Annex A > Chapter 30 - Concerns 1995 and after > Concerns 1995
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Concerns 1995
January
Joshua Loveday's surgery
1 In late December 1994, it was planned to operate on Joshua Loveday in January 1995.
2 His clinical history was that on 22 June 1993, he was born the second son of Amanda Jayne Evans and Robert Loveday at Gloucester Maternity Hospital. [1] Soon after returning home on 30 June 1993 Joshua's mother noticed that he was having difficulty feeding, and mentioned this to a visiting midwife. The midwife recommended that Joshua should be seen by his GP. It was decided that he needed immediate attention. He was taken to Gloucestershire Royal Hospital, and referred from there to Bristol.
3 Joshua's parents met Mr Dhasmana at the BRI. He explained that Joshua would require an immediate operation, without which he would die, and that later on he would require a `Switch' operation. The next morning, 1 July 1993, Joshua underwent a `banding' operation performed by Mr Dhasmana. He recovered slowly, returning after about two weeks to the main recovery ward in the Bristol Royal Hospital for Sick Children (BRHSC), [2] and after about a further month to Gloucestershire Royal Hospital, where he remained for about two weeks before returning home. [3]
4 After his return home Joshua was seen at monthly outpatient clinics at Gloucestershire Royal Hospital. His mother described the clinics in her written statement to the Inquiry:
`... Joshua was seen once a month, in the local outpatient clinic, by a member of staff from Bristol. Normally, a man called Dr Martin saw him. Dr Martin would usually ask whether Joshua was feeding properly, and he expressed his satisfaction as Joshua got better and put on weight. Dr Martin would do simple diagnostic tests, such as weighing Joshua, and, usually, he would look at his fingers.' [4]
Joshua's mother described his general condition during this time:
`Generally, Joshua reached all his milestones, and, although he was small for his age, he grew steadily. He appeared to be a normal, healthy baby. He was never on tablets, and he did not suffer unduly from illness. He was still pink, although he became purple when he was upset.' [5]
5 In the spring of 1994, Joshua Loveday and his parents were seen again by Mr Dhasmana in Bristol. At this meeting Mr Dhasmana again explained Joshua's condition and drew diagrams of Joshua's heart and a normal heart. [6] He again mentioned that a Switch operation would be needed. Joshua's mother stated that Mr Dhasmana had said to her that there was a success rate of 80-85% in the case of the Switch operation. She stated that Mr Dhasmana did not offer any alternative to the Switch operation, did not mention the possibility of brain damage occurring during the operation, and did not make clear what `failure' might consist of. [7] Mr Dhasmana, she stated, told her that the operation would occur when Joshua was aged between 3 and 5 years old. Joshua's mother explained that:
`Both Bert and I felt generally reassured by this interview'. [8]
6 On 23 May 1994 Joshua had a cardiac catheterisation which showed that the initial diagnosis of double outlet right ventricle with subpulmonary Ventricular Septal Defect (VSD) was correct. [9]
7 On 20 June 1994 Drs Joffe, Martin, Hayes, Wilde and Jones, together with Mr Wisheart and Mr Dhasmana, met at a joint cardiac surgical meeting and discussed Joshua's case. [10] At this meeting the clinicians decided that Joshua looked:
`... suitable for an arterial switch operation with closure of VSD'. [11]
8 In November, Joshua was taken again to the outpatient clinic. Joshua's mother stated that this meeting confirmed her and Joshua's father's belief that the operation was routine but that it would not take place for some time to come. [12]
9 Dr Martin told the Inquiry that he saw Joshua at the clinic in November:
`... I spoke to Mr Dhasmana towards the end of November when we were talking about scheduling ... We were talking about the fact that I had seen Joshua Loveday in the Outpatients Department and I was concerned about his waiting.' [13]
10 Mr Dhasmana told the Inquiry that he knew Dr Martin had seen Joshua in November because:
`I am not exactly certain whether he [Dr Martin] wrote me a letter or sent me a memo or telephoned to say: "Janardan, what is happening with this patient, you have promised an operation in 4 to 6 months and it is more than 6 months, I saw him, he is getting quite blue?"' [14]
11 Accordingly, an operation was set for 12 January 1995. Joshua's mother stated that while she and Joshua's father had misgivings about the operation, they felt that it was an appropriate time for Joshua to have his operation as it allowed him time to recover fully before he was to start school. They decided to confirm with the hospital that they would bring Joshua for admission into the BRI on 10 January 1995. [15]
12 Mrs Herborn, a sister in cardiac theatres at the BRI, stated in her written evidence to the Inquiry:
`I was horrified when I saw this on the monthly list for January after the Christmas holiday, and immediately pointed it out to Dr Bolsin. He already knew about it and told me not to worry, it would not take place. Between then and the 11 January. I spoke to him again and also to Professor Angelini. I was assured each time that they were dealing with it. I had made up my mind that whatever happened I would not scrub for it, nor would I alter the daily roster when I noticed that Alison Reed had a day off on 12 January. Alison Reed was Mr Dhasmana's favourite scrub nurse. She was very experienced and would have been his first choice. Apart from her there were only Kay Armstrong and myself available ... Kay Armstrong agreed with me and was also unwilling to scrub for the case.' [16]
13 Professor Angelini told the Inquiry that he went to see Mr Wisheart on 6 January 1995 to:
`... persuade him ... of how unwise it was to go ahead with this [the Joshua Loveday] operation ... .' [17]
`On Friday 6th January, six days before the scheduled operation, Professor Angelini came to me in my office on behalf of Dr Bolsin and himself and spoke to me as Medical Director. He indicated that it was the view of Dr Bolsin and himself that this operation should not proceed.' [18]
`He showed me some figures which were written on a piece of paper in his hand and which I cannot now recall, which purported to be the results of Mr Dhasmana's surgery for the switch operation. I was familiar with his results for this operation and I did not recognise these figures. I said so.' [19]
16 Immediately after the meeting with Professor Angelini, Mr Wisheart stated that he telephoned Dr Bolsin. Mr Wisheart stated that in the course of this conversation, he and Dr Bolsin agreed on two matters:
`... (1) that it was extremely foolish to be in a position where we were arguing about verifiable facts [Mr Dhasmana's outcome data] and that Mr Dhasmana and one of the anaesthetists should work together to establish agreed data on the results of the arterial switch operation in all age groups; and (2) that after that data had been urgently gathered there would be a meeting of the whole Paediatric Group to review this decision to operate on Joshua Loveday ... . It was not possible to convene the meeting until Wednesday 11 January 1995 because of people's legitimate commitments on the Monday or Tuesday.' [20]
17 Professor Angelini wrote to Mr Wisheart on 10 January 1995. Professor Angelini explained that he wrote the letter:
`... as the final attempt to see whether by putting my concern in writing this could have somehow convinced them or - I do not know what - but it was literally the final attempt'. [21]
18 In the letter Professor Angelini wrote:
`I would like to put into writing my concern with regard to the "switch"operation planned for next Thursday January 12th. Given the circumstances which we all know, and the considerable degree of pressure coming from different quarters, for example the anaesthetists and the nursing personnel, I think it would be better not to proceed with this operation.
`Sorry to have to write to you in this manner but I feel that I must disassociate myself from the potential consequences if this operation was to proceed as planned.' [22]
19 Professor Angelini told the Inquiry that he had been in contact with many other people before he both went to see and subsequently wrote to Mr Wisheart in his capacity as Medical Director:
`I had spoken with Dr Roylance. I had spoken with Dr Doyle [Peter] at the Department of Health. Dr Sheila Willatts, Professor Farndon, you name it. I did not have anything else I could do except writing this letter, and that is the last thing.' [23]
Counsel to the Inquiry asked Professor Angelini what response he had received from Dr Roylance. He replied:
`The usual type [of response], the "recorded message": "This is a matter for the clinical people''.' [24]
20 Professor Angelini was asked what response he would have expected Dr Roylance to give:
`By that time, there had been no meeting of all the people involved because the meeting took place the night before the operation, so that was after I had spoken with Dr Roylance. But the issue was a more fundamental one here. The people who were trying to take the decision on whether to go ahead or not, not only were making a decision 12 hours before an operation, but somehow they were all emotionally involved in this business of the switch operation. They were not in any position to take any sensible decision.
The reason I went to see Mr Wisheart and then Dr Roylance was simply to say to them, "You are senior people, you are in a position to stop this operation which is not urgent. Why do you not just think about this. Why do we not assess this with a cool head before embarking and doing the surgery which may end catastrophically for the child, and then what we have proved?" So the people who were taking the decision were too much emotionally involved in what was going on. I think that was a wrong decision, and the Chief Executive and the Medical Director should have appreciated that the decision should not have been left to these people.' [25]
21 Joshua's parents took him to the BRI on 10 January 1995. For themselves, they were allocated accommodation in a shared house near the hospital. On 10 January, they were invited to sign a form giving consent for the operation. They were not told that there was to be a meeting on the following day to decide whether or not to proceed with the surgery. Joshua suffered from Taussig-Bing syndrome. [26] They were not told that Mr Dhasmana had operated on only one child suffering from such a syndrome beforehand. That child had died.
22 On 11 January 1995 Joshua was given two surgical baths in preparation for his operation. [27]
23 Dr Martin did not see Joshua upon admission to the BRI, as indicated in the following exchange:
`Q. Apart from seeing him [Joshua] in outpatients in November 1994, did you see Joshua Loveday again before 11 January 1995?
`A. No, I did not see him on that admission at all.
`Q. On 11th January 1995, is it right that you had last seen Joshua on 21st November 1994?
`A. That is correct, yes.' [28]
24 Dr Peter Doyle told the Inquiry in his oral evidence that, on 11 January 1995, he had telephoned Dr Roylance to advise him of the fact that concerns had been expressed to him by Professor Angelini. Dr Doyle noted that Dr Roylance had told him that he would be guided by the Medical Director (Mr Wisheart) and that, at the very time that he and Dr Roylance were speaking, Mr Wisheart was at a meeting to discuss the situation. [29]
25 Dr Doyle stated that Mr Wisheart telephoned him on the next morning (12 January) to inform him that the outcome of the meeting had been to proceed with the planned operation, since the view of the meeting had been that the results of non-neonatal heart surgery were as good as the national average.
26 Dr Christopher Monk spoke to Mr Wisheart during the day on 11 January, expressing the view that the risks of going ahead with the proposed operation exceeded the possible benefit. [30]
27 At 5.30 pm on 11th January, a meeting of clinicians was held in the Catheter Laboratory at the BRHSC. Present were the cardiologists Drs Joffe, Hayes and Martin; the surgeons Mr Dhasmana and Mr Wisheart; and the anaesthetists Drs Masey, Monk, Bolsin and Pryn (who left midway through). Two notes of the meeting were made at or about the time: one by Dr Monk and the other by Dr Martin.
28 Both notes stated that there was a discussion first as to the outcomes at Bristol of Arterial Switch surgery, and second as to whether or not to proceed with the planned surgery on Joshua Loveday. Dr Martin's note described the discussion of outcomes as follows:
`The results for neonatal arterial switch for patients with intact ventricular septal were discussed in passing. The overall mortality has been 9/13 (69%). It has previously been decided to halt the neonatal arterial switch programme for the moment pending the development of the new unit.
`In total, since February 1988, a total of 28 patients have undergone an arterial switch operation with closure of VSD. This included patients who have undergone coarctation repair and pulmonary artery banding, those with multiple VSDs and those operated on in infancy without prior pulmonary artery banding. Four patients have been operated upon by Mr Wisheart who is no longer undertaking arterial switch operations. This leaves 24 patients operated on by Mr Dhasmana during the period of February 88 to December 94. Overall mortality for this period is 8/24 patients (33%). Mortality was higher in the first 2 years presumably reflecting the learning curve for the operation. Over the period of 1990 to 1994 15 operations were performed with 3 deaths giving an overall mortality of 20%. 8 of these patients were over one year of age with one death (121/2% mortality).
`Reviewing the figures it was clear that the mortality at the start of the programme was high but had improved significantly over the latter few years. These mortality rates were compared to published data. From the multi-centre study in the United States, the mortality for transposition with multiple VSDs was 22% and for transposition with single VSD was 16%. Based on the UK registry the mortality for treatment of transposition with VSD (majority would have had an arterial switch operation) was 19.5% in 1990, 17.6% in 1991 and 12% in 1992. There was discussion on these results and it was felt that our more recent results were similar to that for published data and, therefore, acceptable.
`There was a discussion amongst the group on these results and there was general agreement that, based on the mortality figures it was appropriate to continue with an arterial switch programme in children outside of the neonatal period.' [31]
29 Dr Monk's note recorded that:
`Under discussion it was decided that the outcomes of Bristol were within the expected range of mortalities but not in line with the best reports from centres such as Melbourne, Great Ormond Street, Birmingham or Boston. These figures did not support the withdrawal or stopping of the present non-neonatal programme, the question was asked distinctly by CRM [Dr Monk] and all members with the exception of SP [Dr Pryn] (absent) agreed that the programme should continue.' [32]
30 Dr Monk's note, but not Dr Martin's, recorded that:
`General and specific discussion on the risks of performing surgery with a fatal outcome was discussed and the option of delaying for a week or until the arrival of the new surgeon was proposed strongly by SNB [Dr Bolsin] as much could be lost by the death of the child.' [33]
31 Mr Wisheart set out his recollections of the meeting in his written evidence to the Inquiry:
`Data was presented and, after adjustment to a detail, was agreed. In as much as one could derive reliable and relevant information from recent publications, the literature was reviewed. My recollection is that it was agreed by all present that Mr Dhasmana's results for the switch operation outside the neonatal period lay within what would be expected from this review of the literature. His results in children over 1 year of age were better. Mr Dhasmana's results were for the period 1990 to 1994.
`I believe that Dr Bolsin also accepted this view of the data, but he put the point that the operation should nevertheless not be done for "institutional reasons"and because of the possible "political consequences". There followed a discussion at the end of which most of us remained quite unclear as to what he meant by these two phrases. Most people felt that the decision should be made on clinical grounds and in the best interests of this individual patient and not for extraneous or political grounds. All those present with the exception of Dr Bolsin confirmed the decision and plan to operate on Joshua Loveday.' [34]
32 In his evidence to the Inquiry, Dr Bolsin explained what he had meant by what he described as an `institutional reasons', in the following exchanges:
`The focus in 1992 in setting up a data collection was that we were looking at the major factors in which we had intuitively surmised that some of the surgical factors may be important. So we had confined ourselves to the surgeons as opposed to including cardiologists and anaesthetists and other things, so the whole thing had evolved over that period.' [35]
33 Counsel to the Inquiry explored the issue further with Dr Bolsin:
`Q. Again going back to the process of question and answer about being quite rightly self-critical and excluding yourself as a cause of excess mortality because your procedures were exactly the same as others -
`Q. - the intuitive approach you have described arose, did it, out of essentially that process, your logbook, your focus on your logbook, your focus upon your own experience with children and in essence was it perhaps a question "It is nothing I am doing, so it must be something the surgeons are doing"? It is a very crude way of putting it, but is that broadly how the intuition arose, do you think?
`A. Yes, I think what we were wondering was whether the surgical techniques and the surgical management of the cases was one of the major causes for serious morbidity and mortality.' [36]
34 In a written account Dr Bolsin described the meeting of 11 January 1995:
`One of the features of the meeting was the production (for the first time) of the mortality figures for all "switch" operations undertaken by both surgeons from 1988-95. These data had been collated by both the surgeons and Dr Underwood and Dr Pryn (Consultant paediatric cardiac anaesthetists involved in the "switch" programme). The fact that the surgeons' figures had to be modified at that meeting to produce the actual results suggested that these figures had only just become available. This was the first time that the results for this operation were reviewed by a multidisciplinary team. The results confirmed that the overall mortality rate for the neonatal arterial "switch" operation was 67%. These figures were worse than my estimates of July 1994.
`I put forward the view that there was an obvious institutional problem with the arterial "switch" operation in Bristol and that, particularly in view of the recent events, to expose a child to unnecessary risk when the Trust was already committed to a new surgeon and a new site was unwise. The meeting was presented with data from the "switch" programme which had been sub-divided by age (over or under 1 year) and year of operation (before or after 1990). The meeting was asked whether, on the information presented for the specific category into which the prospective patient fell, there was enough evidence that the results in Bristol were "significantly worse" than the "national average"? It was apparent that the effect of the precise subdivision of the data was to create a small group, in comparison to which the Bristol results could not be said to be worse. The numbers were small and the "national average" comparator was itself contentious containing an unknown number of non-"switch" operations for transposition of the great vessels. I had to agree that the data, as it was presented, would make it very difficult to demonstrate with any degree of certainty that the Bristol performance for the small subgroup selected was statistically worse. This disregards the context of the unit's long standing poor record with complex operations. The group was asked if the operation should proceed. I asked for my opposition to be minuted; I was a minority of 1.' [37]
35 Dr Sally Masey, consultant anaesthetist, stated in her written evidence to the Inquiry that she attended the meeting of 11 January 1995. She stated that she had been part of the group that put together the statistics that were discussed during the meeting:
`Prior to this meeting, Dr Pryn, Dr Underwood and myself had made an effort to try and have a list of all the non-neonatal switches performed with their outcomes. Dr Underwood and myself looked at our personal records of cases for which we had anaesthetised and checked through theatre books. Dr Pryn referred to computer-generated information. Dr Pryn took this information to the meeting so it could be cross-referenced with information supplied by Mr Dhasmana.' [38]
36 Dr Masey explained that the conclusion reached at the meeting was:
`... unanimous agreement, including Dr Bolsin, that there was nothing in the figures to suggest that Mr Dhasmana should not proceed with Joshua's operation the following day.' [39]
37 Dr Stephen Pryn, consultant anaesthetist, stated that he helped Dr Masey and Dr Underwood to prepare the figures which were presented at the meeting on 11 January. He explained in his written evidence to the Inquiry that, notwithstanding that the figures that he had helped to prepare which seemed to show that Mr Dhasmana's results were comparable to those in the rest of the country, he felt that:
`... it would be preferable for this patient either to await the arrival of Mr Pawade or to be transferred to Birmingham. However, Dr Martin, the cardiologist involved, explained that Joshua's condition was poor and he required urgent surgery, such that it was not reasonable either to defer operating until May or to transfer him to Birmingham. I had to leave the meeting early, but at the time I left my understanding was that, since Mr Dhasmana's recent survival rates for children over a year old appeared to be within the range of other UK centres, and given the apparent urgency, the operation was to go ahead.' [40]
38 In his note of the meeting of 11 January 1995, Dr Monk wrote:
`SNB [Dr Bolsin] was pressed for an explanation of the reasons behind informing the Department of Health prior to the meeting to discuss whether the programme should proceed the next day. The working relationship between himself [Dr Bolsin], Peter Doyle and the Department of Health funding for his audit programme was so intertwined that SNB felt unable not to tell Peter Doyle of the forthcoming event.' [41]
39 Dr Martin also prepared a minute of a side-meeting between him, Mr Wisheart and Mr Dhasmana, which took place after the discussions in the meeting: [42]
`After this general discussion there was a joint discussion between myself, Mr Dhasmana and Mr Wisheart regarding whether it was clinically appropriate to proceed with Joshua's operation the following day. Joshua is already 18 months old and quite severely blue. We have recently reviewed the clinical and angiographic data and felt that he is suitable for an arterial switch in our unit. With his cyanosis being quite severe it was felt unwise to postpone surgery for a matter of months. Based on the results that we have discussed, we did not feel it was appropriate for referral to another centre. The decision, therefore, was made to proceed with the planned arterial switch operation the following day.' [43]
40 Dr Martin explained his view further in the following exchange:
`Q. ... is it right that a decision that there is no reason not to do a particular series of operations becomes, in any individual case, a reason to do it?
`A. I think we felt that there was no reason not to do it. There are many reasons to go ahead and do an operation in that setting that we were faced with there. We had a child already in hospital, prepared for surgery. You had a child that was well at that stage, no intercurrent infections, so there is an opportunity to do it. His parents were, if you like, ready to go ahead, so there are many reasons why you would go ahead in that situation. You do not cancel operations lightly the night before, so there are positive reasons to proceed.' [44]
41 Dr Monk's note also dealt with the side-meeting. Not being present, he could not note what happened at the side-meeting, only its outcome. His note recorded:
`The meeting dissolved with the support for the continuation of the programme but with an awareness of the political dangers. Doctors Dhasmana, Wisheart and Martin discussed the need for the child's operation and decided that its clinical condition merited an immediate intervention and considered a delay inappropriate. This was accepted with a greater or lesser degree of happiness and conversation outside of the meeting was held between JDW, SNB and CRM regarding the representation of the Trust by SNB and the inappropriate channels of communication that the Department of Health were using.
`The meeting decided that immediate action by the Medical Director and John Roylance to contact the Department of Health to submit the figures for the paediatric programme was an absolute priority.' [45]
42 In his written evidence to the Inquiry Mr Wisheart gave his account of the
side-meeting:
`... I then had a conversation with Mr Dhasmana and Dr Martin. I asked Dr Martin what his views on the urgency of the operation were. My recollection is that he said it should be carried out within a week, although his recollection is that he said it should be carried out within a month. I spoke to Mr Dhasmana [sic] that the circumstances of the debate and this meeting were such that there would be considerable pressure on him while undertaking the operation. He indicated, without any ambiguity, that he felt he would be able to do the operation and that this extrinsic pressure would not [be] a factor.' [46]
43 Mr Dhasmana told the Inquiry of his view of the side-meeting:
`... I was myself quite surprised, really. Maybe Mr Wisheart would have another answer, but I was surprised that if this has been discussed in there, then why call outside?' [47]
44 Mr Dhasmana was asked by Counsel to the Inquiry whether the side-meeting may have been called because he was to be Joshua's surgeon and Dr Martin was his cardiologist and so a separate meeting with only him and Dr Martin might have been useful. Mr Dhasmana replied:
`... there was nothing new which we mentioned there to Mr Wisheart'. [48]
45 Dr Martin told the Inquiry that he thought:
`... he [Mr Wisheart] was concerned about the potential political repercussions if you like of it going ahead and questioned whether - there was certainly discussion as to whether that might influence Mr Dhasmana's performance in the operation and that was a concern I shared.' [49]
46 Mr Wisheart told the Inquiry of his view of the background to the discussion that took place at the side-meeting. He said:
`The meeting took place on a Wednesday, 11th January. Certainly on the Wednesday, possibly on the Tuesday, I had two conversations. One was with Dr Willatts [50] and one was with Dr Monk. What I remember of the two conversations, because they were both quite long and I may not remember everything, but what I do remember was what was similar in them both. What each of them represented to me was the point of view that this present difference of opinion created an additional pressure for the people who would be caring for Joshua Loveday. On the one hand I felt the point they were making to me was a relevant and important one. I did not, as has been suggested by some, feel that it constituted a veto to the operation, I felt it was an important consideration.
`On the other hand, as a surgeon I do know that surgeons frequently have to operate under pressure of a whole variety of types. So pressure is not unusual. However, in the light of the importance of the point they had made to me I felt it was very important that I should represent that point to Janardan, to Mr Dhasmana, with Dr Martin. That is why we had the conversation. I know I made the point, and it is certainly possible that in making the point I suggested to them that the operation should be postponed, suggested how that might be done and so forth; that is certainly possible, in trying to put the point to them in a range of different ways so that I was satisfied it had been properly considered.' [51]
47 Counsel to the Inquiry explored the reasons for a possible postponement of the operation with Mr Wisheart:
`Q. If you sought a postponement or proposed that the operation should be postponed in the wording that you used to the Clinical Directors [52] [which referred to pressure on the surgeon and the surgical team], you were using as an argument, matters which had no direct bearing on the clinical needs of the patient, were you?
`A. Well, they had a direct bearing on the clinical ability of the team to provide a service to the patient.
`A. At least they had a potential direct bearing, excuse me.
`Q. You queried the clinical ability of the team given the circumstances?
`Q. That is where we come back to the semantic difference possibly between asking the question and proposing postponement.
`A. I did not just want to ask a question, get an answer and go away. I was putting it quite seriously and expecting it to be seriously considered. I think it is clear, although the recollection has escaped me, that I probably put it in a variety of different ways and that this was perceived at any rate, certainly by them, possibly by me at the time, to be a proposal, an attempt to persuade them.
`Q. What did you want to achieve?
`A. I wanted to protect everybody involved from the possibility that an operation would have been carried out by somebody who was not truly fit on that day to do it.' [53]
48 Mr Wisheart continued in the following exchange:
`Q. Did you at the start of this conversation consider that there was a risk to the patient given the ability of the team under the pressure that they were to perform the operation?
`A. I considered there was the possibility.
`Q. Tell me, you go on in your description to the Clinical Directors to describe Dr Martin's advice. [54] How do you now recollect Dr Martin's words?
`Q. So you saw him as saying "This operation should not be postponed for longer than a week"?
`A. Yes.' [55]
`... Dr Martin joined with me in putting the question [of extra pressure affecting Mr Dhasmana's ability to work] to Mr Dhasmana once I had articulated it - Mr Dhasmana was positive that the discussion was over, that was past and it would have no impact on his ability to undertake the operation. So the subsequent discussion was pushing him and exploring that, but he remained resolute.' [56]
50 Mr Wisheart stated in his written evidence to the Inquiry:
`He [Mr Dhasmana] indicated, without any ambiguity, that he felt he would be able to do the operation and that this extrinsic pressure would not [be] a factor.' [57]
51 Dr Martin was asked about the degree of urgency of the operation on Joshua:
`... I did not personally feel that was in Joshua's best interests [to delay the operation] because any further prolonged delay without any obvious gain to him in the longer run, I did not see that that was in his best interests. You know the question was whether, if you like, the political considerations should take precedence over the clinical considerations for Joshua and being one of the clinicians involved I felt that his clinical status was important.' [58]
52 Mr Wisheart said that, had Dr Martin expressed the view that the operation was urgent in that it had to be carried out within three months:
`I think it might have led me to prolong the conversation a little bit but I think that the essential points had been covered in the larger meeting and - I mean this was not a passing conversation, the one we are discussing, this was a 20 to 30 [minute] conversation. The points were seriously and repeatedly put and I did feel that I had received a serious answer and one that I was prepared to accept.' [59]
53 Mr Wisheart was asked whether the question of referring Joshua to a different centre was explored:
`It did not really impact as an issue. Had the decision been that the team were not competent to undertake the operation, then whether the operation had been needed within 24 hours or a week or whatever, the patient could have been referred. The issue in my mind was never that the patient could not be referred physically, or because of his immediate clinical need; the issue primarily was, were the team competent to undertake the operation? Then the other considerations were secondary to that.' [60]
54 Dr Martin was also asked whether there was anything which had prevented the referral of Joshua to another centre:
`No, I would have been quite happy referring him elsewhere, in fact we referred many patients after this to other centres, but I was basing that assessment in the letter on the group review of the figures and also of Joshua's situation which unanimously suggested it was clinically reasonable to proceed with the planned surgery. There was nothing stopping me referring him away. Mr Dhasmana could have referred him away.' [61]
55 Mr Wisheart was asked about his knowledge of a proposed independent review of the results of paediatric cardiac surgery:
`Q. Were you the only person, do you think, at the meeting who had any inkling that Dr Roylance was minded to call for an independent [review] -
`A.Yes, I think that is probably correct.' [62]
56 Asked why he had not told Mr Dhasmana that a review of results was in all probability imminent, Mr Wisheart replied:
`... in essence I felt that that would be to add further to the pressure on Mr Dhasmana. I do not know whether that was a right judgement or a wrong judgement, but that was my recollection of what I thought at the time.' [63]
57 Mr Wisheart continued in the following exchange:
`Q. Did you know at the time that had he [Mr Dhasmana] known that there was to be a review in the paediatric cardiac surgery generally, he would have chosen not to operate?
`Q. That might suggest he was actually quite fragile in his confidence at the time?
`Q. And he is a person, is he, who is perhaps more than most self-critical?
`A. He is self-critical, but not lacking in determination or concentration.
`Q. Is determination sufficient, do you think, to avert some of the potential effects of the stresses?
`A. I do not know whether it is sufficient, but it is certainly necessary. I am sure many things are necessary in order to cope with the stresses but I think determination and mental discipline is certainly one of them and I believe he showed that he had that, at least to the best of my ability to understand him, knowing him.' [64]
58 Mr Wisheart agreed with Counsel's suggestion that perhaps Mr Dhasmana could be so keen to help his patients that he could sometimes be prone to ignore external pressures and think that once in the operating theatre he would be focused on the operation and nothing else:
`I suppose it is because of that possibility that I pursued the matter from a number of different angles with him and extended the conversation to the length it was and so I thought I was exploring that with him.' [65]
59 Counsel to the Inquiry asked Dr Martin for his view on Mr Dhasmana's state of mind:
`I guess it is something you are going to have to ask him, exactly what his feelings were, but the impression I gained was that he was not reluctant to proceed. I certainly did not gain that impression. He naturally listened to everyone's concerns and I think he took careful notes of what people said. I presume he was reassured by the fact that as a group we had all sat down and looked at it and felt it was appropriate for him to continue. We specifically, in that separate meeting, did discuss whether we thought, if you like, the political aspects, perhaps the implied criticism there had been, might affect his performance in theatre. That was a concern. But he assured us that that was not the case and I was happy under those circumstances to give my approval, or support him, if you like, in the decision to proceed with the operation. When it comes down to it, it has to be his decision. I cannot make him do an operation. I was concerned that we might be put in a situation where he was going into it, as you put it, reluctantly, but I did not gain the impression that was the case.' [66]
60 Mr Dhasmana described his feelings before and after the meeting, in the following exchange:
`Q. There must have been great pressure on you?
`A. Going into the meeting, but coming out, I felt very good, because people supported, I thought, you know, people supported me. People expressed their trust and belief in me, so I was feeling very much better.' [67]
61 Mr Dhasmana was then asked:
`Q. When you came out of the meeting, you knew what you had not known when you went in, that the Department of Health had been contacted; that Mr Wisheart's view was that the operation should be postponed if at all possible?
`A. It was not his view like that. He was asking the question, whether it can be postponed. I mean, that was the question and he said, you know, "Here we have in a way a loose cannon, and if the patient dies, which is possible with any cardiac patient, this could happen". And we felt that this was a clinical meeting and we should not really be deciding on the basis of political repercussion.' [68]
62 Mr Wisheart was asked by Counsel to the Inquiry whether he had any regrets about the fact that the operation on Joshua Loveday was neither stopped nor referred to a different centre:
`In the light of the outcome of the operation in relation to Joshua and in the light of all the other outcomes of the operation, it is impossible not to regret that decision. Looking back at the actual basis of the decision, I am conscious of this point that you raised about not telling Janardan of the decision to have the outside advice and of course that has been an issue elsewhere as well, but that apart, I feel that the discussion at the meeting - first of all the decision to have the meeting and the discussion at the meeting and the subsequent discussion, all those steps I felt were open and were very clear-cut in their outcome.' [69]
63 Counsel to the Inquiry asked Mr Wisheart what he meant by `that apart':
`From what you tell me if that information had been made known then Mr Dhasmana - says he would have decided not to do the operation. I can say no more.' [70]
64 Joshua's parents met Mr Dhasmana on the evening of 11 January 1995. Joshua's mother stated that once again Mr Dhasmana drew a diagram for them. She stated that he quoted a success rate of 80-85% for the operation and asked them to sign a consent form. Mr Loveday signed this form. Joshua's mother stated that she was keen that they should see Joshua before he was given his pre-operative medication the next morning. She explained that she had already asked a nurse to call them before Joshua was given the medication and she confirmed with Mr Dhasmana that this would happen. [71]
65 Mr Dhasmana was asked by Counsel to the Inquiry whether he informed Joshua's parents about the meeting of clinicians which had taken place before he met them on the evening of 11 January:
`That is my deepest regret, really. With what happened at the end, I regret that I did not really tell them everything when I met them. I wish I had. But at that time, I just had come out from a long tiring meeting, having heard the supporting ways, and I felt quite confident that there would be no problem and this child would be moving about tomorrow or the day after, and I do believe that I felt, you know, that I would be causing more anxiety by telling them what had happened, which, in retrospect, I accept is not right. I do regret that very sincerely and I wish I could really have told them what had happened before.' [72]
66 On the morning of 12 January Joshua's parents stayed with him until he went into the operating theatre. At that point they stated that they were advised to go out for the day and then to telephone the hospital at about 4.00 pm. [73]
67 In her written evidence to the Inquiry, Joshua's mother stated that they duly returned to the hospital at around 4.00 pm. Joshua was not out of surgery so a nurse showed them round the Intensive Care Unit (ICU), to acclimatise them to the setting that Joshua would be in on his return from the operating theatre. The nurse who was showing them around telephoned the operating theatre to find out how Joshua was progressing. She returned to tell Joshua's parents that the operation was still going on as there had been some complications. The nurse then showed them where they would be staying whilst Joshua was in the ICU. [74]
68 Joshua's mother stated that, at around 6.00 pm, the nurse who had been looking after them came into the room where they were watching television and told them that Joshua had died. The nurse sat with them both for a short time and told them that there would need to be an autopsy and an inquest. [75]
69 Joshua's mother stated that Mr Dhasmana arrived to speak to them about half an hour later. Joshua's mother described the meeting in this manner:
`He [Mr Dhasmana] was still dressed in his surgical green gown, and even had his white cap on; he must have walked straight over from theatre. There was blood spattered all down the front of his gown. He looked remorseful, and said, "I'm really sorry". He kept repeating, "I'm so sorry", all through the subsequent meeting with us. By this time, I could not function, let alone talk to him - I just kept saying "Oh my God, oh my God". Because this was the case, Bert talked to Mr Dhasmana, who explained that the part he had tried to fix was too small. Bert shook his hand, and said, "Thanks, mate, you've tried your best".' [76]
70 Joshua's mother stated in her written evidence to the Inquiry that, on arrival home, they telephoned the hospital and were told that Joshua would be in the Chapel of Rest and that family and friends could visit when they wanted. Joshua's parents decided to go to see Joshua the next day. They met Helen Vegoda, Counsellor in Paediatric Cardiology, who described what the Chapel of Rest would be like. After they had seen Joshua, Joshua's parents went to see Mrs Vegoda again. At this meeting she explained that they could have a meeting with Mr Dhasmana if they wished. Joshua's mother stated that they felt that they had said everything they wished and, therefore, declined the offer.
71 Joshua's mother stated that a few days later she telephoned Mrs Vegoda to enquire when the inquest, which the nurse at the hospital had mentioned, would be taking place. Joshua's mother stated that, in reply, Mrs Vegoda told her that there would not be an inquest and that she and Joshua's father:
`... had received all the investigative care to which [they] were entitled.' [77]
72 Mrs Vegoda, commenting on this, stated:
`I cannot recall such a telephone conversation but it was not uncommon for bereaved parents to see me, as a first point of contact after a bereavement, ... I would never have dismissed a parent's query regarding a post mortem or inquest ... I most certainly would never have suggested that a family were not entitled to any investigation they felt were [sic] appropriate.' [78]
73 A coroner's post-mortem was carried out on Joshua on 13 January 1995. [79] The post-mortem report described Joshua's condition up to the point of his admittance to the BRI on 10 January 1995. The report described how, during the operation on 12 January 1995, the pulmonary banding, which Mr Dhasmana had inserted on 2 July 1993, was removed after heart-lung bypass was established. After this procedure was carried out the repair of the transposition of the arteries was attempted. [80] The post-mortem report stated:
`The pulmonary artery was transected just below the band and the two coronary arteries implanted in the pulmonary artery. The right coronary artery appeared rather taut at this stage.' [81]
74 It was later noted in the post-mortem report that:
`It was realised that the right coronary artery was very taut ... . An attempt was made to mobilise the right coronary artery but this caused injury to the main artery, and it was then decided to re-implant the right internal mammary artery to the right coronary artery at the site of the injury ... right ventricular function did not show improvement.' [82]
75 In his letter to Joshua's GP, after Joshua's death, Mr Dhasmana explained:
`This was a rather tricky anastomosis as both of these vessels were very small, less than 1mm in diameter.' [83]
76 After examining the body, Dr Michael Ashworth, the consultant paediatric pathologist, stated:
`The abnormalities present were complex and the surgery complicated by difficult coronary artery transfer.' [84]
Further events in January
77 On 16 January 1995, Dr Doyle wrote an internal memorandum to Dr Graham Winyard, Deputy Chief Medical Officer, and Dr Gabriel Scally, Director of Public Health, South & West NHS Executive. The memorandum was entitled `Paediatric Cardiac Surgery: Bristol Royal Infirmary'. In the memorandum Dr Doyle described how Professor Angelini had approached him about concerns over paediatric cardiac surgery at the BRI. Dr Doyle explained that Dr Bolsin contacted him on 11 January 1995 to inform him that a `Switch' operation had been listed for the following day. Dr Doyle stated that he advised Dr Bolsin to discuss the matter with Professor Angelini and Dr Bolsin's anaesthetic colleagues and, if enough of them agreed that the operation should not take place, to:
`... make every effort to persuade their colleagues to postpone the operation and/or make arrangements for the operation to be done at another centre.' [85]
78 In the memorandum, Dr Doyle also indicated that the operation had taken place and that Mr Wisheart had telephoned him to inform him of the outcome:
`This has been a difficult and traumatic episode for all concerned. There will doubtless be a good deal of heart searching among those involved and a lot of questions have been raised. Perhaps the first question is whether the death was avoidable? We may not know the answer to that question for some time (if ever?). If it was, where does the blame lie? What could/should have been done? Possibly most importantly, how can differences of professional opinion or interpretations of audit data, be resolved without putting patients at risk? It would seem that we need a well recognised and acceptable mechanism for getting independent advice on such difficult questions.' [86]
Dr Doyle's memorandum concluded:
`I have spoken to Dr Roylance (Trust CE) today who assures me that he is setting up an immediate internal enquiry to establish the facts followed by an independent enquiry using outside experts (cardiothoracic surgeons). I expect to hear the results in due course including any recommendations for the future conduct of paediatric CT [cardiothoracic] service in Bristol. I do not believe any further action is required at present but am happy to be advised by yourself or copyees.
`One other general point is whether we should consider initiating discussions with the profession about mechanisms for resolving professional differences without putting patients at risk.' [87]
79 Mr Wisheart stated in his written evidence to the Inquiry:
`We [he and Dr Roylance] made the decision to seek external advice to help the Trust resolve internal differences of opinion. There is uncertainty as to whether we made that decision before or after the meeting of the 11 [January 1995].' [88]
80 Dr Bolsin stated in his written evidence to the Inquiry:
`A meeting took place between at least one senior civil servant from the Department of Health, [Dr] Peter Doyle, Dr Roylance and senior Trust officials in Bristol. My understanding of this meeting was that the Trust was now required to undertake an investigation into paediatric cardiac surgery and abide by the findings and recommendations of the investigators.' [89]
81 Professor Angelini described in his written evidence to the Inquiry what he saw as:
`... a general unwillingness from any quarter to draw in anybody from outside to give us an honest opinion of what we were doing, and indeed it was only after the death of Joshua Loveday that Dr Roylance sought external advice.' [90]
82 On 16 January 1995 Professor Angelini wrote to Dr Roylance:
`... it is sad that we have failed to resolve the issue of paediatric cardiac surgery work internally. In view of this, I share your opinion that an enquiry should be held on the paediatric work carried out in the Department of Cardiac Surgery from 1988 to the present day. I think this is the minimum requirement, given the recent circumstances ... .' [91]
83 Professor Angelini was asked by Counsel to the Inquiry in the following exchange whether the letter of 16 January showed that he knew, or thought, that Dr Roylance had by then decided upon an inquiry:
`Q. So Dr Roylance had by this stage decided there should be an enquiry, had he not?
`Q. That is what the letter said?
`A. It was me putting words in his mouth to force his hand, to have the enquiry ... This is the reason why I cc'd it to everybody, because I was hoping that now, forcing his hand, he could not wriggle out once more and perhaps we now were going to have a really proper look at the results of paediatric surgery.' [92]
84 In his written evidence to the Inquiry, Mr Alan Bryan, a consultant cardiac surgeon at the BRI, described the decision to commission the inquiry as `good' but `belated'. He considered that the decision was `a response to crisis'. [93]
85 On 19 January Professor Vann Jones, Clinical Director of Cardiac Services, wrote to all the cardiac surgeons, stating:
`Dr Roylance has requested that I call a meeting between all the Cardiac Surgeons, myself and himself to discuss the present situation with regard to the "Switch" operations. I would be very grateful if you could make every effort to attend as this is a matter that has to be clarified once and for all.' [94]
86 Professor Vann Jones wrote again to his colleagues on 23 January 1995 stating:
`I was dismayed at the meeting of the Cardiac Surgery Associate Directorate last Tuesday to find how divided and acrimonious the atmosphere is in Cardiac Surgery. I was also sorry to hear and indeed to see how our colleagues in less favoured positions in the directorate are being abused. I don't think we should be bandying terms like "disloyalty" or "lack of co-operation" about. I also thought it was distressing to see the Perfusionist so interrupted that he couldn't get a word in edgeways particularly as the person berating him didn't even turn around to face him.
`I am not trying to single out any individual for particular attention but surely we can take steps to make these meetings more constructive and much less acrimonious. Giant steps have been taken to improve the profile of Bristol Cardiac Services in the past decade and it really is sad to see the way the present situation is developing. I hope once again we can get the whole thing on amicable terms and if there has to be some straight talking let's not air our views quite so publicly.' [95]
87 In his written evidence to the Inquiry, Dr Doyle stated that he spoke to Dr Roylance and Mr Wisheart after the operation on Joshua Loveday and:
`... advised that an outside independent inquiry into both the immediate case and the wider issue of the overall results of the paediatric cardiac surgical service was now essential.' [96]
88 Dr Doyle wrote a further internal memorandum on 24 January 1995 addressed to Dr Winyard and Dr Scally. In this memorandum he further updated his colleagues on the situation developing in Bristol:
`It is still not clear whether there is a serious problem with cardiac surgery or whether this is a serious breakdown in professional relationships. There is cause for grave concern that the Trust has not taken action to resolve the problem; that children's lives might have been put at risk and that rumour and innuendo have been allowed to spread apparently unchecked.' [97]
`I spoke to Dr Roylance (Chief Executive) this morning and advised him in the strongest possible terms to stop complex neonatal and infant cardiac surgery forthwith and to expedite the proposed Enquiry that we discussed the previous Monday. ... I also advised Dr Roylance that yourself and other colleagues in the Department now had to be informed of the situation.
`You will see from this that I have informed Secretary of State's office, Press Office and CA-IU [Corporate Affairs-Intelligence Unit] in case the story leaks to the media. I am not sure whether further action is required at present but am happy to be advised by you or copyees.
`Suggested line to take if required.
`We are aware that concern has been expressed about the neonatal and infant cardiac surgical services at Bristol Royal Infirmary. We do not know at present whether there is any basis for the concerns but have advised the Trust to set up an immediate Enquiry and to cease complex neonatal and infant cardiac surgery until the facts have been established.' [98]
89 On 25 January 1995, Dr Doyle wrote once more to Dr Roylance:
`There is clearly a growing belief that childrens' [sic] lives may have been put at unnecessary risk. Until such doubts can be resolved, it would be extremely inadvisable to undertake any further neonatal or infant cardiac surgery.
`I recognise that this is a very difficult situation for all concerned. The doubts raised can only be resolved by an impartial enquiry and I feel sure that everyone would benefit from disinterested and objective advice. I would therefore suggest that you take all reasonable steps to expedite the proposed Enquiry.
`As you will appreciate, I will have to inform colleagues in the Department about the circumstances as they are currently known to me. I should be grateful if you would let me know as soon as possible of any additional facts that you feel are relevant and what you decide to do. I also expect to be informed, in confidence, of the outcome of the enquiry as soon as they are available.' [99]
90 Dr Roylance replied to Dr Doyle's letter on 26 January 1995. [100] In his letter, Dr Roylance confirmed that the UBHT had ceased to perform complex neonatal and infant cardiac surgery, although he indicated that the UBHT reserved the right to perform such surgery in an emergency if it was in the best interest of the patient to do so. Dr Roylance also confirmed that the Trust was in the process of appointing outside experts to lead an inquiry into its paediatric cardiac surgery service. Dr Roylance indicated that Professor Marc de Leval [101] had already accepted an invitation to be one of the outside experts. Dr Roylance went on to express concern to Dr Doyle over the way in which the matter had come to Dr Doyle's attention:
`... this matter has developed, apparently on the basis of views or whispers by "staff of the Bristol Royal Infirmary and outside Cardiac Surgeons". We do not know whether any facts are on your table. We have had no opportunity to inform you of the results of our work which we are always ready to do, and which was done annually in the context of being a supra-regional centre between 1984 and 1993. Yet we now find ourselves with no practical alternative to a temporary stoppage of infant work following your letter.' [102]
91 Mr Wisheart described in his written evidence to the Inquiry the action taken, once it was decided to set up an external inquiry:
`Dr Roylance asked me as Medical Director to take the initial steps in setting up the enquiry. I sought the advice of Mr John Parker, who is now deceased, but was then President of the British Cardiac Society. He advised me to approach Mr de Leval and Dr Hunter.' [103]
92 Professor Marc de Leval and Dr Stewart Hunter [104] were invited by Mr Wisheart to:
`... assist us resolve some problems arising out of the fact that we are receiving conflicting professional advice in the field of paediatric cardiac surgery. The Trust is committed to the maintenance of the highest standards in this field and now ask you for your authoritative and disinterested advice. The conflicting advice has arisen in the area of the Switch operation for neonates, but has now broadened beyond that.' [105]
93 Professor de Leval explained in his written evidence to the Inquiry:
`I was contacted by Mr James Wisheart in his capacity of Medical Director at UBHT to assist them in resolving some problems in the field of paediatric cardiac surgery ... We were urged to visit UBHT as soon as possible and to issue a report without delay.' [106]
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Footnotes
[1] WIT 0417 0002 Amanda Evans
[2] WIT 0417 0008 Amanda Evans
[3] WIT 0417 0009 Amanda Evans
[4] WIT 0417 0009 Amanda Evans
[5] WIT 0417 0009 Amanda Evans
[6] WIT 0417 0010 Amanda Evans
[7] WIT 0417 0010 Amanda Evans
[8] WIT 0417 0010 Amanda Evans
[9] MR 0164 0022; Medical Records of Joshua Loveday. See Chapter 3 for an explanation of these terms
[10] MR 0164 0034; Medical Records of Joshua Loveday
[11] MR 0164 0034; Medical Records of Joshua Loveday
[12] WIT 0417 0011 Amanda Evans
[15] WIT 0417 0013 Amanda Evans
[16] WIT 0255 0016 - 0017 Mrs Herborn
[17] T61 p.184 Professor Angelini
[18] WIT 0120 0455 Mr Wisheart
[19] WIT 0120 0455 Mr Wisheart
[20] WIT 0120 0455 - 0456 Mr Wisheart
[21] T61 p.184 Professor Angelini
[22] UBHT 0052 0277; letter dated 10 January 1995
[23] T61 p.185 Professor Angelini
[24] T61 p.186 Professor Angelini
[25] T61 p.186 Professor Angelini
[26] See Chapter 3 for an explanation of this term
[27] WIT 0417 0014 Amanda Evans
[30] UBHT 0054 0011; Dr Monk's minute of the later meeting on 11 January 1995
[31] UBHT 0054 0013; Dr Martin's minutes of the meeting
[32] UBHT 0054 0011; Dr Monk's minutes of the meeting
[33] UBHT 0054 0011; Dr Monk's minutes of the meeting
[34] WIT 0120 0456 - 0457 Mr Wisheart
[37] UBHT 0052 0176 - 0177 ; `An account of the events occurring in the Bristol Royal Infirmary and United Bristol Healthcare Trust Department of Paediatric Cardiac Surgery 1989-1995', Dr Bolsin, October 1995 (emphasis in original)
[38] WIT 0270 0016 Dr Masey
[39] WIT 0270 0016 Dr Masey
[40] WIT 0341 0045 Dr Pryn
[41] UBHT 0054 0011; Dr Monk's minute
[42] UBHT 0340 0350; Dr Martin's minute
[43] UBHT 0340 0350; Dr Martin's minute
[45] UBHT 0054 0012; Dr Monk's minute
[46] WIT 0120 0457 Mr Wisheart
[50] Dr Sheila Willatts, a consultant in anaesthesia and intensive care medicine at the BRI, and consultant in charge of ICU at the BRI since 1985
[52] Mr Wisheart's `Statement to the Clinical Directors of United Bristol Healthcare Trust', 3 June 1996, at UBHT 0054 0004 - 0008
[54] UBHT 0054 0007. In his `Statement to the Clinical Directors of United Bristol Healthcare Trust' dated 3 June 1996, Mr Wisheart stated: `Dr Martin advised that the operation should not be postponed for longer than one week on account of the patient's severe cyanosis. When pressed he adamantly insisted that one week was the absolute maximum'
[57] WIT 0120 0457 Mr Wisheart
[61] T77 p.136 Dr Martin. In Dr Martin's minute of the meeting he states that referral was discussed but thought to be inappropriate in Joshua's case; UBHT 0054 0013
[71] WIT 0417 0015 Amanda Evans
[73] WIT 0417 0016 Amanda Evans
[74] WIT 0417 0017 Amanda Evans
[75] WIT 0417 0019 Amanda Evans
[76] WIT 0417 0019 Amanda Evans
[77] WIT 0417 0021 Amanda Evans
[78] WIT 0417 0027 Mrs Vegoda
[79] MR 0164 0021; Medical Records of Joshua Loveday
[80] See Chapter 3 for an explanation of these clinical terms
[81] MR 0164 0022; Medical Records of Joshua Loveday
[82] MR 0164 0022; Medical Records of Joshua Loveday; see Chapter 3 for an explanation of these clinical terms
[83] MR 0164 0019; Medical Records of Joshua Loveday
[84] MR 0164 0028; Medical Records of Joshua Loveday
[85] DOH 0001 0009; memorandum dated 16 January 1995
[86] DOH 0001 0010; memorandum dated 16 January 1995
[87] DOH 0001 0010 - 0011 ; memorandum dated 16 January 1995
[88] WIT 0120 0457 Mr Wisheart
[89] WIT 0080 0126 - 0127 Dr Bolsin
[90] WIT 0073 0018 Professor Angelini
[91] UBHT 0217 0138; letter dated 16 January 1995
[92] T61 p.193 Professor Angelini
[93] WIT 0081 0028 Mr Bryan
[94] UBHT 0061 0255; letter dated 19 January 1995
[95] UBHT 0082 0083; letter dated 23 January 1995
[96] WIT 0337 0003 Dr Doyle
[97] DOH 0001 0015; memorandum dated 24 January 1995
[98] DOH 0001 0015 - 0016 ; memorandum dated 24 January 1995
[99] UBHT 0061 0282 - 0283 ; letter dated 25 January 1995
[100] PAR2 0001 0026 - 0027; letter dated 26 January 1995
[101] Professor Marc de Leval: consultant paediatric surgeon, Professor of Cardiothoracic Surgery, Great Ormond Street Hospital
[102] PAR2 0001 0027; letter dated 26 January 1995
[103] WIT 0073 0108 Mr Wisheart
[104] Dr Stewart Hunter: consultant in paediatric cardiology, Academic Department of Cardiology, Freeman Hospital, Newcastle upon Tyne
[105] UBHT 0061 0337; letter from Mr Wisheart dated 25 January 1995
[106] WIT 0319 0001 Professor de Leval