Annex A > Chapter 27 - Concerns 1992 > Concerns > Concerns raised with the SRSAG
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Concerns raised with the SRSAG
57 The Working Party Report commissioned by the SRSAG had been completed and was delivered by Professor Hamilton, Chairman, Executive Committee of the Society of Cardiothoracic Surgeons and Chairman of the RSCE Working Party, to Sir Terence English with a covering letter dated 19 June 1992. [72]
`Following the first meeting of the present Working Party in February 1992, a questionnaire was sent out to the ten designated Centres and to Oxford and Leicester in addition. This requested returns for annual figures and mortality for the years 1998, 1989, 1990 and 1991, for all Neonates and Infants (under 1 year of age) who underwent open and closed heart surgery ...'. [73]
59 The data received as a result was summarised in Table 1 [74] appended to the Report. [75]
60 The Report addressed the question of the required number of designated centres for NICS. It recommended that:
`... 9 Centres now be recognised for Supra Regional designation and funding ... [they] are: Great Ormond Street, Birmingham, Liverpool, Leeds, Wessex, the Royal National and Brompton Hospital, Bristol, Newcastle and Leicester.' [76]
61 Sir Terence was asked for his reaction, initially, to the recommendation that Bristol continue to be designated. There followed this exchange:
`Q. What argument would you derive from the data and from what you have already told us as to your knowledge of Bristol, which would justify its continued designation as a centre for the neonates and infants?
`A. That it was functioning at a lowish level, certainly not the lowest; and that it was still regarded as being an important centre.
`Q. In terms of your own reasons for supporting it earlier: geography was not essential, and potential appears to be belied by the trend downwards?
`A. Potential still has not been realised, I agree.
`Q. Is it not the case that if you were to apply your own approach to it, you would have said, "Well, this trend really argues against there ever being a realisable potential here, now"?
`A. I certainly did not think that at the time that I received this report.
`Q. If you had the benefit of hindsight, do you think you might have taken that view?
`A. I think that I should have initially given a more critical analysis, or given more critical analysis to Table 1 of the Report, but I had asked a group of very responsible clinicians to look at this. They had accepted the terms of reference; they had collected a lot of data, come up with a report that I could understand their reasoning for wishing to continue to advise that the service be designated and how this could be achieved. And the recommendations to ask Guy's to either amalgamate with another London unit or fail to continue to get funding, and similarly, to ask Harefield to amalgamate with the Brompton or face withdrawal of funding, and to recognise that Leicester was doing good work, these all struck me as being perfectly reasonable at the time.' [77]
62 On 2 July 1992 Sir Terence (as President of the Royal College of Surgeons of England (RCSE)) wrote a letter to Dr Halliday, enclosing the Hamilton Working Party Report, the conclusions of which at this stage he supported. His letter concluded:
`The Working Party collected a lot of data on which to base their recommendations and should be congratulated on a report which has the full support of the Royal College of Surgeons'. [78]
63 Sir Terence also wrote to Professor Hamilton on 2 July 1992, thanking him for a `balanced and authoritative report' that had the full support of the RCSE. [79]
64 In a letter to the Inquiry received after the conclusion of oral evidence, Professor Hamilton stated that, although mortality was quoted in one of the tables `it is possible that insufficient attention was given to these figures by the working party'. [80]
65 On 3 July 1992 there appeared a further article in `Private Eye':
`Mrs Bottomley [81] claims that whistle-blowing "through the correct channels" will get results. Staff at the United Bristol Healthcare Trust (UBHT) have been whistling about the dismal mortality statistics in the paediatric cardiac surgery unit since 1988. ... And while UBHT's chief executive, John Roylance, the Royal College of Surgeons and Duncan Nichol, [82] the chief executive of the NHS Management Executive are all well aware of the problem, they seem more concerned with silencing the blowers.
`In America, the mortality rate for arterial switch, an operation to connect congenitally transposed arteries from the heart is now 0 percent. Nearer to home in Birmingham, it is 3 percent. In Bristol, despite the fact that the operation has been performed since 1988, it is 30 percent. Sadly, consultant cardiologists at the Bristol Children's Hospital continue to refer patients to their surgeons "to support the local unit". As a recently retired and very eminent cardiac surgeon in Southampton says: "Everyone knows about Bristol".' [83]
66 Dr Hammond was asked by Counsel to the Inquiry about this article in the following exchange:
`Q. ... the next one which deals with figures. It is the bottom left-hand column: "Mrs Bottomley claims that whistle-blowing through the `correct channels' ... will get results. Staff at the UBHT have been whistling about the dismal mortality statistics in the paediatric cardiac surgery unit since 1988."
`Just pausing there, in "Eye" 793 you had not said anything about staff having raised these concerns internally since 1988. ... What was the basis for saying that?
`A. I would presume 1988 is the year that Dr Bolsin arrived at the Bristol Royal Infirmary?
`A. So he told me that staff had been concerned. Whistle-blowing can be whistle-blowing among colleagues on a unit, it can be to the Chief Executive, it can be to the consultant. I do not mean whistle-blowing as in taking it outside the hospital. But if I mention 1988, I presume it is when Dr Bolsin arrived at the hospital and that was his view then.
`Q. So the source for it was probably what Dr Bolsin told you?
`Q. How many meetings did you actually have face-to-face with Dr Bolsin?
`A. I had one meeting face-to-face, and then I phoned him on perhaps four or five occasions over the course of 1992.
`A. No. I then, at the end of 1992, the beginning of 1993, moved to Birmingham to take up a lectureship and lost contact.
`Q. Which is why when you talk about what Dr Bolsin was doing in 1993 ...
`A. It was taken from stuff in the print media already.
`Q. "While UBHT's Chief Executive ... John Roylance, the Royal College of Surgeons, and Duncan Nichol, Chief Executive of the NHSME, are all well aware of the problem, they seem more concerned with silencing the blowers." "The problem" is what, dismal mortality statistics?
`A. Yes. I had one anonymous source who when things were written in "Private Eye" about cardiac surgery would photocopy the columns and add comments and then circulate them to me, rather like the Brompton whistle-blower. My experience of whistle-blowers, if people whistle-blow anonymously, they tend to use scattered targets, so they will go as in the [case of] Brompton to this Inquiry, to "Private Eye" and to the Down's Syndrome Association. [84]
`There was one person I did not have a clue what the identity was who was photocopying the "Private Eye" columns, sending one copy to me and sending counter copies to various institutions. The one I remember most was Duncan Nichol, because I thought what an odd choice of person to send the column to, but it was clear to me this person did not know who was accountable for the problem either, so he was sending articles. The tone was written in a similar style to the Brompton tone, which is why I acted so quickly when I got the Brompton letter, so it was not in harsh, aggressive doctor-speak.
`Q. I will come back and touch on the Brompton letter at a later stage, if I may, but here the source that was sending you photocopies of what was in "Private Eye" with comments appended and sending round a circulation list: do I take it that was not the same source as the source of the information, the other high level source to which you have already referred?
`A. No, it was giving information such as "parents on the unit are told they are in the best hands, or they are in the best unit, or whatever, and the results do not seem to bear this out", but they did not give me any specific figures.
`Q. So that is the anonymous contributor by post?
`A. Yes. It was completely anonymous, even to me.
`Q. This article goes on: "In America the mortality rate for arterial switch, an operation to connect congenitally transposed arteries from the heart, is now 0 percent. Nearer to home in Birmingham it is 3 percent. In Bristol, despite the fact the operation has been performed since 1988, it is 30 percent. Sadly, consultant cardiologists at the Bristol Children's Hospital continue to refer patients to their surgeons `to support the local unit'" and that is in quotes. Where did the figures come from?
`A. Again, it would either have been Dr Bolsin or A N Other. They were the only two sources I had of figures.
`Q. Let me just move off this screen for one moment. Remembering the date, it is 3rd July 1992, ... can we have UBHT 61/165 on the screen: "Hospital Medical Committee, Audit Committee, medical audit meeting report". I do not know if you picked this up from having looked at the transcript, but in case you have not, I will take you through it. At this stage we have been told - there are records to demonstrate it - monthly audit meetings in respect of paediatric cardiac surgery or what is called "paediatric cardiology" here. Meetings, one of them chaired by Mr Dhasmana, and we can see those who were in attendance. Dr Bolsin is not one of them. The audit topic and criteria reviewed: "Results of arterial switch" done by Mr Dhasmana, that is what "by JPD" means, I think. "Findings and observations": mortality similar to reported results, particularly if ... "consider earlier experience, higher mortality from VSDs and when in hospital for long time prior to switch. Action taken: persevere ...".
`That audit meeting appears to have looked at mortality for transposition of the great arteries with a ventricular septal defect, and concluded that the findings are similar to reported results, but presumably had figures in front of it, or may well have had figures in front of it. Did anyone talk to you about that meeting?
`A. Not the meeting, no. I presume what you are going to go on to say is that the results that were published in "Private Eye" were similar to the results in that meeting, but I was not told specifically about the meeting, no.
`Q. Were you told where the figures came from?
`Q. Do you know whether it was Dr Bolsin or your other source who gave you those figures?
`A. No, I do not. I cannot say. Whatever the case, there must have been somebody ... if it was Dr Bolsin, there must have been somebody who had told Dr Bolsin because he was not at the meeting, but I cannot be sure which of my sources gave me that information.' [85]
67 Sir Terence English was asked during his evidence about the identity of the `eminent cardiac surgeon' referred to in the 3 July article:
`Q. Just pausing there, you knew the identity, did you not, of the eminent consultant surgeon who had just retired from Southampton?
`A. I presume it was Sir Keith Ross.
`Q. It could not be anyone else, could it?
`A. No.' [86]
68 In 1986 Sir Keith Ross was elected to the Council of the RCSE and served for two years as the College's representative on the Council of the Royal College of Obstetricians and Gynaecologists. Earlier in the 1980s, he was one of the small group of surgeons who founded the Specialist Fellowship in Cardiothoracic Surgery in the Royal College of Surgeons of Edinburgh, which subsequently became the Intercollegiate Fellowship. In 1989 he was made a Fellow of the Royal College of Surgeons of Edinburgh and awarded the Bruce Medal. He retired in 1990. [87]
69 Sir Keith, in his written evidence to the Inquiry, stated that a meeting:
`... of the Working Party [of the RCSE], which was held on Friday 8th May 1992 at the Royal College of Surgeons, was dominated by the perceived need to maintain the number of supra-regionally funded units at nine. Therefore, a great deal of time was taken up considering applications from Leicester and Oxford and also trying to find a solution to the Brompton/Harefield problem, which had resulted in the number of centres rising to ten. The problem presented at Guy's Hospital also received a great deal of attention. This did not prevent close scrutiny of the crude mortality figures in Table 1, which indeed showed that in 1989 and 1991 the Bristol figures were the highest recorded. However, in 1990 the Bristol mortality was only 13% for neonates and infants. Unfortunately, there is no comment on these facts in the Report itself, and at this stage it is hopeless for me to try and remember what discussion actually took place. It cannot be emphasised enough that the Working Party on 8th May 1992 was completely unaware of the situation evidently developing in Bristol, which, so far as the Royal College of Surgeons was concerned, came to a head with the arrival of Dr Zorab's letter dated 15th July 1992. On a purely personal note, I would add that this comment also applies to myself, whatever the implication of the hearsay evidence in "Private Eye".' [88]
`I did not write to "Private Eye" and can see no reason why I should have done so. Nor have I had any direct contact with Dr Phil Hammond. I suggest that the real significance of the remark, ascribed to me by innuendo, has to be the implication that what is now perceived to have been a very serious situation in Bristol was so widely known that it would have included the members of our working party. Carried to its logical conclusion, the inference is that we chose to do nothing about it. This is manifestly absurd, because if the members of the working party had indeed had such information available to them, little else would have been discussed [at a meeting of the working party] on 8th May 1992. That this did not happen confirms the lack of available evidence beyond the crude mortality figures show in Table 1 of the report, [89] and perhaps helps to put the journalism into perspective.' [90]
71 On 2 July 1992 Sir Keith wrote to Mr Wisheart saying:
`I am writing to you in some distress because I have just been told of a comment about Bristol paediatric cardiac surgery, supposedly made by someone that could only have been me by inference, in "Private Eye". Please accept my complete and unqualified denial of any such comment - not only have I not discussed your unit with anyone outside the Working Party on Supra regional recognition of paediatric cardiac units, I can honestly say I have no knowledge of your results. I can only assume that some malicious person who knows I sit on the Working Party has, for some reason best known to themselves, seen fit to ascribe this comment to me. As always in this sort of situation, there is nothing I can do except acquire an even deeper hatred of the behaviour of the press.' [91]
72 In his written statement to the Inquiry, Sir Keith stated:
`Finally, I stand absolutely by my comment made in a personal letter to James Wisheart dated 2nd July 1992. Of course, as a member of the working party I was aware of Bristol figures up until 1991, but when I wrote the letter to Mr Wisheart it was half way through 1992 and I had no idea whether the trend in his results was improving or deteriorating or staying about the same.' [92]
73 Dr Hammond stated in his written evidence to the Inquiry, in relation to the 3 July article and the quote `attributable to' Sir Keith:
`... I am unable to give full details as I have not yet been able to contact the source. However, I know from another source in Southampton that in 1992 and before, there were concerns about the poor results for complex paediatric heart surgery in Bristol. This was also the view that I received from sources in other centres at the time.
`I did not name Sir Keith Ross in the column because my source did not wish to name him. The aim was to bring the matter to the attention of a senior member of the specialty who could use his influential position as part of the 1992 Royal College of Surgeons Working Party to investigate the matter. As he was already retired, I felt there would be no threat to his career in raising concerns about Bristol ... I was confident that the column would be brought to his attention, that he in turn would bring the matter to the attention of the Working Party and that appropriate action to protect patients would take place.' [93]
74 Dr Hammond's views as expressed in the 3 July article were explored further in the following exchange:
`Q. Again, just focusing on what is said in the bottom of the left-hand column, "nearer to home in Birmingham, 3%". The source appears to be an individual with access to comparable or comparative information from different centres?
`A. Yes. Or it may be that I was given the information and I went to another source and said "Can you compare it to other centres for me", so it does not necessarily mean that the same source gave me the two bits of information.
`Q. "Sadly consultant cardiologists ... continue to refer patients to their surgeons `to support the local unit'." That is in quotes. Is it in fact a quote?
`A. I do not know. I presume it was told to me as a quote, otherwise I would not have written it as a quote.
`Q. "As a recently retired and very eminent cardiac surgeon in Southampton says, `Everyone knows about Bristol'." The "recently retired and very eminent surgeon in Southampton" is Sir Keith Ross, is it?
`A. I found out subsequently, yes.
`Q. Because you found out subsequently, that suggests he did not say this to you?
`A. No. But neither did he write to "Private Eye", and say "I did not say that".
`Q. And given your own recent experience in relation to the "Telegraph", you would not blame him for that, I take it?
`A. I would not. Having seen his letter to James Wisheart he was absolutely outraged by this, whereas I was not outraged by being misquoted by that journalist. If you were outraged by something, you would take action to set the record straight. I find it extraordinary that he did not.
`Q. He never spoke to you, never met you; is that right?
`Q. The quote which is attributed to him - how far does it take us? It talks about "everyone knows about Bristol". Knows what?
`A. My feeling was that he would not specifically have access to individual operation information; it was a general feeling that the journalistic tactic here was to find somebody in a very senior position who sat on either one or both working parties, who is in a position to act. This particular surgeon was chosen partly because he was retired and it was thought that there would be no threat to his career by raising concerns. And that I had a source in Southampton who said this was the general view at the time, that Bristol was known to have low numbers, no specialist heart surgeon, not the place you would want your own children to go.
`Q. The process points you have been talking about ...
`A. My recollection of this particular statement is that I would have - written like that, it would probably mean this comment was made privately and was not meant for public consumption, but the reason I used it was to alert this particular person that there was a very severe problem here, knowing he was on the Working Party, knowing he would have to sign up to the recommendations of the Working Party having read this.
`Q. Forgive me for a moment so I understand this. If the surgeon says "everyone knows about Bristol", it follows whatever there is to be known, he knows?
`A. Not necessarily, no. I would dispute that. I would think in general terms it was known within the paediatric cardiac surgery community in 1992 that Bristol had major problems.
`Q. You may not be following the question. What I would like you to focus on is the words attributed to Sir Keith Ross, the words which are attributed to him in quotes, and you have told us that that must have been given to you as a quote because that is what you do, "everyone knows about Bristol".
`If the quote means that everyone knows that Bristol has particular problems, then he, the speaker, uttering those words, is recognising those problems by uttering those very words, is he not?
`Q. So this would be someone who knows, upon whom you are relying as a source of knowledge in your article?
`A. I am not saying specifically that he knew the specifics of individual operations. I was told that he was - I believe he was on the original Working Party and so would have known that Bristol was a significant outlier then, and I believe he was on the current Working Party. That was the context in which I used the quote. I would also say that when I talked to people in other units, it was quite common for anaesthetists to be operating with a surgeon and to say, "Why has this baby bypassed Bristol?" Over the years I have had this general comment from the Hammersmith, Brompton, Guys, Southampton, Oxford and Cardiff as a sender, where anaesthetists have queried why babies are not going to Bristol. There have been some quite harsh comments which I could not possibly repeat because I think they would be libellous, and there were some general comments that for this sort of operation, you do not go to Bristol, as in "everyone knows about Bristol". I do not think that people would necessarily know specific results for specific operations, but my general feeling at that time is that it was known within the community that it was not the place, for example, to send your own children.
`Q. The point of the last few questions I have been asking you about the surgeon who was sending knowledge on which you rely in your article, is to ask what was the particular point in drawing the surgeon's own knowledge to his attention so he can do something, when the assumption is that he knows it already?
`A. From what I have just said, I do not think he knew the true nature of all the problems, but he should have known having been on two working parties that there was a problem with Bristol. This was a journalistic tactic to ensure that he took action.
`Q. So by "everyone knows", what is Delphic about it is the word which might come after "knows", as to "knows what about Bristol"?
`A. Yes. As I say, I am not a surgeon, but my few insights into this particular community is that they are quite close-knit and people speak and trainees speak at meetings and that was the general concession, that "everybody knows that Bristol has problems".
`Q. Do you accept what Sir Keith Ross has said to us, to the effect that he, for his part, did not have any knowledge that Bristol was under-performing?
`A. As I have said in my statement, I have not been able to identify the precise source of that particular piece of information, so I cannot confirm or refute; all I can say is that Sir Keith Ross never challenged that piece of information.' [94]
75 On 3 June 1992 the Bristol paediatric cardiac clinicians had held a meeting to review the results of the Arterial Switch operation. [95] Towards the end of that meeting Mr Dhasmana mentioned figures similar but not identical to those that subsequently emerged in the 3 July `Private Eye' article.
76 In July 1992 Mr Dhasmana's secretary gave him a copy of the `Private Eye' article that someone (not identified in evidence) had passed to her. [96] When he read it he discovered that the figures quoted were the reverse of those discussed in the June meeting. He said:
`... what it quoted was, what surprised me, what I mentioned at the end of the meeting was quoted here the wrong way round ... I had mentioned that at the end of the meeting, when we finished, somebody made a type of remark, "Okay, Janardan, what is the result nowadays in Birmingham?" because I did not really know, and the last results I had known was 5 percent, but I mentioned - "I am sure Birmingham would now be doing 0 percent" - it was a little light-hearted remark. Then it got a bit more serious. "And America?" - I said "I do know Castaneda, they got 3-5 percent". So in a way, when I saw this thing, I said "It is my words being quoted here, but it is the other way around" because I mentioned America 3 percent and Birmingham 0 percent. Here it says Birmingham 3 percent and America 0 percent. So it was my quotation which has been mentioned here, but of course it is the wrong way around.' [97]
77 Mr Dhasmana subsequently questioned all those present at the meeting of 3 June 1992 [98] to seek to find out who was responsible for passing information from the meeting to `Private Eye'. No-one admitted responsibility. [99]
78 Mr Wisheart (who said he had a general perception at the time that adverse comments were being made about the performance of paediatric cardiac surgery), said he made: `no effort whatsoever' [100] to discover who made the comments to `Private Eye' because:
`... as Dr Roylance pointed out to me, but I think to a much wider circle also, that it was really an irrelevance who was the source of the information because we would not do anything about it anyway because if that was within their rights to do and so forth and we would not be taking any action as a consequence of that. So there was therefore no further reason to think about that and I think I had put it, if not out of my mind, at least to the back of my mind.' [101]
79 The July article had further consequences. On 15 July 1992 Dr John Zorab (Medical Director of Frenchay Hospital and a consultant anaesthetist) wrote to Sir Terence English at the RCSE. He enclosed a copy of the article from `Private Eye'. [102] His letter stated:
`Some time last autumn, I made one or two efforts to get to see you in order to discuss the delicate and serious problem of mortality and morbidity following paediatric cardiac surgery in Bristol. I have no vested interest in this and the problem is outside my immediate sphere of influence but great anxieties were being expressed by some of my colleagues at the Royal Infirmary. In the event, I never made contact with you and the matter passed from the forefront of my mind.
`Matters have come to a head once again and the enclosed piece from "Private Eye", whilst possibly having some inaccuracies, quotes some statistics which have been confirmed elsewhere. One of the newer consultant cardiac anaesthetists feels that the mortality rate is too distressing to be tolerated and is job-hunting elsewhere.' [103]
80 On 21 July Dr Zorab's letter was forwarded to Sir Terence by Sir Norman Browse, (who had taken over from Sir Terence as President of the RCSE, Sir Terence having left office on 8 July). [104]
81 Sir Terence explained in the following exchange that the letter from Dr Zorab had acted as a `stimulus' to him to go back to look at the data in the Working Party Report more carefully: [105]
`Q. When you were prompted by Dr Zorab's letter you then went back to Table 1 and looked at it more carefully?
`Q. What you looked at was, to you, disturbing?
`A. Now taken in conjunction with Dr Zorab's letter, yes.
`Q. Taken in conjunction with the letter, not just the figures on their own?
`A. No, because the figures ... all they can do is to suggest that there could be a problem there, they are very crude. They are dealing with very small numbers. They fluctuate. It is of concern; it needs further investigation ...
`Q. And it was the combination of the figures on their own which required further investigation and the concerns relayed to you by Dr Zorab, that led you to suggest that these concerns were so great that Bristol should be de-designated as a centre?
`A. Yes.' [106]
`Q. What it suggests is that unless someone had been prepared to complain, there would be no closer look?
`A. Well partly, but also what it suggests was the great difficulty of making anything out of the mortality statistics that were provided as they were. They were very inadequate, incomplete, as I say, un-risk stratified, disaggregated, not coming from individual surgeons.' [107]
83 Sir Terence dictated a reply to Sir Norman on 25 July 1992, prior to his (Sir Terence's) departure that day for Pakistan. [108] He also dictated a letter to Dr Zorab on the same day. [109]
84 The 1992 `Working Party Report' was due for consideration by the SRSAG at its meeting on 28 July 1992. Sir Terence's letter to Sir Norman stated:
`Although I was aware that Bristol was not one of the best paediatric cardiac surgical centres, I had not appreciated that the situation was as serious as described by John Zorab. Bristol was included as one of the centres for designation. However, it is clear from a review of Table 1 in the Report [110] that their mortality statistics both for the infant age group and the older age group is worse than [those of] any other centre. David Hamilton agrees that sufficient attention was not paid to this by his Working Party.' [111]
85 Sir Michael Carlisle, then Chairman of the SRSAG, told the Inquiry that he did not see the letter from Dr Zorab until the Inquiry provided it to him in 1999, prior to his giving oral evidence. [112] Sir Michael thought that the letter ought to have been drawn to the SRSAG's attention. He said:
`A. I am appalled, if that sort of correspondence was around on 15th July? I cannot remember the date of that Advisory Group meeting. [113]
`The other point I have to say is that if this sort of information had been around, even on a person-to-person basis, without any member of the Advisory Group, whether he is the President of the Royal College of Surgeons or not, and it was not reflected to the Group, I would take a very strong view about that indeed.
`I regard it, I have to say, I am sorry, I am trying to retain control of myself ...
`A. I would regard it almost as, forgive the business allusion again, as making investments when your company is insolvent. I think it is appalling. If that was the case.' [114]
86 Sir Terence told the Inquiry that he spoke to Professor Hamilton twice by telephone, probably on 23 and 24 July 1992. [115] Sir Terence's contemporaneous handwritten notes of the conversations, produced for the Inquiry, indicate that he and Professor Hamilton discussed mortality rates for various procedures at Bristol. [116] The data discussed was not simply that in the Working Party Report but included other data of which Sir Terence was previously unaware. [117]
87 Professor Hamilton, in his letter to the Inquiry referred to above, [118] confirmed that he had two telephone conversations with Sir Terence, one on 23 and one on 24 July 1992. Professor Hamilton wrote:
`Sir Terence suggested to me that he wished to alter the recommendations of the working party with respect to Bristol only, in the light of information he had received recently regarding the high mortality rate that was occurring in Bristol at the time. ... I am sure that we discussed mortality ... .'
88 Sir Terence and Professor Hamilton agreed that it should be recommended to the SRSAG that Bristol be de-designated. Sir Terence was asked:
`Q. So I understand the basis upon which you were suggesting de-designation: was that because, as you emphasised throughout your evidence to us, that one would want to consider outcomes and mortality data and so on to see whether small numbers meant that a unit was not really viable, or was it because to allow Bristol to go forward might prejudice the chances of the others?
`A. It was both, I think.' [119]
89 Professor Hamilton and Sir Terence agreed that the latter should speak to Dr Halliday. Sir Terence telephoned Dr Halliday:
`Q. Did you tell Dr Halliday that Bristol's mortality record appeared so bad that it required investigation?
`A. I believe I told him the content of my discussions with Professor Hamilton.
`Q. Did you tell him about the Zorab letter?
`Q. Did you tell him about the "Private Eye" article?
`A. I do not know whether I did or not.' [120]
90 Subsequently, in written evidence to the Inquiry dated 2 December 1999, Sir Terence indicated that he did not, in fact, mention Dr Zorab's letter to Dr Halliday. [121]
91 Sir Terence was told by Counsel to the Inquiry that Dr Halliday maintained that Sir Terence never said anything to him about mortality statistics. Sir Terence replied:
`It was the only reason why I would have ever got into this. The report had gone on, gone through. The activity figures were all there. We were not questioning those. The whole issue of having to do something at such short notice arose through Dr Zorab's letter and a review of mortality statistics and that was made absolutely clear to [Professor Hamilton and Dr Halliday] - and that was - I mean, again, the reason for Professor Hamilton reconsidering his position ...' [122]
92 Later in his evidence, Sir Terence reiterated that he had spoken to Dr Halliday:
`Q. I press you again on this. In the light of your obvious uncertainties as to what happened until you saw the documents, are you still sure that you said to Dr Halliday something about mortality statistics at Bristol and how disturbing they were?
`A. Absolutely. There could be no other explanation of the correspondence and what I had said there.' [123]
93 Dr Halliday's evidence to the Inquiry on 29 April 1999 concerning the conversation with Sir Terence was:
`... he rang me either the night before the meeting or on the morning of the meeting, [124] and I am confident of that because we left the briefing of the Chairman to the very last minute, so that anything that arose that was relevant to the Group's discussion would be in his briefing. So that was normally completed about 24 hours before the meeting.
`Sir Terence said he could not be at the meeting, and I put it to him that he would not be particularly happy with the outcome, because it was my expectation that the Advisory Group would not accept the recommendations of the College, and that really we had very little alternative but to de-designate the service. Sir Terence asked me to make it known to the Advisory Group that since the Report had gone in, he now had reservations about Bristol. He was not specific, and I assumed he was referring to the ongoing problem that we have discussed so much and that was all.
`So at the Advisory Group I did report that Sir Terence had spoken to me; that I had told him what was likely to happen ... and he had said he wanted his reservations about Bristol to be noted.' [125]
94 When he gave oral evidence for a second time to the Inquiry, Dr Halliday maintained that Sir Terence had not mentioned concerns about rates of mortality at Bristol:
`He never mentioned mortality at any time.
`For Terence English to have raised mortality in cardiac surgery to me would have really rung bells because, as you are probably aware, Sir Terence was the lead behind setting up the Society's Registry. He believed that the Registry was the only way in which you could carry out audit in cardiac surgery and in fact point blank refused to provide evidence to the Department other than in an anonymised form on cardiac surgery and for him to raise mortality with me would have really rung bells, but he never did so and he does not say now in this letter [126] that he did.' [127]
95 Sir Terence accepted that, save for his letter to Sir Norman Browse and a short reply to Dr Zorab, he did not put his concerns about mortality at Bristol in writing to the SRSAG, the Department of Health, the UBHT, the SWRHA or elsewhere. Sir Terence explained that the reason he did not do so was:
`I felt that the Medical Secretary of the Supra Regional Services Advisory Group understood our concerns, and that it was up to him to take it up with the Trust and if the Trust then wanted to look at matters further, they could ask us either directly or through the Supra Regional Services Advisory Group.' [128]
96 Sir Michael's recollection was that Dr Halliday had reported to the meeting of 28 July 1992 along the lines recorded in the minutes: [129]
`... I think it was a telephone conversation - I cannot be absolutely sure - but he did report in those terms to the Advisory Group, the words, as far as I can recall, that were said there [i.e. in the minutes of the meeting].
`I have to say, my interpretation, to the best of my knowledge, was that the reasoning behind that was the difficulty in increasing volumes. ...
`There was certainly nothing said about the quality of the service.' [130]
`Q. ... did you ask him what the concerns were?
`A. He did not offer an explanation of his concerns and I assumed his concerns were the usual ones, that is that the referral rate and the throughput was low.' [131]
98 But, as Dr Halliday acknowledged: `Everyone knew and had known for years about the referral rate and the throughput being low'. There was `nothing new' in that point. [132]
`That would be, would it not, a very surprising reason for him [Sir Terence] at the eleventh hour as it were to telephone you and say "I have reservations about Bristol on those grounds"?' [133]
100 Dr Halliday replied in the following exchange:
`A. It was a very unusual telephone call. I mean I have received a Report written by the leading experts in Europe on a subject, blessed by the President as being an authoritative report and, as he said in his letter, all the data that was available had been considered. He said that at the last paragraph of his Report, words to that effect. Then to ring me up and say "I want to withdraw the Report", it was an astonishing telephone call.
`Q. So you asked him why he changed his mind, presumably?
`A. No, no, it is not for me to question the President of the Royal College of Surgeons why he wants to withdraw a Report by his experts; that is a matter for him and the College. My concern was that we had the report of the College by the leading experts. It does not matter whether an individual is the President of the College or the Secretary of the College or any other office, it is only one opinion as opposed to all the experts involved in formulating that original Report. His view was only one view, but he could have taken Presidential action and withdrawn the Report. He could have insisted that that Report was withdrawn and I would have withdrawn it.' [134]
101 Dr Halliday, in evidence to the Inquiry, said that he told Sir Terence during their telephone conversation that it was not possible to withdraw the Report. Dr Halliday said that Sir Terence then responded:
` "If it cannot be withdrawn, I have major reservations [135] about Bristol and I want these reservations to be communicated to the Advisory Group" and I said, "Yes, I will do that".' [136]
102 Sir Terence insisted in his written comment on Dr Halliday's [supplementary written] evidence to the Inquiry that there was no question of his asking for the Working Party Report to be `withdrawn'. He stated that what he wanted was that Bristol be removed from the units recommended for designation, because of the concerns he now had about its mortality data. [137]
103 In his oral evidence to the Inquiry on 7 December 1999, Dr Halliday maintained `that Sir Terence was proposing to take unilateral action and withdraw the Colleges' Report'. [138]
104 Later in his evidence there was the following exchange:
`Q. `So it was not withdrawal of the Report, it was amending the Report really rather than withdrawal?
`A. Yes, but what was to be achieved? Since 1987 the profession had been on warning that they were not meeting the Supra-regional Service criteria and we would have to de-designate. The profession argued they would be able to rationalise the service. So we gave them the benefit of the doubt and we asked them to do reports. They did reports and they did reports and each time they failed to bring about the rationalisation we had hoped for. We had reached the stage where the Advisory Group had decided there was no way back, this was the crunch time.
`The fact that he was going to take back his Report and amend it really had no great significance for the outcome of the Advisory Group meeting because all the criteria that had to be met were not being met.' [139]
`... Sir Terence as a member of the Advisory Group and an individual intimately involved in this speciality was well aware the Advisory Group had given the cardiac surgeons as much leeway as they possibly could to bring their house in order so that it could continue to be designated. Sir Terence knew that the crunch time was 1992 and to suggest that he wanted his Report back again to amend and then resubmit, there was not time to do that.' [140]
`... I am not sure why we are sweating over Bristol. It did not matter at all to the outcome of the decision of the Advisory Group whether the College had recommended de-designation of Bristol or designation of Bristol because the problem we had was that there were already 13 units in England, there was one about to start in Wales and there were two in Scotland carrying out this work; the criteria of the Supra-regional Advisory Group [were] therefore not being met.
`Whether Bristol was a factor in this discussion or not was really quite irrelevant. Taking Bristol out, we still had 12 units in England, which was too many for a designated Supra Regional Service. You have to take in mind that this was a funding arrangement and only a funding arrangement.' [141]
107 Dr Halliday was asked whether Sir Terence was expressing the view that Bristol should be de-designated. Dr Halliday replied:
`Yes, obviously - when I say "obviously" no, I do not know. He was saying "I have reservations about Bristol" but he did not clarify that and he could have done. If I had been in his shoes having just received a letter from Zorab warning him that things were not well in Bristol, I think I would have offered an explanation to myself rather than me having to extract it from him.' [142]
108 Sir Terence, during an interview for the television programme `Dispatches', broadcast on 27 March 1996, said that when, in 1992, he reviewed the results of paediatric cardiac surgery at Bristol, he found its mortality levels to be `disturbingly high'. [143] He also told `Dispatches' that when he advised the Department of Health that Bristol should be de-designated, he was effectively advising that the SRS for NICS should cease in Bristol.
109 At its meeting on 28 July 1992, at which Sir Terence was not present, the SRSAG:
`... noted the Royal College of Surgeons Working Group report which recommended that the service should continue to be designated and the number of designated units should be reduced from the current 10 to 9.' [144]
110 The minutes of the 28 July meeting continued:
`Dr Halliday reported that since receiving the Royal College of Surgeons report, he had been approached by Sir Terence English, who indicated that since submitting the report he now had reservations about the continued designation of the Bristol unit.
`The Advisory Group discussed the issue at length but concluded that it was unrealistic to expect to restrict the delivery of the service to those units for which the Royal College of Surgeons report recommended continued designation.' [145]
111 Sir Terence told the Inquiry that the fact that his concerns were expressed in this way was a cause of concern to him. Dr Halliday pointed out that the minutes of the meeting of 28 July 1992 do not seem to have been the subject of any amendment at the next meeting, in September 1992, which Sir Terence did attend. [146]
112 The SRSAG decided to de-designate the whole NICS stating that this was `... a fairer decision in terms of medical and surgical rights of patients than to restrict designation to a few surgical units.' [147]
113 There was the following exchange with Sir Michael Carlisle about the words in the minutes:
`Q. One of the difficulties that we have in making sense of what is said there is that the thesis, up until now, and the advice, has been that it is in a patient's best interests that there should be a designated service. It is contrary to a patient's interests that there should be proliferation of services, and it would be desirable to use whatever efforts one could, within obviously the limits of time, to restrict proliferation of services?
`Q. One appreciates that there may have to be a bowing to the inevitable, but is there any particular reason that you can help us, why is it described as a "fairer decision in terms of the medical and surgical rights of patients" than the continuation of a system with sufficiently few designated units to achieve the objects of the system?
`A. I have a little difficulty with that, in retrospect, I have to confess. I think it goes back to the proximity of service, the geographical element. I am sorry, I cannot help you more than that. I find it a slightly ambiguous paragraph myself, in retrospect.' [148]
114 Sir Terence said that he was unable to understand the logic of the reference to `... fairer decision in terms of medical and surgical rights'. [149]
115 Mr Steven Owen, the Administrative Secretary of the SRSAG from January 1992 to February 1996, was also asked about these words:
`I find it difficult to answer that question after this period of time, frankly, but I think it is simply a recognition that the nature of the service had changed, proliferation was widespread, and it was simply accepting reality. I think the de-designation decision itself was an acceptance of reality.' [150]
116 Sir Michael was asked what the SRSAG might have done had the Working Party recommended a greater reduction in the number of centres being funded by the SRSAG for NICS:
`Q. Suppose that Professor Sir Terence English's Working Party had come up with the suggestion that there are six names, six centres, which the Royal College recommended for continuing designation. Do you think that probably the Advisory Group would have said, "Okay, we will retain designation for those six"?
`A. I think it is highly likely.
`Q. So it follows, does it, that the real problem or the real cause of de-designation of the service was not the fact that it was a mature service and was not the input from Guy's, it was simply a function of numbers?
`A. It was proliferation.' [151]
117 In his supplementary statement to the Inquiry Dr Halliday stated that:
`My assessment of the likely outcome of the Supra Regional Services Advisory Group meeting [on 28 July 1992] was that the NICS service would be de-designated. The [SRSAG] had no alternative. In such circumstances Sir Terence's reservations were not important. Of course I had no way of knowing how serious these reservations were.' [152]
`Had the NICS service continued to be designated but Bristol was to have been de-designated then Sir Terence's reservations would have been extremely important and the [SRSAG] would have wished to know in detail what these reservations were. I would therefore have been pressing Sir Terence for details. In the context of the [SRSAG] meeting however the details of Sir Terence's reservations were irrelevant.'
119 Dr Halliday told the Inquiry that July 1992 was when the SRSAG's involvement with NICS ended:
`A. No, it was de-designated in 1992. It was funded for two years after that, but that was not a matter for the Advisory Group.
`Q. It remained, did it not, the responsibility of the Advisory Group?
`A. No, it did not, no.' [153]
120 Professor Hamilton wrote to Sir Terence English on 3 August 1992. In addition to the two telephone conversations he had with Sir Terence in July 1992, prior to the SRSAG meeting, Professor Hamilton had also spoken to Sir Keith Ross (a fellow member of the Working Party) on the morning of Monday 27 July 1992. Professor Hamilton said in his letter to Sir Terence English:
`I hope that you had a highly successful trip to and safe journey back from Pakistan, and are refreshed after a demanding but successful term as President.
`Following our telephone conversations of Thursday evening, July 23rd and Friday afternoon 24th, I was not entirely happy about our agreement to take Presidential and Chairman's action over the Working Party's report. On reflection, I realised a possible specific source of "breach of confidentiality" which could arise, and a further feeling that the de-designation of one of the Units would probably "leak out" in the course of time. Also, the members of the Working Party were unanimous in their findings and gave considerable thought to their recommendations. Like you, I was unable to contact Keith Ross but did so early on Monday morning, [July] 27th, after he had returned home from holiday. He was equally concerned that we had changed the Report and suggested, on reflection, that we should both speak with Norman Halliday to reverse the decision and the instructions that you had given him. The report is an advisory document to be considered along with other letters and "reports" - both in ... and heresay [sic] evidence no doubt, and as such, the Working Party could be requested by the Advisory Committee on Supra Regional Funding to reconsider the mortality figures of specific units (or unit), and possibly to amend its findings.' [154]
121 Sir Keith in his written evidence to the Inquiry stated:
`It is safe to say that when David Hamilton telephoned me at home on 27th July 1992, when I had just returned from Scotland, I had no idea of the events leading up to the telephone call. I am sure David Hamilton did his best to explain the sequence of events, but under the circumstances (and I have no clear memory of the conversation), I must have agreed with his concern regarding the working group's conclusions being altered. Whether he or I suggested telephoning Dr Halliday is immaterial but he had to be given our views. There was no way that I could have talked with Terence English, who was either in or on his way to Pakistan, nor was there time to reconvene the working party before the SRSAG meeting, which was due the next day or the day after. ...
`Finally, I have no recollection of suggesting to Dr Halliday that the working party could be requested to reconsider the mortality figures of specific units with a view to possibly amending its findings. I would like to think that I would have recommended this, but as explained above, this never happened.' [155]
122 When he was shown Professor Hamilton's letter of 3 August 1992 in the course of his first appearance at the Inquiry, Dr Halliday said:
`This letter changes the whole context. My discussion with Sir Terence, or at least his discussion with me about his concerns about Bristol simply meant that he had reservations about Bristol and therefore he was not entirely happy with the Report from the College.
`This letter would suggest that there appears to be more to it than that, and I cannot comment on that.' [156]
123 Dr Halliday accepted when he gave oral evidence for a second time that the letter suggests that the discussions between Professor Hamilton and Sir Terence had involved the issue of mortality findings. [157]
124 Sir Michael was emphatic that he had no knowledge of the contact between Professor Hamilton, Sir Keith Ross, Sir Terence English and Dr Halliday and knew nothing of the discussions suggesting alterations to the Working Party's Report. [158]
125 After returning from Pakistan and learning what had occurred at the meeting of the SRSAG on 28 July 1992, Sir Terence had indicated, in correspondence with the Administrative Secretary and the Chairman, that he wished to speak to the issue of de-designation of NICS at the next meeting of the SRSAG, on 29 September 1992. [159]
126 Sir Terence spoke at the meeting, as was explored in the following exchange:
`A. I think that at my last meeting of the Group, I certainly spoke to my concerns about the de-designation of the service. I do not think I did mention Bristol specifically at that time. That is where the matter rested. I then left the Group. I know that Professor Browse knew of my concerns, but I think he did not feel any need to take them any further forward, and indeed, should not have, unless I had specifically asked him to, and I did not.
`Q. Because he left them with you?
`Q. So it was, as it were, your responsibility?
`Q. And you had expressed them orally to Dr Halliday, but not otherwise?
`Q. And never, it seems, from what you have said, thereafter expressed those concerns?
`Q. Do you think, perhaps, that you ought to have done so?
`A. I think it is a difficult question. I think that I probably should have written at least to the Chairman of the Group, Sir Michael, formally about it, if I had not brought it up to the open meeting, the last one I attended. I suspect that probably is what I should have done.
`Q. Although it may be difficult now in retrospect to say why you did not, can you help as to why you might not have done?
`A. I think I was very cross that the Group had failed to accept the very considered advice of the professional working party that they had commissioned. That may have had something to do with it.
`Q. So you felt outwith the group?
`Q. You simply did not think about raising the issue anywhere else?
`A. No. No. And would not. As I say, I think the right thing probably would have been to have written formally to Sir Michael.' [160]
127 Sir Terence said that after the 29 September meeting (his last as a member of the SRSAG) he felt that the matter was closed and beyond his further intervention. [161]
128 At the end of his oral evidence, in response to a question from the Chairman, Sir Terence said that, in retrospect, he should have done more to bring his concerns about Bristol to the attention of others. He said:
`... I do accept the implied criticism, and indeed, the criticism that I should have done more to bring my concerns to the Supra Regional Services Advisory Group specifically about the mortality and the concerns expressed by Dr Zorab, than I did, and in retrospect I think I should have.' [162]
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Footnotes
[72] RCSE 0002 0162; letter from Professor Hamilton to Sir Terence English dated 19 June 1992
[73] RCSE 0002 0165; Working Party Report
[74] RCSE 0002 0169; Table 1 `Neonatal and Infant Cardiac Surgery' dated 23 June 1992
[75] RCSE 0002 0165 - 0166 ; `Report from the Working Party set up by the Royal College of Surgeons of England on Neonatal and Infant Cardiac Surgery: Supra Regional Funding and Designation' dated June 1992
[76] RCSE 0002 0167; Working Party Report 1992
[77] T18 p.126-7 Sir Terence English
[78] DOH 0003 0013; letter from Sir Terence English to Dr Halliday dated 2 July 1992
[79] RCSE 0002 0179; letter from Sir Terence English to Professor Hamilton dated 2 July 1992
[80] WIT 0044 0004 Professor Hamilton
[81] Virginia Bottomley MP, former Secretary of State for Health
[82] WIT 0351 0004. Duncan Nichol was the Chief Executive of the National Health Service Management Executive in England between January 1989 and March 1994. In his written statement to the Inquiry he stated: `I had no personal knowledge and received no report of any concerns around paediatric cardiac surgical services at the Bristol Royal Infirmary.'
[83] SLD 0002 0005; `Private Eye' , 3 July 1992
[84] An anonymous letter was received by Brian Langstaff, Q.C., Counsel to the Inquiry, alleging that there was a cause for concern in relation to the results of children's heart surgery at the Royal Brompton Hospital. This letter was forwarded by the Inquiry to the Chief Executive of the Royal Brompton Hospital and the fact that this had happened, and that the Chief Executive had then ordered an inquiry, received media attention in August 1999. WIT 0283 0069; letter dated 1 June 1999
[86] T18 p.134 Sir Terence English
[87] WIT 0031 0001 Sir Keith Ross
[88] WIT 0031 0006 Sir Keith Ross
[89] DOH 0002 0113; Working Party Report June 1992
[90] WIT 0031 0008 Sir Keith Ross
[91] JDW 0003 0130 - 0131 ; letter from Sir Keith Ross to Mr Wisheart dated 2 July 1992
[92] WIT 0031 0009 Sir Keith Ross
[93] WIT 0031 0014 Dr Hammond
[98] UBHT 0061 0165; Medical Audit Meeting Report, 3 June 1992
[102] SLD 0002 0005; `Private Eye', July 1992
[103] RCSE 0002 0188; letter from Dr Zorab to Sir Terence English dated 15 July 1992
[104] RCSE 0002 0191; letter from Sir Norman Browse to Sir Terence English dated 21 July 1992
[105] T17 p.124 Sir Terence English
[106] T18 p.150 Sir Terence English
[107] T18 p.115 Sir Terence English
[108] RCSE 0002 0193; letter from Sir Terence English to Sir Norman Browse dated 25 July 1992
[109] RCSE 0002 0195; letter from Sir Terence English to Dr Zorab dated 25 July 1992
[110] RCSE 0002 0169; Working Party Report 1992
[111] RCSE 0002 0193; letter from Sir Terence English to Sir Norman Browse dated 25 July 1992
[112] T15 p.74 Sir Michael Carlisle
[113] The meeting was on 28 July 1992
[114] T15 p.75 Sir Michael Carlisle
[115] T18 p.151, p. 154 Sir Terence English
[116] WIT 0071 0047 Sir Terence English
[117] T18 p.155-6 Sir Terence English
[118] WIT 0044 0004 Professor Hamilton
[119] T18 p.152 Sir Terence English
[120] T18 p.157 Sir Terence English
[121] WIT 0049 0029 Sir Terence English
[122] T18 p.160-1 Sir Terence English
[123] T18 p.184 Sir Terence English
[124] Dr Halliday's recollection, that Sir Terence's conversation with him was on the day of the meeting or the day before, is not consistent with the contemporaneous correspondence. Sir Terence was in Pakistan from 25 July 1992. The meeting was on 28 July 1992
[126] WIT 0049 0029 - 0033 Sir Terence English
[128] T18 p.165 Sir Terence English
[129] See later, paras 109 and 110, for the minutes
[130] T15 p.73 Sir Michael Carlisle
[135] The minutes of the SRSAG meeting of 28 July 1992 refer to Sir Terence's `reservations' without the qualification `major'
[137] WIT 0071 0067 - 0068 Sir Terence English
[142] T89 p.159 Dr Halliday; there was no evidence before the Inquiry that Dr Halliday sought an explanation
[143] T17 p.4-5 Sir Terence English
[144] DOH 0002 0099; minutes of the meeting of the SRSAG of 28 July 1992
[145] DOH 0002 0099; minutes of the meeting of the SRSAG of 28 July 1992
[146] WIT 0049 0012 Dr Halliday. The minutes of the July meeting were agreed as a `correct record' DOH 0002 0155; but the issue is not so much what Dr Halliday reported in July as whether what he reported is what Sir Terence thought he was going to report
[147] DOH 0002 0099; minutes of the meeting of the SRSAG of 28 July 1992
[148] T15 p.78-9 Sir Michael Carlisle
[149] T18 p.168 Sir Terence English
[151] T15 p.42-3 Sir Michael Carlisle
[152] WIT 0049 0034 Dr Halliday
[153] T89 p.170. Dr Halliday explained that Chris Spry, a member of the SRSAG, organised a continuing funding arrangement with Regional General Managers for a transition period which lasted until the spring of 1994
[154] RCSE 0002 0197; letter from Professor Hamilton to Sir Terence English dated 3 August 1992 (emphasis in original)
[155] WIT 0031 0006 - 0008 Sir Keith Ross
[158] T15 p.77 Sir Michael Carlisle
[159] RCSE 0002 0200 (from Sir Terence to Mr Owen), RCSE 0002 0202 (Mr Owen's reply) and RCSE 0002 0205 (from Sir Terence to Sir Michael). None of the letters made reference to problems at Bristol
[160] T18 p.174-5 Sir Terence English