Annex A > Chapter 30 - Concerns 1995 and after > Concerns 1995 > May onwards
<< previous | next >>
May onwards
Further clarification of the `audit figures'
245 Dr Joffe replied to the article of 15 April in the `British Medical Journal' in a letter published on 6 May 1995. [299]
246 Dr Black, [300] who had collaborated with Dr Bolsin in his analysis of data on PCS, responded to Dr Joffe's letter by writing to Dr Joffe on 23 May. [301] Dr Black, in his written evidence to the Inquiry, stated:
`... I expressed surprise that no attempt had been made to check the accuracy of our tabulations. I invited Dr Joffe to check at least that the patients whom he had classified as dead were indeed dead. Dr Joffe replied on 9 June [302] ... and accepted my offer to supply the names and hospital numbers of the patients we believed had died after undergoing operations in the three categories about which we had concerns. This I did with the covering letter of 15 June 1995 ...'. [303], [304]
247 A meeting took place in June 1995, chaired by Dr Roylance, involving Dr Joffe, Mr Wisheart, Mr Dhasmana, Dr Bolsin and Dr Black.
248 Dr Black stated that it became apparent that there were:
`... serious errors in our tabulation of operations with VSD. There was 1 duplicate entry of a patient (who had been entered in error from each of the two main registers and whom I already mentioned in my covering letter): there was 1 who died after hospital discharge and readmission and, in 3 of the remaining 4, patients had undergone more serious operations than had been entered into the original registers.' [305]
`Dr Joffe, Mr Wisheart and Mr Dhasmana were justifiably indignant and we were profoundly embarrassed over our errors in classifying the VSD operations. We apologised immediately and agreed that a full and public apology was due.' [306]
250 In September 1995, Dr Bolsin wrote to Dr Roylance indicating that he and Dr Black were `dismayed and embarrassed to have made the mistake' [307] in relation to the VSD operations.
251 Counsel to the Inquiry discussed the figures with Dr Bolsin in the following exchange:
`Q. Were those figures when it came to VSD in fact in error?
`Q. To the tune of 500 per cent?
`A. I think we come to that "lies, damn lies and statistics". There were some errors. Another way of looking at it would be to say that we collected something like 3, 000 data sets on 286 patients and we got six or seven of the fields wrong, so exactly how you look at it lies somewhere between the spectrum you have put and the spectrum I have put.
`Q. If one focused on VSDs, so this is a conclusion of the report analysis, is it right or is it wrong to say the result, as produced by the analysis, is 500 per cent wrong?
`A. That is a factual statement.' [308]
252 Mr Wisheart discussed the figures in the following exchange:
`Q. ... in fact there was an arithmetical error which was subsequently acknowledged in that series which showed that, instead of there being the number of deaths claimed, that had been overstated by something like 500 per cent?
`A. 500 per cent, that is correct.
`Q. Far from being a miserable failure, the VSD series would be, would you say, one of the success stories of the unit in the 1990s?
`A. I believe it was, yes.' [309]
253 Mr Wisheart continued in the following exchange:
`Q. When ultimately were those errors corrected so that others knew they were in fact errors?
`A. The first one, the one regarding ventricular septal defect correction, was eventually corrected, in the sense that it was agreed by Dr Bolsin and Dr Black that there was an error, in the second half of September 1995 and there was a letter from Dr Bolsin to Dr Roylance following that meeting in which he acknowledges the error.
`Q. We have that letter in the Inquiry.
`A. Unfortunately, although he had placed the information in the public arena he had never placed the correction in the public arena prior to the GMC findings.' [310]
254 During the course of Counsel's questioning regarding his relationship with Dr Bolsin, Mr Wisheart was asked:
`Q. ... do you feel that there was any impediment preventing Dr Bolsin from telling you about the results of his own audit?
`A. I absolutely do not. I mean, we worked together week in and week out in the Infirmary. I rarely operated on private patients and occasionally did so, and he shared in that practice with the other anaesthetists. We discussed his research. I believe there was every opportunity.' [311]
255 In a letter to Dr Black on 24 July 1996, Professor Farndon expressed his attitude towards the concerns over paediatric cardiac surgery:
`My conversations with James were prompted by anxieties expressed to me by Sheila Willatts and Cedric [312] among others. ... If Sheila and yourself continue to have reservations why are these not examined openly and with a disinterested party to reach definitive decisions? If the data requires further analysis then let it be done. If the data is clear in its statement then let that statement be declared. I think I am correct in remembering from Wednesday's meeting that you had a meeting with James and that this meeting discussed the data and its meaning further. This must mean that there is still not a clear view on whether there is a problem or not. For my part, making comment on your stance, I cannot now understand how you can relinquish any responsibility to continue the search for truth. I do not know why you cannot continue to strive and correct the situation that you feel is "fundamentally wrong".
`... All I have ever wanted to do in this whole business is to see data that we can all agree states the matter as fairly and objectively as we can. I desperately hope that I would not point the finger at a colleague unless I was absolutely sure of the reason that I were pointing that finger.' [313]
Mr Dhasmana's paediatric practice
256 The March 1995 protocol contemplated that Mr Dhasmana would continue to perform paediatric cardiac surgery. [314] Once Mr Pawade arrived, Mr Dhasmana's work began to dwindle. Mr Dhasmana told the Inquiry that he was `very upset' that he was no longer performing paediatric cardiac surgery because:
`... I have shown in my record that I was improving, and the last five years of my work ... except for the arterial switch, was better than average in the country. The de Leval and Hunter committee also in a way supported that.' [315]
257 Dr Roylance stated in his written evidence to the Inquiry:
`As it turned out, the total number of paediatric operations required was within Mr Pawade's capacity and the Paediatric Cardiologists tended to refer all of their cases to him as the dedicated Paediatric Cardiac Surgeon.' [316]
258 Dr Roylance stated in his written evidence to the Inquiry that he began discussing with Mr Dhasmana the amendment of his contract to limit him to operating on adults. [317] Dr Roylance stated that he recognised that Mr Dhasmana `... was, at first, reluctant to give up paediatric cardiac surgery, which he very much enjoyed ...'. [318]
259 On 1 September 1995, Professor Vann Jones wrote to Dr Roylance:
`I came back from holiday and learned with some dismay that the recommendation of myself, Chris Monk and David Hughes has not been implemented, namely, that all the operations on children should be done by Mr Pawade. I gather that Janardan is scheduled to do five operations this month. I feel an opportunity has been missed for a reasonable honourable withdrawal from the Paediatric Service for Janardan and we would be grateful to know what course of action you are planning considering that the advice of the three Clinical Directors involved seems to have been rejected.' [319]
260 Professor Vann Jones accepted:
`If John Roylance had been getting opinions or advice from two different sources, he was not obliged to take mine ... that there were two sides to the argument, I totally accept that.' [320]
`The Trust did not stop Mr Dhasmana or myself from operating ... Dating back to the spring of 1994 (and before that to 1990-91) the proposal was that when the new paediatric cardiac surgeon came, he and Mr Dhasmana would do the paediatric work and I would withdraw. That is what happened. Later, in 1995, Mr Dhasmana also withdrew from paediatric cardiac surgery.' [321]
262 In a letter dated 13 September 1995 to Dr Roylance, Professor de Leval wrote:
`I am led to believe that the quality of Mr Dhasmana's work is not disputed and that the main reason for his dismissal is the public perception that he is part of the bad image that has tarnished the institution during the recent months. If that is correct it is ... an extremely serious precedent and I believe that the matter ought to be discussed at the highest levels.' [322]
263 Professor de Leval sent a copy of this letter to various people, including Sir Terence English, who was by then President of the British Medical Association. Sir Terence wrote to Dr Roylance:
`I was aware that the review conducted by Mr de Leval and Dr Hunter this year exonerated Mr Dhasmana from any hint of professional incompetence with regard to his paediatric cardiac surgery. It does seem therefore completely unjust that he should be treated in this way which will inevitably be seen by the local community as evidence that he was indeed incompetent at his job.' [323]
264 Professor de Leval pursued the matter further, sending another letter to Dr Roylance reiterating the points made in his first letter. [324] Dr Roylance responded on 17 October 1995:
`I tried hard to encourage Janardan to make the decision to withdraw from paediatric cardiac surgery himself ... Janardan was unwilling to make this decision, and I understand and sympathise with his reasons. I have ... invited him to renegotiate his programme to provide for some of the increase in adult cardiac surgery for which we now have contracts.' [325]
<< previous | next >> | back to top
Footnotes
[300] A letter was also written by Dr Bolsin to the `BMJ' on 25 May 1995: BMA 0001 0015
[301] WIT 0326 0033; letter from Dr Black to Dr Joffe
[302] WIT 0326 0037; letter from Dr Joffe to Dr Black
[303] WIT 0326 0039; Dr Black's letter
[304] WIT 0326 0018 - 0019 Dr Black
[305] WIT 0326 0019 Dr Black; see Chapter 3 for an explanation of clinical terms
[306] WIT 0326 0019 Dr Black; see Chapter 3 for an explanation of clincial terms
[307] UBHT 0061 0053; letter from Dr Bolsin to Dr Roylance (undated)
[308] T80 p.16 Dr Bolsin; see Chapter 3 for an explanation of clincial terms
[309] T92 p.98-9 Mr Wisheart; see Chapter 3 for an explanation of clincial terms
[312] Dr Sheila Willatts and Professor Cedric Prys-Roberts
[313] UBHT 0150 0024 - 0025 ; letter dated 24 July 1996
[314] WIT 0106 0127; protocol
[316] WIT 0115 0031 Dr Roylance
[317] WIT 0115 0031 Dr Roylance
[318] WIT 0115 0031 Dr Roylance
[319] UBHT 0146 0027; letter dated 1 September 1995
[320] T59 p.199-200 Professor Vann Jones
[321] WIT 0115 0029 Mr Wisheart
[322] UBHT 0061 0346; letter dated 13 September 1995. Mr Dhasmana's contract of employment was terminated by the UBHT with effect from 3 September 1998
[323] UBHT 0061 0348; letter dated 25 September 1995
[324] UBHT 0061 0349; letter dated 12 October 1995
[325] UBHT 0061 0352 - 0353 ; letter dated 17 October 1995