Annex A > Chapter 17 - Communication Between Healthcare Professionals and Patients > Parents' evidence on communication with clinicians and the process of obtaining their consent to surgery > Parents
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Parents
137 Justine Eastwood, mother of Oliver, told the Inquiry of her experience of communicating with clinicians in the following exchange:
`A. ... I had got to know Mr Dhasmana over a long period of time. I knew that I understood the way he spoke and things he was saying. Mr Moore and Dr Mather, [161] perhaps it is because I did not know them so well, I do not know. They perhaps used more technical terms with me. I did have a particularly difficult conversation with them, which I think is what we are talking about.
`Perhaps they were not quite so approachable. Maybe that is the word I am looking for. Maybe I did not feel confident enough to ask the right questions with them, whereas I always felt very confident asking Mr Dhasmana.
`Q. There were occasions, were there, when some staff appeared to show a lack of sensitivity in their relationships with you? There was one doctor who made a comment that you took exception to, asking if Oliver was Down's syndrome?
`A. Yes. We were actually in the ward for a very short period of time. Dr Hayes had actually asked the therapist to speak to me, because Oliver was unable to suck, because we were trying to introduce the bottle to him. She felt a speech therapist would be useful. It was actually the speech therapist who made this comment, because she had been given a few notes on Oliver, and I believe it was a Junior Registrar who had actually told her that Oliver was a Down's syndrome child, so she did say to me, "When did you realise that Oliver was a Down's child?"and I said "Just now". It was a little bit of a shock. So it was a mistake by somebody which, you know -
`A. Very upsetting. I do have to say, he did come and apologise profusely later in the evening, but very upsetting, yes.
`Q. From what you are describing, the communication skills varied from doctor to doctor?
`A. Exactly, yes. We dealt with so many people, this is the trouble. I would not say there was probably one person in that hospital who did not know Oliver or his case, so we were dealing with an awful lot of people down the line, really.
`Q. You make the point in your statement of the honesty of Mr Dhasmana in the sense that he refused to exaggerate the chances of Oliver's survival.
`Q. Did you find that unsettling, or helpful, or helpful only in retrospect, or what?
`A. We just felt he was being honest. He was not putting us under any false illusions. We knew that Oliver was extremely unique with his problems, he had heart problems and also problems with his trachea, and unfortunately - I mean, there was hope, but nobody ever, particularly Mr Dhasmana, never built our hopes up, which is how we wanted it. There was no getting away from the fact that we were dealing with a very difficult situation.
`Q. We have heard Mr Dhasmana described to us as "brusque" or "abrupt" at telling someone bad news. From your dealings with him over some time, do you think he might be perceived in that way?
`A. Might be. In the very first pages of my diary, I did actually write he came across as a negative man. Maybe that could be looked at as brusque. I would not say so, though. It was perhaps his manner. I never thought of him in that way. Everyone comes across in a different way. We had the opportunity to get to know him over a year, and I certainly would not put him down as a brusque uncaring man.
`Q. What made him seem negative?
`A. Because he never built our hopes up. If anything, he went the other way. I would say he was just honest. He did not build our hopes up, perhaps, in the way we wanted him to, because things were looking so grim, but he was just that way.' [162]
138 Justine Eastwood told the Inquiry her views on whether parents who had just been told that their child had a heart defect were given sufficient information:
`I think everybody initially is bemused and confused by it all. My experience is, there were many books around. There were plenty of people to try to explain things to you if you did not understand it, but again, from what I saw, if you did not understand it, people came back and told you again and again, until you perhaps did understand. You were not left with one conversation and then they walk away and let you get on and hopefully muddle it through. It was not like that.
`If my memory serves me correctly, I vaguely remember there was actually a little booklet that had been made by parents and professionals for parents, and I believe it was something like that that we actually first read. So it was very basic, but it just gave us some sort of insight into heart problems.' [163]
139 Karen Welby, mother of Jade, described the approach of Mr Wisheart in 1984:
`Because I was very, very upset, taking Jade off to theatre and I wanted to have - I wanted to think she was going to come out and everything was going to be fine, but he was not going to let me believe that for one minute. He wanted me to understand she was possibly going to die on the operating table. I did not want to accept it, so I thought he was very cruel to tell somebody who was almost hysterical that their daughter was probably going to die. Obviously later on I realised that that is what he should have said to me, that is what I needed to know; I did not need to be given any false hope, and I appreciated that from then on, that he was very, very honest and that whenever he said to me that things were looking good, then I could breathe a sigh of relief, and think "Mr Wisheart says she is going to be okay".' [164]
140 Karen Welby described the difficulties of understanding what was happening:
`... I found it very difficult to understand everything that was going on anyway. I was only young myself [20 years old] and I was in such a state of shock ...' [165]
`Probably after her operation I started to get a better understanding of what was going on. I remember that she was shaking and in quite a state before her operation, and nobody seemed to be telling me the truth about what was happening then. They were making excuses of her being upset because she had had X-rays done. When I went back later, she was still that way and I thought, "This is not right. Nobody is telling me quite what is going on here." I did actually demand to see a doctor, to have that explained to me. They explained that the drug they had her on to keep the valve open, they were not quite sure of the amount they were giving her, they thought might be upsetting her, but they thought if they reduced it again, her valve might shut off.' [166]
142 Sheila Forsythe, mother of Andrew, told the Inquiry of her experience in 1986:
`I asked the questions and I found that everybody answered them to the depth that in fact I was asking the question to. If the staff could not actually answer the question because they had not the time to explain it, they would actually come back and answer the question to my level of understanding later, and I used to tell parents, when they came into the BRI, that they must ask the questions and keep asking the questions until they were satisfied to the level of information that they required. There was never any problem so far as we were concerned.' [167]
143 Michelle Cummings, mother of Charlotte, referred to the factors that can affect parents' perceptions of any information that they are given:
`I think the difficulty as well is that it has to be recognised that there are some people, and perhaps all of us at different times, during the time our children were in hospital, you reach the point where you actually cannot take the news that you are being given. You physically and mentally cannot take any more and you shut off. That is a problem, because that, then, opens the opportunity for later down the road to actually come back and say, "Actually, I was not told that", when in fact you were told it; it was just that you have mentally, for preservation purposes, shut off. I think that is a very real problem.' [168]
144 Diana Hill, mother of Jessica and James, told the Inquiry of the conflicting information she was given in 1989 by Dr Joffe on the one hand and Mr Dhasmana on the other. Diana Hill first saw Dr Joffe when Jessica's heart condition was diagnosed:
`... he explained to me she had a VSD. He said what it was, he said basically it was a hole in the heart but it seemed to be that there was no concern from him about this.' [169]
`The one thing I do remember is that he did not relay any concern, it just seemed that it was a VSD, a hole he hoped would close up and that is all it seemed like. I mean I cannot remember him saying anything about pulmonary hypertension to me.' [170]
145 Diana Hill said that nothing was said to her at all about Jessica's attendance for echocardiography and the appearance of the pulmonary artery and turbulent flow: [171]
`Nothing was said to me at all. The only thing I can remember was Dr Joffe saying to me that he wanted to wait for the hole to close.' [172]
`He said he wanted to do a catheter just to see how bad I think the VSD was. I remember him going over the catheter procedure because he said to me "There is always a chance that a baby can die having this procedure". That is what put me off having the whole thing done because I thought "Gosh, I am going to lose my baby having this done". It seemed quite a big thing compared to the reasons. I thought there was nothing wrong with her, it seemed like there was nothing wrong with her and they were doing this catheter and she could die having this catheter. That is what he explained.' [173]
`I was worried that she was going to die having that catheter because he did tell me sometimes that can happen, yes, it made me worried.' [174]
147 Diana Hill then described her initial meeting and communication with Helen Vegoda:
`I think she was trying to help me but I am surprised she did not feel that I did not want her there because I did - I was saying it in a way, I did not just tell her to go away because I thought that was not the nice thing to do, but she must have known I just did not want her there, I did not. She would say things that were helpful that were making me worse. I just remember at the time in the hospital I really wished she had not been there. After the hospital, when I saw her after she was helpful.' [175]
148 Diana Hill told the Inquiry of her recollection of a meeting after the catheterisation:
`... I remember them putting on some X-rays on a screen in the room. Nobody ever said to me she had a bad condition of pulmonary hypertension, nobody ever explained to me because if they had I would have then been prepared for it, they had not, it was just still the same as what I knew before, she had a VSD and that seemed to be what she had and that was it.
`... I just assumed from what Dr Joffe had said that he was waiting for her hole to close and was waiting for her lungs to develop. If this did not happen, he said possibly she may need an operation in the future. The future - I came to the conclusion she would probably have an operation when she was 1, 2, but he did not say anything was really wrong with her, he never said she was going to die or anything. I actually thought I had a well baby, although she might need an operation later.' [176]
149 Diana Hill then described her meeting with Mr Dhasmana:
`He introduced himself, said "Hello", we sat down, I sat down with my mother and he just said to us, he said "There is nothing I can do for her" and he said it quite matter-of-fact and it just was something I was not expecting to hear at all. I thought I was going there to hear him say she would have an operation in a year's time but he just said "There is nothing I can do for her", he said she was inoperable.' [177]
`When I saw Mr Dhasmana, after he said there was nothing he could do for her, she is inoperable ... he just saw how shocked we were. He was shocked at the fact we did not know. It was written all over his face.
`He then said "Because of her age, 7 months" - which at this time she was not 7 months, she was about 8 and a half months, but he kept saying she was 7 months - he felt he had to give her the chance of operating. He said as time was going on her pulmonary hypertension - he was the first person to tell me about her pulmonary hypertension, I had never heard about it before. He drew diagrams and he explained to me what was happening and as time was going on he would not be able to perform the surgery. He said to me if another month elapsed he would not be able to do the surgery. So he told me to come in on 16th August and he would perform the operation on the 18th.
`There was no choice. He then proceeded to say that he was going on holiday that day and [Mr] Wisheart would be doing the post-operative care. As soon as he said this I thought, "No, she is not going to have proper continuity of care". I told him this. I said, "I do not want Mr Wisheart doing the post-operative care, I want to have the same surgeon". Everything was telling me, signs were telling me I did not want her to have it done now here. All of a sudden I had this well baby and then suddenly she was going to die, it was like she was just going to die.' [178]
`... he said, and I remember these words like yesterday: "The surgeons get the worst job of telling the patients".' [179]
151 Diana Hill stated that she (and her mother) did not like Mr Dhasmana's bedside manner, which they both thought was `extremely arrogant'. [180]
152 In his notes Mr Dhasmana recorded that `High risk explained. Mother broke down.' [181]
153 Diana Hill told the Inquiry of her feelings:
`It was a shock. I just wanted the floor to open and take me away. I had a well baby crawling around on the floor at this time.
`He then had to test her heart, he had to check her chest, check her heart and do all those things. I could not cope. I was in a terrible state, my mother was in a terrible state, we were all in a terrible state, none of us knew, none of us knew that she was this bad.' [182]
154 Diana Hill's mother had a meeting with Mr Dhasmana the next day. Diana Hill told the Inquiry that the reason was:
`... because Mr Dhasmana wanted us to make a decision there and then to have the operation. I felt I could not make that decision because part of me was telling me I wanted to take her to America to have this operation because she was the most precious thing, I would have done anything for her. It just did not feel right for her to be having it done there. I cannot explain what it was, I think it was just the shock that I had not been told before, that is what made me feel like that and I thought "No, I am not going to decide today, I want to think about what else I can do".
`So my mother rang him the next day because she was quite upset how Dhasmana - he was quite arrogant and blunt, his whole manner, his body language you know was quite blunt and arrogant. So she rang him up the next day asking if there was anywhere else we could take her. He said "No, Bristol is the best place"and then he said "I do not have to operate, you know".
`He was very matter-of-fact with everything. He did not relay any sort of compassion. I mean I was in shock, my mother was in shock. It is like, there was no sort of compassion from him at all, it was just very matter-of-fact, "This is what I am doing" - it almost felt you were lucky to be having this operation, I was lucky to be having this operation on that day.' [183]
155 Diana Hill recalled the discussion she had with Dr Joffe after the meeting with Mr Dhasmana:
`I had a discussion with Joffe about two days later and I remember it because I remember feeling really, really anxious about the whole thing and he then gave me 70/80 [184] per cent chance that Jessica would be okay. This was a different statistic to what I had from Mr Dhasmana. Mr Dhasmana had given me 50/50 per cent that she would live so I knew it was like she could die. But Dr Joffe was giving me a 70/80 per cent chance she would live. Even then when I spoke to him it was as if she was going to live with this operation. It seemed like he was not concerned at all.' [185]
`... I remember him painting a picture to me that it was going to be quite - that it was like she was not going to die. I remember him saying to me there was a 70/80 per cent chance she was going to be okay because automatically I thought - it made me feel better actually when he said that because I thought perhaps she is going to be alive. I wanted somebody to tell me she was going to live and he was doing that.' [186]
156 Diana Hill described her anxiety at the passage of time:
`Things worried me like, I know she was getting older, it was getting worse and I just remember fixing this month in my head, Dhasmana saying she was 7 months and in actual fact she was not 7 months, she was 8 and a half, so by that time she was getting older anyway and then it was another month later she had the operation, so by the time she had the operation she was 9 and a half months. Surely if she is inoperable she is not going to live because "inoperable" means she cannot live.' [187]
`... I did not want her to have it done here but the fact is I did not have much time to take her anywhere else although I wanted to.' [188]
`People were explaining to me what was going to happen, you know, there is no doubt about that. But you could just tell from some people, some of the medical staff [189] were telling me "You could pull out if you want to". It almost felt as if she was not going to live.' [190]
`It was very difficult because I had a baby who was very well. She was by this time - well, she was standing up, she was babbling, she was crawling. I did not have an ill baby on my hands so it was very hard to watch this well baby that they were saying was inoperable who was going to die, who was ill. I could not believe it.' [191]
158 In her written evidence to the Inquiry Diana Hill expressed the view that:
`I think that Dr Joffe did not tell me how serious Jessica's condition was, and that Mr Dhasmana covered up for him.' [192]
159 Helen Rickard, mother of Samantha, told the Inquiry of her and her husband's experience after Samantha's catheterisation:
`Andy and I obviously waited at the hospital for Samantha to come back out of the theatre ... Dr Jordan came back up to the ward with Samantha, where we were waiting. We both looked at him expecting him to be forthcoming with some kind of information about what they had done, what they had found. That did not happen. Dr Jordan was not willing to talk to us. He said that he would need to discuss the findings with his colleagues and we would be contacted after that.
`I asked to see Samantha's medical records at that point and I was told no, that would not be possible. We were basically just left there with no information again.' [193]
160 Kathleen Tilley's daughter, Lauren, underwent a Switch operation performed by Mr Dhasmana in February 1988. Lauren died on the operating table.
161 The problem with Lauren's heart was discovered within hours of her birth. In her written evidence to the Inquiry, Kathleen Tilley described meeting Dr Jordan in the ICU at the BRHSC:
`He told us that they were unsure what the problem was but she was having difficulty breathing and there was obviously a heart condition. He told us that they would need to take her down to do a cardiac catheter and a scan. He explained exactly what they would do and that was to cut Lauren and then feed a tube through so that they could actually find out exactly what the position was.
`I had no complaints about the way we were treated at Bristol nor have I any complaints about the procedures or the explanations that we were given.' [194]
162 As regards being told about the diagnosis of Lauren's problem, she stated that Dr Jordan:
`... told us that Lauren had a condition which was known as the Transposition of the Greater [sic] Arteries and also had a hole in her heart. He said that they would operate immediately. He explained to Glyn [her husband] and myself exactly what the condition was and what they were going to do ... I was devastated and although I accept that Dr Jordan did his utmost to explain the operation in detail to us so that we knew what was going on, it was not until I returned home a week later and I spoke to a family friend who was a nurse, that I fully understood the implications of the condition that Lauren had. I place no blame on Dr Jordan for my lack of understanding and can only put it down to my emotional distress.' [195]
163 As regards the timing of Lauren's operation, Kathleen Tilley stated:
`... at one of the regular monthly check ups at Dr Jordan's clinic at the Royal Gwent Hospital in Newport he told me that he thought that it was time she needed the operation. Both at the time and in hindsight I was surprised at the decision that was taken. I had no idea why the decision was taken to operate at that meeting. No explanation was given. It is true that Dr Jordan said that she had not put on any significant amount of weight since she was born. However, that was nothing new. She was not distressed, and her breathing was as good as it had been throughout the period and I am therefore at a loss to understand the reason for the sudden rush. I use the word "rush" because almost immediately after being told that she should have the operation we received a letter from the Bristol Children's Hospital giving us a date for the operation for 29th February 1988.' [196]
164 Kathleen Tilley met Mr Dhasmana two days before Lauren's Switch operation. She stated that:
`He introduced himself and confirmed that he would be operating on Lauren. He then went on to explain what procedure he was going to undertake.
`Mr Dhasmana said that this was an operation which had not been performed for very long and that he himself had not done it many times. He said the chances of success were 75%. I must admit that when he said that he had not done it very often both Glyn and I were very perturbed. Glyn then asked him about the operation and questioned him about what he had said. Mr Dhasmana replied that it was not a common operation but that despite that and despite the fact that he himself had not done this particular operation very often, it was in his opinion the best thing for Lauren.
`As a result of that answer neither of us questioned him any further about his ability to undertake the operation or the chances of Lauren's survival. The conversation took at least half an hour but at no time during the conversation was it made known to us that there was any other choice. We were not offered any other explanation nor were we told at this or any other time that there were other centres and other surgeons with far higher success rates. So far as Glyn and I were concerned, at the time, we trusted the surgeon in front of us and we accepted the information which he gave as we had no reason, at that time, to doubt it.' [197]
165 She said later in her statement:
`Lauren was operated on in 1988 and I accept that she was one of the very first to be dealt with by Mr Dhasmana. I therefore accept that there may have been no trend at that stage and that insofar as Lauren is concerned it might not be appropriate to complain about the failure to disclose the actual morbidity rate. However, as a mother and a member of the public, I do have serious concerns about the management of the hospital, from at least 1990 onwards because they should have made sure that the significant losses of childrens lives was investigated. The fact that they did not do so means that they failed both in their duty to the individual children as well as their duty to the general public which the hospital served.' [198]
166 John Williams' daughter, Melanie, had a successful Switch operation in September 1988. A few weeks after her birth in September 1983, Dr Jordan had diagnosed that Melanie had TGA, amongst other cardiac problems, and, according to Mr Williams, he had `explained that due to her age and all of her complications, it would be impossible to correct all the problems with one operation ...' [199]
167 Mr Wisheart performed the first operation on Melanie. John Williams stated that:
`We were very impressed by Mr Wisheart, whose conduct towards us had given us every confidence in him. His advice had been very positive but at the same time realistic. We also fully understood that this was only a temporary solution and that further surgery would be needed at a later age.' [200]
168 He stated that when he saw Mr Wisheart in April 1987:
`... he [Mr Wisheart] went through Melanie's problems with us and talked about the possible surgical options. He explained that he felt the best option was the Switch operation, because he felt that this would give Melanie the best long-term chance.' [201]
169 According to John Williams:
`... there was never the least suggestion that we might have considered going elsewhere other than to the Bristol hospitals, partly because of the adverse publicity surrounding other centres, but more importantly because we were very happy with what had been achieved so far and the way in which it had all been done.' [202]
170 He described the advice and information given to him:
`We met with Mr Wisheart on the 3rd September, and he reiterated to us that the operation was by no means straightforward. Nevertheless he said that her overall prospects would be good if she came through the operation. He also said that it was going to be a long difficult operation, and that he intended to undertake it jointly with Mr Dhasmana. We met with Mr Dhasmana and his way of expressing things came over as a little more pessimistic, not so as to suggest that he viewed the situation differently from Mr Wisheart but reflecting the different temperaments of the two Surgeons. Also he had not seen Melanie before, and he also mentioned that scar tissue from the previous operations could possibly give rise to problems. We also met with the Anaesthetist prior to the operation.
`The operation that was to be undertaken was a "Switch" as the main arteries were the wrong way round. We were told that this was a new and relatively difficult technique, and we understood that the Surgeons had not done many of these operations before. Mr Wisheart had set out to us three possible courses of action, of which the Switch operation gave the best long-term prospects, and he gave quite a clear recommendation that this was the best option to take. The other options would have meant, in layman's terms, that the "wrong" side of the heart would still have been carrying out the wrong function, but the hope would be that the heart would redevelop to cope. These might be safer on a short-term view, but in the longer term, the Switch, if successful, would be a better solution. I understood that there was a relatively high degree of risk, and as far as I can recall I think it was put to us as a 25% risk, but we accepted that as a risk worth taking in the circumstances. This was certainly the choice that Mr Wisheart encouraged us to take, and I was glad that he gave us a firm and positive lead in taking the decision.
`We were happy as to the procedure for giving our formal consent to the operation. We had been given a great deal of medical detail, and that we had been given a proper and balanced assessment of the very real risks involved in the operation, and of which we had been made aware long before it came to the point of signing the Consent Forms.' [203]
171 Christine Ellis' son, Richard, had a non-neonatal Switch operation in June 1991. It was performed successfully by Mr Dhasmana. Mrs Ellis described meeting Dr Jordan and being given the diagnosis:
`... I saw a female doctor in Doctor Jordan's team along with my husband. She told us that Richard required a balloon catheter operation to enlarge a hole in his heart in order to allow better mixture of his blood. She told us that a balloon catheter procedure was the prelude to a Switch operation. When the Switch operation took place would depend upon the progress that Richard made following the balloon catheter procedure. She indicated that Richard was seriously ill. She may have discussed the risk factor of a balloon catheter procedure, but I cannot remember that happening.
`The balloon catheter operation took place without incident ...
`I do not think anyone gave a prognosis or discussed the risk factor of this particular procedure.
`There were no discussions on standards of care or success rate, but the procedure was discussed in detail.
`There was no discussion about whether a referral to another centre was required.' [204]
172 Christine Ellis stated that she met Mr Dhasmana on the day before Richard's operation and that Mr Dhasmana `dealt with the detail of the planned surgery.' [205] As regards the information and quotation of risks which she was given before consenting to the operation, she stated that:
`Mr Dhasmana came over as friendly caring and concerned. That particularly struck me about him. I was left in no doubt that he wanted to do his best for my husband and I and Richard.
`Mr Dhasmana explained the surgery that was going to be carried out the following day. He drew diagrams for us to illustrate what was going to happen. He drew a diagram showing a normal heart. He drew a diagram showing the current problem with Richard's heart. He drew a diagram showing us what he was going to do to put that right. He could see that we had not taken on board exactly what was to happen the first time and he went through that all again until he was sure we understood what was to happen.
`Mr Dhasmana told my husband and I that the operation would take about eight hours and it is my recollection that he gave a sixty-forty chance of success.
`Mr Dhasmana said that if the operation did not take place then the balloon catheter would not last forever and as Richard got bigger he would be at risk. It was better for surgery to take place earlier rather than later.
`I was in no doubt that the operation had to take place whatever the risk.
`I remember the whole discussion as being unhurried, kind and friendly and I felt very comfortable.
`I was quite aware that any surgery would have risks under general anaesthetic.
`I had no discussions with the anaesthetist Doctor Masey prior to the operation as far as I can recall.
`There was no suggestion that either this operation or the balloon catheter operation should have been done elsewhere than at the Children's Hospital in the first instance and the BRI in the second instance.
`I do not recall whether the percentage success rate explained by Mr Dhasmana was the hospital's success rate, his success rate or the general success rate.
`I and my husband had no difficulty in giving consent to the operation and we did.
`I cannot recall the likelihood of future surgery or protracted drug regimes being discussed or side effects or other complications or alternative treatment methods.' [206]
173 Julie Johnson's son, Max, underwent a Switch operation in June 1994 which was performed by Mr Dhasmana. Max died a few days later.
174 Julie Johnson stated in her written evidence to the Inquiry that she remembered meeting Dr Alison Hayes in December 1993 who performed a cardiac catheterisation and an echocardiogram on Max so as to obtain a clearer picture of his heart. Mrs Johnson stated:
`Dr Hayes told us that Max's main arteries were switched round from their normal position. Both outlets came from the right ventricle of his heart. Dr Hayes told us that he also had a Coarctation of the Aorta, and that the aortic arch was severely underdeveloped. In addition, there was a hole between the bottom two chambers of Max's heart. Dr Hayes stated that, normally, this was a serious defect in itself but, since Max had no blood supply into the bottom left chamber, the hole was helping to keep him alive at this stage.' [207]
175 Julie Johnson stated that Dr Hayes then introduced her and her husband to Mr Dhasmana who informed them that:
`... Max needed open-heart surgery, but that, due to his size and age, it would be better to give him closed-heart surgery first, as soon as possible. He would then need one more operation, which would take place around his first birthday, when he would be older and stronger. This would increase his chances of surviving open-heart surgery. Mr Dhasmana told us that the closed-heart surgery would involve reconstructing Max's aortic arch, resection of his coarctation, and putting banding on his pulmonary artery. These procedures would, basically, "patch him up" until he was older.' [208]
176 Julie Johnson described what she was told about the risks involved in the surgery:
`Dr Hayes said that there was about a 33% risk to Max's life from the closed-heart surgery. She then stated that the risks of open-heart surgery would be a bit higher - I did not ask her to quantify this latter risk as a percentage, as I did not really want to know at this stage. I then asked Mr Dhasmana if there was any possibility of brain damage occurring as a result of this surgery. He said, "No, he will either live or die on the operating table". I did not realise or believe that there was a risk to Max's life post-operatively, in the Intensive Care Unit (ICU). I was not offered a choice of different types of surgery, or of another hospital or consultant surgeon. I asked if I had any alternative, but they said that Max would die without surgery. We agreed to allow surgery to take place.' [209]
177 Following tests in March 1994, Julie Johnson stated that she and her husband were informed by Dr Hayes that Max was suitable for the Arterial Switch operation. [210]
178 In April 1994 Steve and Julie Johnson met both Dr Hayes and Mr Dhasmana to discuss the Switch operation. Julie Johnson stated that:
`... we initially saw Dr Hayes. She said that the surgery held serious risks for Max's heart, due to the fact that he had never used the left side of it. She said that it might take Max up to a fortnight to recover from surgery. I asked Dr Hayes if there was any alternative course of action, but she said that Max was getting sluggish, and needed surgery. We then spoke to Mr Dhasmana, and again asked him if Max would sustain any other injury, such as brain damage. He replied that the risk was all in the surgery, and that Max would either "live or die on the operating table". He also said that brain damage was "virtually unheard of". Mr Dhasmana did not quantify any risks as a percentage.' [211]
179 The day before Max's Switch operation, Julie Johnson met Mr Dhasmana to discuss the operation. Her recollection of events is that:
`He drew me a rough sketch of what he intended to do the following day, and said that, if the surgery was successful, Max would lead a near-normal life afterwards. I mentioned that Dr Hayes had said that it could be up to two weeks before we would know if the surgery had been successful, since Max's left side was turning to muscle. He said that she was being quite pessimistic; they had seen far more of this type of case in the BRI than in the BCH. He also said that he was quietly confident, and would be able to know if the surgery had worked in just three to four days. He added that Max had done well these past months despite his heart problems, that he was a strong baby, and that I owed it to him to give him a chance of a normal life. I felt more confident than before after this meeting.' [212]
180 Timothy Davies' son, Richard, underwent a neonatal Switch operation performed by Mr Dhasmana on 28 May 1992. Richard died on 8 June.
181 Dr Jordan diagnosed that Richard had cardiac problems within hours of his birth. Timothy Davies stated that he remembered rushing back to the hospital to meet Dr Jordan:
`He told me that they had already performed one operation on Richard. He said that they had put a balloon in to keep the airways open. While I was trying to take this in, Dr Jordan made it clear that this operation had to be performed, and that is why it was carried out so quickly. Dr Jordan then went on to say that Richard's arteries were the wrong way round in the heart. He produced a diagram [213]... on a piece of paper headed "Transposition of the Great Arteries". I did not take any notice of the writing on this piece of paper and Dr Jordan did not draw my attention to any of it. What he did do was point to the picture of the heart on the left, showing the normal position, and explained that Richard's heart was like the one on the right. He said that, basically, the blood was being pumped the wrong way, and that Richard needed a further operation.' [214]
182 As regards any information and advice and the process of consent, Timothy Davies stated that:
`Dr Jordan stated that, normally, they could leave babies in Richard's condition for between 6 months to a year. However, he then said something like, "We have decided that due to the severity of his condition we need to operate within the next 4 days." Having said that there had to [be] the operation within the next four days Dr Jordan said that he had a Consent form with him for the operation to go ahead.
`Having received no advice as to why I was at the hospital until Dr Jordan came in to see me, I found myself taken aback by what he was saying. I felt numb. I wanted to ask questions, but I thought "He is a Surgeon [215] and you can trust your child's life into his hands". I therefore just signed the Consent form. I had not read any of the information given on the sheet describing Transposition of the Great Arteries or taken in anything from the Consent form. I was too numb to take it all in. All I thought was that it had to be dealt with quickly. I was not given any time to think about matters, but just did what I thought was the right thing and signed the form. I cannot think that Dr Jordan was with us for longer than 10 minutes. As soon as I had signed the form, Dr Jordan left the room and Julie and I were left alone again.' [216]
183 Timothy Davies stated in his written evidence to the Inquiry that he did not meet with Mr Dhasmana or any other doctor before the operation to discuss what was going to happen:
`The only persons we saw were the nursing staff. At no point can I recall any Doctor or Consultant coming to see me to explain what was going to happen.' [217]
184 On the day of the operation, Timothy Davies accompanied Richard to the BRI by ambulance:
`On the way to the Bristol Royal Infirmary, the nurse said to me that we were very lucky; Mr Dhasmana was one of the best. She said that he had done a 36-hour operation a few days ago. I asked if the person had lived, and she said yes. I remember thinking that he must be a brilliant surgeon. This was the first time I had heard Mr Dhasmana's name.
`I met with an anaesthetist at the Bristol Royal Infirmary. I believe she was Su Underwood. She told me that it was time for Richard to have his first batch of injections. She said "he'll see you later". I remember feeling very distressed at this point, and said something to the effect that "he isn't going to come back". The anaesthetist said "yes he will - he'll be fine".' [218]
185 Timothy Davies stated that he met Mr Dhasmana for the first time two days after the operation, while he was in the ICU:
`Later that morning, at about 5.30 am, a man came in. He came up and said good morning. He said the operation had gone well, and then went off into what seemed to be the nursery section of the room. I followed him in there, and asked him who he was. He said he had performed the operation. I asked him if he was Mr Dhasmana. He said that he was.' [219]
186 As regards his feelings about signing the consent form for the operation, Timothy Davies stated:
`... I blame myself for killing Richard, because I signed the consent form. I keep asking whether I did the right thing; I just cannot get this out of my mind. I know that, had I not consented to the operation, Richard would not have lived anyway, but did I do the right thing in signing that form? I keep asking if I should have asked questions and found out more. What would have been the position if I had done so?'. [220]
187 Douglas Bwye's son, Jason, underwent a neonatal Switch operation performed by Mr Dhasmana in July 1992 but died during the operation. In his written evidence to the Inquiry, Douglas Bwye recalled the events immediately preceding his signing the consent form:
`... Mr Dhasmana explained once again the operation that he was to perform. He said the success rate was 80% and not the 70% from the previous doctor. In addition, however, he did not make it sound as straightforward. He informed us that not only did he have to deal with the greater arteries but that there were also other smaller ones which had to be swapped which he said were more complicated. Although he was giving us a higher percentage of success rate I did not feel that he was as confident of the outcome of the operation as the previous doctor. Mr Dhasmana was not with us very long although I accept that may well have been because of what he told us and there were few questions which I had to ask. I confirm that I signed the consent form although I cannot recall whether I read it or not. Mr Dhasmana said that Jason would need further surgery when he was older because of the growing process and although I was disappointed at that at least I had the consolation of thinking that Jason would be stronger and more able to cope with any further procedure.' [221]
188 About seven days previously Douglas Bwye stated that had met another doctor in the hospital whose name he did not know:
`... a doctor sat down with us and drew a diagram for us of the condition which Jason had. He explained that it was not a condition that they were unused to and that although there was a risk which he placed at 30%, there was an operation that they could do. I then asked him what happened in the 30% of cases where they were unsuccessful. He did not reply to that question but told me to focus on the fact that other than the heart defect which Jason had, he was well. I left that and did not pursue it again.' [222]
189 As regards the process of being informed, Douglas Bwye stated that everything happened `so quickly that it was almost like a blur.' [223] He added:
`... such was the confidence that both Janine and I had in the surgeons, that we felt it was wrong to interfere with them by asking [too] many questions. I am not saying that they refused to answer questions I am just saying that we did not feel that it was our place to ask questions which we may have thought of.' [224]
190 Douglas Bwye told the Inquiry in the following exchange that he could not remember events happening even though they were recorded in Jason's medical records:
`Q. When did anyone next speak to you about Jason?
`A. It is a difficult question to answer, that, because it was not necessarily one person coming back and telling me what the situation was. It was sort of on-going all the time. I was asking questions all the time. At the end of the day, I just realised that he was not right and that he was in an incubator, and I was just sort of thinking, "Well, they know what they are doing, so ..."
`Q. Would you like to have a look ...[at MR 0403 0035] This is a note ... from the Special Care Baby Unit. It reads: "Parents visited and seen by Dr Bradford who explained that baby possibly had pneumonia and that oxygen and antibiotics were necessary at present." [225]
`Do you remember seeing a Dr Bradford?
`Q. Do you remember an explanation being given to you as to what might be wrong with Jason?
`A. I cannot remember the explanation that was given to me of what they thought was wrong at that time, but shortly after, I was told that it was not what they thought it was and that the oxygen was not in fact helping. They kept upping the level of oxygen up to 100 per cent, I think, and it still was not really having any effect.' [226]
`Q. There is a drawing which is in the medical records. I am going to ask you to look at it. It is [MR] 0403 0101... What I do not know ... is whether the diagram we see here is one which you saw and if so, whether it was done at this earlier occasion, just after the septostomy, or whether it was done later on when you spoke to Mr Dhasmana in respect of getting consent for the bigger operation later on.
`A. That drawing on there I do not think was done immediately after the septostomy, because in the room at the time I can remember the doctor grabbing a piece of paper to do it on, and as far as I could see, it was scrap paper. I do not remember seeing any of the writing on it, no.
`Q. So that was probably something which was done later on?
`A. Yes.' [227]
192 Douglas Bwye returned to the diagram in the following exchange:
`Q. Can we go back to the little picture that was drawn which I said I would come back to at a later stage?
`This picture: was that one drawn by Mr Dhasmana?
`A. I do not remember that being drawn.
`A. I do not even recognise it, only because I have seen another picture drawn by someone else that was similar, but I do not actually recognise that.
`Q. It is obviously not a picture drawn for Mr Dhasmana's or any doctor's benefit, because they would know the anatomy, so it must have been done for you or your wife at some stage?
`Q. It is in Jason's records so we assume - we may be wrong - that is to do with Jason and something that one of the doctors, whoever it was, may have said to you?
`Q. Did more than one person, so far as you can remember, draw diagrams to explain to you what was involved?
`A. I can only remember one person drawing a diagram.
`Q. You cannot recall this diagram as being the one that was then drawn, because that was done on a piece of paper which was pulled across towards you?
`Q. So whoever it was who drew this, if it had anything to do with Jason - I appreciate it is in his records, it may be a mistake - but if it is anything to do with Jason, you cannot recall it being done?
`A. No.' [228]
193 As regards quoting risks, Douglas Bwye told the Inquiry:
`He [Mr Dhasmana] volunteered the 80 per cent success without me asking, because I had already asked previously, when the balloon septostomy was done, and I had been told 70 per cent, so I was not asking him, because as far as I was concerned, I already knew. He volunteered that to me. ...
`The reason I remember that so well is because as soon as he said a 30 per cent chance of failure, I said, "Well, can you tell me why those 30 per cent fail?" But he did not tell me why. He just said "The main thing for you to do is to focus on the fact that other than that, Jason is well." So it looks good, basically. ...
`I cannot remember the exact words. He just said - I think he said something like, "All being well, we would expect 20 per cent chance of failure, but ..." We did not really sort of understand why there was a difference in what he said, but it just did not seem to matter at the time. We just thought, "Just do it", basically.' [229]
194 It is recorded in the medical records that the nature of the operation was explained and 25 per cent [230] failure rate quoted to the parents. The following exchange then took place:
`Q. Are you sure that it was 20 per cent that he mentioned, as opposed to 25 per cent?
`Q. Because you have had difficulties, I think, recollecting precise words, precise conversations, precise identities throughout the brief period we have already been discussing?
`Q. But you are convinced that it was 20 per cent?
`Q. And it was that way round: 20 per cent risk of failure as opposed to 80 per cent chance of success?
`Q. The reason I ask if you are sure is, if we can go to MR 0403 0068, this is Mr Dhasmana's own entry, 27th July 1992.
`"Seen [that relates to you rather than Jason] for arterial switch repair tomorrow. Nature and risks (25 per cent) explained to parents, agree. Consent" [231] and a tick.
`So he has made a note at or about the day that he saw you that he had said 25 per cent?
`Q. If he said 20 per cent, he might - it might be suggested on his behalf, why should he write 25 per cent? Again, I just ask you: it may be, perhaps that he may have said, "Well, the risk is 20 per cent, it could be more, it could be 20 to 30 per cent, something like that", which would, if you are going to pick one figure, you pick a figure in the middle and you pick 25 per cent. Did it come out like that at all, do you think?
`A. All I can say to that is two things. Firstly, in view of the fact that first we were told 70, then he told me 80, it does not surprise me that the final thing that was written was 75.
`Q. But he did not know you had been told 70. You did not tell him?
`A. No. What I mean is, if one can tell me one thing and one can tell me the other, it does not surprise me what gets written down is something else. In view of the type of person that I have learned Mr Dhasmana is, that does not surprise me, that he would write down something that had not been said.
`Q. In any event, you are certain that he said 20 per cent to you?
`Q. Why was it that you agreed to the operation?
`A. Because we wanted Jason to live.
`Q. If he quoted 50 per cent or 60 per cent, you would still have given consent, would you?
`A. Yes.' [232]
195 Clare Steel's son, Jonathan, underwent a Switch operation performed by Mr Dhasmana in March 1993 which was successful.
196 Clare Steel was trained as a nurse and health visitor. In her written evidence to the Inquiry she described how she was told of Jonathan's diagnosis and the need to refer him to the BRI:
`Dr Martin diagnosed that Jonathan had a condition known as Transposition of the Great Arteries ...
`Dr Martin recommended that Jonathan should be immediately transferred to Bristol for this treatment. He explained that Jonathan's cardiac condition was very serious but he nevertheless gave me confidence. In hindsight, I feel Dr Martin was not entirely straight with us. He must by then have known of the poor success rate for these operations at the BRI. He must have known that this rate was significantly below the national average. He did not tell us about this and I was left feeling confident that my husband and I were making the correct informed decision in allowing our son to go to the BRI for the surgery described by Dr Martin. He could have referred Jonathan to Birmingham but there was no discussion of this and I believe that Dr French [referring consultant paediatrician at Taunton and Somerset Hospital] was ignorant of the problems at the BRI.
`... I feel that my husband and I were let down by the staff at Bristol who were the only people who could have known of the poor success rate of infant cardiac surgery at the BRI. I include Dr Martin specifically in this criticism as well as Mr Dhasmana.' [233]
`I do not think that the nursing staff or Junior Doctors who we saw most of the time were aware of the failing success rate for infant cardiac surgery at the BRI. This was probably due to the split sites. I suspect that Dr Martin knew of the situation as he was a Consultant Cardiologist and should have been aware.' [234]
198 Clare Steel recalled her meeting with Mr Dhasmana before the operation and the discussion of the nature of the operation and the attendant risks:
`Mr Dhasmana explained to Norman and myself that Jonathan's condition was very serious and that it was a major operation. He told us that during the course of the operation, the heart would have to be stopped and then re-started. He said that he wanted us to understand the risk of death and of brain damage. He did not in so many words say that the risk of brain damage would stem from any delay or difficulty in re-starting the heart but Norman and I understood this in any event. He told us that 8 out of every 10 babies undergoing the operation did well. He told us that he did not know how long Jonathan would be in intensive care following the operation - it could be 2 or 3 weeks. He also said that until recently the operation used to be performed at 8-9 months but experience now showed that the lifelong result was likely to be better if the surgery was carried out at 10 days due to the possible enlargement of the heart associated with any delay...
`Norman and I understood that Jonathan would die or remain very sick without the surgery described by Mr Dhasmana. We were therefore bound to conclude that the surgery should proceed. We were given confidence in the knowledge that it was now known that the operation was better performed at 10 days and not 8-9 months. Although Mr Dhasmana told us that 8 out of 10 children undergoing surgery did well, we were not informed that the record at the BRI was far worse. If we had been told of the poor success rate at Bristol, our consent to the surgery being performed there by Mr Dhasmana would not have been given. Jonathan could have been transferred to Birmingham or London following his septostomy. In hindsight, we would have expected him to have informed us of his own poor success rate in performing this type of cardiac operation upon infants. We would have expected him to have informed us of the option to have the surgery performed elsewhere such as Birmingham. Because we were not so informed, there was no discussion at all about the option of other centres. As far as we were aware, Bristol was a specialist centre for such cardiac surgery and we assumed that the 8 out of 10 success rate applied to Bristol given the context of the conversation. Had we known the true success rate at Bristol we would certainly have opted to have Jonathan transferred elsewhere.' [235]
199 Janet Edwards' daughter, Sophie, underwent a neonatal Switch operation performed by Mr Dhasmana in April 1993 but died during the operation.
200 Sophie's cardiac problem was recognised at birth and she was transferred to Bristol with her mother immediately. Janet Edwards stated that although at the time she was dazed [236] and distressed, [237] she remembered meeting Dr Jordan:
`At some stage Dr Jordan came to see me and told me that they were going to take Sophie down to what he described as the Echo Room. The purpose of that was to have a better look at her heart. He also said that whilst she was there they may have to undertake some surgical procedure. He may have said exactly what they were going to do but I was too upset to take it in [and] due to my condition it was all above me at that stage.' [238]
`Dr Jordan came to see me at 5.00 pm, and told me what they had done. He brought me some Polaroid pictures of Sophie. They were not very good but I was glad to have them and I was glad to see him as he gave me a reasonable amount of information. He was charming and polite and I was grateful. ... During one of my meetings with Dr Jordan, after they had undertaken the surgical procedure on Sophie, he confirmed to me that she was going to need surgery. I cannot recall exactly what he said.' [239]
201 Janet Edwards described meeting Mr Dhasmana before the operation and the information and the quotation of risks which he gave her:
`Mr Dhasmana came to see me at about lunchtime on Friday. He explained the operation which Sophie required. He called it a Switch Operation and he drew a diagram. He went on to tell me that this was an operation which had recently been invented and that it was now thought that the best time to undertake the operation was in the first month of life. He said that Sophie's chance of not surviving was 1 in 5 and I discussed with him my concerns about resuscitation and brain damage... I asked him whether this was the only operation she would have to undergo. He did say to me that some children when they are about five have to have a further operation because the scar tissue does not expand. He pointed out to me that the little boy in the bed next door in the Baby Unit was recovering from a Switch Operation and was doing well. He seemed positive and confident; he gave me hope and I never thought that Sophie would not pull through. I thought that he was a god and that he was going to make things right.
`I accepted everything Mr Dhasmana said and I would not have dreamed of questioning him unless he had said something which made me think twice in view of my medical training. [240] I had the utmost faith in him in view of his position and never once doubted anything that he told me.
`On the Sunday morning we were with Sophie when Mr Dhasmana arrived to see Ken. I cannot recall whether Mr Dhasmana had previously told me the time for the operation but he confirmed that it was to be Tuesday.
`I cannot remember specifically what Mr Dhasmana said as I was not feeling well. I do remember that Mr Dhasmana mentioned an 80% success rate. I think I recall him doing a further drawing to assist Ken in understanding what he was going to do and I do definitely remember him explaining once again about the possibility of a further operation when Sophie was about five years old.' [241]
202 As regards signing the consent form, Janet Edwards stated:
`... I had become aware of a small problem with the Consent Form. I had assumed that Ken would be going to Bristol but he had decided not to. I think that he wanted to stay near to Sarah and myself. In any event, the Consent Form had to be faxed to Barnstaple and was then signed by Ken and returned.' [242]
203 Stephen Willis' son, Daniel, underwent a Switch operation performed by Mr Dhasmana in May 1993. Daniel died on the operating table.
204 As regards the referral of Daniel to Bristol, Stephen Willis stated in his written evidence to the Inquiry:
`I recall specifically enquiring of Dr Richardson [consultant paediatrician] why Bristol and I was told that Bristol was the nearest. There was more to the conversation but that was the only specific reason that I can recall being given for the transfer to Bristol. At no time were we given any other information as to the level of care that we were to expect at Bristol or the possibility of referral to any other Centres.' [243]
205 At the BRI, Dr Joffe confirmed that Daniel had TGA. Stephen Willis stated that he and Michaela Willis then met Mr Dhasmana:
`... Mr Dhasmana came onto the Ward. He explained to us that the cardiac catheter had gone well but confirmed that Daniel would, nevertheless, need an immediate operation. We were left in no doubt that the operation should be performed as soon as possible. He then went on to explain that there were two operations that Daniel could have. One was known as sennings and the other operation was the switch operation. Mr Dhasmana could say nothing good about the sennings and was extremely positive about the switch.
`Insofar as the sennings operation is concerned he stated that it was one that has been done for a long time and that there were drawbacks with it. He said that Daniel's quality of life would not be as good ... and that Daniel would require further surgery probably in his teens. I think he did give a success rate for the sennings operation but I cannot recall with any certainty what that was. In contrast Mr Dhasmana was very upbeat about the switch operation. He said that it would be a total repair and that Daniel's quality of life would be fine after the operation. My abiding memory of his comparison between the two operations was that with the sennings Daniel would always be short of breath would not really be able to play sport very well whereas with the switch operation he should have a reasonably normal life.
`I do recall that Mr Dhasmana was not forthcoming with the success rates ... I specifically asked for the success rate of the switch operation and was told unequivocally 80-85%. I did not ask Mr Dhasmana whether that was his personal success rate but as he had given me the success rate I assumed that as he was undertaking the operation then it was his. On the basis that I had specifically asked him what were Daniel's chances the response that I received of 80-85% meant to me that it was Daniel's chances of success were 80-85%.
`It should be said that Mr Dhasmana explained by diagram how each of the operations would be performed and that we were under no doubt what he was going to do.
`After the explanation by Mr Dhasmana we were left in no doubt that we had little or no alternative but to opt for the switch operation. The positive nature with which he had dealt with the operation itself and Daniel's chances as opposed to the very downbeat way he dealt with the sennings left us with no choice ... I asked him once again to confirm, which he did, that the success rate that he had given me for Daniel's chances of survival was accurate. He repeated the figures again to me. I then specifically asked him whether this was the best place for Daniel to be or whether there was somewhere else that the operation should be performed. Mr Dhasmana's reply was in words to the effect that Daniel would be fine. I took this to mean that Daniel would be no better off anywhere else.' [244]
206 Mr Dhasmana was asked by Counsel to the Inquiry on what he based his assessment of risk in the case of Daniel Willis:
`A. I have a huge problem with the neonatal Switch in a way to know, really, how can I quote my own statistics, because I have not got any running series of success. So there, I was going mostly on the basis of published literature and the American paper which I quoted before, which was going on the medium sized centre, what they would expect, and knowing about the term which is not really accepted, earlier experience, I am using the term here.
`Q. So the position would be for someone like the Willises that they were getting a perception of the risks in the literature but not the risks in your particular unit?
`Q. Was that not effectively misleading, do you think?
`A. I did not think at that time - we are talking of 1992/93, there was no guideline, and almost all surgeons were quoting, whenever they were starting a new operation, what they were expecting from published literature.' [245]
207 Stephen Willis described an event in relation to signing the consent form:
`... whilst I was away ... I believe Michaela saw a Doctor and signed the Consent Form. Michaela amended the Consent Form by adding the words "based on the information given to me by Dr Dhasmana". After the transfer to the BRI we were informed that the Consent Form had been lost and I was required to sign a further Consent Form. I believe that the Consent Form signed by my wife has subsequently reappeared.' [246]
208 Stephen Willis recalled that after Daniel's operation:
`Mr Dhasmana was wearing his operating gown which was green and blood was splashed all over his chest and left shoulder. He was obviously distressed, there were tears in his eyes and he said that Daniel was dead. I can specifically recall him saying that the operation had been a success but he could not get his heart to beat again and he did not know why he could not save Daniel.' [247]
209 Stephen Willis stated that:
`We believed that Daniel had received the very best of care, in the best place and that our son was one of the unlucky 15%. We believed that we had taken the decision that we had in his best interest and it was no fault of anybody else that he died. It was for those reasons that we felt that his death could not be avoided and we did not feel that immediate feeling of devastation usually experienced when loosing [sic] someone very close and we accepted it as inevitable.' [248]
`Although we accepted at the time and still do that there was a risk to Daniel in the operation it is true to say that had he gone to Birmingham, Southampton or to Great Ormond Street his chances of survival in 1993 would, in my view, have been greatly enhanced. Secondly, I would like to highlight the excellent standard of care that Daniel received at the Bristol Children's Hospital. This was, as I have pointed out in my statement, in total contrast to the situation to be found at the Bristol Royal Infirmary.' [249]
`If my wife and I had received the true statistical information or a true reply to my second question I can say without any fear at all that we would have insisted that Daniel be operated on at the Centre where he had most chance ... Taking into account either of the criteria which I requested Bristol was not that place.' [250]
210 Erica Pottage's son, Thomas, had a Switch operation performed by Mr Dhasmana in July 1993. Thomas died on the operating table.
211 Dr Joffe diagnosed Thomas as having TGA. Erica Pottage stated that Dr Joffe informed her that Mr Dhasmana would carry out the necessary operation. She stated that Dr Joffe explained that:
`Mr Dhasmana would decide whether to perform the switch operation (he explained what this would entail and the fact that it had to be carried out within the first two weeks of birth) or another operation at 18 months which he described as "extra plumbing" which would require further surgery as Thomas grew older. Dr Joffe said that the switch operation was quite new (2 to 3 years) but they had been very pleased with the success rate.' [251]
212 Erica Pottage described her meeting with Mr Dhasmana:
`We went to see Mr Dhasmana who drew pictures of Thomas's heart problem and explained the operation to us. At this point I asked "What are the chances of Thomas's survival?" Mr Dhasmana said "We do not like to quote statistics. It is a serious operation and Thomas is a small baby." Mr Dhasmana said "Only one child has had to return for further surgery following a Switch operation". My husband and I believed Thomas was in the best possible hands. We signed the consent form on this basis. Had Mr Dhasmana told us the truth about the statistics, we would not have given our consent. We feel that Mr Dhasmana should have referred us to another Hospital where Thomas had a greater chance of survival.' [252]
`I do not believe that we were told the whole truth regarding Thomas' chances of survival. I felt we were given little background information about the operation. My husband and I were not told about the lack of success of the operation in Bristol. We were not told where the best chance of a successful operation was.
`The doctors and consultants were the experts and we looked to them to advise us truthfully about Thomas' chances of success and whether, if Thomas went to another children's unit, he would have a higher chance of success. We were not told that, apart from Thomas's heart problem he was a healthy baby. We thought we had given our son the best possible chance of survival based on the information we were given at the Bristol Hospitals and we took some comfort from that when Thomas died. Now we find that this was not the case and I feel that we have been "cheated".' [253]
214 Malcolm Curnow's daughter, Verity, underwent a shunt operation which was performed by Mr Dhasmana on 12 September 1990. Verity died on 16 September 1990.
215 Malcolm Curnow, in his witness statement, stated that:
`While I was concerned about Verity, Mr Dhasmana's views on the risks of the operation were very reassuring, and I was confident of a favourable outcome.' [254]
216 Malcolm Curnow stated that when he met Dr Jordan and was given the diagnosis, the explanation of the condition was minimal. Malcolm Curnow stated Dr Jordan recommended that since Verity appeared to be coping well they should take her home and `feed her up'. [255] Malcolm Curnow stated that subsequently:
`Mr Dhasmana explained that it [the operation] was a simple procedure.' [256]
217 In his oral evidence, Malcolm Curnow's attention was drawn to a letter dated 23 February 1990 written by his GP (Dr Stephen Straughan) to Dr Jordan which read:
`This baby is now seven weeks of age, diagnosed by yourselves as having pulmonary atresia with VSD, with I understand a very small or non-existent pulmonary artery which makes immediate surgery impossible. She has been reviewed in Exeter by Dr McNinch. The parents, who are extremely sensible, understand the situation well and are coping admirably. Verity is gaining weight.
`They have requested for genuine reasons that they are followed up in your clinic in Bristol rather than being seen in Exeter and if it were possible to arrange this, I would be most grateful.
`I am sure this stems from the positive and helpful way the family were treated during their stay in Bristol when Verity was a week old.
`They remain optimistic, but do realise the precarious position that Verity is in.' [257]
218 Asked whether the letter was a fair reflection of what he was feeling at the time, Malcolm Curnow told the Inquiry:
`A. We were certainly aware that Verity, as I said, was not going to be normal for the rest of her life. We knew that surgical intervention was certainly a possibility.
`We did not know whether it was a probability or not, and we understood the situation to be precarious as it is said there, in view of the fact that the next 9 months were very much in the hands of the Gods. ... We did not know whether a shunt operation was going to be required or whether it was not. Our concern was to keep Verity well, which we were doing, but we knew that the future was uncertain and that was our understanding of the situation.
`Q. So your use of "precarious" by the GP, if it were interpreted to give the impression that you knew that Verity was on a knife-edge between survival and death, that would be wrong?
`A. That would be wrong.' [258]
219 After the death of Verity, Dr Jordan wrote a letter to Malcolm and Jane Curnow, which read in part:
`As you know, we felt that although the prospects looked generally poor, we should make the attempt as I and all my colleagues felt that her outlook without some attempt at operation was extremely poor and we could be fairly certain that she would not have managed to survive another 6 or 12 months without some sort of intervention.' [259]
220 Responding to the suggestion that the words `As you know, we felt that...' [260] meant that Dr Jordan knew that Verity's chances of survival without an operation were limited, Malcolm Curnow insisted that he and his wife had not been told so. Malcolm Curnow told the Inquiry that his understanding was that without an operation, Verity would be able to live up until her teens. [261]
221 Michelle Cummings' daughter, Charlotte, underwent a Sennings operation performed by Mr Wisheart in June 1988. Charlotte died in March 1989.
222 Michelle Cummings stated in her written evidence to the Inquiry that Dr Jordan informed her of the heart defect and the diagnosis:
`He told me that Charlotte had transposition of the great arteries a large hole in the lower chambers which cut through the bicuspid and tricuspid valves and narrowing of the aortic artery.
`Doctor Jordan told me that he felt that something could be done to put things right, but that would involve two operations before she was one year old.' [262]
223 Dr Jordan referred Charlotte to the care of Mr Wisheart, whom Robert and Michelle Cummings already knew. Michelle Cummings stated that:
`Robert [Mr Cummings] and I were confident in Mr Wisheart because Robert had been under Mr Wisheart's care for many years in connection with his congenital heart defects.
`I asked for a meeting with Mr Wisheart and saw him that afternoon. I remember being very nervous. I well recall Mr Wisheart coming across as being calm, soft spoken, patient and extremely kind. He went over again what Doctor Jordan had already told me several times, until he was sure I understood exactly what Charlotte's condition entailed. I recall him drawing diagrams to illustrate the problem. He explained why the aorta had to be corrected before the main operation could take place. He said that he feared that as Charlotte got older, the aorta would constrict, making her problems worse.
`Mr Wisheart said that Charlotte's case was very unusual. He said that he had experienced all the problems that Charlotte had in one form or another in different patients, but never all of them together in one patient.
`I recall Mr Wisheart saying to me that Charlotte would most likely not reach her second birthday if there was no surgical intervention and even then provided she did not deteriorate before surgical intervention could take place.' [263]
224 Michelle Cummings described the meeting she had with Mr Wisheart (in February 1988):
`Mr Wisheart described the operation that he was going to perform for Charlotte. I was pleased about the meeting because it gave me an opportunity to ask Mr Wisheart about the availability of a switch operation. I had heard that a switch operation was available in America. I asked Mr Wisheart if this was possible for Charlotte. Mr Wisheart said that these operations were only at that time being performed in London. He said that at that time London had only done four such operations on children and hadn't had great results. Mr Wisheart went on to say that in America the procedure was still in its early stages. Some seven procedures had been carried out on children in America and again, not with great results. I remember offering that I would pay for the switch operation if it would help Charlotte. Mr Wisheart was quite forthright in saying that he felt that the risk wasn't worth taking. He also said that even if the operation was available, the nature of Charlotte's defects were such as to exclude her as a candidate for such a procedure. He explained that a switch procedure was to put the arteries back the right way round, but that procedure would be too much for Charlotte because of her condition. I was happy to accept Mr Wisheart's explanation. I remember that he was kind, but candid in the matter.
`Mr Wisheart went on to explain the operation that he was going to carry out for Charlotte. It was to be a Sennings Procedure. He explained that Charlotte's heart had the wrong chamber acting as the pumping chamber, which in Charlotte, was opposite to where it should have been. Mr Wisheart said he couldn't change that. He had to get the blood and oxygen going the right way round. He said he would do that by carving little canals and making little bridges to allow that to happen. He explained he also had to graft a wall in the lower chambers where the hole in the heart was (AVSD) and try and patch the valves because Charlotte had leaking valves.
`I remember Mr Wisheart taking a great deal of time with me drawing diagrams and explaining the problems and procedures and indeed going over them several times.
`Mr Wisheart explained how the operation would go. He said that the first stage was to cool the body down to enable it to be put on by-pass. I think he said it took three hours to slow down the body and to open up and clamp preparatory for the heart being put on by-pass. I remember him saying that that procedure was done by a separate team.
`Mr Wisheart explained that there could be problems. He explained that not all patients were compatible with heart by-pass and that there was some risk attached to that, but that they would only know whether or not Charlotte was incompatible when she was put on the by-pass.
`Mr Wisheart explained that there was a risk of brain damage because of the length of the operation and the amount of the anaesthetic required.
`Mr Wisheart said that once the heart had been stopped and Charlotte put on by-pass, there was only a certain amount of time allowed within which the surgery could be carried out before she had to be taken off the by-pass. I do not remember how long Mr Wisheart said that period was.
`Mr Wisheart said that there could also be problems taking Charlotte off the
by-pass. Charlotte would have to be warmed up after the surgery and then taken off the by-pass and that could be a problem time.
`Mr Wisheart was very specific about brain damage risk associated with by-pass and anaesthetics. He said that compared with past times anaesthetics were very much better and the risk very much less, but nonetheless there was still risk.
`I remember asking Mr Wisheart what backup plan he had if he opened Charlotte up and realised that the planned operation couldn't be done.
`Mr Wisheart said that there was always a risk of opening up a patient to find that the situation was worse than that anticipated. He said that couldn't always be planned for and that one would have to address and assess each situation as the need arose.
`Mr Wisheart said there was a risk of Charlotte dying on the operating table if the problems were greater in fact when she was opened up, than had been anticipated.
`Mr Wisheart warned that it was possible that Charlotte would end up on a pacemaker for the rest of her life, or might be paralysed for the rest of her life.
`Mr Wisheart warned that after the operation there was another problem, namely with ventilation in that not all paediatric patients are compatible with ventilation and that there were difficulties sometimes associated with taking a paediatric patient off ventilation because paediatric patients could become ventilation dependent.
`I remember asking Mr Wisheart whether in his opinion Charlotte would live to grow up. Mr Wisheart said he couldn't tell me that. I remember him saying "One hopes that by doing this operation she will live a normal healthy life." He said he couldn't say for sure that that would happen. He said that he would do everything that he could for Charlotte and would do his best for her.
`Mr Wisheart said that the success rate of the operational ie (Sennings) procedure was 75%. I think that was the figure, but I might be wrong.
`I remember I discussed with Mr Wisheart the Mustard Procedure and reasons why that was not appropriate. I forget the detail of that. I didn't make a note.
`I remember Mr Wisheart saying there was a risk that the channels that he created would narrow, in which case a further operation would be indicated and that further operation was not always very successful.' [264]
225 As regards giving her consent for the operation, Michelle Cummings stated:
`On the morning of the 13th June 1988 before Charlotte went down to the operating theatre for surgery Mr Wisheart saw my husband and I to sign the consent form ... in February he [Mr Wisheart] had gone into great detail as to the operation to be performed and its associated risks and prognosis. On at least one occasion since then I had gone through the whole thing again in detail with Mr Wisheart and indeed we had gone through the whole thing again after Charlotte's actual admission to the BRI for the surgery, consequently I signed the consent form with full knowledge of everything which was involved.' [265]
226 In a letter dated 31 October 1998, she said:
`James Wisheart was particularly meticulous in planning the operations. All the avenues were explored and every consideration was taken into account and most importantly that it was the best choice for the child and that we as parents were informed every step of the way. Never were we mislead [sic] or misinformed.
`The statistic given for success did not mean the survival of the child, but for the success rate of the operational procedure being performed. We were never led to believe that this was an indication of our daughter's survival rate. Mr Wisheart went to great pains to point out that even if the operational procedure was a success there was no guarantee Charlotte herself would be able to cope.' [266]
227 Carol Kift, mother of Steven, stated in her written evidence to the Inquiry that Steven went to the BRHSC under the care of Mr Wisheart on 26 August 1986 and was operated on the next day for Coarctation of the Aorta at the BRI. She stated that she and her husband were in shock and her memory of what happened just before the operation was `rather hazy'. [267] But she stated:
`... I certainly don't remember Mr Wisheart explaining anything about the operation or its risks. The staff kept their distance from us as if they did not have the time to be involved with individual patients. We just consoled ourselves with the fact that Harefield had recommended the operation.' [268]
228 Carol Kift said that she was alarmed when the operation seemed to be taking hours longer than planned:
`... Mr Wisheart came out of the operating theatre to meet us. He told us that the surgery was still going on because they had discovered complications with Steven's arteries during the course of the surgery. This rather confused us because no abnormality in the arteries had been revealed by the scan. He gave no further explanation but went back into the operating theatre. Although Mr Wisheart had not been rude, we felt that his manner left quite a lot to be desired.
`... Neither Mr Wisheart nor any of the other staff explained what effect, if any, the problems with Steven's arteries would have. However, our main concern at that point was Steven's size. When he had gone in for surgery he was normal size, but by the time he had got to intensive care the next day he seemed much bigger. It was as if he had suddenly grown. I commented on this to the nurse and she told me that Steven's kidneys had failed, and that he had not been to the toilet since the operation. No one had seen fit to tell us this until we asked.' [269]
229 Carol Kift stated that, `Our major criticism of the BRHSC is that we received so little explanation and guidance about Steven's care ... Mr Wisheart, in particular, seemed to talk at us rather than to us.' [270]
230 Amanda Boyland, mother of James, stated that in 1990:
`Five hours after our arrival at the Children's Hospital, Mr Wisheart came to the families room to speak to us. He confirmed that James had a hole in the heart, but he also said that James had a narrowing of the aorta, which had constricted, in other words it had closed up. Mr Wisheart then left the room, but came back and said that James had horseshoe kidneys which were at the front of the abdomen instead of at the back. He said that this was not a problem, it wouldn't affect James in any way.
`Mr Wisheart then told us that he would operate on James's heart in the morning to widen the aorta. Mr Wisheart came over as a real gentleman, he was very quiet and he smiled a lot. I trusted him completely. He drew diagrams to explain things so that I would understand what he was telling me. At the time I thought I had understood, but I didn't realise how ill James was. I didn't realise at that time that he could die.' [271]
231 As regards the consent form, she stated:
`The next morning, 9th May 1990, the hospital phoned me in the late morning. They said that they needed me to go back to the Children's Hospital to sign a consent form for the operation ... The nurses asked us to wait in the families room. It was then that my mother-in-law arrived. An anaesthetist came to the families room to see us. He explained the anaesthetic procedure to us. My mother then informed him that there was a family history of hyperpoxy, an allergic reaction to anaesthetic. He explained that due to this he would use a neutral anaesthetic. I was then asked to sign the consent form for James's operation, which I did.' [272]
232 Amanda Boyland stated that, after the operation, Mr Wisheart came to see her:
`He told us that ... during the operation he had done what he had wanted to, and that the operation had gone well. He said that it was slightly more complicated than expected, as the narrowing of the aorta was lower than had been first thought. He had put a band on the aorta to keep it open to increase the blood flow to the heart and to keep the aorta from narrowing further in the future. Mr Wisheart said that he had not repaired the hole in James's heart, but they had had a closer look at it during the operation and discovered that the hole went through all four chambers of the heart. We were told that Mr Wisheart would remove the band and repair the hole at a later date, before James reached the age of 5. We [were] also told that the next 24 hours would be crucial for James.' [273]
233 Amanda Boyland referred to an incident after the operation:
`In the afternoon, James suddenly took a turn for the worse. At the time Dr Martin, Dr Jordan and Mr Wisheart were with James as they were doing their ward rounds. They asked us to leave, so once again we went to wait in the families room. Mr Wisheart came to tell us that James's kidneys were failing. My mother asked him to put James on a dialysis machine. Nursing staff brought the dialysis machine to the ITU. I cannot recall the exact time that it was brought to the ward. We do not know if James was attached to it. The doctors and nursing staff were huddled together. I heard one of them say that it was only brought to keep the family happy.' [274]
234 Amanda Boyland described a subsequent consultation with Mr Wisheart, at which he explained the next operation:
`My parents and I took James to Bristol Children's Hospital to see Mr Wisheart in early November 1991. He explained the operation that James was going to have. He drew diagrams to make it easier to understand. I could never take everything in at any of the meetings with Dr Jordan, Dr Joffe or with Mr Wisheart. My mother would understand what we were being told, and when we got home she would explain everything to us. At this meeting we were told that during the operation the band on the aorta would be removed and the hole in James's heart would be repaired. I thought that Mr Wisheart said that the operation had a 95% success rate but my mother's recollection is that Mr Wisheart said that the success rate was 85%. I understood this to be Mr Wisheart's opinion [of his own] success rate, as did both of my parents. Mr Wisheart would be doing the operation, it was his success rate that mattered. He said that he knew what he was doing, he said that he had confidence in himself, he believed that the operation would be a success. We were not told that there were other centres where the operation could be carried out. We were not given the choice for the operation to be performed anywhere else. No comparison of success rates at Bristol with anywhere else was provided to us.
`We had been told by nursing staff on previous visits that Mr Wisheart was the best in his field. Dr Jordan and Dr Joffe had endorsed this opinion. Mr Wisheart told us that James would have to have the operation before he was five years old, otherwise he would die. This was the first time anyone had actually said outright that James would die without the operation. We were told that James' operation would take place the following year.' [275]
235 Amanda Boyland recalled that:
`James had also been to see the hospital dentist. The food supplement, Polymer, had rotted James's teeth and he now had an infection in his mouth ...
`Mr Wisheart came to see me on the ward. He asked me whether I wanted to cancel the operation because of the infection in his mouth. I asked him what his opinion was. He told me that he thought it would be best to go through with the operation as planned. On this advice I signed the consent form. Mr Wisheart at this time reiterated that the success rate for this operation was 95%. He said that nothing could go wrong. I believed him, I trusted him completely. ...
`On the day of the operation, 9th February 1993, my mother and I arrived on the ward early in the morning. ... Around 8.30 am my mother took James down to theatre. We had been told that the operation would take between 4 and 6 hours.' [276]
236 Amanda Boyland stated that whilst they waited for James to come out of theatre: `Every so often we would ask a nurse to ring down to theatre to ask after James. We kept being told that everything was fine.' [277]
`James had been in theatre for 141/4 hours. He had been connected to the by-pass machine for the duration of this period. A couple of hours after being brought up to the ITU James had to be taken back down to theatre.
`Mr Wisheart came to see us. He told us that the operation was successful but that they had had difficulty getting James off the by-pass machine. I was told that when they had disconnected James from the machine they could not start his heart. They had attempted to do this 4 times. Thus, James was brought back to ITU still on the by-pass machine. At that time the operation wound had not been stitched up.
`I have been recently been told by Dr Martin, one of the consultants in Bristol, that the machine was an untested and unused adult heart by-pass machine and that in effect James was being used as a guinea pig to see if it worked. The machine was the only one available at the time and therefore the operation should not have gone ahead.' [278]
238 The UBHT responded to Amanda Boyland's statement by stating that the heart bypass machine had been used on both adults and children for many years prior to James' surgery, that the appropriate disposable pieces were available in various sizes and that the cardiac unit had had two such machines for many years. [279]
239 Amanda Boyland described the events surrounding James' death:
`I had been told that James was now well on his way to recovery, apart from the fluctuations in his blood pressure. However in the early hours of Sunday 14th February, there were serious complications ... I was told that James had suddenly deteriorated. James was still on the ventilator at this time, but I was told that one of his lungs was filling up with blood. In effect James was drowning in his own blood ... Mr Wisheart was then on the ward with James. My mother asked him to drain the lung. Mr Wisheart told us that it would take a week to drain the lung, my mother replied that it didn't matter how long it took, all we wanted was for James to get better.
`On the Sunday I was holding James in my arms when all the alarms started going off. I asked the nurses what the alarms were for. They said that it was only the alarm for his feeding tubes. They turned the alarms off. They then said that James had gone. He had died in my arms. It then dawned on me, although they did not tell me this, that they had switched off the machines so that James would die. They had not asked my permission to do so at all.
`I have since been told that at the time the alarms went off, Mr Wisheart had refused to give James any further medication to keep up his blood pressure and the food bags which contained medication once empty were not replaced ...
`We asked the nurses if we could see James. They said we should wait until they had got him ready. James was detached from all the equipment and monitors and wrapped in a blanket. We were all given the chance, in privacy, to hold James and to say goodbye to him.' [280]
240 The UBHT responded that machines were only turned off after all tests had been done to ensure that a patient was dead. It stated that the family would have been involved in the detailed discussions surrounding the planning and turning off of the machines. It went on to say that family members might have found this so traumatic that they may not now be able to remember it clearly. In relation to the withdrawal of treatment, in the form of drugs and food, the UBHT stated that it is very unlikely that discussions took place without the family being involved in them. [281]
241 Penelope Plackett, mother of Sophie, explained what she was told in 1988 by the clinicians caring for her daughter:
`The cardiac catheterisation was carried out at the Bristol Children's Hospital by or under the supervision of Dr Benatar when Sophie was about 3 months old. Dr Benatar confirmed the diagnosis of Truncus Arteriosus Type I. He told me this was the easiest form of Truncus Arteriosus on which to operate. On the second day of that hospital visit, at which I was accompanied by Sophie's father, we were seen by Mr Dhasmana. Mr Dhasmana had Sophie's notes and the results of the cardiac catheterisation. We met him in a little room in the baby unit at the Children's Hospital. Mr Dhasmana confirmed that Sophie had Truncus Arteriosus Type I. He also told me this was the easiest form of Truncus Arteriosus on which to operate. He stressed the urgency of operating but said that he wanted a lung biopsy to be carried out to establish that she had not suffered hardening of the arteries. He said that an operation to correct the heart defect would only be of benefit if there had been no lung damage. Mr Dhasmana gave the impression of being remote and vague. He did not inspire confidence ...
`Mr Dhasmana carried out the lung biopsy in Bristol on 24th October 1988, when Sophie was about 31/2 months ...
`After a fortnight, I telephoned Mr Dhasmana to ask if he had received the results of the lung biopsy. He told me that the pathologist at Bristol had been unable to draw any conclusions and that he had asked Great Ormond Street to assist. As Mr Dhasmana had stressed the urgency of the operation, I was very anxious. A further 3 weeks went by. I saw Dr Orme [282] at his clinic in Exeter, and he told me that Dr Berry, the pathologist at the BRI, had informed him that the results had arrived. He also stated that I should make contact with Mr Dhasmana. I therefore telephoned Mr Dhasmana. He told me that he had just heard from Great Ormond Street. [283]
`He said that although the biopsy was favourable, he still had serious misgivings about operating on Sophie because there had been a considerable time lapse since the biopsy was done. He said those four or five weeks could have had a disastrous effect on Sophie's lungs and she could, by now, be inoperable.' [284]
`... Mr Dhasmana told me that he had decided to operate on Sophie "to give her a chance". He said he was going to operate on 22nd November (1988). Sophie was then 5 months old. I have since become aware of a letter from the GOS pathologist in Sophie's medical records, in which he confirms that any damage to her lungs was reversible. I find it hard to reconcile this letter with Mr Dhasmana' s account of it.
`Throughout this period, Sophie's paediatrician, the cardiologists and Mr Dhasmana all said that, although there were risks, Sophie would have a normal life if the operation was successful. Nobody mentioned the risk of brain damage. I was not given any information about Mr Dhasmana's record in Truncus Arteriosus procedures. Nor was I informed of the complexity of Truncus Arteriosus in comparison to other types of congenital cardiac open-heart surgery. Mr Dhasmana did not tell me that he had by this time carried out 4 Truncus Arteriosus operations. I now know that, of these, three of the patients had suffered from Truncus Arteriosus Type 1. All four of the children had died during or soon after the operation.' [285]
`We were admitted to the BRI with Sophie on Friday 19th November 1988. Sophie's father and I shared a room with Sophie. We saw Mr Dhasmana at about 6:00 p.m on Monday 21st November 1988, the evening before the operation, when he was doing his ward rounds. Our discussion with Mr Dhasmana lasted about half an hour. He explained that Sophie would be put on a heart/lung machine and that he would divide her single heart chamber into two and would then fit an artificial valve and artery. He said this would mean the pressure in her lungs would be reduced and her condition would improve. He said the operation would take up to 12 hours. Sophie's father was with me throughout this discussion. Mr Dhasmana examined Sophie, who looked healthy, strong and well. She had continued to develop normally; she was capable of holding her head up, grasping toys and enjoying her baby bouncer. Having told us on the previous occasions when we had met him that she had a 50/50 chance of survival, Mr Dhasmana now said that, because she was so well, her chances of surviving the operation were 80/20. Once more, he told us that if the operation was a success she would lead a completely normal life. He said she would need another operation - possibly as early as at age 3 - to fit a larger artificial valve and artery when she had outgrown those that would be fitted in this first operation. Mr Dhasmana mentioned no other risks and, therefore, I did not think there would be any. In my mind, Sophie was either going to live or die. If she survived the operation she was going to lead a completely normal life. Mr Dhasmana had said that she might not see her first birthday if she did not undergo surgery, and this convinced me that it must be right to proceed with the operation. On the basis of the information given to us by Mr Dhasmana, I signed the consent form.
`... Later that evening, Dr Benatar came to see us. We relayed what Mr Dhasmana had told us, including the fact that if Sophie did not have her operation she would be dead before her first birthday. Dr Benatar confused us totally by saying that this was not necessarily right, and I asked him if there were any other options. He said that we could leave her, but that she would be continually exhausted and would have a miserable life; she might eventually need a heart/lung transplant. We felt there was no option but to proceed with the operation the next day.' [286]
242 Penelope Plackett stated that after the operation:
`Mr Dhasmana told us that the operation had gone very smoothly and that she was making a good recovery. We found this reassuring. We asked him how long it would be before they would know that all was going to be well with Sophie and he said "usually 48 hours". During the first two postoperative days in ITU Sophie had a number of episodes of tachycardia, during which her heart rate would soar to 170-180. These were controlled by drugs ... Once the first 48 hours had passed, we began asking if Sophie was going to be alright. We found the staff extremely reticent, and none of them volunteered any opinion as to the outcome. With hindsight I am sure they knew something was wrong. From about 7:00 a.m. until midnight each day, I was always at Sophie's side. Mr Dhasmana and Dr Masey came to see Sophie on their rounds, but I don't remember any visit from a cardiologist. [287]
`... After a week, Sophie was weaned off her sedation and began to breathe for herself as the ventilator was turned down. I do not know why she remained on the ventilator for so long. At one point, within the first day after coming off the ventilator, Sophie suddenly opened her eyes. They were completely blank and unfocused and her arms and legs began to thrash more or less continuously for the next 2 days. During this period of fitting, Sophie did not sleep at all and we were extremely worried ...
`A neurologist from the Children's Hospital or Frenchay, a Dr Schutt, came over to the BRI and examined Sophie. He carried out an EEG and asked us how we thought she was. We tried to be positive and pointed to the minute signs of improvement. In a conversation which lasted barely 2 minutes, Dr Schutt shot us down in flames. He told us (in front of a nurse, whose name I do not recall) that Sophie would never see, hear, move, or even suck or swallow. He said all her brain had ceased to function, apart from the cerebral stem. He said she would be severely epileptic. He stated that nothing could be done for her and that we should take her home and look after her. He said that, if she went into cardiac arrest, we should not resuscitate her, and should let her go. He did not say why this had happened. He asked us if we had any questions but we were too shocked and distressed to respond. This was just over 2 weeks after the operation. We were absolutely shattered and decided to go home that night to pass on the news to family and friends.' [288]
243 Sophie was then transferred to the BRHSC. Penelope Plackett continued:
`Despite the news we had been given by Dr Schutt, Mr Dhasmana told us at one point that this might just be a temporary swelling of the brain which would get better in time. Looking back, this was a particularly cruel thing to say. It gave me false hope. Mr Dhasmana persuaded me, much against my will, that I needed a break and should go home to Exeter for the weekend. I did so, although I did not feel that I could trust the staff to give Sophie proper care and attention. When I returned to Bristol, she had an appalling case of nappy rash with noticeable burns on her skin. She had obviously been left in a soiled nappy for a long time. I hated every second of the time Sophie and I spent at the Children's Hospital. I hated the nurses and the whole place. It was a nightmarish blur.' [289]
244 Penelope Plackett stated that:
`Other than information as to the drugs that had to be administered, we were given no advice on how to care for a child in this severe condition either by the staff at Bristol Children's Hospital or at the Royal Devon & Exeter Hospital. Whereas Dr Orme had been supportive before the operation, his attitude had now changed. He said this kind of thing can happen and he was defensive of Mr Dhasmana.' [290]
245 Philippa Shipley, mother of Amalie, had moved to Swansea in 1986. Amalie's care was transferred to the Bristol team. Philippa Shipley stated that Dr Joffe was happy with Amalie's condition at the first meeting and the consultation was brief. [291]
246 In February 1988 Amalie was admitted to the BRHSC, as arranged by Dr Joffe. [292] After carrying out a catheterisation, Philippa Shipley stated that Dr Joffe discussed what he had learnt:
`... he said that everything was looking good and that Amalie's open heart operation could be delayed for a good while yet ... The meeting only lasted about 2 or 3 minutes ... We did not see Dr Joffe again and Amalie was discharged the following day.' [293]
247 Philippa Shipley recalled that she and her husband heard of Mr Dhasmana when they received a letter asking them to attend an appointment with him, [294] which they attended on 20 April 1988:
`With very little introduction, he explained that he thought Amalie should have her Fontan operation as soon as it could be arranged. This was completely contrary to everything we had been told before, and I argued with him, pointing out that Dr Joffe had said Amalie would be fine for a good while longer yet. Mr Dhasmana cut me short, saying "Don't come into me with hearsay." ... He ... dismissively said, "There is significant medical evidence that children who weigh as little as 10kg can undergo this operation". The meeting lasted less than 15 minutes. Soon after... Andrew [Mr Shipley] wrote [295] to Dr Joffe asking if the operation might be postponed ... I was very upset after the meeting with Mr Dhasmana ... I cried tears of anger at the way we had been treated ... We found him impatient and arrogant but we felt we had to take his professional advice, because we could not pretend to know what was the best course of treatment for our daughter.' [296]
248 As regards the risks of the operation, Philippa Shipley stated that in January 1989, on the ward, after an echocardiogram had been performed, Mr Dhasmana:
`... said that Amalie was "just above the line where this operation is possible". Nonetheless he said that she had more than a 50% chance of coming through it. He did not mention any other risks, such as organ failure or brain damage.' [297]
249 Philippa Shipley described events during and after the operation:
`Helen Vegoda ... sat with us while we waited, but I did not find her presence at all helpful. Ms Vegoda passed the time by talking about family days out at St Fagans, Cardiff ... Mr Dhasmana came to see us ... He told us that things had not gone as well as he had hoped ... He said we could go to see her in ITU. He warned us that she was a dusky pink colour. Amalie was a horrific sight ... She had not been cleaned properly ... there was blood in her hair and on her chest and the incision was not very adequately covered ... Amalie's appearance was so awful that after her death I asked close family and friends not to visit her and pay their last respects since I knew they had only seen her at Christmas and would be appalled by her appearance. I was standing, trying to take this in, when I became conscious of Helen Vegoda physically pushing me towards the bed. I had not approached it myself, and she had taken it upon herself to encourage me to get closer to my daughter ... When we went back to see her [Amalie], we were told that her kidneys had failed. The doctor who explained this to us asked if Amalie was our only child. When we said that she was, he put his head in his hands and sighed.' [298]
250 Lorraine Pentecost, mother of Luke, told the Inquiry how she came to know, in 1985, that Luke had a heart problem and required an operation:
`... The day he [Luke] had his operation was the first I was told that there was definitely a heart problem. I was at home and I had a telephone call asking me to come over because he had deteriorated during the night. ... I arrived at Bristol and I signed for him for a catheter. They sent him to have a catheter. I signed a form for the catheter. Luke came back from the catheter and it was - it seemed to be panic stations. I was told he had TAPVD and they were going to have to operate the same day, they were going to operate that afternoon ... I did not have a choice, they said they have to operate immediately.' [299]
251 Lorraine Pentecost described what Mr Wisheart told her about the operation which Luke needed in the following exchange:
`He told me that Luke had TAPVD; that if he did not operate he was going to die.
`Q. Did he give you some idea of what TAPVD was?
`A. He ripped a piece of paper out of a notebook and with his pen he drew a quick diagram.
`Q. You say "quick"; how long was your chat with him?
`A. Couple of minutes, five minutes at the most.
`A. No, my husband at the time was with me.
`Q. You discussed afterwards what had been said to you. No doubt you discussed what had been said to you afterwards?
`Q. Did you both take the same messages away from the meeting?
`A. We were both led to believe that even though he said he had never seen this type of operation before -
`A. Yes. He said he had never done this type of operation before and he had never seen one, but he did know of a surgeon who had done one. He said he was going to contact him. I was led to believe that Luke's condition was so rare that only a few - only one doctor had ever operated on it before.
`Q. Did that give you the idea that it obviously was something which was really quite serious?
`A. No, I was always led to believe that it was just basically a vein that had to be cut off, twisted round and stitched back on again. I know he said it was a 1 in a million chance of Luke actually having this, but he was so full of confidence, he was so full of himself to say that "Yes, this is an unusual type of operation, but I can do it". I mean he never put any doubt in my mind that he was capable of doing it.
`Q. If he was expressing confidence or giving you the impression of confidence, for what reason did you think he was saying to you, "Look, I have never actually dealt with such a case before but I know somebody who has and I will speak to him"? What did you think he was trying to convey by that?
`A. At the time I never really thought about it, I mean I had just been told that he had this heart condition; that if they did not operate he was going to die. I never really thought that much about it at the time. I just thought if he does not have it, he is going to be dead.
`Q. So in effect you had no choice?
`A. No, I was given no choice.
`Q. Whatever Mr Wisheart had said, you would have, assuming you had got the message from him that the situation was critical, you would have agreed to the operation, would you?
`A. Yes. This surgeon that he spoke to or said he was going to speak to, I did not even know if he was in the country. There is major heart surgery all over the world. I just took it that Mr Wisheart was the only one who could do it, you know. I had no choice.' [300]
252 John Mallone, father of Josie, told the Inquiry that he felt that all he had received from the healthcare professionals in 1990 was `reassurance', as opposed to useful information, and that he was not informed of the risks associated with the operation:
`... Our daughter ... was born in hospital and she never went outside. After a couple of days when she was not feeding properly, we constantly were given reassurance that it will be just some problem with a teat, try a different method and so on. Then it became obvious that she was not well, a heart murmur was detected and she was taken down to the SCBU, Special Care Baby Unit, and we were still being given reassurance all the time and we subsequently learned that the staff on that unit had suspected she had a coarctation because her femoral pulses were weak. They did not tell us about that at the time; they kept trying to make us feel that everything was okay.
`... When it became apparent that she did have a serious heart problem, she had an echocardiogram and then Mr Wisheart - eventually after another couple of doctors saw us - came and explained to us she was going to need an operation for coarctation and later when she was older she would have to have open heart surgery as well, but he was immensely reassuring. He used the future tense, not conditional or anything. "She will never climb Mount Everest, " he said, "but she will be able to ride a bike and run around like other children." There was never any doubt coming from him that, you know, she was safe, they would make her better, which we found immensely reassuring.
`... But there was never any mention of any possible risk ... She was paralysed as a result of the operation and the band itself was not of the right tension, so she subsequently died. But there was no mention of any possibility that she would be paralysed, for instance, or brain damaged or anything like that. We were only given the opinion, a positive outcome was going to happen.' [301]
253 In his written evidence to the Inquiry, John Mallone stated that he had no recollection of Mr Wisheart's ever quantifying the chances of a successful outcome for the operation, but that his wife: `clearly remembers him saying that there was a 95% chance that everything would be fine.' He also stated that: `No risks other than that of Josie dying were mentioned.' [302]
254 John Mallone subsequently told the Inquiry:
`We were given a figure of 95 per cent success rate by Mr Wisheart himself, I think - if not him, by a junior doctor whom we saw on the same day. We saw two doctors who both explained what would happen in the operation and it was either Dr Ruth Gilbert or Dr Wisheart, I think, who gave that figure ... We had [it] explained to us twice, by both this junior doctor and this surgeon who was going to perform the operation, and I felt I understood what was going to happen.' [303]
255 John Mallone indicated that the state in which he found Josie after her operation shocked him as `she looked like a corpse in suspended animation'. [304] He stated that Mr Wisheart spoke to him and his wife after the operation and explained that the operation had not gone exactly as planned but had nonetheless been successful. [305]
256 John Mallone recalled that:
`... Mr Wisheart was there ... at 3.00 in the morning. One concern ... that we both had at the time - was that he was operating at the end of a day when he had been at work since 9.00 in the morning. He started this operation at 7.30 in the evening and did not finish it until 3.00, finally went home some time after 4.00 and he was back on the ward at 8.00 in the morning. I could not understand how anybody could do that, physically stay awake that long and perform complex surgery, but he was there and he said he thought the operation was okay; he had performed the coarctation and everything was going to be all right, I think, at that stage.' [306]
257 John Mallone told the Inquiry that on 8 December 1990, Dr Martin told him that Josie had become paralysed `from the waist down or possibly even higher ... during the operation ...' [307]
`... We had a conversation with the unit's third Cardiologist, Dr Joffe. His prognosis was the gloomiest we had yet heard; indeed, he seemed to think Josie had no chance of surviving. He told us that she was not responding to any of the treatment, and that the "law of diminishing returns" was setting in. He asked whether there was anyone we wanted to see her before "the end". Did we have photographs of her? Were there any special clothes we wanted her to wear? He said he was going to consult with Mr Wisheart.
`At about 6 p.m. that day, there was a conference at which Mr Wisheart, Dr Martin, Dr Joffe, another doctor and at least two nurses discussed Josie's care. Our participation was not sought. At one point, I walked past the meeting and clearly heard Dr Joffe asking "But would you be considering this if it were ab initio?"
`... When the conference had come to an end, Mr Wisheart and Dr Martin came and spoke to us about what they [had] been discussing. They went through what had happened so far, and Mr Wisheart told us what they wanted to do next. He said that all the problems with Josie's weight had been due to problems of chemical balance which had now been rectified. In his opinion, the chylothorax was likely to mend itself: he had never had to re-operate to repair the chyle duct. However, he said that they were fairly certain that Josie was now suffering from chylothorax on the right side of her chest as well. His suggested remedy was the insertion of a further chest drain on that side. He said that it was not yet clear what would happen with the paralysis; he knew of no child as young as Josie who had suffered permanent paralysis as a result of this operation, and the youngest he had ever read of was nine months old. His overall view was that there was every reason to proceed with treatment.
`... When he was talking about inserting a further chest drain, Mr Wisheart stressed that he was just there to provide us with advice. I said, "You mean, if we say don't do it, then you won't?" He replied, "No, I would try to persuade you otherwise." This provides a fair summary of Mr Wisheart's dealings with us; he would supposedly present advice but, in fact, he was merely informing us what they were going to do. At the end of our long meeting with Dr Martin and him, we did not feel very convinced of the arguments with which we were being presented, but felt powerless to affect the outcome anyway.
`At about 10 p.m., the new chest drain was put in place by Mr Wisheart's registrar (a man who had, until that moment, had nothing to do with Josie's treatment).
`At about 11.30 on Sunday morning, Josie's saturations suddenly dropped, and a subsequent X-ray showed left-sided pneumothorax (i.e. a punctured left lung). I have no doubt that this must have been attributable to an incident that had occurred the previous morning: a doctor who we had never seen before had introduced himself to us as "a consultant" and, after pronouncing Josie's ventilator "a bit low" had turned it up drastically. The ventilator was set to 50 breaths-per-minute, which was 100% higher than it had been the day before, and 50% higher than at any point in the fortnight since Josie's operation. The pressure was also drastically increased. We never saw the doctor again, and never discovered his name.' [308]
259 John Mallone described the events leading up to Josie's death:
`Mr Wisheart, Dr Martin and a nurse called Joyce spoke to us. They said that the looseness of the band meant that too much blood was getting to Josie's lungs and, as a result, she could not adequately ventilate herself. We were offered two alternatives. The first was that they remove the artificial ventilation, giving Josie a chance of making it on her own without really expecting her to do so. The second was to do another operation to tighten the band; however, if this course of action was chosen, it would be necessary to do a diagnostic catheterisation first. They made it clear that this procedure, in itself, had a risk attached to it. I do not know why they even mentioned this course of action as a possibility, since we had, by this stage, already made it quite clear that we did not want Josie to go through another operation. By now, Dr Joffe's earlier pessimistic approach to us began to seem by far the most human we had encountered. I got quite angry with Mr Wisheart, since he was now saying that it was possible to stop treatment whereas, before, he had seemed determined to go on to the bitter end. The only thing that appeared to have changed was that they now thought the paraplegia was almost certainly permanent. This meeting was a most unpleasant one. Ann would not speak. I was angry.
`After over a month of looking on, feeling as if we had no say in Josie's treatment, we had been presented with a huge decision: the choice between, on the one hand, letting our daughter die and, on the other, demanding the continuation of the increasingly painful and apparently futile fight for her survival. Mr Wisheart had stopped giving us instructions masquerading as advice and seemingly abdicated all responsibility for planning Josie's care. I now know that deaths at units like Bristol's are only counted as statistically significant if they occur within thirty days of an operation and, in my most cynical moments, I wonder how much of a coincidence it was that the point at which Mr Wisheart deferred to us for the first time came immediately after this watershed. For me, it is a travesty that Josie was, as far as Mr Wisheart's record is concerned, a success.
`We decided to refuse further treatment. Nothing we had been told gave us any hope that there was a genuine chance of Josie surviving without being put through what we considered an unjustifiable amount of further suffering, and the risk of an even less dignified death. Joyce, the nurse, said that we mustn't feel that we'd given her a death sentence, but we both felt dreadfully guilty, even though we hoped that we were doing the right thing.' [309]
260 John Mallone told the Inquiry that he found Dr Joffe:
`... actually the most human of any of the doctors that we met and I found the way in which he broke this news to us, I think it was done very sensitively, I thought he came across as a very caring human being and I did not feel it was done brutally at all. The shock came when at the end of the conversation he said "I will go off and talk to Mr Wisheart about it", the shock came when we were then told, after they had had a discussion about it for over an hour at which I could hear Dr Joffe arguing strongly that she ought to be allowed to die, the shock came when Mr Wisheart said he wanted to continue treatment. I found it appalling that we could have been told "There is nothing more we can do for her" and then a matter of hours later being told "We can go on and do this, this and that." I think they should have got their story straight before they spoke to us ... I do not know why treatment was continued. I guess Mr Wisheart may have felt some kind of sense of his own pride in his work perhaps that he did not want to have this child die if he thought she could survive, I can understand that. What I do not understand is why, after having said "We can continue treating her", another two weeks later when nothing had changed in her condition whatsoever, at that point we were told if we wanted to, we could take her off the ventilator now and let her die ... when one of them says "Your daughter is about to die" and the other one is saying "No, she is not", I felt they should have spoken to one another beforehand.' [310]
261 Maria Shortis' daughter, Jacinta, was operated on by Mr Dhasmana in November 1986. Jacinta died in January 1987.
262 In her written evidence to the Inquiry, Maria Shortis recalled Dr Joffe sitting with her husband and her and that he:
`... started to draw a normal heart for us to see. He then drew a diagram of Jacinta's heart. It was readily apparent that Jacinta did not stand a chance of survival. She was completely dependent upon her patent ductus arteriosus to keep her alive until she was two or three. Dr Joffe listed the conditions from which she was suffering as absent septum, pulmonary atresia, transposition of the great arteries, and defective tricuspid and mitral valves. He said that Jacinta was 1 in 3 million, and that he would never see another baby like her in his lifetime. He also stated that he was surprised she had been born alive. Because her patent ductus arteriosus would close after a few days, Dr Joffe said that it would be necessary to perform a shunt operation during the first week of Jacinta's life. Dr Joffe said that he was impressed Jacinta had weighed so much at birth, and had been born so effortlessly. When we asked him about our options, he said that we could turn off the Prostaglandin that was keeping her ductus open. He stated that, if we chose to follow this course of action, she would "succumb" in about 48 hours. Dr Joffe then said that Jacinta was a strong little baby and, in his opinion, worth fighting for. He said that the shunt operation was not risky, and made it very clear that it would give Jacinta a few years of life. I specifically asked him what her quality of life would be for those two or three years. Dr Joffe assured me, categorically, that she would have as near normal a childhood as possible. I felt that I could not ask Dr Joffe to switch off Jacinta's life support at this stage, if there was some quality of life she could experience with her parents and her brother. We therefore agreed to go ahead with the operation.' [311]
263 Maria Shortis stated that Dr Joffe told her that a cardiac catheterisation would have to be done, and that she asked Dr Joffe about the risks involved:
`We asked about this, and about the inherent risks involved. We were told that there were no risks, which prompted me to comment that nothing in life is ever risk-free. At no point did Dr Joffe tell us about the effects of infections, jabs, drugs or post-operative care upon Jacinta. If we had known what questions to ask, we would have raised these issues. Instead, we agreed to the catheterisation procedure going ahead, and signed the appropriate forms.' [312]
264 Maria Shortis stated that Dr Joffe then later informed her that he: `had spoken to Mr Dhasmana, the consultant paediatric cardiac surgeon, and that Jacinta had been listed for surgery the following afternoon.' [313] Maria Shortis recalled that Dr Joffe said that they were to see Mr Dhasmana the next morning who would give them details of the operation he was to perform. Maria Shortis went on:
`Dr Joffe stated that we were very lucky to be at a centre of excellence. I felt very relieved by this.' [314]
265 Maria Shortis described meeting Mr Dhasmana:
`... we were shown into a small room by a nurse from ITU, who I think was called Jeanette, for our consultation with Mr Dhasmana. As we sat down, Mr Dhasmana said, "Had I got to you before the consultant cardiologist, I would have told you that your daughter is inoperable, and have asked you why you want to put her through such misery. I have cancelled the operation." It came out in a burst of frustration and anger, and I found the way Mr Dhasmana informed us of his decision was totally unprofessional. I heard Tim groan, and saw him slump back in his chair. My initial response was, "But you didn't get to us first." I was trying to collect my thoughts, and wondered what Dr Joffe had based his decision on. I had the impression that Mr Dhasmana was telling us the truth, but that his communication skills were appalling: he appeared to have blurted out his own decision, rather than presenting us with reasons. At no point had Dr Joffe stated that the surgeon did not think that Jacinta was inoperable. Now, I was faced with the possibility that my child's operation would not go ahead, and a surgeon who was evidently angry with his colleague. I felt as though I had been drawn into inter-departmental hospital politics, particularly between these two men.
`Following his outburst, I said, "Mr Dhasmana, do you not want to operate on Jacinta because she is going to die anyway?" I believed this question would give him the opportunity to answer in the affirmative. Had he believed it to be a waste of time, I could and would have accepted it. However, Mr Dhasmana's reply struck me as illogical and cowardly, and made me cross. He moved back in his chair and shouted, "I am not talking about death, I just like to see my patients through." The implication of this was that he liked to have a good success rate. However, when I asked him about this, he informed me that there was no problem with this operation, and that Jacinta would come through it easily; he quoted me a 95% success rate ...
`I felt that I was dealing with someone who could not give a straight answer, and said, "Mr Dhasmana, having cancelled her operation, what do you want to do with Jacinta?" He replied that he wished to take her off all her drugs, and monitor her progress. I interpreted this as meaning that he wanted to let her die, since Dr Joffe had already told us that Jacinta would die within 48 hours if she was taken off her medication. I therefore informed him of Dr Joffe's opinion. Mr Dhasmana stated that he had seen patients whose patent ductus arteriosus was still open and functioning at the age of 18. I remarked that I suspected these patients did not have five major heart defects. However, by this stage, I was so stressed by this conversation that I consented to Jacinta being taken off her drugs to see how she coped. I remember that Mr Dhasmana appeared to be very relieved, but also surprised at my reaction. I added that, as her mother, I wanted her to be put back on her drugs if she became cyanosed, and in danger of dying, since I was not yet ready to say goodbye to her. Mr Dhasmana seemed pleased that I had agreed with his plan, but stated, "As you have been promised the operation, I suppose I shall have to do it." He said this in a sulky manner, and it seemed such an unprofessional way to end our conversation that I left the meeting in some distress.' [315]
266 Maria Shortis stated that on the day before the operation, she saw Dr Joffe, who apologised for what happened in her meeting with Mr Dhasmana:
`He said that Mr Dhasmana was an emotional sort, who upset parents, but he could reassure me that Jacinta could and would have an operation. Dr Joffe seemed dismissive of Mr Dhasmana, and I was surprised by his apparent lack of professional loyalty. I did not raise my concerns that the lack of communication in the BCH was adversely affecting the level of care Jacinta was receiving, as I was too exhausted. Additionally, I had been told many times that the BCH was a centre of excellence by both Dr Joffe and the nurses. I believed that the staff were skilled experts in cardiac surgery, even if they did not have much skill in talking to parents.' [316]
267 Maria Shortis stated that Dr Joffe informed her that Jacinta's operation would go ahead the next day, and that:
`... the operation carried very little risk, and quoted a 90% success rate. He also stated that we should give her the best opportunity.' [317]
268 Maria Shortis recalled that:
`I was very aware, throughout the course of this conversation, that the cancellation and subsequent reinstatement of Jacinta's operation had very little to do with me directly.' [318]
269 Maria Shortis stated that:
`Following Jacinta's death, I realised how optimistic Dr Joffe had been in his appraisal of her quality of life, post-operatively. For Jacinta, death must have been a welcome relief. For us, it was terrible ... I now believe that, had Mr Dhasmana seen us before Dr Joffe, he would have told us that there was no operation which could give Jacinta a reasonable opportunity of normal life. However, he did not, and it appears that he did not feel able to assert his views against those of his colleagues.' [319]
270 Maria Shortis expressed her feelings on the matter now, in her statement to the Inquiry:
`I am still appalled at the lack of information that was available to us. I believe that Mr Dhasmana should have told me that one of the risks of the large shunt he fitted was heart failure ... Dr Joffe, who recommended that Jacinta should have the shunt operation, never explained that heart failure would be one possible outcome. I also wish I had known what the side-effects of Digoxin were, as I found it terrible to watch my daughter's condition deteriorate, due to a lack of proper nourishment. Jacinta experienced all the side-effects associated with Digoxin, and it is awful to imagine that I gave her a drug which might have caused her death. At the time, I asked what the associated side-effects of Digoxin were, but never received a straight answer from any of the hospital staff. If I was the parent of a child who should be alive today, I do not know how I should feel towards the medical and nursing staff of UBHT. However, I do feel that Jacinta did not receive competent treatment, and that I and my family were burdened by unnecessary grief and guilt.' [320]
271 Paul Roberts, father of Andrew, explained to the Inquiry the steps he took in 1985 to be sure that he understood what the various healthcare professionals told him and his wife:
`... It was a lot to take in at the time, but we had a lot of help by the people who were looking after us ... a lot of the people around us at the time, we had an extremely good health visitor. We had a health visitor who also lived across the road from us. We just talked to everybody we could. That was the biggest help, really. We just kept on talking to everybody at the hospital, friends, and eventually, as I say, that helped us through it, really.' [321]
272 Tony Collins, father of Alan, told the Inquiry:
`We had had it explained to us several times, but I understood the problem to be Alan had a blocked and narrow aorta ... Mr Wisheart had actually drawn pictures when we saw him of what the problem was and what he was going to do to repair it, and also [Dr] Jordan and Dr Joffe came to see us and all drew pictures at that time of what was going to happen ... Mr Wisheart and Dr Jordan and Dr Joffe had all told us that Alan's chances were not particularly good because of the amount of time he had been unwell leading up to being in Bristol, so the chances of his survival were not very good at all. I could not actually put a percentage on it, but I think it was less than 50 per cent ... They told me but I cannot remember now what it was. I just know it was a little below 50 per cent.
`... The situation we were in to begin with was the fact that Alan either needed to have the operation or he was not going to survive, so you can look at that and say there is no option, really. Given an option now, we would still have let Alan have the operation.
`... There were so many things happening on the day with Alan having to have this operation and all the rest of it, that odds and - lots of different things we were told did not really register in the sense of all we were worried about was that Alan survived the operation.
`... They said because of - not the amount of time of the operation, but they said there was a possible chance Alan could have brain damage or be paralysed from the waist down, the ultimate one being the fact he may not survive.' [322]
273 Susan Francombe's daughter, Rebecca, was diagnosed in 1986 about 18 hours after birth as having a heart problem. [323] She died aged 5 days, after an operation performed by Mr Dhasmana.
274 Susan Francombe told the Inquiry:
`Certain things are very clear. Certain things stand out in my mind, certain pictures from throughout almost five days of her life. Other things are a blur and I do find difficult to remember.
`Some things I have not gone over and over, but in the light of the past two or three months, since I decided to contribute to the Inquiry, things have come to light, things have got stirred up. For example, I have since read her medical records, in the past two weeks, which I had never seen before.' [324]
275 Susan Francombe said that matters were always explained in an informative and caring way, with efforts being taken to make sure that she understood. [325]
276 Susan Francombe described meeting Mr Dhasmana for the first time:
`He had said that he had seen Rebecca as well as seen the results of the catheterisation and the cardiogram, the previous investigations. He drew us pictures of what that had shown and explained that surgery definitely was the only option; that he had not seen a heart formed in that way ever before, but he either said he was going to or later told us that he had consulted other cardiac surgeons in a London hospital.' [326]
277 Susan Francombe agreed that her impression was that Rebecca's condition was something which Mr Dhasmana had not met before, and that he was informing himself about how best to deal with it. [327]
278 Susan Francombe told the Inquiry that she discussed the likelihood of success of the operation with Mr Dhasmana:
`A. I thought he had said 50:50, but my husband remembers it was less than 10 per cent. I am quite prepared to think that I have blanked that out. My husband is better at remembering things than me.
`Q. What you do remember is Mr Dhasmana indicating that he had never come across the particular problem before?
`Q. So plainly, any estimate of success he was giving you was in that context?
`Q. And what was the alternative to the operation?
`Q. So there was no alternative?
`A. There was no alternative.' [328]
279 Susan Francombe wrote a letter to Mr Dhasmana on 21 January 1987, in which she and her husband said:
`... we could not leave it unsaid how grateful we are at all you did for our daughter Rebecca. We often think of the marvellous care and attention you gave her ...' [329]
280 John McLorinan's son, Joseph (Joe), was born with Down's syndrome. He had AVSD, which was successfully operated on by Mr Wisheart on 14 February 1991.
281 John McLorinan described in his written evidence to the Inquiry the diagnosis and explanation which he was given by Dr Joffe:
`... he came in ... he was very calm and soothing and very professional, and he explained very carefully that the initial diagnosis was correct and that Joe did have profound heart problems, and he explained that there was a hole in the middle of the heart and the valves were not working properly and blood was sort of slushing around and not doing a proper job and that was affecting the breathing and everything else ...
`He explained it [AVSD] very thoroughly. Probably he explained what it was there and then, and so we grew into the term ...
`He made it quite clear that there were ... options.' [330] The first option was to let nature take its course and the second was to do banding on the pulmonary artery.' [331]
282 John McLorinan told the Inquiry that Dr Joffe explained the option of heart surgery:
`... the possibility was suggested that eventually, if we wanted to, we could be referred to the heart surgeon who would open the heart up and do a full repair, put it all back together again. But right from the outset, it was explained all sorts of hurdles and difficulties and dangers and it was looking so far ahead and in fact Joe was so ill at the time we were looking almost an hour or a day ahead.' [332]
`... we did not really consider any other option than the full repair, because having brought a child into the world, we thought we would "go for broke", you know, it was not fair on Joe just to let him live a few months or a few weeks or whatever, he ought to have the opportunity of as full a life as possible, so we did not really consider either of the first two options, in all honesty. We wanted to go for it ... we understood that he might not even get as far as corrective surgery. It was in many ways, talking to Dr Joffe, and people later on, in many ways it was depressing, because they were saying, "But, if, it might not, we have not got there yet, there is this problem." So they were very good at calming us down, "There is this problem, there is that problem, we cannot guarantee this."... I think surgery at that stage was so far in advance and perhaps so indeterminate that certainly no statistics were mentioned. We just knew it was a very difficult time.
`... I think I should also explain that Joe not only had the heart problem, we were also made very aware of the Down's syndrome and that Down's syndrome people reacted very differently to things and were more susceptible to infection, and also he had this Hirschsprung's disease which was a major problem as well. Apart from the cardiac problem he was a whole mess as well and things all piled on top of each other, so it was very difficult to comprehend anything beyond an immediate fault. We were just very, very aware of how delicate his life was.' [333]
284 John McLorinan described the time when his son was getting worse:
`They were explaining what was happening, one step forward, two steps back. They were explaining the different drugs they were going to use, but on the heart business they were failing because the heart was not able to shift the blood and fluid around the body, so it was accumulating, getting worse and worse. The situation was just deteriorating and they were in the best possible way saying "We cannot do anything else" sort of thing. We really got to the stage where we thought we would be called into a discussion to say, "Well, do we call it a day?" [334]
285 Joe's deterioration is recorded in the minutes of the joint cardiac meeting of 21 February 1990:
`... in the light of Joseph's poor progress and difficulty being weaned off ventilation, it was felt that a palliative operation would be preferable to attempting a complete correction, which is likely to have a low likelihood of success.' [335]
286 John McLorinan discussed the effect information could have:
`One small incident I recall which happened before this operation is that we had had a consultation with Dr Joffe to discuss Joe's future and treatment. He made reference to some of the problems lying ahead but he had talked about this in a balanced way and also talked of what we might hope for in due course. Following this meeting, I left Gill in the waiting area ... When I came back to pick her up I could not see her in the waiting area, and found that she had been taken by a nurse to have some privacy in a small ante room.
`She was upset and I talked things through with her and it became apparent that she found herself focusing on the difficulties ahead and the negative side of things, particularly the fact that the Cardiac Catheter procedure could come up with the result that Joe would be inoperable: on the other hand there had been much in our discussion with Dr Joffe that had been positive, and by the two of us talking it through together, we drew out these positive aspects. It seems to me illustrative of how a person's reaction to advice can depend very much on the listener as to what he or she focuses on, and how they react to that information.' [336]
`It struck home to us very much the importance of listening carefully and the fact we tended to select what we wanted to remember. We were in such a state of tension ... we were both in such a state of worry and anxiety, it had gone on for so long, and we were so desperate for Joe to get fixed, that we were there listening and just by chance the brain would snatch on to one piece of information, it might be a good piece or a bad piece, but just the sort of things that stuck.' [337]
288 John McLorinan said that Mr Wisheart quoted a risk of 50:50:
`I think we were very well aware of the fact that even though Joe had had the banding, he was not doing particularly well and obviously his prognosis of life was not very good, and we realised that to make a success of Joe's life and any sort of permanency of life, we would have to have the surgery done. We have these figures here, 50:50, and these percentages, that is a big thing. I suppose our understanding of the statistics - we are both teachers and I sort of specialised in statistics and psychology in my final year - we are very much aware of statistics as something you can use one way or another without co-efficients of validity and reliability and all that. You spend years studying these things in education, and they say statistics do not mean very much anyway. By 50:50, we understood that Mr Wisheart, through the totality of his experiences and his skill - we understood there was as much chance of Joe succeeding in the operation as failing. Putting it crudely, it was on the toss of a coin, but we wanted him to have that chance and we were confident.' [338]
289 As regards referral to other centres, John McLorinan responded in the following exchange:
`There were all sorts of rumours going on about reforms in the NHS and we were hearing stories and that, so we realised which hospital we would have been under had we moved up North [Yorkshire]. Our belief was that there was nobody up there with sufficient skill to perform these sort of operations; they would not have been offered. People in that situation were told, "I am sorry, it is inoperable."
`Q. Can I just ask you, you said that your belief was that there was nobody who had sufficient skill to carry out that operation up north?
`Q. On what was that judgment based?
`A. I believe there was somebody appointed at a later date in this hospital who was in fact trained under Mr Wisheart in Bristol.
`Q. Well, you were making a judgment at that time?
`A. Yes, at that time, we were told -
`Q. At that time you were told by whom?
`A. As I said, Gill was a bit worried about this, so she asked Dr Tizzard, I think she was part of Dr Joffe's team. She made enquiries and came back and said, yes, she understood it would not be possible.
`Q. Was that because nobody had enough skill to operate up north, or was it because -
`A. That is what we believed: that they did not do that operation in that particular place.
`Q. That may be two different factors: one is that nobody has the skill to carry it out; the second factor, which perhaps you mentioned, was that nobody would want to carry it out?
`A. Yes. I think there are two quite distinct issues here, and I think that is one of the reasons why I actually gave up the job and moved back down here. Certainly I believe that the information was correct that they were not doing that operation there, but secondly, as the previous witness said, this is Down's Heart Group, and we were members of the Down's Heart Group. The Down's Heart Group obviously were promoting the support of children with Down's, with heart problems, and they were doing research and coming up with alarming statistics, that people with Down's syndrome were not being offered equal chances of these operations.
`Q. So from that, you thought there might be a problem in persuading another hospital to offer Joe this operation? Is that a fair summary?
`A. We were certain of that, and we were also certain that we would not get a better surgeon, a better team; we could not do better anywhere else. Quite apart from the actual operation itself, the follow-up afterwards'. [339]
290 John McLorinan told the Inquiry of his discussion with Mr Wisheart on the day before Joseph's operation:
`... we understood it was a very, very serious operation with a very high risk. We were aware of little marks on Joe's notes saying that he was at very high risk, even from anaesthetic. Again, we have this thing of 50:50 and tossing a coin, but Mr Wisheart quite plainly said what he was going to do, it was a by-pass, a very intricate operation, and even if everything went well and he took him off the by-pass for some reason, some of these operations did not work. They had not got far enough in advance of understanding why these things did not work. He said sometimes it is one of those things that just does not work. He could not guarantee anything ... there just was not an alternative because he was not thriving. He would have died sooner or later.
`... we were fully aware of the risks and fully aware of the operation, but we signed it [Consent Form] willingly. We did not feel pressured. All the time we got the impression that Mr Wisheart and the other staff were putting forward all the alternatives, all the risks and that, and we were making the choices, but we desperately wanted to give Joe the chance. We thought he might die, but it is better - it is a horrible thing - for him to lose his life than die horribly later on, and we had this wonderful chance of getting him fixed.' [340]
291 After the operation, John McLorinan said that Mr Wisheart took his time and explained how things had gone. [341]
292 John McLorinan concluded that his experience in Bristol: `sort of refocused my understanding of the role of the doctor, to almost be the servant of the patient or the patient's guardians. We were very much empowered to make the decisions. We really felt we were given what we needed to make the decisions, and it was our genuine free decision.' [342]
293 Belinda House's son, Ryan Batt, successfully underwent a Sennings operation performed by Mr Wisheart in 1990.
294 Belinda House told the Inquiry that she remembered Dr Joffe explaining the diagnosis in a calm and caring way and being receptive to questions. [343]
295 Belinda House described her meeting with Mr Wisheart on 3 January 1990 in the following exchange:
`Q. What did Mr Wisheart explain to you?
`A. He confirmed ... [that Ryan] had simple transposition, and that there was an operation he could perform called the Sennings, and it was quite a successful operation, but he still did say, I think, there was a 30 per cent chance it could fail.
`Q. You say "I think". Is that something you have a clear recollection of, or is that something that is rather faint in your mind?
`A. Well, I could not decide whether it was 30 or 35 per cent, but at the time there was a reason for that, because he would not have survived until - he would have survived until he was 2 years old and to me, there was no question about him having an operation.
`Q. So whether it was 30 or 35 per cent, it made little difference to you?
`A. Whether it was 1 per cent of survival, I would still have had it done.
`Q. Because that was Ryan's only chance of surviving for about two years?
`Q. So he told you that there was an operation called a Sennings procedure?
`Q. What did you understand that that procedure would involve?
`A. We understood that it was to redivert the flow within the heart of the blood, because at the moment it was two closed circuits and they wanted to divert the oxygenated to the pumping side.
`Q. And that would take place within the heart?
`Q. Did you ask any questions about whether or not a procedure could take place outside the heart?
`A. Yes. We said "Why cannot the aorta and coronary artery just be swapped over?" because it seemed a lot simpler. He explained to us there was an operation that could do that, called the switch, but there were a lot of problems at the time, because the carotid artery was severed and it stopped the blood actually going to the muscle of the heart. At that point, Ryan would have been too old for that operation.
`Q. When you say there were a lot of problems because of the treatment of the carotid artery, was that something you understood would be a particular problem in Ryan's case, or was that a general problem with the development of the switch operation?
`A. We felt that was a general problem in the development of the switch operation.
`Q. Did you discuss how far developed the switch operation was at that time?
`A. I remember discussing it a little bit further, and we were given the impression that the switch operation would be - would, in the future - well, when it was developed, it would be carried out on babies that were very young, and I felt that Mr Wisheart thought that this would be very traumatic for babies at an early age, because in two weeks - I know he was waiting for Ryan to be strong enough to have his operation and the two did not add up.
`Q. You say Mr Wisheart was telling you the switch operation was being developed. Did he discuss with you where it was being developed at the time?
`A. He did mention America, but I cannot remember any other places.
`Q. Did he discuss, therefore, whether or not it was being developed in the UK at the time?
`A. I cannot remember if that was said or not.
`Q. Can you remember whether there was any discussion of whether it was being offered in Bristol at the time?
`A. I am pretty sure it was not being offered in Bristol at the time. I think he said that.
`Q. Would it come as a surprise to you, therefore, Miss House, to learn that at that time there had been approximately nine Arterial Switch operations carried out in Bristol?
`Q. Because your recollection is of Mr Wisheart telling you it had not yet been developed in Bristol?
`A. I had the impression it was not developed in Bristol.
`Q. Why do you say you had that impression? Can we just explore that further?
`A. Because I cannot remember him exactly saying it had been developed in Bristol. It was just a feeling I had.
`Q. So is it a fair summary to say you were being told that the operation was being developed, but it was at an early stage in its development?
`Q. And there was a discussion of the fact that that development was taking place in the USA?
`A. I cannot say the development is in the USA. I know USA was mentioned, but I cannot remember any other hospitals being mentioned, or any other -
`Q. At any rate, you got the impression that Ryan was considered to be too old for the arterial switch?
`Q. And that therefore, partly because of that, partly because the switch was at an early stage of development, a Sennings operation would be the appropriate one?
`Q. You mentioned that it was suggested there would be a 30 to 35 per cent risk of mortality, even if that was carried out?
`Q. Was there any discussion of any other risks attached to the operation?
`A. I know at the time we were very aware that even if he came out of the operation, you know, the recovery time was very crucial and as the days went on, he would become stronger, but it was the first few hours that were very crucial after he had had his operation.
`Q. How did Mr Wisheart help you to understand the way in which this operation would be carried out?
`A. He spoke very clearly about it and he drew diagrams to explain to us, and of course, he allowed us to ask any questions, so we explored it. I think that is all.
`Q. Did you feel that you were being given an adequate opportunity to understand the nature of the operation?
`A. Totally, yes, because it was an atmosphere where you felt you could ask any questions, whatever question it was. You did not feel as if you were going to be made to look kind of silly by asking any questions. I cannot remember what questions we did ask, but I know we asked a range of questions.' [344]
296 Belinda House commented on the communication between Mr Wisheart and Dr Sally Masey (the anaesthetist) and the teamwork:
`I can remember them being there, and I can remember them discussing things together ... Everything that Mr Wisheart would say would be reiterated by Sally, and the team seemed a very tight-fitting organisation, really. They were all speaking the same language ... we never heard a different word from both of them, although I cannot remember them discussing something together in front of us.' [345]
297 Belinda House recalled that before the operation, they were allowed to take Ryan down to the anaesthetic room and witness the pre-medication being administered. [346]
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Footnotes
[161] Cardiologist at the BRHSC
[162] T95 p.75-7 Justine Eastwood
[163] T95 p.69-70 Justine Eastwood
[167] T95 p.74 Sheila Forsythe
[168] T95 p.80-1 Michelle Cummings
[171] MR 1761 0053; letter from Dr Joffe to Dr Vulliamy (Paediatric Registrar)
[180] WIT 0263 0007 Diana Hill
[181] MR 1761 0020; medical records of Jessica Hill
[184] MR 1761 0037; this figure is quoted in a letter from Dr Joffe
[189] WIT 0263 0009 - 0010 ; Diana Hill mentions a House Officer, Helen Vegoda, a nurse she believes is called L Syonng and Dr Bolsin
[192] WIT 0263 0014 Diana Hill
[194] WIT 0230 0003 Kathleen Tilley
[195] WIT 0230 0004 Kathleen Tilley. See Chapter 3 for an explanation of clinical terms
[196] WIT 0230 0007 - 0008 Kathleen Tilley
[197] WIT 0230 0008 - 0009 Kathleen Tilley; Mr Dhasmana's response to this is at WIT 0230 0036 - 0037
[198] WIT 0230 0014 Kathleen Tilley
[199] WIT 0140 0002 John Williams
[200] WIT 0140 0002 John Williams
[201] WIT 0140 0003 John Williams
[202] WIT 0140 0004 John Williams
[203] WIT 0140 0005 - 0006 John Williams
[204] WIT 0023 0003 - 0004 Christine Ellis
[205] WIT 0023 0006 Christine Ellis
[206] WIT 0023 0006 - 0008 Christine Ellis
[207] WIT 0178 0004 Julie Johnson. See Chapter 3 for an explanation of clinical terms
[208] WIT 0178 0005 Julie Johnson
[209] WIT 0178 0005 Julie Johnson; Mr Dhasmana's response to this is at WIT 0178 0026 - 0027
[210] WIT 0178 0008 Julie Johnson
[211] WIT 0178 0008 Julie Johnson; Mr Dhasmana's reponse to this is at WIT 0178 0027
[212] WIT 0178 0010 Julie Johnson
[213] WIT 0160 0016 - 0017 Timothy Davies
[214] WIT 0160 0006 Timothy Davies. See Chapter 3 for an explanation of clinical terms
[215] Dr Jordan was in fact a consultant cardiologist and not a surgeon
[216] WIT 0160 0006 - 0007 Timothy Davies
[217] WIT 0160 0009 Timothy Davies
[218] WIT 0160 0009 Timothy Davies
[219] WIT 0160 0011 Timothy Davies; Mr Dhasmana's response to this is at WIT 0160 0019 - 0020
[220] WIT 0160 0015 Timothy Davies
[221] WIT 0002 0005 Douglas Bwye
[222] WIT 0002 0003 Douglas Bwye
[223] WIT 0002 0006 Douglas Bwye
[224] WIT 0002 0006 Douglas Bwye
[225] MR 0403 0035; medical records of Jason Bwye
[230] MR 0403 0068; medical records of Jason Bwye
[231] MR 0403 0068; medical records of Jason Bwye
[232] T6 p.28-30 Douglas Bwye; Mr Dhasmana's response to Douglas Bwye's evidence is at WIT 0002 0013 - 0014
[233] WIT 0510 0003 - 0004 Clare Steel
[234] WIT 0510 0005 Clare Steel
[235] WIT 0510 0007 - 0009 Clare Steel
[236] WIT 0005 0001 Janet Edwards
[237] WIT 0005 0002 Janet Edwards
[238] WIT 0005 0002 Janet Edwards
[239] WIT 0005 0002 - 0003 Janet Edwards
[240] Janet Edwards is a community nurse
[241] WIT 0005 0003 - 0004 Janet Edwards. In response, Mr Dhasmana said he would have given a mortality figure of `around 30%', WIT 0005 0011
[242] WIT 0005 0005 Janet Edwards
[243] WIT 0285 0002 - 0003 Stephen Willis
[244] WIT 0285 0005 - 0007 Stephen Willis
[246] WIT 0285 0008 Stephen Willis
[247] WIT 0285 0011 Stephen Willis
[248] WIT 0285 0012 Stephen Willis
[249] WIT 0285 0014 Stephen Willis
[250] WIT 0285 0015 Stephen Willis
[251] WIT 0260 0002 Erica Pottage. See Chapter 3 for an explanation of clinical terms
[252] WIT 0260 0003 Erica Pottage; Mr Dhasmana's response to this evidence is at WIT 0260 0007 - 0008
[253] WIT 0260 0004 Erica Pottage
[254] WIT 0004 0006 Malcolm Curnow
[255] WIT 0004 0003 Malcolm Curnow
[256] WIT 0004 0005 Malcolm Curnow; Mr Dhasmana's response to this is at WIT 0004 0015
[257] MR 2374 0102; medical records of Verity Curnow. See Chapter 3 for an explanation of clinical terms
[259] T3 p.42 Malcolm Curnow and MR 2374 0084; medical records of Verity Curnow
[262] WIT 0123 0008 Michelle Cummings. See Chapter 3 for an explanation of clinical terms
[263] WIT 0123 0009 - 0010 Michelle Cummings
[264] WIT 0123 0014 - 0018 Michelle Cummings. See Chapter 3 for an explanation of clinical terms
[265] WIT 0123 0019 Michelle Cummings
[266] WIT 0123 0035 Michelle Cummings
[267] WIT 0461 0003 Carol Kift
[268] WIT 0461 0003 - 0004 Carol Kift
[269] WIT 0461 0004 Carol Kift
[270] WIT 0461 0006 Carol Kift; Mr Wisheart's response to this evidence is at WIT 0461 0011 - 0012
[271] WIT 0232 0003 Amanda Boyland
[272] WIT 0232 0004 Amanda Boyland
[273] WIT 0232 0005 Amanda Boyland
[274] WIT 0232 0006 Amanda Boyland
[275] WIT 0232 0008 Amanda Boyland
[276] WIT 0232 0009 - 0010 Amanda Boyland
[277] WIT 0232 0011 Amanda Boyland
[278] WIT 0232 0011 Amanda Boyland
[279] WIT 0232 0032 UBHT
[280] WIT 0232 0011 - 0013 Amanda Boyland
[281] WIT 0232 0032 UBHT
[282] Sophie's paediatrician
[283] WIT 0012 0004 - 0005 Penelope Plackett
[284] WIT 0012 0014 Penelope Plackett
[285] WIT 0012 0005 Penelope Plackett. See Chapter 3 for an explanation of clinical terms
[286] WIT 0012 0006 - 0007 Penelope Plackett; Mr Dhasmana's response to this is at WIT 0012 0016 - 0019
[287] WIT 0012 0009 Penelope Plackett
[288] WIT 0012 0009 Penelope Plackett
[289] WIT 0012 0011 Penelope Plackett. The UBHT's response to this evidence is at WIT 0012 0022; Mr Dhasmana's is at WIT 0012 0020
[290] WIT 0012 0011 Penelope Plackett
[291] WIT 0392 0009 Philippa Shipley
[292] WIT 0392 0010 Philippa Shipley
[293] WIT 0392 0011 Philippa Shipley
[294] WIT 0392 0011 Philippa Shipley
[295] WIT 0392 0042; letter from Andrew Shipley to Dr Joffe
[296] WIT 0392 0012 Philippa Shipley; Mr Dhasmana's response to this is at WIT 0392 0073
[297] WIT 0392 0015 Philippa Shipley
[298] WIT 0392 0016 - 0017 Philippa Shipley. The UBHT's response to this evidence is at WIT 0392 0074
[299] T95 p.138 Lorraine Pentecost. See Chapter 3 for an explanation of clinical terms
[300] T95 p.152-4 Lorraine Pentecost
[301] T95 p.131-3 John Mallone
[302] WIT 0155 0005 John Mallone
[303] T95 p.158-9 John Mallone
[304] WIT 0155 0006 and at T95 p.161 John Mallone
[305] WIT 0155 0006 John Mallone
[306] T95 p.161-2 John Mallone
[307] WIT 0155 0008 and at T95 p.161 John Mallone
[308] WIT 0155 0010 - 0012 John Mallone
[309] WIT 0155 0014 - 0015 John Mallone; Mr Wisheart explained his approach at WIT 0155 0064 - 0065
[310] T95 p.184-5 John Mallone
[311] WIT 0222 0009 Maria Shortis. See Chapter 3 for an explanation of clinical terms
[312] WIT 0222 0010 Maria Shortis
[313] WIT 0222 0010 Maria Shortis
[314] WIT 0222 0010 Maria Shortis
[315] WIT 0222 0011 - 0013 Maria Shortis
[316] WIT 0222 0014 Maria Shortis
[317] WIT 0222 0015 Maria Shortis
[318] WIT 0222 0015 Maria Shortis
[319] WIT 0222 0021 Maria Shortis
[320] WIT 0222 0023 Maria Shortis
[323] WIT 0349 0001 Susan Francombe
[324] T68 p.9-10 Susan Francombe
[325] T68 p.11 Susan Francombe
[326] T68 p.11-12 Susan Francombe
[327] T68 p.12 Susan Francombe
[328] T68 p.13 Susan Francombe
[329] MR 2181 0012 - 0013 ; letter to Mr Dhasmana dated 21 January 1987
[330] T2 p.128-9 John McLorinan
[331] WIT 0122 0001 - 0002 John McLorinan
[332] T2 p.131-2 John McLorinan
[333] T2 p.133-5 John McLorinan
[335] MR 2469 0171; minutes dated 21 February 1990
[336] WIT 0122 0005 John McLorinan
[337] T2 p.150-1 John McLorinan
[339] T2 p.159-61 John McLorinan