Annex A > Chapter 17 - Communication Between Healthcare Professionals and Patients > Communication after the operation and when the child died > Involvement of the GP, health visitor and social services after surgery
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Involvement of the GP, health visitor and social services after surgery
371 Susan and Kenneth Darbyshire stated that:
`The support we had when we took Oliver home was faultless. Our GP Dr Chris Irvine and the health visitors Anne and Rosemary. Anne would make three time weekly visits and Rosemary would always be there if Anne was not available.' [431]
372 Julie Johnson said that Mrs Vegoda had arranged for her to be visited by a health visitor when she returned home. She described this arrangement in the following exchange:
`Q. I think it is right, is it not, that there was some follow-up support at [sic] which Helen Vegoda took some steps to organise?
`Q. In particular, with the Social Services department?
`Q. And I think it is not necessary to go to the correspondence, but you are aware of correspondence, for example, in 1993, between Helen Vegoda and the Social Services department?
`Q. And that Helen Vegoda was in contact also with your GP and health visitor?
`Q. Did the health visitor continue to visit you and Jessica after her discharge from hospital?
`Q. How did you find that? Was that of assistance?
`A. I found that of assistance, yes.' [432]
373 Linda Burton, mother of David, told the Inquiry about contact from the health visitor:
`The day after David's surgery ... the health visitor from our local practice turned up at my house and informed my parents that the surgery had received news from Bristol that David had had his operation and that things were not going well. We did not know that.' [433]
374 Jean Sullivan described contact between UBHT and her GP:
`The second night [after Lee's death] I spent at my mother's and whilst I was there my GP came down and told me that I had to make an appointment to see him. When I eventually saw him he read to me a letter which had been sent by the hospital to him. That was the letter signed by the Registrar Mr Chatterjee. Once he had completed reading it I told him that it was wrong. I told Dr Perkins that that was not how it had happened and I told him exactly what Mr Wisheart told me. He said to me that what he had read [to] me was in the letter and that the hospital, not I, knew what they were talking about.' [434]
375 Helen Rickard told the Inquiry:
`My GP called to see me, I believe the following day that we had returned back from the hospital. He had obviously been notified by the hospital of Samantha's death, and he called to my house, which was next door to the surgery, and asked if there was anything that he could do. I initially asked him for medication, which I was given ... and then I sought counselling ... [which was arranged through the GP]'. [435]
376 After Jessica's death, Diana Hill told the Inquiry that she saw Mr Dhasmana to find out more about what happened:
`When he came back from holiday my sister and I went to see him because I felt nothing had been done correct for her [Jessica], I had this feeling nothing had been done properly for her. We went to see him and he said "You know the critical bit was going to be after the operation" and he was even then very matter-of-fact, very blunt. It was as if he was watching the clock to get me out of the room ... He was always very blunt. There was not a compassion to him, it was a very blunt man. He appeared a very sort of blunt, matter-of-fact man which I found uneasy because I was trying to get questions out but I felt I should not be asking those questions ... I was feeling rushed ... and it was just his bodily manner, everything, I just felt I should not be asking these questions. ... He said it was a very rare case, which confused me because I was told she had a VSD ... No [he did not explain why her condition was rare]. I mean he drew diagrams, when we saw him he went into depth about the pulmonary hypertension, but he was saying she was a very rare case which I could not quite understand ... It came across that she had a very rare thing that no other baby had.
`... I then thought "They are not going to have the right drugs then" and it came across that they would not have done. I do not know, it seemed very - not quite right. I mean at the time when Jessica was on ITU two other babies died as well and I remember that to this day, two other babies died and I remember thinking "Why are these babies dying?" and I asked a nurse and she just said it was a bad patch and that is something I can remember ... When me and my sister left him [Mr Dhasmana] we felt really uneasy, we felt we did not really know anything more than we knew. I wanted really to see somebody to tell me something proper. Because Mr Wisheart had never seen us after Jessica died, I think we saw a Registrar who just went over things. I wanted to see somebody who I thought knew what they were talking about. That is why we went back, we were just uneasy with what happened to Jessica.' [436]
377 Diana Hill explained her reasons for not arranging to see Mr Wisheart after Jessica's death:
`Because when Jessica died it was like we were told to get our bits, it was all a bit of a rush because she died at 3.00. We were then at 6.00 told to get ... I was trying to keep alive basically because I did not want to be here in this world any more. At 6.00 we were told to get our stuff, we were told to get Jessica's stuff and so we collected our stuff from the room, we collected Jessica's stuff from the room. The thought of going to see Mr Wisheart or somebody just did not cross my mind. Helen Vegoda came to see us.
`... I think it is because I never met him [Mr Wisheart]. I never met Mr Wisheart therefore I thought Mr Dhasmana would be the one to explain and tell me what happened. But really when I think of it, Mr Dhasmana was not there either, so who would be the best person to tell me?' [437]
378 Linda Burton told the Inquiry that a few days after the operation she was called to the hospital because David's condition was deteriorating:
`We met a Registrar again, I do not know who it was, never seen him before, who said that they were having problems with David's saturation levels. They were having to bag him more often than previously. They suggested about 6 o'clock in the evening that it would be a good course of action to insert a chest drain, which they did. We were informed that Mr Wisheart was not in Bristol ... [at] about 10 o'clock at night a consultant anaesthetist was called in, and it was explained to us that David's lungs were becoming very stiff and that it was taking greater effort on the part of the nurse who was doing the bagging to actually force the oxygen, air, whatever it was, into his lungs. This was then explained to us, that the condition would probably get worse to the point where the lungs would be so resistant to this bagging process that if it went on too long, his lungs would burst ... They suggested that the course of action open to them was to give him a massive dose of Frusemide ... After the consultant had explained that they had given him a great dose of Frusemide, the idea was to try and drain off, so we understood, fluid from his body to enable his lungs to function. When it was explained to us that his lungs could possibly burst, I took my husband and my mother-in-law into the family room which is attached to the ITU, the unit, and when the nurse came with us, I said that it was pretty obvious that David was not going to make it, was it possible to turn the ventilator off. The consultant anaesthetist came to see us, a very nice chap, and understood what I was asking him to do. He explained that it was not possible, that he was not allowed legally to do what I was asking, and that, having given him this dose of Frusemide, they then had to wait and see what effect this drug would have. If it proved to be ineffective, they could then put him back on the ventilator; the ventilator would then fail to oxygenate his blood adequately, his blood saturations would drop. They would drop sufficiently that he would become brain dead, and then they could turn the ventilator off ... we actually were given no choice. I had asked him to turn the ventilator off. He informed us he could not do that and that he had to - that he had given this dose of Frusemide and if that had no effect, then they would put him back on the ventilator and the ventilator would fail to oxygenate his blood because of the problems he was having and brain death would occur. We agreed that ... that is what would happen. The anaesthetist explained to us that unfortunately he had no idea how long it would take for the saturation levels to reach that critical point, but ... it would happen eventually. We returned to ITU. The nurse on duty suggested that we sort of, you know, held David's hand. I insisted on holding him. It took seven minutes ... After David had died, once the saturation levels had dropped, the consultant anaesthetist came along. He took one look at the readings ... they had tumbled - and he said death had occurred. He switched the ventilator off. The nursing staff then suggested that if we returned to the family room, which is a short walk ... from the IT unit, that they would dismantle all the life support equipment and then we could go back and see David.' [438]
379 She described an encounter with a `junior doctor' immediately afterwards:
`We had barely got back into the [family] room and sat down when a doctor appeared, a junior doctor. I have no idea who he was; I can only assume he was a junior doctor, because he came through the door with a piece of paper in his hand. He approached my husband and asked him to sign this piece of paper. When my husband asked him what it was, he said it was an agreement for the hospital to do a post-mortem. I mean, we had literally come out of ITU and got back into this family room, I mean, a matter of minutes, five minutes at the outside, and there was this junior doctor suggesting that we should agree to a post-mortem. This had never been raised with us.
`... When the doctor appeared with this piece of paper, asking my husband to sign it, we were both horrified. It had never arisen that a post-mortem would be necessary. We understood that because David had lived as long as he did after surgery that a post-mortem was not required. However, the nurse who was with us, who came with us back to the family room after David died, was horrified at this doctor's lack of sensitivity, and ushered him out of the room. She then came back and said, you know, "You obviously have time to think about this. It is a hospital post-mortem and it will enable learning to be done from David's death." Obviously David's operation had not been successful and it would enable them to find out why. We spent some time discussing this between us, and in the end, we concluded that something good in the way of learning of what, if anything, went wrong ... that they could gainfully acquire from David's case, that we would give permission for a post-mortem.' [439]
380 Linda Burton recalled an encounter with the duty nurse:
`After David had died, the nursing staff dismantled his life support machine equipment, and we returned to ITU to see him. The nurse on duty at the time, when she came to take us back to ITU, had obviously been smoking. We had this discussion over the merits of smoking on a cardiac ward, considering smoking is supposed to be one of the main reasons of cardiac disease, [and she apologised]. [440] She said that she never ever had come to grips with the death of a child and that they had had a bad week. We knew ourselves they had lost at least two other children that week.' [441]
381 Linda Burton told the Inquiry that she and her husband later:
`... wrote a letter to Mr Wisheart thanking him for what he had done.' [442]
382 Mr Wisheart wrote [443] to them expressing his sympathy, apologising for his absence and inviting them to see him if they wished.
383 Linda Burton said that they did not return to see Mr Wisheart but that they:
`... asked for a copy of the post-mortem. When we got it, we took it to our GP. He readily admitted that bits of it were beyond him, that it was too technical, but he did inform us that a page was missing from it, but we felt that we probably were not going to ever really fully understand the technicalities of David's death. We felt as satisfied as we could have done that everything that could have been done for him had been done.' [444]
384 Stephen Willis stated that some efforts at communication during Daniel's operation were `insensitive and distressing'. [445]
385 He stated that when he and his wife Michaela returned to the hospital while Daniel was still in the theatre:
`We were introduced by Helen Stratton to a nurse who was from the Intensive Care and who we were told would be supervising Daniel's care on his return from the theatre. I and ... Michaela, were on an immediate high because we immediately assumed that Daniel had come through the operation. I said to Helen Stratton, "Does this mean that Daniel is okay?" She replied "Oh no there are many problems"... To have caused us to be elated by her first sentence only to dash that elation in answering my question was cruel and indeed was the worst moment that we were to experience other than being told Daniel had died'. [446]
386 Stephen Willis stated that when he asked her to explain `many problems', Miss Stratton was unable to satisfy him with her answers and went to get Mr Dhasmana. [447]
387 Stephen Willis said Mr Dhasmana explained that:
`... there were indeed complications and that he could not get Daniel off the life support machine. For some reason ... things were not working and he was going to go back and have another try ... things had worked for a while but then they had failed and he had to put him back on.' [448]
Mr Dhasmana then left and they were taken to a parents' room.
388 Stephen Willis stated they were:
`... left in this room for a significant amount of time and during this period I made repeated attempts to contact Helen Stratton to find out what was going on. At no stage was I able to contact her as she was unavailable.' [449]
389 Having found Miss Stratton, Stephen Willis stated:
`She came back to the room with me and it was there that she said to us that we should not hold out much hope. That was ... a second and very depressing piece of information that she had given us and she then left.' [450]
390 Stephen Willis stated that there was no further communication until he was told that Daniel was dead:
`... we were visited by Mr Dhasmana and Helen Stratton at approximately 8.30 pm. 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 ... I felt sorry for him because of his distress ... at that particular moment we felt more for him than in reality the grief that we should be feeling.' [451]
391 After Mr Dhasmana had left, Stephen Willis stated that Miss Stratton persuaded them to go and see Daniel. He was also offered and accepted a lock of Daniel's hair and a print of his footprints. [452]
392 John McLorinan stated in his written evidence to the Inquiry:
`In the weeks following the operation ... Mr Wisheart was regularly monitoring the situation, and when we met with him, he was helpful and informative. He often seemed to be turning up at all times of the day or evening, whether it was to see our son or other patients of his ... We were kept well informed at every stage. Issues and procedures were explained to us well, and medical notes were readily made available to us, and we were made to feel comfortable and involved ...' [453]
393 Marie Edwards told the Inquiry that she welcomed the polaroid photograph of Jazmine that Helen Stratton gave her after Jazmine died. After seeing the photo, she said that she made up her mind that she needed to see Jazmine. Helen Stratton asked her if she wanted Jazmine in a shawl or a Moses basket: [454]
`They brought her in a shawl. We spent about an hour, an hour and a half with her and the last half an hour I had Helen Stratton coming in, asking that she thought it was enough time now and she would bring a nurse in to actually take Jazmine away from me, and I had actually said to her "I need more time" and she said "Okay, but I actually finished work at 7.00" and I said "Yes, but I really need some more time" and she said to me "I will ask the nurse to come in in 15 minutes, will that be enough?" and I said "I do not know, but I do not think so" and with that I said to Helen "Would it be possible to take Jazmine down to the Chapel of Rest?" "Well, she is not going there", she said. I said "Fine, can I take her to the morgue?" I needed to know where she was going to be laid to rest. She said, no, that was not possible. She said, "No-one is allowed to go down there." I said "Fine". The whole time Jazmine was in hospital I knew where she was, in the theatre, in an anaesthetic room, I knew where she was and the thought of leaving her and not knowing where she was really upset me. With that, my partner said, "It is hospital rules, just let it go." So I said, "Fair enough, I know that she will be on this side of the building." About 20 minutes later, that would have been about 7.20, she brought a nurse in - she said "I am going to go and get a nurse now" and I actually walked over to Helen Stratton ... I actually handed Jazmine over to Helen Stratton knowing that she had never held a dead body, a dead baby, but I felt compelled in doing that so she would never bully another parent into handing their child over when they are clearly not ready to let go ... [and I felt] frustrated that I had to give up this last moment with my daughter.' [455]
394 In response, Helen Stratton stated that she would not have put pressure on parents in the manner described by Marie Edwards. She stated that it was usual for parents to spend about 2 hours on the ward with their child's body (with no fixed time limit), after which she might start to discuss the need to remove the body to the mortuary. She further stated that she had no finishing time and she commonly worked late hours especially when a child died. Miss Stratton confirmed that it was against hospital policy for relatives to be taken down to the hospital mortuary. She also stated that it was incorrect to say she had never held the body of a dead baby. [456]
395 Samantha Harris recalled in her written evidence to the Inquiry the day when her daughter, Kimberley, died and how the she was told of this by one of the nursing staff. She stated that on returning to the hospital, a Ward Sister met her and she was then informed, by telephone, by one of the surgical team that they were having trouble in getting Kimberley off by-pass. Samantha Harris stated that the Sister said `things were not looking good.' [457]
396 Samantha Harris stated that subsequently the Sister came to see her again and they sat on the bench between the ward and the parents' accommodation:
`I remember that she put her arms around me, and told me that Kimberley was dead. I think that she was crying too ... A male member of the surgical team arrived to explain what had gone wrong. He said they could not get Kimberley off by-pass and that they were sorry. A short while after this, Mr Dhasmana came to see us. He was accompanied by some other men and was dressed normally, rather than in his theatre gown. They also said they were sorry and Mr Dhasmana stated that they had not been able to get her off by-pass and that they did not know why.' [458]
397 Samantha Harris stated that she met Mr Dhasmana later to discuss the post-mortem report:
`Mr Dhasmana agreed to write to my local hospital, requesting that I should undergo a scan during my next pregnancy, to identify any congenital heart condition. I felt reassured ...' [459]
398 Erica Pottage remembered how, during Thomas' operation, Helen Stratton had informed her twice that `they could not get Thomas off the by-pass machine although the operation was successful.' [460] She stated that she was told that this was not unusual.
399 Erica Pottage continued in her statement, explaining that:
`At about 6 pm Mr Dhasmana came to us to say Thomas had a massive heart attack and he had lost him. He seemed genuinely upset. My husband and I could not take it all in. We were asked if we wanted to see Thomas which at the time seemed horrifying. Helen Stratton said most parents in these circumstances want to go home straight away, so we packed up our belongings and my husband drove us back to Teignmouth ... Looking back, I felt the care we received as parents was appalling ... The nurses were very kind but they were only interested in my medical condition. I did not receive any counselling and had nobody to talk to about my worries and concerns.' [461]
400 In response, the UBHT stated that:
`One can understand that Mrs Pottage felt very alone ... although it is to be noted that she had been seen by Mrs Helen Vegoda ... at the BRHSC.' [462]
401 Susan Francombe's daughter, Rebecca, died shortly after her operation. Susan Francombe recalled that she did not see Rebecca when her condition deteriorated. She stated that `We were encouraged to go away, which is something that I have regretted ever since.' [463] She also said that she was told that although Rebecca's condition had deteriorated, the operation had gone well. [464]
402 Susan Francombe stated that she was `provided with no aftercare and support following the death of our child.' [465] She told the Inquiry that her GP came once, prescribed Valium and left. [466]
403 Susan Francombe stated that Mr Dhasmana wrote a personal letter expressing his sympathy, which was `consistent with his compassionate approach throughout the whole experience.' [467] Susan Francombe also wrote a letter [468] of gratitude to Mr Dhasmana.
404 Anne Waite, mother of Caroline, told the Inquiry of her experience when Caroline died:
`... We ... were staying behind at the hospital at the BRI in Carolina House. We were rung to say that Caroline's blood pressure had dropped dangerously low, there was not much time, could we get over there as quickly as possible. We rushed over there, we were put in a room with a fish tank ... I cannot remember who it was came to see us, I think it was a nurse came to see us. She said "She is in a bad way, we are doing internal cardiac massage, we do not know how long she has left", if she was going to stay alive. We were left again for a while and the next thing, we saw Mr Dhasmana. He came out, theatre cap on, gown on, covered in blood. "I am sorry", he said, "she is dead." He said "I tried everything, I did everything I could, we could not revive her." We then were taken to a room while she was being cleaned up because we wanted to see her. We had offered her organs to transplantation but due to the drugs she was taking they were unable to be transplanted, he told us. He also told us there would be a post-mortem by the Coroner's request. We also were in favour of that because we wanted to know why she died because we were not given any answers.
`... Once you are given a 5 per cent risk, you think it cannot happen. It is an eventual situation that probably does not happen anyway. You are in pretty high spirits, you are given a 95 per cent chance of everything going right and then suddenly you are one of that 5 per cent that go wrong. It has put me in a position where I cannot trust doctors any more, it has completely dashed my faith in doctors, I could not trust any of them with my other three children. If they had to go into hospital now I do not know what I would do.
`... We were taken to a room where we telephoned our parents back in Newport to say Caroline had died and could they come up as soon as possible for a visit because that is the last time they would probably see her. We were left about an hour and a half with constant pots of tea and pats on the back, sort of thing. We went to see Caroline after she had been cleaned up. She was still in a bad way, she was still attached to tubes, she still had a tap on her hip into the femoral artery - she had no catheter in. She had dried blood around her nose, quite a nasty state to look at. She was very blue and when I actually picked her up then she actually passed urine all over me which I found very distressing. You do not expect that to happen, you know, you expect the bodily fluids to be out of the body by that time. She had been dead for about 1 hour and a half, somewhere round then. But we were left with her ... on the ward with the curtains drawn around until we were ready for our parents to come over and see her and then we left.
`... I did ask could we come back up to Bristol and see her because obviously I did not want to say goodbye at that point, I wanted to see her later on in the day ... and maybe the next day. We were told not to go down to the morgue because it was a nasty place, very dark place, very creepy, "You do not want to go down there" ... "Remember her as she was and see her back in Newport when she comes back home."
`Unfortunately when she got back to Newport she was not in the same state. Obviously travelling makes a difference to a body and she was bruised, very bruised on the head. It did not feel like the same child as I left in that bed.
`... I held her until she actually developed rigor mortis, I could not let her go.
`The last memory we have of Caroline is in a coffin, a massive bruise on her forehead and a soft-feeling chest, which we could not understand, a crinkly sort of material underneath which felt to me like a dressing and padding.
`... She had quite a lot of her organs taken unknown to us.' [469]
405 Tony Collins described his experience after the operation on his son, Alan:
`Mr Wisheart came to see us after the operation and said that everything had gone well, but the next twenty four to forty eight hours would be critical. We felt confident from his manner that things would be alright ... Helen Vegoda was available at all critical time[s] during Alan's stay ... She was there when Alan came back from surgery. She was in and out to see us during Alan's stay.' [470]
406 Christine Ellis' son, Richard, was operated on successfully by Mr Dhasmana. She stated in her written evidence to the Inquiry that she was quite happy that she was informed by way of pictures what Richard would look like in the ICU and that this prepared her. She praised Mr Dhasmana, as he came to see them frequently after the operation and explained what to expect. She stated further that the nurses too were friendly and efficient. [471]
407 Malcolm Curnow described his and his wife's experience after surgery:
`My wife was shocked by the tubes coming out of her. I was ... worried ... by Verity's colour. She was not bright pink, as Mr Dhasmana had said that she would be. Rather, she was ashen grey ... In the recovery room, we saw Mr Dhasmana for the last time. When he came in, his head was bowed, and he did not look me in the eye. He said, "Sorry, when I opened her up, things weren't as I expected." He gave little explanation for the disparity between the prognosis and the result other than that he could not do the shunt he had intended, and that he had had to do something different. He said that he did not know whether this would work or not. I had the impression that Mr Dhasmana knew it was unlikely that Verity would survive. No cardiologist came to see us during the day.' [472]
408 After Verity's death, Malcolm Curnow stated:
`I went back to our room to find some clothes for Verity ... No-one said anything. The staff seemed upset, but took it as a matter of course. I still felt that the question of how such a simple operation could have gone so tragically wrong was unanswered ... Both my wife and I felt under pressure to leave the hospital. We were not given adequate time to mourn, or to be left alone. I felt as if we were on a conveyor belt. One of the nursing staff asked us to clear our room, as it was needed by another family ... we were taken to the Chapel of Rest to see Verity ... It was cold, dimly lit, and felt subterranean. I did not find it reassuring or welcoming. We were left alone with Verity for about ten minutes. We were then taken back to the hospital, where we were informed that the relevant documents would be forwarded to us in the post ... As we left, we were approached by the doctor who had tried to resuscitate her in ITU. He stated that one in a thousand children die of heart disease, and that it was just unfortunate that it was ours.' [473]
409 Malcolm Curnow told the Inquiry:
`I recall the presence of what I believe to be the cardiac liaison nurse, who made some very what I felt were inappropriate comments, such as, "I know how you feel." No-one can know how we felt at that time, unless they have lost a child of their own, and I am afraid I was probably very intolerant of that person, and I wanted her nowhere near me or my wife, so our contact was extremely brief ... From our point of view, the time between the moment your child dies and that you leave the hospital is probably the most critical of all. At that point, you are trying to come to terms with the loss of your child; you are confused, emotional and extremely stressed. But you can be extremely rational through it all as well. What you want is answers; answers to questions: Why did my child die? Why am I in this situation? Why me? If somebody could have spent just a little bit of time explaining or even just being available to sit with us and to answer any of the questions we had at that time, it would have been appreciated.' [474]
410 After Verity's death, Malcolm and Jane Curnow wrote to Mr Dhasmana. [475] Dr Jordan replied, in response to their letter to Mr Dhasmana, explaining why Verity died, giving follow-up advice and discussing fundraising for equipment for the Intensive Care Unit. [476]
411 Michelle Cummings stated that Helen Vegoda was available at all critical times throughout Charlotte's stay in the BRI and the BRHSC [477] and was very supportive. [478]
412 Michelle Cummings was present in the hospital when Charlotte died:
`I walked through the doors ... and another mother came through the door screaming at me, that something was wrong with Charlotte and I had to come quickly. We went back into where she was, and she was totally delirious and screaming, like I have never heard. She was screaming terribly, in pain, and all the emergency people were arriving and they were trying to stabilise her. This went on for some time, and I think it was about - this happened around half 1, and at one point I had her on my lap trying to give her oxygen, and she was fighting, her bodily functions went and they had to put her in a nappy. It was about 3 o'clock. I phoned Rob - we were told that he ought to come up - and at 4 o'clock they moved her to the intensive care upstairs. Dr Jordan and the other doctors, they fought so hard to save her. She had septicaemia throughout the body and her heart was failing. She just screamed and screamed and screamed, just awful screaming and pain. They could not sedate her because they were desperately trying to keep her going and her heart was getting slower and slower. Eventually, one of the doctors came out and said that she was, you know, going. She was going. We went in and I asked them to switch off, because basically, her heart was beating so slow, she was getting no oxygen to her brain and she had not done, I think it was for over half an hour, anyway. They said, "Will you sit with her for a while?", and "You think about what you want to do", and they lifted her off the bed and she was still all drips and everything, and they gave her to me. She died in my arms at a quarter to 6: that was it.' [479]
413 Michelle Cummings described her contact with staff after Charlotte's death:
`They were brilliant. I mean, Helen [Vegoda] came to visit us. She wrote letters on our behalf to the Council for us to move. After Charlotte died and we went to the hospital, she was always there to greet us. She helped us around and one of the doctors would always be there to greet us and support us if we went to the Chapel of Rest and that included Mr Dhasmana on one occasion, I have to say. We met him, he came to look for us, I think it was the day after Charlotte died, and he met us in the corridor. He was incredibly, extremely distressed that Charlotte had died. I remember him giving me a big hug and expressing his sorrow: an incredibly genuine man, and very sensitive to our loss.' [480]
414 Michelle Cummings stated that Mr Wisheart came to see them after Charlotte's death, as soon as he finished operating. She went on that she remembered `dressing Charlotte and with Dr Jordan cleaning her shoes.' [481]
415 Michelle Cummings stated that Dr Jordan explained the procedure for autopsy and indicated that she could come back when ready to discuss it. Michelle Cummings stated that she returned on three occasions to discuss the autopsy and that Dr Jordan explained how and why Charlotte had died. [482] She told the Inquiry that the meeting she had with Dr Jordan was quite a `sensitive meeting and very candid and very informative.' [483]
416 Timothy Davies' son, Richard, underwent a Switch operation performed by Mr Dhasmana in 1992 but died shortly afterwards. Timothy Davies described, in his written evidence to the Inquiry, his experience after the operation and after Richard's death:
`Mr Dhasmana ... invited us into his office. He sat behind his desk, removed his glasses and said something to the effect of "All weekend I have been thinking about sewing him up - what do you want me to do?" I said, "You're the surgeon!" That was all I can remember being said to us. At about 4 pm, Mr Dhasmana came into the waiting room and I am sure he had tears in his eyes. He bowed his head and said "I am very sorry, he is gone." I went berserk, running up and down the corridor, screaming my head off. Eventually, I calmed down ... The nurse came in and said that we could see Richard ... he was carried into us in a Moses basket. They had cleaned him up, but his arms were still bruised with all of the injections. The nurse stayed with us for about 10 minutes. She then said she had to take Richard. I said I did not want her to but, naturally, I had to let him go ... We were told that I had to ring the Coroner's office the next morning. I remember doing so from a phone box, and being very distressed. I am sure the Coroner's Officer ... stated that the cause of death recorded on Richard's death certificate was congenital heart disease. Just hearing it said to me caused me such distress that I broke down in the phone box. I knew this was the position, but that did not stop the impact of what was being said to me. I remember that I had to collect Richard's birth and death certificates at the same time.
`It was arranged for Julie and myself to meet Mr Dhasmana [five to six months after Richard's death]. Dr Joffe was also there. There were a lot of questions we wanted to ask; we wanted to know what had gone wrong. We were told that Richard had congenital heart disease, and that the death was probably due to an infection. That was it.' [484]
417 Maria Shortis recalled her conversation with Dr Joffe after Jacinta's death:
`Early the same morning [22 January 1987], I contacted Dr Joffe to tell him of Jacinta's death. His first words to me were, "She shouldn't have done. That surprises me. But, Mrs Shortis, you always thought she would die early." He did not offer me any condolences. His final comment left me feeling that I had wished my child's death upon her. As her carer, I felt responsible for her well-being, and Dr Joffe's words only made me feel more guilty...' [485]
`The GP and our Health Visitor were great. The GP had always wondered what the hospital was trying to do. Both agreed with me that she could not have gone on living for very long in the state she was in, and neither appeared to be particularly surprised. My GP organised some counselling for me whilst Jacinta was still living, and this continued for a short time following her death. I have no complaints regarding the Health Centre, the visiting GPs or the Health Visitor. Many of them came to Jacinta's funeral.' [486]
`I received no support from the hospital, or from any of the voluntary organisations associated with it. In 1987, Dr Joffe let me read the post-mortem report, but I do not feel that this constitutes adequate emotional support. In 1995, I had a meeting with Dr Joffe, during which we discussed Jacinta's care, and his prognosis. Dr Joffe maintained that she should not have died so soon, but did not appear to be able to give me any reasons as to why she should have lived.' [487]
420 On 28 January 1987 Mr Dhasmana wrote to Tim and Maria Shortis offering his `heartfelt condolences.' [488] On 17 February 1987, Tim and Maria Shortis wrote to Dr Joffe. Apart from requesting another appointment to see him, they wrote, `... thank you for explaining ... the results of Jacinta's post-mortem ... Thank you so much for the help and courage you gave us.' [489] Tim and Maria also replied to Mr Dhasmana expressing gratitude and support. [490]
421 Justine Eastwood recorded in her diary that:
`We knew that things weren't right when Mark [Mr Eastwood] saw Mr Dhasmana and Pat Weir [the anaesthetist] walking down the corridor with heads bowed. The family room where I was sitting was quickly cleared of other parents by one of the nurses and we had the news broken to us by Mr Dhasmana and Pat Weir who were both crying.' [491]
`We had the news of Oliver's death broken very gently and privately to us. Privacy, at times like these, was uppermost on the minds of the staff. We were given the option to clean Oliver up and prepare him after his surgery which I declined. We were then allowed as much time as we required just to be with him alone. I remember being spoken to about the necessity of a post-mortem and inquest because of the circumstances under which Oliver died. We did speak with the coroner at a later date about the findings of the inquest.' [492]
423 John Mallone described how `on the morning of Friday 11th January it was clear that Josie was going to die.' He stated that screens were put up to give them privacy and Josie was taken out of her incubator and placed on a pillow. [493]
424 John Mallone described his experience after Josie's death:
`Dr Martin came and certified her dead. He said that there had to be a post-mortem. We immediately replied that we did not want one. He said that it was a legal requirement to protect patients. We argued against it, saying that he knew exactly why she died. He made it clear that we did not have a choice, assuring us that Josie would not look any different, as the pathologist would cut into her from behind ...
`A young doctor called Caroline expressed her condolences and said that she felt that they "had learnt something, " hastily adding "I hope you don't think that it was some kind of experiment." Eventually, we took Josie down to the Chapel of Rest where we laid her in the little crib ... We didn't feel under any pressure to leave the hospital; we found the nursing staff exceptionally kind and sensitive after Josie's death ...
`We came to visit Josie in the Chapel of Rest each day. We had been warned that the post-mortem was to take place on Monday 14th January, so we braced ourselves as we went to see her that evening. To our relief, Dr Martin's promise that she would be "the same old Josie" held true. She did not look any different. We returned the following day, Tuesday 15. When we saw her, we were horrified. She was dressed in another baby's clothes, she had blood on her face and her expression had changed completely. We learned that they had postponed the post-mortem for one day without telling us, and that this was the result. We were very distressed and angry.
`A month or two after Josie's death, Ann and I arranged an appointment with Dr Martin, so that we could discuss what had happened. He went through the post-mortem report with us, and I remember being surprised that it did not mention the pulmonary artery banding. We wanted to know why Josie had been born with heart defects. He said that no one really knew. He tried to reassure us that it was unlikely to be the result of anything either of us had done, but that, having had one child with a heart defect, there was an increased risk of having another. I thought to myself "How can you increase 100%?"
`At the meeting with Dr Martin, I asked if I could look at Josie's medical records. He arranged for me to do so, and I spent three or four two-hour sessions reading through them and taking notes. I just wanted to understand what had happened to our daughter; I was not suspicious or looking for anything in particular, I just wanted to know more about Josie ... I found the experience quite helpful in my attempts to come to terms with losing her.
`After Josie's death, I went on many occasions to see Helen Vegoda, the BCH bereavement counsellor, the last occasion being in 1995. We also returned to the ITU at Christmas and on anniversaries of Josie's death for several years. We were always received warmly by the nursing staff.' [494]
425 John Mallone stated that he had no further contact with Mr Wisheart after Josie's death:
`Mr Wisheart didn't make any contact with us after Josie's death. There could be good reasons why he wasn't available at the precise moment she died, but even a brief letter would have been welcome. It would have meant a lot to think that he actually noticed.' [495]
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Footnotes
[431] WIT 0125 0006 Susan and Kenneth Darbyshire
[434] WIT 0016 0012 Jean Sullivan
[435] T52 p.160-1 Helen Rickard
[440] WIT 0001 0010 Linda Burton
[442] T5 p.49 Linda Burton; the letter is at MR 0267 0027
[443] MR 0267 0026; letter from Mr Wisheart
[445] WIT 0285 0010 Stephen Willis
[446] WIT 0285 0010 Stephen Willis
[447] WIT 0285 0010 Stephen Willis
[448] WIT 0285 0011 Stephen Willis
[449] WIT 0285 0011 Stephen Willis
[450] WIT 0285 0011 Stephen Willis
[451] WIT 0285 0011- 0012 Stephen Willis
[452] WIT 0285 0012 Stephen Willis
[453] WIT 0122 0011 - 0012 John McLorinan
[455] T95 p.190-2 Marie Edwards
[456] WIT 0414 0027 Miss Stratton
[457] WIT 0302 0012 Samantha Harris
[458] WIT 0302 0013 Samantha Harris
[459] WIT 0302 0016 Samantha Harris
[460] WIT 0260 0003 Erica Pottage
[461] WIT 0260 0003 - 0004 Erica Pottage
[462] WIT 0260 0006 UBHT
[463] T68 p.17 Susan Francombe
[464] WIT 0349 0003 Susan Francombe
[465] WIT 0349 0006 Susan Francombe
[466] T68 p.25 Susan Francombe
[467] WIT 0349 0006 Susan Francombe
[468] MR 2181 0012 - 0013 ; letter from Susan Francombe to Mr Dhasmana
[470] WIT 0021 0008 Tony Collins
[471] WIT 0023 0010 Christine Ellis
[472] WIT 0004 0006 - 0007 Malcolm Curnow
[473] WIT 0004 0008 - 0009 Malcolm Curnow
[474] T3 p.62-3 Malcolm Curnow
[475] MR 2374 0092; letter from Malcolm and Jane Curnow to Mr Dhasmana
[476] MR 2374 0084 - 0085 ; letter from Dr Jordan
[477] WIT 0123 0025 Michelle Cummings
[478] WIT 0123 0031 Michelle Cummings
[479] T3 p.166-7 Michelle Cummings
[480] T3 p.178 Michelle Cummings
[481] WIT 0123 0031 Michelle Cummings
[482] WIT 0123 0032 Michelle Cummings
[483] T3 p.170 Michelle Cummings
[484] WIT 0160 0013 - 0014 Timothy Davies
[485] WIT 0222 0020 Maria Shortis
[486] WIT 0222 0021 Maria Shortis
[487] WIT 0222 0022 Maria Shortis
[488] MR 2388 0067; letter from Mr Dhasmana
[489] MR 2388 0064; letter from Tim and Maria Shortis
[490] MR 2388 0066; letter to Mr Dhasmana
[491] WIT 0022 0135 Justine Eastwood
[492] WIT 0022 0015 - 0016 Justine Eastwood
[493] WIT 0155 0016 John Mallone
[494] WIT 0155 0017 - 0019 John Mallone
[495] WIT 0155 0060 John Mallone