Annex A > Chapter 29 - Concerns 1994 > Concerns > December
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December
114 On the evening of 8 December 1994 a scheduled meeting of the Paediatric Heart Club took place at Dr Joffe's home. [143] Mr Dhasmana told the Inquiry that Dr Martin and he had discussed the proposed Switch operation on Joshua Loveday after Joshua had been seen in Gloucester in November 1994. [144] Mr Dhasmana and Dr Martin decided, and Dr Joffe agreed, that the meeting of the Paediatric Heart Club was a suitable occasion on which to discuss the issue of Mr Dhasmana's performing non-neonatal Switch operations. After the decision had been taken to dedicate the meeting to a discussion of the non-neonatal Switch series, Mr Dhasmana told the Inquiry that he:
`... made personal telephone calls and communicated to everybody that I would be grateful if they attended this meeting, all of them.' [145]
115 Mr Dhasmana said that he asked Dr Bolsin to attend:
`... when I talked to him he looked in his diary, he said "Sorry, I am busy at that time somewhere else but I will see what I can do". In the end he did not turn up.' [146]
116 Mr Dhasmana was asked about the meeting in the following exchange:
`Q. So the meeting then took place. What discussion was there about the Joshua Loveday operation? Was it about the operation or was it about the Switch programme itself?
`A. It was about the older Switch programme. It is just I intimated to them that: "I have got a patient on my list to be operated on".
`Q. So no specific conversation about that particular patient, just about the Switch programme?
`Q. Were there any figures discussed at that meeting?
`A. I took my hand notes because I was not going to that meeting without any information with me. So in my hand I had written down all the Switches which I had done right from number 1 in 1988 - I am talking of all older Switches - until the last one.' [147]
117 Mr Wisheart, in his written evidence to the Inquiry, stated:
`... there was a long and detailed discussion as to whether it was appropriate for Mr Dhasmana to continue to do the Arterial Switch operation in older children. For the purposes of the discussion, all sides of the debate were examined and data was provided to that meeting. The meeting concluded that Mr Dhasmana should continue to do the Arterial Switch operation in older children.' [148]
118 Mr Wisheart stated that Dr Joffe, Dr Martin, Dr Hayes, Dr Masey, Dr Underwood, Dr Pryn, Dr Wilde, Mr Dhasmana and he were present at the meeting. Mr Wisheart stated that Dr Bolsin was not present. [149]
119 When Dr Masey was asked about the meeting, she said that she had `very little recollection of the subject matter' of the meeting. [150] As regards the discussion of the non-neonatal Switch series, she said:
`My recollection was that the results in the older Switches were acceptable, yes, were within acceptable ... were acceptable, yes.' [151]
120 Dr Pryn and Dr Underwood both had a very poor recollection of the meeting and what was said at it. [152]
121 No minutes were made of the meeting.
122 On 15 December Professor Vann Jones, having received some further data from Mr Wisheart, wrote to Mr Wisheart acknowledging receipt of the data:
`I looked through the figures with interest and certainly as far as I can see all the groups to which statistics could be sensibly applied equal or better the national average. As you know there are many small groups some better, some worse than the national average but where one single event totally distorts the picture. I personally feel very re-assured about the figures and would stoutly defend them if they ever become the subject of further debate.' [153]
123 Subsequently, in his oral evidence to the Inquiry, Professor Vann Jones said that he had:
` ... made assumptions that that must be validated data. I did not know until later on, for instance, that the whole thing was anonymised and lumped together ... I had no idea in those days, it was just people sending forms in and the whole thing was lumped together, so therefore any particular centre that was not performing was just lost in the overall ... .' [154]
124 Dr Bolsin stated in a report in October 1995 that at some point in December 1994 he contacted Dr Doyle at the DoH in the light of the proposed operation on Joshua Loveday:
`When it became apparent that the operation was very likely to proceed, and after consultations with Mr Bill Brawn (Consultant paediatric cardiac surgeon, Birmingham Children's Hospital) and Mr John Parker, [155] I contacted Dr Doyle and told him of my grave concerns over the safety of the patient. Professor Angelini also contacted Dr Doyle for the same reasons.' [156]
125 Mr McKinlay, in his written evidence to the Inquiry, stated:
`By Christmas 1994 I had reached the point where I told Dr Roylance that I wanted an independent inquiry and he agreed ... it is my recollection that he or Mr Wisheart had started to explore with the Royal College of Surgeons the identification of experts who might conduct the inquiry.' [157]
126 Mr McKinlay was asked about this part of his statement when he gave oral evidence:
` ... I can remember going away for the Christmas break and saying, "John [Dr Roylance], I think we need to have an inquiry."
`Q. That would have been into what, precisely?
`A. Into whether or not there was a problem ...
`Q. Dealing only with the neonatal Switch operation ... ?
`A. No, I think at that time the concerns must have been broader; they really had to cover the behaviour of the Unit as a whole. At that time I thought that the centre of [the] problem was the neonatal Switch, but it really should be a wider inquiry.' [158]
127 Mr McKinlay's evidence included the following exchange:
`Q. If you and Dr Roylance had agreed that by Christmas, why was one not set up by Christmas, or early in January?
`A. I thought that Dr Roylance agreed with me, but he had to go off and think about it. I thought that in January he started the mechanism for setting up an inquiry, to find the people to actually do the job.
`Q. Before any question of the Joshua Loveday operation? [159]
`A. I thought so, but ... I cannot pin that down.' [160]
128 According to Dr Roylance, the decision to hold an inquiry was made rather later:
` ... I decided to have an inquiry when I was told that the child [Joshua Loveday] had died.' [161]
129 Mr Graham Nix stated that he could not recall precisely when he first became aware of an inquiry involving independent experts to report on paediatric cardiac surgery although:
`... it was probably in very late 1994 or early 1995. I understood that independent experts were to be called in, to advise Dr Roylance by providing an outside view of the problems in the paediatric cardiac service.' [162]
130 As regards the proposed operation on Joshua Loveday, sometime in December 1994 or early January 1995, Professor Angelini made a telephone call to Dr Martin, consultant paediatric cardiologist, who was at a peripheral clinic outside Bristol. Professor Angelini said of the telephone call:
`I questioned to him the wisdom of doing this case in the BRI. I also told him that this was not an urgent case and there was no need to do this operation and if he felt that the child needed an operation, we could have him sent to Birmingham, to Bill Brawn, who was perhaps the best surgeon in the land, to do this operation safely.' [163]
131 Professor Angelini's evidence continued:
`Q. Did Dr Martin agree that the operation was urgent or not? Or did he agree it was not urgent?
`A. He agreed it was not urgent.
`Q. So what did you understand his justification being for carrying out the operation?
`A. His justification was since this child was not a neonate, the results on the non-neonate were much better than the results on the neonate, therefore he was justified to go ahead with the operation.' [164]
132 Professor Angelini told the Inquiry that he asked Dr Martin why Joshua Loveday, who had been waiting for his operation for some time already, could not wait until Mr Pawade took up his position. [165] Professor Angelini said that Dr Martin had told him:
`... in his view the competence of the surgeon to do this operation in a child of the age of the child we were dealing with, was adequate. Of course, I totally disagreed with this.' [166]
133 Dr Martin told the Inquiry:
`My understanding was that he [Professor Angelini] was questioning whether this operation that was planned as a Switch operation was a neonatal operation and I think I informed him that Joshua was an older child, I may have told him his age, I cannot remember, and I felt he [Professor Angelini] was under the misapprehension that this was a neonatal operation or a younger operation.' [167]
134 Dr Martin told the Inquiry that he did not remember how long the conversation lasted; [168] whether or not the question of transferring Joshua to another hospital was discussed; [169] whether or not the urgency of Joshua 's case was discussed; [170] or whether there was any discussion of why the operation could not wait until Mr Pawade started work. [171]
135 After spending Christmas with relatives, Joshua's parents returned home to find a letter from the BRI advising them that there was a space available in the operating schedule and that, if they wished the operation to go ahead, then Joshua could be admitted to the BRI on 10 January 1995. [172] Joshua's mother stated in her written evidence to the Inquiry that:
`Bert and I thought that both this letter and the previous communication from Mr Dhasmana's secretary were very odd. We had, after all, seen Mr Dhasmana in November, only a couple of weeks before his secretary telephoned. At the previous consultations with both Dr Martin and Mr Dhasmana, neither had indicated that the operation was urgent.' [173]
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Footnotes
[148] WIT 0120 0455 Mr Wisheart
[149] WIT 0120 0455 Mr Wisheart
[152] T75 p.155 Dr Underwood; T72 p.161 Dr Pryn
[153] JDW 0005 0180; letter from Professor Vann Jones to Mr Wisheart dated 15 December 1994
[154] T59 p.129 Professor Vann Jones
[155] The then President of the British Cardiac Society
[156] UBHT 0052 0175; Dr Bolsin's report: `An account of the events occurring in the Bristol Royal Infirmary & United Bristol Healthcare Trust Department of Paediatric Cardiac Surgery 1989-1995', dated October 1995
[157] WIT 0102 0028 - 0029 Mr McKinlay
[159] The operation took place on 12 January 1995. See also Chapter 30
[161] WIT 0108 0130 Dr Roylance; Joshua Loveday died on 12 January 1995, the day of his operation
[162] WIT 0106 0070 Mr Nix
[163] T61 p.183 Professor Angelini
[164] T61 p.183 Professor Angelini
[165] Mr Pawade was due to start work in Bristol in May 1995
[166] T61 p.184 Professor Angelini
[172] WIT 0417 0012 Ms Evans
[173] WIT 0417 0012 Ms Evans