did you understand that to be the position at the
18 time?
19 A. I heard it said that he had said that, yes. I have no
20 personal involvement.
21 Q. But you did not accept it?
22 A. I did not know. I neither accepted it nor rejected it.
23 I have no knowledge or basis on which to do either.
24 Sceptical, I think, would be the correct term.
25 Q. I was going to ask, because otherwise you would have had
0164
1 no basis for feeling that the trust between you and him
2 had been prejudiced, would you?
3 A. Well, I do not know how crucial the precise mechanics of
4 that are. The fact is that he had undertaken an audit,
5 whether it was right or wrong nobody knew, and features
6 of it appeared in the broadsheet.
7 Q. Did you take part in any discussions as to the future
8 career of Dr Bolsin, and whether his employment might be
9 terminated?
10 A. I certainly took part in no discussion that actively
11 considered whether his employment would be terminated.
12 Q. Passively considered?
13 A. I have given some thought to this in the light of
14 certain comments. It is possible that I would have been
15 part of a discussion where a whole range of options --
16 these were heated times, and people -- no precedent and
17 experience, so "What does one do?", is the question. It
18 is quite possible that every possible option was
19 considered, but I can say categorically that whatever
20 might have been put on a list or mentioned as part of
21 a verbal list, I was part of no discussion that ever
22 actively considered his terminating his employment and
23 on the contrary, I was part of a very time-consuming
24 process that attempted to achieve the opposite, namely,
25 the conciliation process.
0165
1 Q. How did that break down?
2 A. As far as I am concerned, it broke down because
3 Dr Bolsin ceased to attend it.
4 Q. Were you, yourself, willing that it should continue?
5 A. Very much so.
6 Q. I want to turn away from the issue of communication and
7 the question of concerns which we have explored
8 generally on Monday and today, save for one rather more
9 general question. It is this: if one goes to the 1996
10 update of a report from Messrs Hunter/de Leval, and we
11 can pick up, I think, at UBHT 61/465, this is the draft
12 version, but I think the published version is no
13 different and if we go through, please, to the last
14 page, 467 [UBHT 61/467], down the bottom of the page,
15 the conclusion that Mr de Leval makes in that paper is
16 the belief that "the Bristol performance from 1992 to
17 1995 in terms of mortality matches favourably with the
18 average UK results as published by the Cardiac Surgical
19 Register..."
20 Pausing there, that is gratifying, I take it?
21 A. Yes.
22 Q. Then he says "...with the exception of open-heart
23 surgery in infancy and in particular, the results of
24 AVSD and arterial switch procedures."
25 To what extent do you consider that the exception
0166
1 that is made or recognised there of open-heart surgery
2 in infancy through the 1990s was apparent to you?
3 A. It was apparent to me largely as a consequence of the
4 poor results in the two groups mentioned. I would like
5 to point out that I do not think it is correct to say
6 that this draft is what appeared in the final document.
7 Q. The final version is 52/102. There we have the final
8 draft, including open-heart surgery in infancy.
9 Do you know why the change was made?
10 A. No, I have no part in it. This was entirely between
11 Mr de Leval and Mr Hugh Ross.
12 Q. But the final words, in any event, included open-heart
13 surgery, with the exceptions that he draws specific
14 attention to?
15 A. It has identified more precisely where the problems
16 lay.
17 Q. One other matter which arises post the operation on
18 Joshua Loveday: you were expecting Mr Ash Pawade to take
19 up his position on 1st May. There was a protocol, was
20 there, which was drafted by Mr Nix, acting as Chief
21 Executive?
22 A. There was.
23 Q. Which agreed, as had been promised to the Department of
24 Health, that there would be no further complex neonatal
25 and infant cardiac surgery performed until the arrival
0167
1 of Mr Pawade, by yourself, except, as the protocol had
2 it, with the agreement of the parent, or words to that
3 effect.
4 A. The protocol provided that I would not do open-heart
5 surgery on infants, I think. There were two periods.
6 There was the period up until 30th April and the period
7 after 1st May.
8 Q. Yes. 1st May onwards, what was the position?
9 A. From 1st May onwards, I was withdrawing from paediatric
10 cardiac surgery, but was expected to do a small number
11 in the ensuing few months with the agreement of the
12 various parties concerned.
13 Q. On 1st May, you in fact operated on Andrew Peacock?
14 A. I did.
15 Q. What was said to the parents?
16 A. I understand that Dr Martin, who was the cardiologist,
17 had a conversation with the parents in outpatients --
18 I do not know the date, but a little while prior to the
19 operation -- about who should do the surgery.
20 I should point out that I had operated on Andrew
21 twice before. We knew each other quite well. In fact,
22 had what happened in early 1995 not happened, then
23 Andrew would actually have been operated rather sooner
24 and the question of him being on or after 1st May would
25 never have arisen.
0168
1 Q. Did you yourself say anything to the parents about the
2 position?
3 A. No, I do not think I myself did, but I think I knew that
4 Dr Martin had, and I think it was better that he should
5 do it, because if they had a view to express, it would
6 have been easier for them to say it to him than it might
7 have been to me.
8 Q. There are a number of matters, individual matters, which
9 I now want to pick up with you, if I may. First -- it
10 may perhaps be not inappropriate that we choose this
11 session to raise the issue with you, having heard the
12 Chairman's statement at the start of this section,
13 although I think you may have missed it -- can we turn
14 to the issue of tissue retention and any consent that
15 was obtained for it.
16 Can we have, please, WIT 348/7? This is a letter
17 from the Coroner of Avon. I want you to have a careful
18 look at it. It is a very short letter. It is from
19 Mr Hawkins, the then Coroner, to Professor Bradfield in
20 the Department of Pathology:
21 "I am told by the Home Office that Ministers are
22 concerned that tissue and organs should not be taken for
23 teaching or research purposes from Coroner's postmortem
24 examination cases.
25 "Accordingly, you are specifically instructed that
0169
1 in no case should any tissue or organ be so taken."
2 It is not a letter to you, it is a letter to the
3 pathologists. Did you know about it?
4 A. Not until about a week ago.
5 Q. There was a letter from you, some little while after
6 this, which we can pick up at UBHT 308/170, talking
7 about the retention of postmortem tissue.
8 "Thank you for your letter of August 6th which
9 suggests that we should be a little more rigorous in
10 stating that we have received the permission of the
11 parents to retain part of the heart. I was slightly
12 surprised to receive this advice as I had been recently
13 told by Dr Sheffield that this problem had eased
14 a little under the jurisdiction of the new Coroner.
15 I would be grateful therefore if you would simply
16 confirm your advice and of course we can discuss it the
17 next time we meet. Thanks for your letter."
18 You were writing this in the context of still
19 thinking that where the Coroner asked for a postmortem,
20 nonetheless the relatives might be spoken to about the
21 possibility that tissue might be retained?
22 A. Professor Berry had raised that question with us as
23 a possibility.
24 Q. Your mention of the Coroner in the text here perhaps
25 suggests your mind was directed to Coroner's
0170
1 postmortems?
2 A. There was a clear distinction between the two.
3 Q. I follow that. What I am asking is: was it your
4 understanding, because you might be the clinician who is
5 involved in seeking the consent of the parents to
6 retention of tissue, might you not?
7 A. Yes, what I meant was, there was a clear distinction in
8 this area of whether or not one needed consent to retain
9 tissue, in our minds at that time, be it right or wrong,
10 between a Coroner's postmortem and a hospital
11 postmortem. In the latter, we understood clearly that
12 it was necessary to have consent for everything
13 specifically. In the Coroner's cases, our perception of
14 things was that it was not so necessary. Looking back,
15 you know, it is regrettable that that is how we felt,
16 but that was the practice we inherited and I think we
17 just had not questioned it sufficiently.
18 Q. What do you think would have happened if you had
19 questioned it?
20 A. I think we would have recognised that it would have been
21 much more appropriate to seek consent from a parent or
22 a family before retaining an organ beyond the purposes
23 for which that was needed in relation to the Coroner's
24 postmortem.
25 Q. There are, I think, three more general questions which
0171
1 I want to address to you. The first of them is perhaps
2 best approached by taking a case we have seen before in
3 the course of this Inquiry and it is the case of
4 Samantha Rickard. Can we have on the screen, please,
5 MR 1637/38? This is a joint cardiac surgical meeting.
6 THE CHAIRMAN: We are just taking out addresses.
7 MR LANGSTAFF: That seems okay. We have, of course, full
8 consent for this. Can we scroll down? It is the third
9 note:
10 "(3) it would be helpful to use ultrasound in the
11 operating theatre to identify any further VSDs. Once
12 the date of operation is planned, please inform Dr Wilde
13 at the time of planning so he has good notice."
14 A few issues arise around this. First of all, it
15 is your "PS", is it?
16 A. I think it is my letter altogether, but I think it is
17 probably my PS as well. It is something that had arisen
18 out of the discussion.
19 Q. And the discussion recognised the need to identify any
20 additional VSDs there might be in this or similar
21 conditions?
22 A. Well, Samantha already had been recognised as having
23 more than one VSD, one additional one had been
24 recognised. We were simply recognising the theoretical
25 possibility that if there was one more, there may be
0172
1 others in addition to that one that we had not at that
2 point identified.
3 Q. The need to give good notice to Dr Wilde suggests that
4 if he had not been given good notice, there might be
5 a problem with actually arranging for the intraoperative
6 echo; is that right?
7 A. I am sure that is right, because Dr Wilde had
8 commitments regularly through the week. So it would not
9 always be easy for him just to drop at a moment's notice
10 whatever it was he was doing. He might be in the middle
11 of a cardiac catheterisation, for example.
12 Q. Was there any reason why this was not a matter of
13 routine, rather than having to be specially
14 commissioned?
15 A. It certainly was not a matter of routine at that time,
16 nor indeed in subsequent years; it would always have
17 been a matter of specific arrangement.
18 Q. Why was it not routine?
19 A. I guess it was a combination of factors, that the
20 provision of people and equipment to do it had never
21 been provided and so that really means that as things
22 have developed, it had not got high enough on the list
23 to provide. To have provided it routinely would have
24 been a very time-consuming matter. It would probably
25 have meant employing an additional person of Dr Wilde's
0173
1 type and status. So it would have been quite a major
2 hurdle to get over.
3 Q. The next issue that I want to raise with you is in
4 relation to audit. Can we have a look at UBHT 98/13?
5 This is the Hospital Medical Committee Steering
6 Committee, page 17 of it. You are chairing the
7 meeting. Can we look at what you say in that first
8 paragraph?
9 "The Chairman pointed out that we must be
10 perceived to be carrying out the national guidelines
11 lest we lose audit money."
12 I must ask you to bear in mind that particular
13 minute. Can we look, exactly the same question is going
14 to arise, at UBHT 1/52, the following month. It is
15 a hospital Medical Steering Committee with you in the
16 chair again, and it is at page 55. In the first minute,
17 5/94, clinical audit, the second last sentence, six or
18 seven lines up from the bottom:
19 "Audit money will come from the Bristol and
20 District and will be delegated to directorates so we
21 must adopt the clinical audit initiative otherwise this
22 money will not be forthcoming."
23 Was there a sense in the meeting, or in yourself,
24 that you were reluctant endorsers of audit; both those
25 minutes might suggest that would be the case?
0174
1 A. I think that would be a quite incorrect conclusion to
2 draw. What these two minutes describe is not a lack of
3 enthusiasm or a lot of enthusiasm for audit; they are
4 describing the transition from medical audit, that is,
5 doctors doing audit alone, to clinical audit, that is
6 the whole team of all the professions involved, doing
7 audit together.
8 Medical audit itself was still a relatively young
9 activity and people were still coming to accept it and
10 being committed to it, so early in that evolution, we
11 were being asked then to change to another format and so
12 that required some persuasion and work. But that is
13 what those minutes are about.
14 Q. Mr Wisheart, I have kept you there for some time.
15 I have only one more question to ask before the Panel
16 may ask you some questions. It is a very general and
17 reflective question, raised really partly by Dr Roylance
18 in what he said to us at the end of his testimony, and
19 in part by comments that Dr Joffe had to make.
20 In this age of the consumer society, and patient
21 autonomy, do you see room for trust in the
22 patient/doctor relationship?
23 A. I believe it is still an essential component of the
24 relationship between a doctor and either a patient or
25 a patient's family, that there is mutual trust and
0175
1 confidence.
2 Q. Do you see the process of giving information to parents,
3 whether it is in general terms by informing
4 paediatricians, for instance, of the outcomes of the
5 unit, or a full description of operation and the risks,
6 and the alternatives and the factors to parents, do you
7 see that as necessarily affecting the trust relationship
8 between doctor and patient?
9 A. Definitely. That is an important part of the basis for
10 the relationship, and obviously it is only if such
11 information is accurate that the relationship can exist
12 on a sound basis.
13 Clearly people's perceptions of need in terms of
14 what information and how much and so forth has altered
15 with time, but whatever stage those perceptions were at
16 at any given time, then clearly that information should
17 be accurately shared.
18 Q. So giving parents and others the information, more
19 information, today compared to some years ago, is
20 critical in maintaining the relationship of the trust
21 and confidence that should exist in your view.
22 Do you see, then, any necessary antithesis between
23 more information and the practice of medicine? It has
24 been suggested to us, for instance, that a downside of
25 giving more information and concentrating upon producing
0176
1 information as to outcomes, for instance, may be that
2 medicine is practised more defensively and therefore the
3 implicit suggestion is that the greater the information,
4 the greater may be the harm in the long term to
5 medicine.
6 What you said in terms of giving parents more
7 information is that that encourages the trust which is
8 the essence of the relationship.
9 Would you like to say anything about that?
10 A. I would like to make two comments, if I may, and the
11 first is not exactly in response to your question; the
12 second one is.
13 The trust, the sharing of information, is
14 a necessary and essential basis for trust, but of
15 course, the trust goes beyond that because there is
16 always an element of uncertainty as to what the future
17 will hold in the care of a patient, whether we are
18 talking about an operation or in the care of a patient
19 with a chronic disorder or whatever, so that while you
20 are expecting something to happen and you discuss that,
21 and you discuss it honestly and fully, you also
22 recognise, because you cannot see the future, that what
23 actually will happen may be different. If this is in
24 the context of an operation, then it is important that
25 the patient -- that on the one hand the patient will
0177
1 have confidence that the doctor or the surgeon will do
2 what is in his best interests, and on the other hand, it
3 is important that the doctor will have the confidence to
4 know that he has the consent and support of the patient
5 to do what has not been discussed but what may be in the
6 patient's best interests.
7 That is just an example, maybe not a very good
8 one, but it is an example of the fact that the sharing
9 of information is essential, but the issue of trust goes
10 beyond it.
11 Yes, the second question was defensive medicine.
12 I do not think that defensive medicine -- well, let me
13 first say what I think you are referring to. I think
14 that you are referring to possible reluctance of doctors
15 or surgeons to undertake treatment in high risk
16 patients; is that correct? Just so that we are not at
17 cross-purposes.
18 Q. That is the suggestion that has been made to us.
19 A. I do not think that arises out of issues of consent.
20 I think that arises out of inadequate understanding of
21 figures and in particular, I think it underlines the
22 importance of risk stratification because the importance
23 of risk stratification is not what I think you and
24 I have discussed it in terms of in the last day or two,
25 when I have been saying this may explain certain events;
0178
1 that is not its real importance. Its real importance is
2 that it protects high risk patients and it preserves
3 their access to treatment because if statistics and
4 figures and league tables are used which do not
5 risk-stratify, then surgeons and doctors will feel under
6 what I think will be irresistible pressure to decline
7 treatment to high risk patients, because it would make
8 those crude unstratified figures look bad.
9 So the importance of risk stratification, to me,
10 in principle, is that it protects the access of high
11 risk patients to the treatment which they ought to have.
12 Q. It is, I think, the first time we have had anyone who is
13 a clinician in the chair where you sit conceding, if it
14 be a concession, that clinical decisions may be made
15 otherwise than in the best interests of patients, but
16 may be made in the interests, for instance, as is
17 implicit in what you are saying, in the interests of the
18 clinician's figures. You are not speaking for yourself,
19 you are speaking generally, but you are speaking of
20 experience of your colleagues and life in NHS?
21 A. I think I am speaking of human nature, with respect.
22 I would like to think that in my own practice I did
23 exactly what you say, made decisions in what I thought
24 were the patient's best interests regardless of the risk
25 and, dare I say it, I think that it is reflected in some
0179
1 of the figures that have appeared here. But all I can
2 say is that I have been told by others that the danger
3 to which I have referred has actually happened in recent
4 years in various places.
5 MR LANGSTAFF: Mr Wisheart, I have asked you enough. The
6 Panel will have some questions.
7 THE CHAIRMAN: The Panel have no further questions than the
8 ones they have already interposed.
9 MR LANGSTAFF: Would you like to have a short break?
10 MR WISHEART: Even a couple of minutes would be useful,
11 thank you, if I may.
12 THE CHAIRMAN: Of course. We adjourn now for five minutes
13 and come back just after 4.30. Thank you very much.
14 (4.25 pm)
15 (A short break)
16 (4.30 pm)
17 MR LANGSTAFF: Sir, I am told by Mr Moon that Mr Wisheart
18 is, if not happy, prepared to carry on and call it a day
19 at the end of the day.
20 THE CHAIRMAN: Translated that means we are about to hear
21 from Mr Wisheart and complete his evidence this evening;
22 is that right?
23 MR LANGSTAFF: Yes.
24 RE-EXAMINED BY MR MOON:
25 Q. On, I think, Monday, Mr Langstaff asked you a very
0180
1 difficult question about the General Medical Council's
2 decision. It is fair to say that there was a fairly
3 long pause before you answered that question.
4 Can I ask you this: why did you wish to appeal the
5 decision of the General Medical Council?
6 A. I wished to appeal it because, while I accepted at least
7 some of the findings, I did not accept others.
8 Q. Can you tell the Panel about the findings that you did
9 and the findings that you did not accept, please?
10 A. Yes, I can. There were in essence, and you will forgive
11 me if I try to be brief and I hope I am not taking any
12 incorrect legal shortcuts, but there were in essence
13 three --
14 THE CHAIRMAN: If you did, Mr Wisheart, I would not notice.
15 MR WISHEART: There were in essence three findings: (1) that
16 I should stop my AVSD series before the last three
17 patients; (2) that I had not given the correct
18 information in the consenting process to the last two
19 patients; (3) that I should have prevented Mr Dhasmana
20 carrying out the Joshua Loveday operation.
21 With regard to the first finding, about stopping
22 the AVSDs, there were two elements. One was that it was
23 their belief that I should have sought the advice of my
24 colleagues at or before I think the twelfth patient.
25 I may say, it was I myself who put that forward in
0181
1 evidence prior to the determination, and, of course, as
2 you have heard, I not only accept it but agree with that
3 view, that I should have done that.
4 The second aspect of that finding is this: that
5 the committee acknowledged that in this series of
6 patients there were a number of unexpected complex and
7 difficult operations -- forgive me for repeating
8 myself. However, although they acknowledged that, there
9 is no evidence that they gave any weight whatsoever to
10 that in their finding. The reason I say that is that in
11 the original charge against me, before they knew
12 anything about the complexity of the patients in the
13 series, they said I should have stopped before the last
14 three patients. The eventual finding, regardless of
15 their acknowledgment of these findings, was that
16 I should still have stopped before the last three
17 patients. It simply seemed to me that I could only
18 conclude that they had given no weight whatsoever to the
19 evidence upon which all the experts agreed on that
20 point.
21 So that was something that I cannot accept.
22 That first finding is of course the central of
23 their three findings. The findings on consent I believe
24 follow logically from the fact that they gave no weight
25 to the issue of the complexities present in the series.
0182
1 The finding that I should have stopped Mr Dhasmana
2 from operating on Joshua Loveday seemed to hinge solely
3 on the fact that I had not informed him of the decision
4 to seek external advice. While I would readily accept
5 that that may have been an error of judgment on my part,
6 I cannot see how that could constitute serious
7 professional misconduct.
8 MR MOON: Can I ask you what proportion of your paediatric
9 patients the AVSD patients accounted for?
10 A. Approximately 3 per cent of my paediatric cardiac
11 surgical practice.
12 Q. You heard Mr Langstaff about an hour ago tell us
13 something of a further report from Professor Evans, one
14 of the statistical experts to the Inquiry.
15 What do you understand Professor Evans to be
16 saying, in summary, in that report?
17 A. I understand him to be saying that in 97 per cent of the
18 operations, either no criticism was levelled or, if
19 there is a question, then it would not have made any
20 difference to the outcome. That is how I understand the
21 scoring. And that in only 3 per cent is there is the
22 possibility that a different conduct of surgery might or
23 probably would have led to a different outcome.
24 Q. Can I move to a different subject, the question of
25 audit? How generally would you describe your attitude
0183
1 to audit at Bristol?
2 A. At the level of myself as an individual and the
3 department within which I worked, I was always keen that
4 we should undertake audit; that we should know what we
5 were doing; that we should know the results of what we
6 were doing and that that information should be openly
7 and freely discussed.
8 When audit then became a larger topic at the end
9 of the 1980s, I think the record is clear that I was
10 promoting the development of audit at its different
11 stages within the Trust when I was in a position to do
12 so.
13 Q. Until the breakdown of your relationship with Dr Bolsin
14 following publication in the Daily Telegraph that we
15 have heard about of the information which was published,
16 how would you have described your working relationship
17 with Dr Bolsin?
18 A. Initially, of course, it was an entirely cordial
19 professional working relationship. He was appointed in
20 1988; I was on his appointment committee. He had
21 interests which indeed I shared, namely, in audit. My
22 recollection is that that certainly continued through to
23 the 1991 or 1992 period of time. Clearly, because of
24 Private Eye and so forth, there were one or two
25 questions then coming in one's mind, but in terms of
0184
1 a working professional relationship, that remained
2 positive and entirely satisfactory. That working
3 professional relationship continued after the Joshua
4 Loveday episode, and only broke down when he, by
5 whatever means, enabled that information to be placed in
6 the public arena.
7 Q. Supplementary to that, do you feel that there was any
8 impediment preventing Dr Bolsin from telling you about
9 the results of his own audit?
10 A. I absolutely do not. I mean, we worked together, week
11 in and week out in the Infirmary. I rarely operated on
12 private patients but occasionally did so, and he shared
13 in that practice with the other anaesthetists. We
14 discussed his research. I believe there was every
15 opportunity.
16 Q. Lastly, you were asked some questions, again I think on
17 Monday, by Mr Langstaff about Down's syndrome children.
18 You described a philosophy which you had said was
19 reflected in some literature about operations upon
20 Down's syndrome children.
21 Why did you not agree with those who said that in
22 certain circumstances one should not operate upon such
23 children?
24 A. I did go to some pains to point out that I did regard at
25 least some people who put forward the other view as
0185
1 being highly ethically responsible, so I would like to
2 make that clear before I say why I disagree with them.
3 My own view was that each patient, whether they
4 have Down's syndrome or do not have Down's syndrome,
5 each patient is a human person and the advice which
6 should be offered should be determined by the merits of
7 the case for them; in other words, the balance between
8 the potential risks and the potential benefits. It was
9 my view that although clearly the prospects in the
10 future for a Down's child, whether one is thinking of
11 either quality or length of life, may not be the same as
12 another child, nevertheless, one can still weigh up the
13 merits. If the balance indicated to me -- and of course
14 not to me alone, to my colleagues as well -- that there
15 was a benefit to that child, then it was our philosophy
16 that they should be offered the treatment.
17 MR MOON: Thank you very much, Mr Wisheart. Sir, I have no
18 further questions of Mr Wisheart.
19 THE CHAIRMAN: Thank you, Mr Moon. Mr Langstaff?
20 MR LANGSTAFF: Sir, Mr Moon has indicated that he would like
21 to say a few words. He asks through me that we should
22 and we have found it appropriate in the past that when
23 representatives have asked to do so, they should be
24 allowed, within a relatively short space of time, to
25 tell us what they have to say.
0186
1 SUBMISSIONS BY MR MOON
2 ON BEHALF OF MR WISHEART:
3 MR MOON: Sir, I am very grateful for that opportunity on
4 behalf of Mr Wisheart. There are really three main
5 areas that I would like to talk to. The first is, what
6 the Clinical Case Note Review in fact, together with
7 other evidence, reveals about Mr Wisheart's competence
8 as a surgeon. I mean no disrespect if I refer to that
9 review as the CCNR.
10 The second area is the importance of risk
11 stratification which Mr Wisheart has touched upon
12 briefly this afternoon. The third area is the conflict
13 which you may perceive between Dr Bolsin's evidence and
14 that of Mr Wisheart.
15 May I start off with the question of issues of
16 competence?
17 This Inquiry has made quite plain from the outset
18 that it is a truly independent inquiry and that it
19 neither accepts nor rejects, for example, the findings
20 of the General Medical Council.
21 To that end, the Inquiry has commissioned its own
22 independent review from a large panel of independent
23 experts. One has, of course, to recognise that the
24 papers indicate that there have been criticisms made of
25 Mr Wisheart's competence as a surgeon, but in my
0187
1 submission, the CCNR shows that those criticisms are
2 largely unjustified.
3 In some of the less responsible reporting of the
4 evidence at this Inquiry, the truth, and perhaps the
5 reality of what happened in Bristol, has become
6 distorted. It would of course be nice if that sort of
7 reporting ceased, but in any event, you will make your
8 own independent findings based on the evidence which you
9 have heard and read over many months.
10 What, on behalf of Mr Wisheart, does that evidence
11 show so far? To a greater or lesser extent, virtually
12 all members of the paediatric surgery team have been
13 criticised in the CCNR for some shortcomings. Indeed,
14 overall, some 30 per cent of the 80 patients' care at
15 Bristol has been criticised at one point or another.
16 But in the context of those general shortcomings, the
17 surgeons, in my submission, have incurred really
18 relatively limited criticism.
19 I would like to take three specific examples of
20 that. There were 23 aspects of care which received the
21 score of 1, which is of course the worst score, but only
22 two of those related to the conduct of the operation.
23 One operation per cardiac surgeon and in the light of
24 the comments Mr Mankad made yesterday, that in relation
25 to Mr Wisheart may be revised, because Mr Mankad in
0188
1 effect suggested that a score of 3 ought to be given for
2 that operation and not a score of 1.
3 49 aspects of care generally were scored 2, and 7
4 of those relate to the conduct of the surgical
5 operation. Again, there may need to be some revision of
6 that figure in the light of Mr Mankad's comments
7 yesterday.
8 Thirdly, and really it follows the first two,
9 really in only 8 or 9 of the 80 patients examined did
10 the conduct of the surgery receive a score of 1 or 2.
11 Of course in those 80 patients' cases, there were
12 actually 100 operations.
13 The 80 cases selected were deliberately selected
14 with a weighting towards complex operations, young age
15 and those children who had not survived; in other words,
16 the most difficult of the cases with which the surgeons
17 would have had to deal. Even in this group, the
18 independent panel of experts had given a score of 1 or 2
19 to less than 10 per cent of the operations so far as the
20 surgeons were concerned.
21 As you heard from Mr Langstaff this afternoon,
22 bearing in mind the weighted nature of the sample, the
23 effect of those findings is that 97 per cent of the
24 total of just under 2,000 operations obtained a score of
25 3 or 4. In fact, 93 per cent obtained a score of 4.
0189
1 So when you consider those findings in the context
2 of the unenviable task of writing your report, I urge
3 you to do so with the modesty which such a vast
4 undertaking really requires. I ask you to ask yourself
5 this question in relation to Mr Wisheart, in relation to
6 each of your selected fields. If I selected amongst my
7 most difficult 100 cases, could I honestly claim to have
8 made only about 10 significant errors in those cases?
9 The question can be put to all the professionals
10 in the room, barristers included. Can any of us claim
11 that in 100 of our most difficult cases we have not made
12 8, 9, 10, significant errors? I ask that rhetorical
13 question, but the question can be posed less
14 rhetorically to the independent experts on the panel of
15 experts who have conducted the CCNR.
16 Of course, when you are a heart surgeon, an error
17 can have terrible consequences, but we are all human,
18 heart surgeons included, and I ask you to bear that in
19 mind when you approach your task of writing your report
20 following this Inquiry.
21 If there were shortcomings, how severe were they?
22 You have heard the evidence of Mr Mankad yesterday as to
23 that. In my submission, that evidence was favourable to
24 Mr Wisheart, even in relation to operations in respect
25 of which the review teams have criticised him. For
0190
1 example, in the case that I adverted to a moment ago,
2 the case of Bridie Kinsman (Mr Wisheart's only score of
3 1), Mr Mankad described the damage in the mitral valve
4 in the operation of 29th November 1995 as being
5 unavoidable, and he scored Mr Wisheart 3 for that
6 operation.
7 Experience: your experience, and all of our
8 experience, in my submission, shows that no centre, not
9 even the best, which undertakes high risk work, is free
10 from occasional experiences or results that are less
11 good than expected. Perhaps you will hear further
12 evidence to that effect. Perhaps this is true because
13 of the hackneyed phrase -- no less true because it is
14 hackneyed; in fact it is probably hackneyed because it
15 is true -- that to err is human.
16 Can I turn now to risk stratification?
17 Mr Wisheart's contention is that risk stratification
18 involves taking account of the additional risk factors
19 which are present within a given category of patients.
20 These factors add to the risk which attaches to that
21 group of patients. These additional factors might be
22 additional congenital abnormalities of the heart,
23 secondary effects of the basic abnormality on the heart
24 or the lungs, and any additional abnormality, illness or
25 disorder which is present in the patient at the time of
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1 surgery.
2 Mr Wisheart respectively invites you to make
3 findings of fact as to whether these risk factors
4 existed or not. His contention, which in my submission
5 has never been successfully refuted, is that in certain
6 subgroups there were additional risk factors. An
7 obvious example you may wish to take is in Mr Wisheart's
8 group of complete AVSDs between 1990 and 1994. There
9 were 15 of those patients, and only 4 of those 15 were
10 free from significant additional risk factors. Most of
11 the additional factors had not been identified before
12 operation, and of the 11 patients with significant
13 additional risk factors, in retrospect, three were
14 judged as inoperable, or virtually inoperable.
15 However, the importance of risk stratification has
16 been underlined by Mr Wisheart in evidence this
17 afternoon. It is to protect high risk patients and
18 their access to surgical treatment. If auditing and
19 surveillance systems which are set up for surgeons do
20 not have robust risk adjustment, then there will be an
21 irresistible pressure, in my submission, upon surgeons
22 not to accept high risk patients for operations. In my
23 submission, such a tendency would not be right in any
24 civilised society.
25 Before I come to my conclusions, may I say just
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1 a word or two about the conflict of evidence between
2 Dr Bolsin and Mr Wisheart?
3 You may or may not feel that you need to resolve
4 those issues of fact between Mr Wisheart and Dr Bolsin.
5 If you do decide that you should resolve these issues of
6 fact when you write your report, I ask you to consider
7 the facts and to put aside Dr Bolsin's protestations of
8 the wronged innocent. The fact exists that Dr Bolsin,
9 on his own evidence, did not tell Mr Wisheart about the
10 audit he had carried out in 1993 until two years later
11 in 1995. You may feel that had Dr Bolsin shared his
12 audit more widely, a positive open and detailed review
13 of that information would have occurred. There is no
14 knowing now what such a review would have led to.
15 So what does Dr Bolsin say is the reason why he
16 did not tell Mr Wisheart about his audit? He says he
17 did not feel he could tell Mr Wisheart because
18 Mr Wisheart had been angry and threatening towards him
19 in a meeting in 1990. Well, you may wish to resolve the
20 question of whether such a meeting ever took place.
21 I ask you to take two factors into account when you
22 approach that task, if you feel you need to.
23 The first is that you heard Mr Wisheart now give
24 evidence over something approaching six days. He has
25 been asked extremely difficult questions by experienced
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1 leading counsel throughout those six days. He did not
2 raise his voice once; he did not manifest anger once.
3 You may feel that Dr Bolsin's depiction of Mr Wisheart
4 is completely at odds with what you have observed of
5 Mr Wisheart's character.
6 The second submission I would ask you to take into
7 account relates to your judgment of the credibility of
8 Dr Bolsin's evidence. You will have formed your own
9 opinions about Dr Bolsin's credibility. It may be that
10 I can leave the matter in this way by saying that in my
11 submission, he did not come across as an accurate
12 witness.
13 Can I just remind you by way of example of what
14 Dr Bolsin said on Day 83, page 63, lines 22 to 25?
15 THE CHAIRMAN: I think you can possibly helpfully move on.
16 We have the evidence. We are not anxious to convert
17 a Public Inquiry into "I did", "You did not", to that
18 level in this context today. Go to your next point.
19 MR MOON: It may be, sir, you do not feel it necessary to
20 resolve those issues of fact in any event, but if you
21 do, I would ask you to contrast that passage with
22 UBHT 61/92. I will leave it at that.
23 May I conclude? In my last address to you,
24 I concentrated on Mr Wisheart's dedication and
25 commitment to patients. Since then, the evidence has
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1 focused on competence. In my submission, the evidence
2 of the Clinical Case Note Review, as supplemented by
3 Mr Mankad, supports the view that Mr Wisheart was as
4 competent a surgeon as we can hope to be in our
5 respective fields. If there were more serious failings
6 at Bristol, then they were systematic failures, not
7 simply errors by this hard-working, dedicated and
8 sincere surgeon.
9 Sir, thank you very much for that opportunity.
10 THE CHAIRMAN: Mr Moon, thank you. Mr Langstaff?
11 MR LANGSTAFF: Sir, it has occurred to me, while I have sat
12 here listening to what Mr Moon has had to say, that
13 I have been remiss in not according Mr Wisheart the
14 opportunity which we have afforded to all other
15 witnesses, and we have, I think, to treat all witnesses
16 in exactly the same way, in asking the final question
17 that I do ask of all witnesses and although it comes
18 after the speeches, I do not anticipate it will lead to
19 any further speech because it is simply this. You have
20 answered questions over time: you are, of course, free
21 to say whatever you may wish in writing still, but is
22 there anything further which you wish to say by way of
23 clarification, explanation, or whatever, to this
24 Inquiry, to complete your evidence to it today?
25 MR WISHEART: There are a few remarks which I would like to
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1 make very briefly in public on the record, and here in
2 this chamber.
3 I wish this evening to repeat and to offer again
4 my deepest regret and sympathy to all parents whose
5 children died at the time of or after their operation.
6 In saying this, my sympathy and regret go to parents and
7 families on all sides of this particular debate.
8 I would like to say to you that my feelings towards you
9 are exactly the same as when I did my best for your
10 child.
11 In making this expression of regret and sympathy,
12 I acknowledge that old wounds have been reopened and
13 that a grieving process has been repeated by many folks
14 here today. Although I, too, am a father, and have
15 children whom I love, I imagine that that only begins to
16 let me understand what it feels like to lose a dearly
17 loved child. So I would just finally wish to tell you
18 that the lowest point of a surgeon's life is when
19 a child dies under his or her care.
20 Thank you.
21 THE CHAIRMAN: Mr Wisheart, thank you. Mr Langstaff, you
22 will tell us about tomorrow morning?
23 MR LANGSTAFF: Sir, yes. Tomorrow we will continue hearing
24 the evidence and we shall hear from parents. We shall
25 hear first from Sharon Peacock. Then we shall hear from
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1 a number of parents. May I say and express my gratitude
2 and appreciation for the suggestions which have been
3 made to me by Mr Lissack, with the concurrence of
4 Mr Sharp, for parents with different perspectives on the
5 issue, which have enabled the Inquiry to programme
6 a number of witnesses in a way which we hope will help
7 the Inquiry to understand what parents say and feel, but
8 despite the number, in a way which will pay due respect
9 to the evidence and feelings of each of those parents.
10 We propose, after we have heard from Miss Sharon
11 Peacock, to hear from Marie Edwards, Anne Waite,
12 Phillippa Shipley, John Mallone, Lorraine Pentecost,
13 Trevor Jones, Justine Eastwood, Sheila Forsythe, Karen
14 Welby, Richard Lunniss and Michelle Cummings.
15 Sir, those are the witnesses from whom we
16 anticipate hearing tomorrow. It will be apparent from
17 the number that we will approach the evidence in much
18 the same way as we have found helpful and instructive
19 when we have had a number of experts who will address
20 the same general topics and themes, and hope to develop
21 some of the factual matters upon which you will
22 ultimately seek to base your report.
23 Thank you, sir. 9.30 tomorrow, and from me, good
24 night.
25 THE CHAIRMAN: Mr Langstaff, thank you. It would be wrong
0197
1 to end what has been a long and difficult day for many
2 of our witnesses, but also many in this room, without my
3 paying appropriate tribute to those behind you whom
4 I know have helped today, and about tomorrow. And
5 I join you also, therefore, in saying good afternoon to
6 everyone, and Mr Wisheart. Thank you, Mr Langstaff.
7 (5.05 pm)
8 (Adjourned until 9.30 on Thursday, 16th December 1999)
9
10
11
I N D E X
PROFESSOR PRYS ROBERTS (SWORN):
Examined by MISS GREY ...................... 1
MR JAMES WISHEART (RECALLED):
Examined by MR LANGSTAFF (CONTINUED) ........ 65
[PANEL'S DECISION ON MR LISSACK'S
APPLICATION TO RECALL WITNESSES, page 147]
RE-EXAMINED BY MR MOON ........................... 180
SUBMISSIONS BY MR MOON ON BEHALF OF MR WISHEART .. 187
25
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001