Annex A > Chapter 29 - Concerns 1994 > Concerns > July
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July
66 Dr Monk stated in his written evidence to the Inquiry that he spoke to Dr Roylance on a one-to-one basis, and gave two dates in July 1994 when he might have done so in relation to the letter signed by the anaesthetists: 1 July and 12 July. He stated that he informed Dr Roylance that there was a problem in paediatric cardiac surgery regarding outcomes, which he was unable to solve as Clinical Director of Anaesthesia. He went on:
`... his response remained unchanging in his assertion that he was the Chief Executive and therefore a manager, that the difficulty lay within clinical practice and therefore it was for the clinicians and clinical directors to solve. He did not accept that the flat management structure of the Trust had failed because it was the Medical Director and the Clinical Director of Cardiac Surgery being criticised. He did not accept the role as a final arbitrator and continued to refer the problem back to the clinicians. ... In spite of discussing the letter's content, the reason for requesting an audit and my concerns JR [John Roylance] again used the logic that, if there was a problem, it was in the clinical area and it was the clinician's responsibility to address. He declined to organise a formal audit, did not accept the existence of a problem and refused a copy of the letter as it was addressed to me and did not require his action. I did not subsequently take the letter to JDW [Mr Wisheart] but assumed that JR would speak to the Medical Director [Mr Wisheart] regarding the content of the letter.' [82]
67 Dr Monk added in his oral evidence to the Inquiry:
`I think he was saying "no" to the fact that it was him that should implement the review; that it was a clinician's problem to go and deal with. But I was saying that I could not deal with that problem and I had come to him as one of his Clinical Directors.' [83]
68 Dr Roylance stated in his written evidence to the Inquiry:
`... I am certain that Dr Monk did not show me the letter. It would be an unusual letter for me to see and I do not believe it is possible that I could have forgotten it. ... I do not believe that Dr Monk discussed with me the existence of this letter or its contents and I am sure that he did not ask me to become involved in organising a review of any paediatric cardiac surgery.' [84]
69 In his oral evidence to the Inquiry, Dr Roylance said that if he had been shown the letter he would have been astonished and would have reacted very quickly and very strongly. [85] He said that a letter such as this was unique and that he found it `astonishing', and the fact that it was signed demonstrated that there was an `astonishing degree of concern being felt by the signatories which they thought was not being addressed one way or another'. [86]
70 The following exchange took place between Counsel to the Inquiry and Dr Roylance:
`Q. How often did you see Dr Monk?
`A. Once a week, twice a week, sometimes more.
`Q. He told us that he took the letter to you?
`A. I am surprised he said that. This is not the sort of letter that I could conceivably forget.
`Q. He maintained, although pressed on the point, that he gave the letter to you? [87]
`Q. And you pointed out, as is the case, that it was not addressed to you and therefore handed it back to him?
`A. That is nonsense, all he had to do was write on the bottom "copy to Dr Roylance" and I was stuck with it; I do not find that remotely feasible, I am sorry.
`Q. He tells us that when he took the letter to you, as he says he did, he told you about the concerns in it and that he supported them?
`A. He is mistaken. I do not think I ought to speculate as to how that mistake comes about but I have absolutely no doubt that I did not see this letter until after I had retired.
`Q. I asked him "What was the response when you (that is Dr Monk) showed him (that is you, Dr Roylance) the letter?". His answer was "The response was that it remained a clinical problem, but he was the Chief Executive of the Trust and it was for the clinicians to solve".
`A. If you believe that, you would believe anything. I mean, the suggestion - please, the suggestion that I would see a letter like this, astonishing as it is, inexplicable as it is and say "I do not want it, nothing to do with me" I find offensive.' [88]
71 Dr Underwood, when asked about the effect that the letter had, said:
`A. I do not think that it led to an open and thorough review of the results. In that sense it was disappointing.
`Q. Did you ever discuss it with Mr Dhasmana?
`A. ... I do not remember doing so.
`Q. Or why no open or thorough review had been taking place in response to it?
`A. No. I do not think I did.' [89]
72 Dr Masey told the Inquiry that she could not recall ever asking Dr Monk: `Look here Chris. What has happened to the open and thorough review we asked for?'. [90] Dr Monk told the Inquiry that he was:
`... greatly frustrated by my [his] failure to achieve the goals, and there were a number of issues or actions that I thought I could take. It would have been appropriate to write to him and give him a copy of that letter. I did not believe it would make any difference at all in the process that we were now in and I did not do so.' [91]
73 In July 1994 the anaesthetists' concerns about the Arterial Switch programme were brought to Mr Dhasmana's attention. Mr Dhasmana told the Inquiry:
` ... Dr Monk told me that that is what the anaesthetists have decided: that in a way if you are really arranging any more Switch operations, you must discuss with us.' [92]
74 Mr Dhasmana explained that for him this meant:
` ... the neonatal Switch was stopped and for older Switches I agreed with them that if I arranged any I would talk to them [the anaesthetists].' [93]
75 On 19 July 1994 Dr Peter Doyle, a Senior Medical Officer at the Department of Health (DoH), attended a meeting in Bristol concerning the audit system of the Association of Cardiothoracic Anaesthetists of Great Britain and Ireland (ACTA). In his written evidence to the Inquiry Dr Doyle stated:
`Once the formal business was completed, Dr Bolsin asked if he could accompany me back to the station. During the trip he explained that he was very concerned about the results of an audit he had conducted into neonatal and infant cardiac surgery at Bristol Royal Infirmary. His primary concern at that time was to seek my advice about how to get those responsible in the Trust to address his concerns.' [94]
76 In his written evidence to the Inquiry, Dr Bolsin stated:
`During this meeting Professor Angelini mentioned the problems of paediatric cardiac surgery at the Bristol Royal Infirmary. Due to pressure of time it was not possible for me to discuss in detail these problems with Mr [sic] Doyle but in the taxi on the way to Temple Mead station I provided the background information and the figures that were available to me at that time. These included the results of the Bolsin/Black data analysis/collection; the Arterial Switch mortality rates (provisional); the recent AV canal data for Mr Wisheart. The discussion on the journey centred on the most appropriate way to deal with [the] problem.' [95]
77 Dr Bolsin told the Inquiry his reason for accompanying Dr Doyle to the station:
` ... I had already been to Dr Ashwell at the Department of Health and been referred to the GMC guidelines which had been deemed inappropriate and I was still concerned about the continued activity in some paediatric cardiac surgical operations in Bristol which I believed were exposing children to risk and I thought that I was now justified in involving another senior medical officer at the Department of Health to try and find out if there was a problem and whether we should be doing something about it.' [96]
78 In the course of his oral evidence, Dr Doyle said:
` ... He [Dr Bolsin] actually handed me an envelope which he said contained the audit results. He did not go on to be particularly specific about what those results showed or when the audit was conducted. He just said, "I have done an audit".' [97]
79 When asked what advice he gave to Dr Bolsin, Dr Doyle stated:
`I explained if there were questions ... it was a matter for the Trust and there were well recognised mechanisms. He said he had tried to bring the results to the attention of people in the Trust, so far without success, so I went on to explain in greater detail about HC(90)9 ... .' [98]
`... the argument over those figures, over the significance of those figures, is an inter-professional dispute. Ipso facto, if the two sides cannot agree as to the meaning of those figures and the importance of those figures, then management has on its hands an inter-professional dispute. That inter-professional dispute requires to be resolved. You cannot allow clinicians in the departments to carry on disputes for many years. It damages the effectiveness of the unit. So management has a requirement to bring in outside independent people who have the skills to look at that, to peer review in effect what is going on and to make recommendations.' [99]
81 Dr Doyle explained why he directed Dr Bolsin to HC(90)9:
` ... One thing I was clear about is that he was one side of an inter-professional disagreement or dispute of some sort. Whether right was on his side at that stage, I had no way of judging adequately.
`There was clearly a mechanism laid out, one which I was fairly familiar with, for resolving these disputes, so the first initial concern on my part was to make sure that the appropriate mechanism was used, was expedited to get on with resolving this dispute.
`The question was, I have asked myself this many times, whether I could nudge the process forward and ensure that the Trust took action fairly speedily to resolve the dispute and to get to the bottom of the argument as to whether there was or was not a case to answer.' [100]
82 Dr Bolsin told the Inquiry that he discussed three options with Dr Doyle. [101] The first and second options (which were, respectively, to go to the Secretary of State, or to the Royal Colleges) were discounted. They would, in all likelihood, mean the cessation of all operations within the Unit and Dr Bolsin said that he felt that there were still beneficial operations taking place within the Unit. [102] Dr Bolsin went on:
`The third course of action was that Mr [sic] Doyle would write to Professor Angelini who was aware of the problems and I had reported to Mr [sic] Doyle that Gianni was aware of the problems and he would then report back to Peter Doyle with the authority of having been contacted by the Department of Health about a perceived problem. It was the third course of action we agreed upon because that preserved operating within the Unit, it would lead to the open review, it would reduce the high-risk operations and the solution would be found, we hoped.' [103]
83 Dr Doyle explained that, because there was an appropriate mechanism for dealing with disputes of the nature Dr Bolsin had outlined to him, he at no time looked at the contents of the envelope that Dr Bolsin had given him. [104] On his return to the DoH Dr Doyle filed the envelope in his personal filing cabinet with the other papers which he had collected whilst at Bristol. [105]
84 On 21 July 1994 Dr Doyle wrote to Professor Angelini. In his letter, Dr Doyle stated that concerns over mortality rates in neonatal and infant cardiac surgery at the BRI had been brought to his attention. Dr Doyle wrote:
`I am sure you agree that this is a matter for very great concern. If the position proves to be as reported to me, the excess deaths are in themselves a tragedy. If the problem has been recognised and adequate remedial steps have not been taken, it becomes an unacceptable tragedy.' [106]
`If there is a problem and, for any reason, you are not able to reassure me that it has been resolved, the circumstances are such that I would be obliged to seek the help of colleagues in the Performance Management Directorate who would doubtless raise the matter formally with the Trust. It is highly likely that some sort of formal enquiry would follow.' [107]
`I recognise that this letter may put you in a very difficult position personally. If there is anything I can do to help, please do not hesitate to get in touch.' [108]
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Footnotes
[82] WIT 0105 0028 - 0029 Dr Monk
[84] WIT 0108 0128 Dr Roylance
[87] In fact, Dr Monk's evidence was that he offered Dr Roylance a copy of the letter but that Dr Roylance refused to accept it; T73 p.165-6 and WIT 0105 0029
[94] WIT 0337 0002 Dr Doyle
[95] WIT 0080 0119 Dr Bolsin. See Chapter 3 for an explanation of these clinical terms
[98] T67 p.27 Dr Doyle. DoH Health Circular HC(90)9 set out the terms and conditions of service for hospital medical and dental staff and doctors in community medicine and community health service. It was introduced on 18 April 1990 and set out two new procedures: one for disciplinary action short of dismissal; and the other for review of the conduct of consultants alleged to have failed repeatedly to honour their contractual commitments
[106] UBHT 0052 0287 Dr Doyle; letter dated 21 July 1994
[107] UBHT 0052 0287 Dr Doyle; letter dated 21 July 1994
[108] UBHT 0052 0288 Dr Doyle; letter dated 21 July 1994