Annex A > Chapter 29 - Concerns 1994 > Concerns > April
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April
24 On 5 April 1994 Dr Monk, Mr Wisheart, Dr Bolsin and Professor Angelini went to dinner at Bistro 21, a restaurant in Bristol.
25 Dr Monk in his written evidence to the Inquiry explained the background to the Bistro 21 dinner:
`In an attempt to depersonalise the continued differences in opinion over the P.C.S. [paediatric cardiac surgery] outcomes I spoke individually with JDW, SB [James Wisheart, Stephen Bolsin] and Professor G. Angelini (GA), I chose these colleagues because it was JDW under criticism, SB had performed the audit and GA supported both SB and the need for change. I spoke with each to explain that the aim was for an informal discussion on the different opinions and that I had arranged a meal at a restaurant (13.4.94) to obtain a non-confrontational atmosphere. Although I directly asked the question whether there were any concerns regarding P.C.S. neither SB nor GA replied. In conversation shortly after with JDW I formed the impression from him that if the concerns were not worthy of discussion at the meal then the concerns could not be major.' [35]
26 Dr Bolsin set out his view of the meeting in his written evidence to the Inquiry:
`In 1993 [sic] Professor Angelini, Dr Monk, Mr Wisheart and myself attended a meeting that was arranged in a restaurant near the hospital, Bistro 21. We were booked in the upstairs room, which was deserted. The meeting proceeded over supper with peripheral discussion of the performance of the unit. There were no direct requests for figures from Mr Wisheart, which led me to believe that he was aware of the results that Andy and I had produced. Certainly my information from both Gianni and Chris Monk was that they had shown the results to the surgeons involved. It was also my understanding that the Chief Executive had been informed of the results and must have discussed them with his Medical Director. It came as no surprise to me that a request for data was not forthcoming at this meeting because as far as I was concerned everybody at the meeting had the results that I, and others, had generated. There was little consequence to the meeting but the issue of poor performance had been raised and I expected a full and open review to ensue as the Medical director of the Trust was aware of the concerns of:-
`1) A Clinical Director of the Trust [sic]
`2) The Professor of Cardiac Surgery
`3) An adult cardiac surgery auditor of National Reputation.' [36]
27 Mr Wisheart responded to Dr Bolsin's statement to the Inquiry:
`I had become aware that Dr Bolsin, with Professor Angelini, were expressing criticisms about paediatric cardiac surgery. Why they were doing this and on what basis was unknown to me. As rumours continued and progressed I expressed the view to Dr Monk that the only satisfactory course was to speak directly with Dr Bolsin and ask him what his concerns were. He agreed and the dinner was set up by Dr Monk and myself for this purpose. I asked the question to Dr Bolsin and Professor Angelini "What are your concerns?" but I did not receive an answer at the dinner party or subsequently.
`Dr Bolsin says that there was no request for figures and of course that is true because I did not know that figures existed. Dr Bolsin, therefore, was mistaken to conclude that I was aware of the figures.
`Neither Professor Angelini or Dr Monk showed me the results, or told me that an audit had been carried out, or that figures existed.' [37]
28 Dr Bolsin discussed the meeting further in the following exchange with Counsel to the Inquiry:
`Q. What was the purpose of going to the meeting? ...
`A. I think Chris Monk invited me to attend the meeting. I think it was at relatively short notice, and my understanding was that we were going to address some of the issues in cardiac surgery and probably paediatric cardiac surgery.
`A. To be quite honest with you, I have not thought about that. I assume it was because we all had an interest in paediatric cardiac surgery.
`Q. Was it perhaps because Dr Monk is the Director of Anaesthesia, Mr Wisheart is the Medical Director and has obviously an input into cardiac surgery, was, had been the Associate Director of Cardiac Surgery?
`Q. Professor Angelini had been a surgeon whom you had talked to about your concerns and because you were known to be expressing or promoting concerns?
`A. It is certainly possible that those are the reasons, yes.
`Q. If that is possible, did you know, at this stage, whether Mr Wisheart had seen your data?
`A. No. I assumed he had, because when I had given it to Dr Monk, he had said, "Right, I will take this on", and Professor Angelini had said, "I will show the appropriate people this data".
`Q. So your understanding was, "Mr Wisheart has a copy of my data and knows it has come from me"?
`A. Yes. He may well have known that it came from myself and Andy Black, yes.
`Q. So there you are, at the meeting, at the dinner: called to discuss your data and the conclusions to be drawn? The way forward? What?
`A. I am not sure. I think it was paediatric cardiac surgery and adult cardiac surgery.
`Q. Did you in fact discuss it?
`A. It was a very unusual meeting because if the agenda or the purpose of the meeting was as you suggest it, the first two courses were spent in small-talk, talking about nothing really to do with cardiac surgery at the BRI, and only latterly did we get into any conversation about cardiac surgery at the BRI at all.
`Q. Is that a reflection of awkwardness in grappling with the subject, bearing in mind that there may be different perspectives on it?
`A. Yes, I think it was the taboo nature of the subject.
`Q. So there you are circling around the issue in the first two courses?
`Q. Talk being whatever it was, Manchester United [Football Club] and so on. When did you get to grips with the subject? Did you ever?
`A. I did not want to raise it, and I do not think I did raise the subject.
`A. Because I felt very uncomfortable raising this subject with that company. I would raise it with -
`Q. That is what you were there for, was it not?
`A. I was not sure that the purpose of the meeting was for me to raise the subject in front of that company. I had already raised the subject with Dr Monk and I had already raised the subject with Professor Angelini, and I would have been happy to contribute to a debate if they raised the subject and it impacted on the data that I had collected or the views that I held.
`Q. So you thought you were there to contribute to a discussion, but not to begin it?
`A. Yes, very much so. I was not prepared to initiate a discussion on the basis of what had happened up until this meeting.
`Q. So if someone had said, "Do you have any concerns about paediatric cardiac surgery?" looking at you or Professor Angelini, you might have responded to it?
`A. If the issue of concerns about paediatric cardiac surgery would have been raised, I would have expected either Professor Angelini or Dr Monk to have taken the lead and said, "Well, actually now you come to mention it, we do have a problem and I do not know, Steve, whether you would like to come in on this one and tell us about your data collection?"
`Q. What Dr Monk has suggested to us he said - because he told us you were getting frustrated that by the end of the evening nobody had grappled with the subject which he had arranged the meeting for -
`A. It was a very difficult subject to grapple with.
`Q. His recollection is that although he does not recall the exact words, he said words to the effect of: "Do you have any difficulties with the paediatric cardiac services?" May I tell you that in comments he has given us, Mr Wisheart says he said words to the same effect, "Do you have a problem with paediatric cardiac services?" Did one, or the other, or both say that to you and Professor Angelini, or you or Professor Angelini?
`A. I think the question, if it arose, would have arisen to the table, so that one person would have been speaking to three others, and I would not have responded to that; I would have contributed to it, but I would not have responded to that -
`Q. Can I take it in stages. Was the question asked?
`Q. If it was asked, why did you not respond?
`A. I would have contributed. I did not want to raise the issue of me being the prime mover in concerns about paediatric cardiac surgery. That was why I was going through every other route possible to press alarm bells to get somebody to come and deal with the issue of paediatric cardiac surgery.
`Q. So Professor Angelini, someone you were on friendly terms with, shared your concerns?
`Q. After the dinner, did you say to him, "Gianni, for goodness sake, why did you not respond to that question? It was not for me, I am a junior consultant, but you are a Professor, why did you not say something?"?
`A. No, I thought in a sense the question in my mind was redundant, in that, at that stage, I believed that both Chris Monk and Professor Angelini had raised the issue with Mr Wisheart so that the issue of concerns was one that was current within this group, within that group; it was not really a question of saying, "Is there a problem?", it is a question of what we are going to do about the problem.
`Q. ... The meeting, you are going to tell me, I know, ended without any discussion actually taking place?
`Q. If a question were asked, as it is suggested to us and you cannot deny was asked, like "Are there any difficulties?" and so on, "What is the problem?", why did it not lead to a discussion there and then?
`A. I am not sure, because Dr Monk was aware of my concerns and Professor Angelini was aware of my concerns. I was aware of my concerns. I thought that Mr Wisheart was aware of the data, and I would have expected a meeting like this to have been dealing much more with solutions than with whether or not there was a problem. As far as I could see, the data coming from the Unit already recognised that there was a problem. My data confirmed the data that recognised that there was already a problem. We should not have been talking about whether there was a problem, "Do you have any concerns?"; we should have been talking about, "What are the solutions to the problems we know exist within this Unit?" and the director should have been very much aware of that.
`Q. The solution you had in mind was the need for an immediate, thorough investigation and review?
`A. Which we had been promised in January when Mr Dhasmana was due to present the data and he did not ...
`Q. Would not this meeting have been an ideal opportunity, bearing in mind your concern for little children in the Unit, to press the case for just such a review?
`A. Yes.' [38]
29 At a later stage in his evidence to the Inquiry, Dr Bolsin had the following exchange with Counsel to the Inquiry:
`A. Could I add one other thing about the Bistro 21 dinner. ... The other possibility and I think this was a very real possibility, was that this was a sort of "bonding" exercise in the Trust, and I think that given the sort of management culture that was overtaking the NHS at this time, those kinds of exercises were seen as quite useful, and I think it is quite possible that I believed that I was going to a bonding, you know, touchy-feely-fuzzy-warm meeting at which we were going to get together, rather than necessarily a meeting at which we were going to address a specific issue of paediatric cardiac surgical mortality. I do not know if that helps?
`Q. I am not sure it does. For what reason do you think, looking back on it, the Bistro 21 meeting may have been a touchy-feely-fuzzy-warm bonding session, as opposed to a dinner intended to sort out differences, if there were differences, as to the performance of cardiac surgery and the interpretation of any figures there were?
`A. I think firstly the venue, holding a meeting in a restaurant, is not a venue for where you will sort something out; it is more a venue where you will have a warm convivial meeting, and I think if we were going to sort out paediatric cardiac surgery, it would have been better to have done it in an office in the University department, or something.
`Q. Yesterday you were telling us that - these are your words "I think Chris Monk invited me to attend the meeting. I think it was at relatively short notice"?
`Q. "My understanding was that we were going to address some of the issues of cardiac surgery, and probably paediatric cardiac surgery."
`A. Yes, but I think it could have been in a "How can we move this forward together?" kind of atmosphere.
`Q. Again, to try and get what you are saying right, are you saying that you go along to address the issues, not with the object of being confrontational, but with the object of producing a resolution?
`Q. So what you would have been looking to achieve from your own point of view from the meeting, was a consensus that matters needed to be moved forward and a plan of action?
`Q. And as it happened, as we know, nothing transpired?
`A. I think if we had been intending to do that in a Bistro 21 atmosphere, it would have been formal and not informal, and the formality was not there.' [39]
30 Professor Angelini gave his view of the Bistro 21 meeting in the following exchange:
`A. That dinner was organised by Dr Monk and the idea of that dinner was to have Mr Wisheart and [Dr] Bolsin together to try to reconcile some of their differences. I was invited, I guess, I do not know, as a sort of honest broker, or outside - I do not know what to call it, but the dinner was organised by Dr Monk.
`Q. Was the dinner the place where Mr Wisheart asked Dr Bolsin and yourself if you would share your concerns with him and Dr Monk about the paediatric cardiac surgery?
`Q. It is right, is it not, that Dr Bolsin did not take any data to that dinner?
`Q. You did not take any data?
`A. No, I was just the guest at a meeting organised by somebody else.
`Q. No data was produced, if I can put it like this, from Mr Wisheart's side?
`Q. So it must follow that presumably if Dr Monk did not bring any data there was no data discussed at the dinner?
`A. Again, the purpose of this meeting, everybody seems to emphasise the need to have these pieces of paper in front of you with the data. The fact of the matter was that we were at a stage where we were trying to get across the message that some of us in the Unit were not happy with what was going on in paediatric cardiac surgery. On the other side, there were people like Mr Wisheart who were not prepared to accept that there was a problem. So effectively, any conversation was almost dead before it started, because we could only agree to disagree. Therefore, there was never the opportunity to expand and go into details of "Let us look at the VSD, whether a mistake has been made; let us look at the AV canal" [40], because there were two opposite views. One view was what was going on was acceptable surgical practice; the other view was that what was going on was not acceptable surgical practice. These two things were impossible to reconcile. As a result of this, there was never any proper conversation which could try to analyse the problem or, if so, how to resolve it. [41]
`Q. Dr Monk had accompanied you to the meeting with Dr Roylance?
`A. Yes, just a few days or weeks before.
`Q. He was also at this dinner with you and Dr Bolsin and Mr Wisheart?
`Q. Did he try to bridge the gap between Mr Wisheart on the one side and Dr Bolsin on the other?
`A. I think Dr Monk was concerned about all of this because of his position, and also because he was genuinely concerned, but again, as it had happened for other people, it was very difficult for him to get the message across.
`A. To Mr Wisheart. I mean, everybody, even the Professor of Surgery who was in a much more senior position, was always finding himself almost embarrassed in having to say to a colleague, a friend, somebody very senior, that his results were not up to scratch. It was always the sort of psychological barrier, if you want to call it, where people could not just get the message across. One reason was that there was apprehension, because as I said, Mr Wisheart was a very influential individual within the Trust. But there was also -
`Q. So does that mean that there was the fear that there would be repercussions?
`A. I do not know if "fear" is the right word, but let us say apprehension.
`A. Yes, even apprehension of what it would be, your future career.
`A. I do not know. Perhaps your career, internal promotion, would have been curtailed down, really.
`Q. How would that come about?
`A. How would that happen? At the end of the day the people who were running the hospital can have a profound effect in the way your practice or your individual practice is run. They may not be so sympathetic when you go and ask for something like, you know, you want to go and improve something in the service, or even on personal grounds.
`Q. Was Mr Wisheart, so far as you are concerned in the spring of 1994, one of the people who was, as you put it, running the hospital?
`A. More or less, yes. I do not know if he was running the hospital, but as the Medical Director he was [on] the Trust Board. Maybe he was not the Chairman of the Hospital Medical Committee at that stage. Before that stage he had been Chairman of everything that moved in [the] hospital, the Division of Surgery, cardiac surgery, everything. We had an Associate Director of Cardiac Surgery, Mr Dhasmana, who could never take a decision. He never ever took a decision because whatever decision he took was going to be turned down or changed by Mr Wisheart.
`Q. So were you scared of Mr Wisheart?
`A. No. And I can tell you why.
`A. I would say not at all, yes, but despite of the fact I was not scared, I was feeling very uncomfortable all the time, because it is not very pleasant to confront a colleague who happened to be senior to - I mean, Mr Wisheart could have been - he is the same age of the person who trained me. He could have been my trainer. And now I was there, confronting him, trying to tell him, "Look, your results are not good". This is very uncomfortable.
`Q. But you did not confront him, because paediatric cardiac surgery was never mentioned at the dinner?
`A. But many times before. That dinner was not organised by me, I was simply there as an observer. I did not organise the meeting, I was not responsible for the talking of anything. I had spoken to Mr Wisheart about the results of paediatric cardiac surgery in a very polite fashion many, many times.
`Q. I think you said, possibly at the GMC, that you discussed the arts, you discussed Manchester United?
`A. Everything. Football, Italy, all sorts of things. One of the difficulties people have to talk to Mr Wisheart, not only because he is a very senior person and is a very authoritative person, but also, he is very fluent. You start a conversation on a subject, you end up with something totally different, you do not know how you got there. He has a very good ability of discussing in the fashion he wishes, and therefore wriggles out if he does not like the kind of conversation that is taking place.
`Q. If that is the perception that you had of Mr Wisheart, does that not make it all the more odd that you should not have made full use of the meeting that you had with Dr Roylance in March when Dr Monk was with you, when there was a chance, with somebody who was higher up the management tree even than Mr Wisheart, indeed, at the top, and you and Dr Monk pulled your punches with Dr Roylance?
`A. I think you British say "You need two to tango". If the other one is not prepared to listen, as I said, short of pinning him down on a chair, I do not know what else I could have done, and so with Dr Monk. Dr Roylance was not interested whatsoever in this kind of conversation. It was like listening to a tape-recorder: "This is not a matter for me. This is a matter for the clinician." This was the message over and over and over. Even when I went to see Dr Roylance, before I spoke to him, before and after the last operation, even after the last operation, this was the same recorded message.
`Q. But it was a matter for the clinicians, was it not?
`Q. The Chief Executive cannot force people to talk about a subject over dinner if they do not want to talk about it?
`A. No, but the Chief Executive can call all the involved parties in a room around the table, which should have happened, and said, "Right, concern has been expressed in the hospital by various sides. I would like first of all to see, if I have not seen it, the data of Dr Bolsin that everybody is talking about"; second, I would have instructed the two surgeons, Mr Wisheart and Mr Dhasmana, to produce their data to be confronted with the one of Mr Wisheart [sic] and then, once the facts were concerned, all the people, not just the surgeons, the anaesthetists and everybody else, discuss this matter, then we decide if we have a problem. If we have a problem, we decide how we are going to solve it. If we do not have a problem, the people who said we had a problem will have to apologise. This never took place.'
31 Dr Monk gave his view of the dinner at Bistro 21 in the following exchange:
`A. The venue was chosen because I had recently organised a large meal there. I had asked the restaurateur to use the upstairs room, which would be private and quiet. It would enable me to produce an environment outside the hospital and to be non-confrontational. I had James Wisheart, who was aware of the concerns but did not have any details. I had Dr Bolsin, who had produced an audit and was asking me to act upon it but was not willing to present this audit to people who could help me form a corpus of opinion and take it forward. And I had Professor Angelini, who was aware of Dr Bolsin's audit and was willing to support it. I therefore produced an environment in which I thought we could, with the least amount of conflict possible, bring together these divergent opinions. To get Dr Bolsin and Mr Wisheart to sit around a table, I would have had to go through a number of conversations in order for them to understand why we are going there. I do not think that Dr Bolsin and Mr Wisheart would just wish to go for a meal to chat about football.
`Q. In fact, did you end up talking about football?
`A. We did indeed. I am a keen Manchester United supporter, having lived there for many years. Professor Angelini had helped me organise a holiday in Italy. Therefore much of the meal was spent, as these meetings are, I presume, talking about generalities before we start to get down to the meat of the conversation.
`Q. What you have said already suggests that you had spoken to Mr Wisheart because - you arranged the meeting, you had spoken to Mr Wisheart, Professor Angelini and Dr Bolsin?
`Q. And your purpose was to get them talking?
`Q. Did each of them know that that was your purpose?
`Q. ... What was he [Mr Wisheart] given by you to understand he should expect to deal with at the meeting?
`A. I believe he knew Steve Bolsin had raised criticisms and he would want to know from Steve Bolsin what those criticisms were.
`Q. What would Dr Bolsin have understood from you?
`A. He and I had numerous conversations about the form of his audit: that, in my opinion, it had been performed in a clandestine manner and therefore its value was lost because it was not owned by people, it was not open; it had not been verified and therefore could be criticised; and that it would be appropriate in this non-threatening environment, supported by me as the Clinical Director and also Professor Angelini, to put forward his data. The danger that I had in having this data and putting it forward to James is that I may not be able to support it from criticism, because my knowledge of it is literally what you have in front of you.
`Q. So at this stage Mr Wisheart would have understood your role to be effectively that of the United Nations, trying to bring peace between the rival views?
`A. I think that is a little excessive in a description. What we had were people with different views upon outcome, and the views were that it was -
`Q. What I am asking is whether he appreciated the role that you sought to fulfil?
`A. I believe so. I may be mistaken about that, but I would have thought that he understood it.
`Q. Was the meeting, the meal, relatively amicable or not?
`A. It was a difficult meeting because people were there with an agenda, and therefore it is difficult to be amicable in those terms where you were there just for a social meal for the pleasure of your colleagues.
`Q. ... At any stage, did the conversation at the meal turn to the issue that had brought everyone together?
`A. It was raised in a very peripheral way on a number of occasions. I felt it was important that we did discuss the issue. Towards the very end, my personal frustrations in not succeeding led me to ask a direct question. I cannot recall the exact words that I used, but I did say, "Do you have any difficulties with the paediatric cardiac service?"
`A. I was looking across the table at Dr Bolsin and next to him was sat Gianni Angelini. It was a table for four, obviously. There was no reply. There was no denial; there was no assertion that there was; there was no answer. At that point my frustration rose to a very high level because I realised that my intent in bringing these people together to discuss the issue ... had failed.
`Q. Did you consider going further and saying, "Look, Steve, you have raised concerns with me. Do you now want to raise them with James?", or anything to that effect?
`A. After asking the direct question and receiving no response my frustration was such that I did not ask those questions. To my recollection, the meal, the meeting, whatever, just disintegrated and we all left.
`Q. And no attempt was made by Professor Angelini on the one hand, Dr Bolsin on the other, or for that matter Mr Wisheart, to raise and grapple with the issue which had in fact brought them to Bistro 21?
`A. All four of us failed to achieve that. An option would have been for me to have put the data on the table and say, "What about that?". I did not do that.
`Q. Did anyone have the data with them?
`A. I certainly did not. James could not because he had not got the data. Whether Professor Angelini or Dr Bolsin had the data, I do not know.
`Q. Did James Wisheart know something of the nature of what had been going on, that there had been a collection of data which showed paediatric cardiac services in a bad light?
`A. I cannot answer for his knowledge base at that time -
`Q. Had he been told in front of you, in your hearing?
`A. I did not tell him that I had in my possession an audit of this form ...
`Q. There may have been suggestions in other forums - you did not give evidence at the GMC, did you?
`A. I was not asked to give evidence by any of the people involved.
`Q. But there may have been a suggestion that there were two camps at this restaurant: you and Mr Wisheart on the one side and Professor Angelini and Dr Bolsin on the other. Would there be any truth in that or not?
`A. I did not see my role as being in any "camp". I was the Clinical Director of Anaesthesia, and therefore I had a management role, but I had worked closely with Dr Bolsin for many years, and I had discussed our concerns. He and I had spoken beforehand, and I had taken it to a non-threatening environment. Had we had this meeting in the Medical Director's office, within the Trust headquarters, then I think that could be a reasonable supposition. But it was not, it was held outside of the Trust.
`Q. You had had the view before this meeting that the concerns which Dr Bolsin had, which you tended to share because you tended to be towards his wing, as it were, of the spectrum of anaesthetist opinion, were major concerns?
`A. They were concerns - I had such concerns that I was willing to work hard to try and resolve the issue.
`Q. After this meal - can we look at your statement [42] that describes Mr Wisheart's reaction to the meal. He was effectively saying to you, "Well, if you are not prepared to raise it to my face", or something along those lines, "then there cannot be much in it". Was that the flavour of it or not?
`A. I think it was an impression that I gained from him that if we had gone to the effort to sit at the table, it was an opportunity that was of such low impact as regards to the Trust management situation, because he was probably the Medical Director at this stage, if they cannot raise it then, when he is at his most open, then what were these concerns? I do not know what JDW actually thought at that time, but I felt - maybe it represents also some of my frustrations - that that was a reasonable summary. [43]
32 Dr Monk was asked by Counsel to the Inquiry about his view of Mr Wisheart's capacity to listen to criticism:
`Q. You valued your relationship with Mr Wisheart, did you?
`A. I value all my relationships with my colleagues. It is an important way of working.
`Q. You had been prepared to suggest and, as it were, host a meeting of Bistro 21 at one stage in order to reconcile what you saw as opposing views?
`A. At that stage the Bolsin data, the audit, had not been presented to Mr Wisheart. There were concerns raised by Dr Bolsin and these had been discussed between many people.
`Q. The point I am driving at is, was it your view throughout the 1990s that Mr Wisheart was someone who was amenable to conciliation, someone who regularly took the bigger picture and would not necessarily hold it too strongly against someone that he was the object of their criticism?
`A. I think everyone finds personal criticism difficult to accept, particularly when you are a senior person, but we would not have got Mr Wisheart to the dining table with Dr Bolsin unless Mr Wisheart was willing to listen to the criticisms.
`Q. So it is your view that he was someone who was willing to listen to criticisms, even though they were personal?
`A. The function of that meal was to achieve that.
`Q. No, I am asking for your view of Mr Wisheart and the extent to which he would be prepared to listen to and accept eventually criticisms which were to an extent personal?
`A. I think Mr Wisheart was very proud of his performance. He was towards the end of his career. To criticise his performance would be very difficult for him to accept, but we did discuss on occasions the concerns over the paediatric service, and he accepted that, with the appointment of a new surgeon, he would give up paediatric practice. He had looked to appoint a paediatric professor of cardiac surgery, and, therefore, he obviously realised that the service would improve by bringing in new blood. So in a way he accepted the criticisms that the service was not as good as it may well have been.' [44]
33 Mr Dhasmana was asked about his views of the Bistro 21 meeting in the following exchange:
`Q. ... Mr Wisheart, Dr Monk, Professor Angelini and Dr Bolsin went out for an evening to a restaurant, Bistro 21 in Bristol. You know that now.
`A. I did not know that until really the GMC proceeding, that they went to some dinner or something like that. And the reason, and purpose that I heard, I felt were quite ...
`Q. Part of the reasoning appears to have been a view that they all four shared that there was a need to discuss matters of concern, if they were of concern, so as to, I suppose, create a harmonious way forward. Did you have any sense, in early 1994, that those with whom you worked were unhappy with any aspect of the Unit's performance?
`Q. (The Chairman): Mr Dhasmana ... when you were talking about the dinner, you said "and the reason for it and the purpose, I felt were quite...", and you did not finish the sentence. I was intrigued to discover what you felt?
`A. I do not know what would have come out in the flow at that time, but I felt no real - I mean that, to my mind, was not the way to discuss the problem in a dinner meeting at the Bistro club.
`Q. (Counsel): What would have been the way to discuss the problem?
`A. Well, if the problem is in the paediatric cardiac surgery, if there is a concern, whether it was relating to me or not, I would have thought that being 1993 [sic] must have related to my neonatal Switch, why did not any of those gentlemen talk to me and I could have also gone to same dinner and probably would have raised the question, or there should have been a meeting of all concerned parties, and an open airing; it should have been aired openly.
`Q. Did you still share an office with Mr Wisheart?
`A. No, I did not. I moved out from the office I think in 1992.
`Q. Did you still see him regularly?
`Q. Did you discuss matters of interest to the Unit in 1994?
`A. I had almost a monthly consultants' meeting arranged during part of my Associate Director job, or post, or appointment, and of course Mr Wisheart I would be meeting quite often in the ITU and other areas, yes.
`Q. Mr Wisheart never mentioned, did he, the fact that he went to a dinner meeting with a view to whatever it was, ironing out concerns that there might be?
`A. Not until after, you know, when it was known to almost everybody else.
`Q. Did you have the sense later on then that you were almost the last to know?
`A. That is a difficult question to answer. I cannot answer that.
`Q. (The Chairman): If we can just press on that question a little bit more, you were, after all, doing the surgery. Did you think it was odd that you were not there at the meeting?
`A. I think that was the word I was really looking for at that time, "odd" to have gone to that dinner meeting. So odd, yes.
`Q. Not odd that others would go, but odd that you were not invited, was what my question was.
`A. Odd that I was not even told.' [45]
34 Dr Joffe told the Inquiry of Mr Wisheart's account to him of the Bistro 21 dinner:
`A. He [Mr Wisheart] mentioned that they had had this dinner together and that he was anticipating that this would give Professor Angelini and Dr Bolsin an opportunity to comment, if they had criticisms which appeared to be the case, so he said, for them to state those criticisms and raise the whole question of data or what they felt was amiss with the performance of cardiac surgery - in this case paediatric cardiac surgery - but somehow the evening went by and this did not happen. ... That is the sum total of my information that I gleaned from that discussion.' [46]
35 Mr Wisheart described to the Inquiry a number of approaches to him, including the Bistro 21 dinner, over doubts about performance figures as indirect and `incomplete':
`Q. The indirect approach you had had in respect of doubts over performance figures ... ?
`A. That would have been the matter of Professor Dieppe [Dean, Faculty of Medicine], talking with me, which we have discussed, the subsequent discussion which I initiated with Professor Vann Jones [Clinical Director of Cardiac Services], and those of course were the main issues that led up to the Bistro 21 dinner when I made inquiries. So those were the approaches which were indirect and in retrospect quite incomplete approaches, yes.' [47]
36 Mr Wisheart told the Inquiry that he had not pursued matters raised by Dr Bolsin after the Bistro 21 dinner:
`Q. You regret as well, in your statements, not having pursued Dr Bolsin in early 1994, when you appreciated that he was said to have concerns but had not discovered what those concerns were?
`A. Well, I had discovered that he was expressing the viewpoint. I am not sure if you are using the word "concern" in the manner defined by this Inquiry. If you are, then I did not know that. I knew that he was expressing criticisms to other people, for a variety of reasons, and I did ask him to tell me what those concerns were in April 1994.
`Q. But you say in your statement - I assume it is right - that you regretted not pursuing him?
`Q. And you give us the reason why you did not?
`A. Yes. I allowed myself to be deflected.' [48]
37 Three days after the Bistro 21 dinner, a report on the activities of the Cardiac Surgery Department was presented by Mr Wisheart, as Medical Director, to the Trust Board. It included the following:
`The work of the department has been of a high standard and includes a larger proportion of high risk cases than in some other centres ... In recent years the results of the work with children has [sic] been excellent, and in infants similar to that reported elsewhere ...' [49]
38 On 18 April 1994 Dr Bolsin went, by appointment, to see Janet Maher, then General Manager of the Directorate of Surgery at the UBHT. Mrs Maher stated that she was unsure why Dr Bolsin, a consultant from another directorate, wanted to see her:
`Dr Bolsin told me that he had been doing some work which had produced data, which he had collected in the form of an audit. I do not recall a time period that this information related to, but it concerned the outcomes following paediatric cardiac surgery. I remember that early on in our conversation Dr Bolsin made reference to the Department of Health. My understanding was that he was on a committee or working party at the Department of Health in relation to other issues. His position on this committee had, however, placed him in a position where he had access to data, and this data was the source of concern which had brought him to me on 18 April 1994. Dr Bolsin said that he had data from other paediatric cardiac surgery centres and the comparisons made with BRI data showed that the results of the Bristol Paediatric Cardiac Unit were not as good, in comparison with other units.' [50]
`Dr Bolsin repeatedly referred to the data upon which he based his concerns. At no stage during that meeting did Dr Bolsin explain what that data was, or show me the data.' [51]
`The potential seriousness of what Dr Bolsin was saying made me feel extremely uncomfortable. I asked Dr Bolsin if he had shared this information with paediatric cardiac surgeons, or if he had shared the information with anybody else. I could not get a clear response from Dr Bolsin on this point. He intimated that he had talked to colleagues in his own anaesthetic department, although he did not identify who they were. He implied having spoken to other cardiac surgeons, but again did not say who they were. He had already by this stage made reference to the Department of Health and discussing it with someone there, although again this person was unnamed. Dr Bolsin's response was extremely unclear and he left me feeling increasingly uncomfortable that he had not actually spoken to the clinicians involved in the work. He appeared to have spoken to some people, but they did not seem to be the people who were directly concerned with paediatric cardiac surgery. I was very concerned that if he did have data, that it ought to be shared and on the table for everybody to have a look at. I remained unsure as to what the data was. I got the distinct impression that he had not discussed his concerns openly with the clinicians in question and I felt this was wrong.
`I said to Dr Bolsin that I felt he should go through the appropriate channels. I told him that I did not know what data he was referring to and that it was inappropriate for me to get involved. I advised him to talk to his Clinical Director, who at that time was Dr Chris Monk. I also advised him to go back and talk to the paediatric cardiac surgeons, Mr Wisheart and Mr Dhasmana. I felt that that was the correct way forward. From our conversation, given that Dr Bolsin had referred to other conversations he had had with other people (again not named), I was not sure just how widely he had discussed it with anybody and I felt that the people directly involved needed to know. I also suggested to Dr Bolsin that he ought to discuss his concerns and whatever data he had available to him in an open audit between the surgeons, cardiologists and the anaesthetists involved in paediatric cardiac surgery.
`I was extremely concerned that Dr Bolsin should deal with his concerns in an appropriate way, talking to the right people. He was implying that Bristol results were not as good as elsewhere and I had no idea what the data was, whether it was accurate and whether this was a real basis for concern. In terms of raising it as an issue, given what Dr Bolsin had told me, it could not just be "left" because it could involve serious accusations concerning patient safety and the competence of the paediatric cardiac surgeons. Any comment that Bristol was not doing as well as elsewhere would have concerned me, but particularly where the person telling me appeared not to have talked it through with colleagues who were involved. I was not sure what Dr Bolsin expected me to do in response to his approach in April 1994 and the somewhat vague information he had given me. He did not ask me to do anything in particular.' [52]
41 Mrs Maher stated that she was concerned as to the action she should take:
`Following the meeting with Dr Bolsin I felt it was inappropriate to simply react to Dr Bolsin's concerns by making wide-reaching enquiries. Because Dr Bolsin had been extremely vague about who he had spoken to, I had no idea whether the matter had already been discussed and addressed elsewhere. For all I knew, if it had been, it may well have been resolved already. I felt it prudent to "sound out" key personnel to see if they were aware of Dr Bolsin's concerns. I felt that the three key people I needed to contact were Dr Chris Monk as Dr Bolsin's Clinical Director, Dr John Roylance as Chief Executive of the Trust, and Mr James Wisheart. Within approximately 1 week of Dr Bolsin meeting me, I had spoken to all three. I do not now recall in which order I spoke to Dr Monk and Dr Roylance. I do specifically remember that I spoke to Mr James Wisheart last of the three, given the possible seriousness of Dr Bolsin's allegations for him personally.
`I spoke with Dr Chris Monk and repeated to him what Dr Bolsin had said to me. I told Dr Monk that it seemed to be about an audit, but that I was unaware of the issues involved. I told him I felt I was not qualified to comment upon what these issues might be. When I spoke to Dr Monk, I recall from my GMC evidence that I was aware at the time that Dr Monk probably knew something of Dr Bolsin's concerns, but that he had not seen any information or data. I do not now recall the details of Dr Monk's response to what I told him, although I believe he was keen to bring whatever Dr Bolsin's data and concerns were out into the open in order that open discussions could take place. I left the meeting believing that Dr Monk would make every effort to open up this discussion and bring whatever issues Dr Bolsin had into an open forum so that they could be resolved.
`In the same week that I spoke with Dr Monk I also spoke with Dr John Roylance, the Chief Executive, in his office. I do not recall which of the two I spoke to first. I repeated what Dr Bolsin had said to me. I got the impression that Dr Roylance may have been in a similar position to Dr Monk, that is someone who was starting to get to know that there was something being raised as a concern, but that the detail of that concern was still very unclear. I would not have expected Dr Roylance to indicate to me how he planned to deal with this information and, quite rightly, I believed he needed time to assess the best approach. My understanding was that Dr Roylance intended to take time and talk to the key people involved, probably including Dr Chris Monk and also Mr James Wisheart. I did not know if he would go directly to Dr Bolsin or not. I cannot remember any other details of my meeting with Dr Roylance.
`Having spoken to Dr Roylance and Dr Monk, I also spoke to James Wisheart. To put this in context, my position as General Manager for the Directorate of Surgery was such that I regularly liaised with all three colleagues, particularly in relation to the proposed move of paediatric cardiac services to the Children's Hospital, on an almost weekly basis. A combination of my level of concern, and the regularity with which I saw these three individuals meant that within about a week of Dr Bolsin's meeting with me I had raised the matter with each of them.
`When I met with James Wisheart, I repeated the substance of my meeting with Dr Bolsin in the same way that I had explained to Dr Monk and Dr Roylance. Mr Wisheart was very concerned, both in terms of not understanding which data Dr Bolsin was referring to, and also that nobody had directly raised any concern with James Wisheart himself. The lasting impression I have about these discussions was that there was a lack of clarity about which data was the basis for the concern, and that it certainly did not seem to have been imparted to the cardiac surgeons involved. When James Wisheart expressed his concern about the basis for Dr Bolsin's comments, I told him that I thought the best person to talk to was Dr Bolsin himself and also to Dr Chris Monk. I remember that Mr Wisheart's main concern was that he did not have access to whatever this data was, or that there was some other data around that he had not seen. I am reminded by my GMC transcript that at the time I gave evidence to the effect that Mr Wisheart had found Dr Bolsin's comments about data confusing, as it did not tie in with Mr Wisheart's own data. I could not recall his exact words at that time and I certainly am unable to recall them now.' [53]
42 Dr Monk described his response to Dr Bolsin's meeting with Mrs Maher in the following exchange:
`Q. In any event, very shortly after that meeting I think Dr Bolsin reports that he went to speak to Janet Maher, and that the following day, he suggests, you came to him and said in effect that it was the wrong approach to go to the manager of the surgical department in order to take his concerns further. What do you say about that?
`A. Yes, I believe I did tell him that.
`Q. So the way in which it worked was, what? Janet Maher had had a word with you and said one of your anaesthetists had come to [her] with this concern, and you then went to Steve Bolsin and said that is not quite the way to do it?
`A. The culture of the Trust at that stage was that the managers at that level had very little input into clinical management and decision-taking.
`Q. I do not want to press you on that, as to why you said it, but just the fact that you did?
`A. I just felt that an explanation of why I said it would be quite appropriate. The person that Dr Bolsin needed to give his data to were the surgeons or the cardiac anaesthetists, not a manager who had no obvious way in which she could influence that problem.' [54]
43 Professor Vann Jones was asked by Lesley Salmon, General Manager of Cardiac Services from October 1993 to October 1994, to convene a meeting of the non-medical staff: the perfusionists, the physiotherapists and the nurses. The meeting, held in April 1994, was, according to Professor Vann Jones, `to inform or to reassure the departmental staff in a situation where there were many rumours flying around.' [55]
44 Professor Vann Jones said that he:
`... told them at that meeting that I still had reservations about some of the data because [Dr Bolsin] had not come back about the information on VSDs. I was not certain by any means about the statistics and that the matter was being looked into. I said "in the meantime, we have to carry on business as usual".' [56]
`I told the non-medical staff of the meeting on November 16th [with Dr Bolsin when] I had been presented with some data that had caused some concern and I had been presented with some that was basically wrong, I thought incorrect, and we waited for their [Dr Bolsin's and Dr Black's] clarification of that.
`Q. The reference to the data that was wrong and incorrect was meant to be a reference to Dr Bolsin's figures on VSD, was it?
`Q. Was it fair to characterise what you said to the meeting as "an attempt to discredit the Bolsin/Black data"?
`A. Absolutely not. The whole point of the meeting, as I recall, was to try and keep our team figure [sic] - inform people as to what might be happening, and as I say, there were moves afoot to appoint a new surgeon and move to the Children's Hospital, so it was an information-providing meeting. There was absolutely no way I was attempting to discredit Steve Bolsin and Andrew Black.
`Q. After that, Dr Bolsin goes on to say [57] you received a letter from Dr Black asking you to retract your criticism of the Dr Black/Dr Bolsin data, which you did by letter. Do you have any recollection of that account of events?
`A. That is also inaccurate. What actually happened was that within about half an hour of the end of that meeting - and it was a very efficient grapevine - within half an hour of the end of that meeting Andy Black was in my office, all fire and brimstone, and not very pleasant. However, I told him to calm down and tell me what the problem was. He accused me of casting aspersions on his statistics, his statistical ability. That is quite a bit different to the data. So we agreed that we had actually not disagreed at the end of the day and there was no, as far as I recall, exchange of letters, but it was certainly a very entertaining half-hour with Andy Black in my office.' [58]
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Footnotes
[35] WIT 0105 0023 Dr Monk
[36] WIT 0080 0118 Dr Bolsin
[37] WIT 0080 0332 Mr Wisheart
[40] T61 p.114-22 Professor Angelini. See Chapter 3 for an explanation of clinical terms
[41] See Chapter 3 for an explanation of clinical terms
[42] `In conversation shortly after with JDW I formed the impression from him that if the concerns were not worthy of discussion at the meal then the concerns could not be major'; WIT 0105 0023 Dr Monk
[49] UBHT 0020 0015. The results reported in Bristol and elsewhere in respect of 1993 are summarised at the end of this chapter
[50] WIT 0153 0019 Mrs Maher
[51] WIT 0153 0020 Mrs Maher
[52] WIT 0153 0020 - 0021 Mrs Maher
[53] WIT 0153 0023 - 0025 Mrs Maher
[55] T59 p.155 Professor Vann Jones
[56] T59 p.148 Professor Vann Jones. See Chapter 3 for an explanation of clinical terms
[57] At WIT 0132 0072 Dr Bolsin says `Professor Vann Jones received a letter from Dr Black asking him to retract his criticism of our data which Professor Vann Jones did by letter'