| Date | Event |
| 1984 | Bristol Unit designated as a supra regional service for neonatal and infant cardiac surgery (NICS). |
| 1984-1985 | Bristol Unit performed 3 operations on children under 1 year. |
| 1985-1986 | Bristol Unit performed 14 operations on children under 1 year. |
| 20 October 1986 | Letter from Professor Henderson and others to South Glamorgan Health Authority describing the service at Bristol for neonatal cardiac surgery as being `at the bottom of the league for quality'. |
| 1986 | Professor Henderson contacted Professor Sutherland expressing concerns about referring children from South Wales to Bristol in view of the poor surgical results. |
| 1986 | Professor Crompton raised the matter of Professor Henderson's concerns with Professor Acheson, who asked him to see Dr Halliday. Dr Halliday confirmed only that there was a problem with waiting lists. Dr Halliday said that as there was no evidence to support the concerns, he could not take the matter any further. |
| Autumn 1986 | Bristol Unit visited by health officials from Wales to explore Professor Henderson's criticisms. |
| 1986 | Returns to the UK Cardiac Surgical Register (UKCSR) showed 24 open-heart operations on children under 1 year, with 6 deaths. |
| 1986-1987 | Dr Perham expressed concern to Dr Keeton about results in the Bristol Unit, and asked if it was appropriate for the South West Region to refer complex cases to Southampton. |
| May 1987 | Mr Neil Hall wrote a report for the Children's Heart Circle of Wales entitled `Meanwhile our Children are Dying'. |
| 16 June 1987 | BBC Wales broadcast a television programme entitled `Heart Surgery - The Second Class Service'. |
| After 16 June 1987 | Mr Wisheart, Mr Dhasmana, Dr Jordan and Dr Joffe wrote a joint (undated) letter to `the Editor', which took issue with the programme's comments about Bristol. |
| 3 August 1987 | Mr Wisheart, Mr Dhasmana, Dr Jordan and Dr Joffe wrote a letter to Dr Chamberlain concerning the Cardiology Group of the Royal College of Physicians' report on the development of cardiological services in Wales. |
| 22 December 1987 | Legal proceedings for defamation against the Heart Circle under consideration. Mr Wisheart wrote to Mr Gray in relation to this. |
| 1987-1989 | District General Managers (DGMs) informed Region both formally and informally at the District Reviews that they had cardiologists who were not happy with referring to the Bristol Unit. (NB This probably relates to adult rather than paediatric surgery.) |
| 1987 | Exeter's reluctance to refer to Bristol made known to Region. |
| 1987 | Miss Hawkins related her concerns to Dr Roylance. |
| 1987 | Bristol Unit's return to the UKCSR for the year ending 31 December 1987 showed 25 procedures on under-1-year-olds, with 7 deaths. |
| 1987 | The Bristol Unit produced its first Paediatric Cardiology and Cardiac Surgery Annual Report. |
| 1 September 1988 | Dr Bolsin commenced his employment and immediately had concern over the length of operation and bypass times. |
| 1988 | The Bristol Unit's 1988 Paediatric Cardiology and Cardiac Surgery Annual Report listed 29 operations on under-1-year-olds, with 11 deaths (over one third). |
| 1989 | Dr Bolsin approached Professor Prys-Roberts about his developing concerns about mortality. Professor Prys-Roberts advised him to collect evidence to create a clear picture of what was going on. |
| 18 September 1989 | Dr Bolsin issued a report of his first year in his post at the BRI. |
| 27 September 1989 | Dr Johnson acknowledged the report and offered support in a letter to Dr Bolsin. |
| 1989 | The Bristol Unit's 1989/90 Paediatric Cardiology and Cardiac Surgery Annual Report showed 40 open-heart operations on children under 1 year old, with 15 deaths. |
| 1990 | Cheltenham's reluctance to refer to Bristol made known to Region. |
| 7 August 1990 | Dr Bolsin sent a letter to Dr Roylance dealing with the appendix to the Application for Trust Status, and asking that the mortality for open-heart surgery on patients under 1 year of age should be addressed. |
| After 7 August 1990 | Dr Bolsin met Mr Dean Hart at the latter's request, in response to the letter he had sent to Dr Roylance. |
| After 7 August 1990 | Dr Roylance telephoned Dr Bolsin in response to the letter addressed to him. |
| After 7 August 1990 | Dr Bolsin's evidence was that he met Mr Wisheart at the latter's request, in response to the letter sent to Dr Roylance. Mr Wisheart denied this. |
| After 7 August 1990 | Dr Bolsin met Dr Williams in response to the letter sent to Dr Roylance. It was Dr Williams' evidence that he also spoke to Mr Wisheart about the letter. Mr Wisheart does not recall this. |
| October 1990 | Miss Hawkins had a meeting with colleagues from Exeter concerning their dissatisfaction with the process of contracting, and their wish to move contracts to other areas. |
| November 1990 | Miss Hawkins spoke to DGMs about concerns which they had with the Bristol Service. |
| December 1990 | Miss Hawkins conveyed this dissatisfaction to the Department of Health. |
| 1990 | Report of the Cardiac Surgical Unit gave figures for open-heart operations in 1990 for under 1 year as 39 operations with 5 deaths. Good results when compared to the UKCSR. |
| 1991 | Dr Bolsin was advised at an anaesthetists' meeting to keep a low profile in the aftermath of his letter to Dr Roylance. |
| 7 January 1991 | Dr Shinebourne visited the BRHSC as Joint Committee on Higher Medical Training of the Medical Royal Colleges (JCHMT) representative in order to assess the establishment of a Senior Registrar post in paediatric cardiology, which he did not recommend. |
| 28 July 1991 | Meeting of the Paediatric Cardiac Surgical and Anaesthetic Group to discuss Unit performance and treatment protocols. Dr Bolsin took the minutes of this meeting, and was subsequently told not to do so again. The minutes refer to there having been a sense that outcomes had `been reaching crisis proportions'. |
| October 1991 | Professor Prys-Roberts again met Dr Bolsin to discuss his preliminary data on mortality. He suggested that Dr Bolsin continue to keep accurate records of outcomes. |
| 11 October 1991 | Professor John Norman wrote to Professor Prys-Roberts about the approach of three cardiac anaesthetists to one of his cardiac team with their concerns over the results of cardiac surgery in Bristol. A discussion between the two of them followed. |
| October 1991 | Bristol Heart Circle started to keep a notebook of patients' details, which included details of bypass time and of outcome. |
| Autumn 1991 | Dr Bolsin spoke to Dr John Zorab about his concerns. Dr Zorab said that he would appraise Sir Terence English informally of the problems. |
| 20 November 1991 | Miss Hawkins wrote to Dr Roylance about the dissatisfaction Region-wide with the rate and `quality of performance' of the Cardiac Unit, having spoken to him prior to sending the letter to ensure that he understood its content. |
| Late 1991 | Mr Martin Elliott was invited to apply for the Chair of Cardiac Surgery at the University of Bristol. |
| 1991 | The Unit's Annual Report showed that there had been 46 open-heart operations on children aged under 1 year in 1991, of whom 14 had died. |
| 3 January 1992 | Dr Roylance replied to Miss Hawkins' letter. Reply drafted by Mr Wisheart, 12 December 1991. |
| 3 January 1992 | Mr Elliott wrote to Mr Wisheart indicating that he had decided not to apply for the Chair of Cardiac Surgery at Bristol. |
| The week following 3 January 1992 | Miss Hawkins spoke to Mr Wisheart about cardiologists' concerns. |
| Early 1992 | Dr Bolsin visited Professor Prys-Roberts to express his concerns again, following which the latter said he would speak informally to Dr Roylance. |
| 6 February 1992 | Mr Steven Owen, Administrative Secretary to the Supra Regional Services Advisory Group (SRSAG), visited Bristol. He received data on mortality during his visit, indicating 30% mortality in the under-1s, which he passed to Dr Halliday. |
| 14 February 1992 | First article published in `Private Eye' which referred to cardiology and cardiac surgery in Bristol. |
| 5 March 1992 | Professor Prys-Roberts met Dr Roylance and probably on this occasion discussed the Bolsin data. |
| 27 March 1992 | Second article published in `Private Eye' which referred to cardiology and cardiac surgery in Bristol. |
| Spring 1992 | Dr Bolsin met Kathleen Orchard and discussed comparative performance of the Bristol Unit. |
| 29 April 1992 | Dr Hammond met Dr Bolsin to show him the figures he had received from his source to check their accuracy. |
| 8 May 1992 | A meeting of the working party of the SRSAG was held at the Royal College of Surgeons, which discussed the need to maintain the number of supra regional funded units at nine. |
| 8 May 1992 | Further article in `Private Eye' about paediatric cardiac surgery (PCS) at the UBHT. |
| After 8 May 1992 | Mr Peter Durie discussed the `Private Eye' articles informally with members of the UBHT Board. |
| May/June 1992 | Mr Dhasmana's secretary gave him a copy of the `Private Eye' article that had been passed to her. Mr Dhasmana subsequently questioned all those present at the meeting of 3 June 1992 to seek to find out who was responsible for passing information from the meeting to `Private Eye'. |
| 3 June 1992 | The Bristol paediatric cardiac clinicians held a meeting to review the results of the Arterial Switch operation. |
| 19 June 1992 | Working Party Report commissioned by the SRSAG was delivered by Professor Hamilton to Sir Terence English. Supported continuing designation of Bristol. |
| 22 June 1992 | Letter sent to Dr Roylance by Ms J Binding, Corporate Affairs, NHS Management Executive, enclosing a letter dated 24 May 1992 written to the Secretary of State by a parent whose child was about to have surgery at the BRI. |
| 22 June 1992 | Dr Bolsin met Professor Prys-Roberts and discussed concerns and data collection. |
| 2 July 1992 | Sir Terence English, as President of the Royal College of Surgeons of England (RCSE), wrote a letter to Dr Halliday, enclosing the Hamilton Working Party Report and supporting its conclusions. |
| 2 July 1992 | Sir Terence English wrote to Professor Hamilton to thank him for the report and to express the full support of the RCSE for it. |
| 2 July 1992 | Sir Keith Ross wrote to Mr Wisheart to deny that comments in `Private Eye' suggesting concern about Bristol standards were attributable to him. |
| 3 July 1992 | A further article appeared in `Private Eye' about the mortality statistics at the UBHT, drawing unfavourable comparison with results in the USA and in Birmingham, UK. |
| 15 July 1992 | Dr John Zorab wrote to Sir Terence English at the RCSE, enclosing a copy of the article from `Private Eye' reporting concern and raising the issue of mortality. |
| 21 July 1992 | Dr Zorab's letter was forwarded to Sir Terence English by Sir Norman Browse, who had taken over from Sir Terence as President of the RCSE. Sir Terence subsequently went back to look at the Working Party Report data. He reconsidered his view as to Bristol's continued designation. |
| 23 July 1992 | Dr Roylance replied to Ms Binding in a letter dictated by Mr Wisheart and signed by Dr Roylance. |
| 23 and 24 July 1992 | Sir Terence spoke to Professor Hamilton twice by telephone and discussed the mortality rates at Bristol, and agreed that it should be recommended to the SRSAG that Bristol be
de-designated. It was also agreed that Sir Terence should telephone Dr Halliday, which he did. Evidence as to what was said about the substance of the reservations was in conflict. |
| 25 July 1992 | Sir Terence dictated a reply to Sir Norman. |
| 25 July 1992 | Sir Terence dictated a letter to Dr Zorab. |
| 28 July 1992 | Meeting of the SRSAG. Dr Halliday communicated the fact of Sir Terence's reservations about the continuing designation of the Bristol Unit to the meeting, but gave no reason for his having such reservations. |
| July 1992 | A decision was taken to de-designate NICS with effect from April 1994 as a supra regional service. |
| July 1992 | Dr Black's daughter began a tabulation of data which had been collected by Dr Black and Dr Bolsin. |
| 3 August 1992 | Professor Hamilton wrote to Sir Terence English saying that the Working Party could be requested by the Advisory Committee on supra regional funding (SRSAG) to reconsider the mortality figures and possibly amend its findings. |
| 29 September 1992 | Next meeting of the SRSAG after July. Sir Terence attended and addressed the matter of his concerns over de-designation of the service as a whole. He did not refer to any specific concerns over Bristol. |
| 9 October 1992 | `Private Eye' published an article claiming that the concerns over PCS at the UBHT had been confirmed by an internal audit of the preceding two years' operations. |
| 1992 | Cardiac theatre nurses expressed concerns over the outcome of PCS operations. |
| October 1992 | Professor Gianni Angelini was appointed Professor of Cardiac Surgery. Shortly afterwards Dr Black and Dr Bolsin presented him with the results of their collection and analysis of data. |
| 19 November 1992 | The Regional Advisor of the Royal College of Physicians, K R Hunter, wrote a report `Regional Adviser's Visit' to the BRI. |
| 7 December 1992 | The UBHT Management Board Meeting noted that a Regional Working Party had been examining cardiac services in the Region and their dissatisfaction with quality and costs in Bristol. |
| December 1992 | Mr Dhasmana visited Birmingham with Dr Masey in order to observe Mr William Brawn at the Birmingham Children's Hospital performing a neonatal Arterial Switch. |
| 5 January 1993 | Mr Wisheart met with Professor Dieppe to discuss the AVSD results. |
| Early 1993 | Professor Farndon became aware of concerns over PCS when Dr Bolsin came to see him. Dr Bolsin left hard copies of his data. |
| Spring 1993 | Dr Masey became aware of the Bolsin/Black data. She subsequently asked for, and was shown, the most recent set of his figures by Mr Dhasmana. |
| 1993 | Dr Sheila Willatts had prolonged discussions with Dr Bolsin regarding outcomes and the course of action he might reasonably take. Dr Willatts spoke to others and Professor Farndon offered to chair a meeting. |
| 1993 | Mrs Mona Herborn expressed to Dr Masey her view that Mr Dhasmana was not capable of performing the Switch operation. |
| July 1993 | Mr Dhasmana visited Birmingham Children's Hospital to observe Mr Brawn operating for a second time. He was accompanied this time by Dr Underwood. |
| 1 July 1993 | Mr Alan Bryan, consultant cardiac surgeon specialising in adult cardiac surgery, took up his post as Senior Lecturer in cardiac surgery at the University of Bristol. Shortly after (in the autumn of 1993), Dr Bolsin presented to him outcome statistics in relation to PCS. Dr Bryan subsequently talked to other clinicians about concerns. |
| September 1993 | Dr Bolsin spoke to Professor Angelini regarding data which had been collected. |
| October 1993 | Dr Bolsin took his data to show Dr Monk, at the latter's request. |
| November 1993 | Professor Angelini talked to Mr Jaroslav Stark, consultant cardiothoracic surgeon at Great Ormond Street Hospital, (amongst others) about the data which Dr Bolsin had given him. At about the same time Professor Keen expressed his concerns to Professor Angelini, who also spoke to Professor Farndon. |
| 16 November 1993 | Dr Bolsin attended an appointment to see Professor Vann Jones, who had become the first Clinical Director of the newly created Directorate of Cardiac Services in the preceding month. Dr Bolsin showed him data for the BRI surgery on children and comparative UK data. |
| 17 or 18 November 1993 | Mr Wisheart went to visit Professor Vann Jones with a different set of figures for these procedures. |
| December 1993 | Dr Jane Ashwell, a Senior Medical Officer at the Department of Health, met with Dr Bolsin at the Royal College of Anaesthetists and discussed outcomes. |
| 13 December 1993 | Dr Ashwell wrote to Dr Bolsin to say that she had spoken to Professor Farndon and had raised the issues discussed. |
| 23 December 1993 | Professor Angelini and Professor Farndon went to see Mr Wisheart to express concerns and to urge the appointment of a new consultant paediatric cardiac surgeon. |
| Latter part of 1993 | Dr Alison Hayes was asked to collate the figures for the Arterial Switch operation. |
| Latter part of 1993 | Dr Stephen Pryn was asked to prepare figures on paediatric cardiac outcome data for the chronological year ending 31 December 1993. |
| Latter part of 1993 | Dr Bolsin showed Dr Davies the data he had collected and Dr Davies encouraged him to show the data to someone in authority. |
| 1993 | The Unit's return to the UKCSR showed figures for open-heart surgery on the under-1s as 53 procedures with 8 deaths. |
| 20 January 1994 | Audit meeting of surgeons, anaesthetists and cardiologists at which Dr Pryn presented some figures, as did Mr Wisheart from memory. Dr Hayes did not produce her data as planned. |
| 10 February 1994 | Dr Bolsin replied to Dr Ashwell's letter, thanking her for what she had done. |
| February 1994 | Professor Angelini began to raise concerns with Dr Roylance. They had at least two meetings between the end of 1993 and March 1994. |
| March 1994 | Professor Angelini and Dr Monk met Dr Roylance. Professor Angelini thought that Dr Roylance had data from Dr Bolsin but did not specifically refer to it. |
| April 1994 | Professor Vann Jones met with Dr Bolsin and Dr Laszlo to discuss Dr Bolsin's revised figures and was persuaded that there was a problem with PCS. |
| 5 April 1994 | Dr Monk, Mr Wisheart, Dr Bolsin and Professor Angelini went to dinner at Bistro 21, to discuss possible concerns. Despite the invitation to do so, neither Professor Angelini nor Dr Bolsin expressed any concerns. |
| 18 April 1994 | Dr Bolsin attended an appointment with Ms Janet Maher, as General Manager of the Directorate of Surgery at the UBHT, and discussed his data and concerns. |
| Week following 18 April 1994 | Ms Janet Maher spoke to Dr Monk and also to Dr Roylance, and repeated to each what Dr Bolsin had said to her. |
| April 1994 | Professor Vann Jones was asked by Miss Lesley Salmon to convene a meeting of the non-medical staff to inform and reassure the departmental staff, which he did. |
| April 1994 | Mr Wisheart completed his two-year term as Chairman of the Hospital Medical Committee. |
| May 1994 | Professor Angelini was visited by Mr Durie and Mrs Maisey to discuss PCS problems. |
| May 1994 | Professor Angelini spoke to Professor Vann Jones about his concerns. |
| 12 May 1994 | Professor Angelini and Professor Vann Jones wrote to Mr Durie about the appointment of a new paediatric cardiac surgeon, commenting that, without this, PCS at Bristol would collapse. |
| May 1994 | Mr Durie raised the Professors' concerns orally with Dr Roylance and asked him to look into them. He subsequently regretted not pressing Dr Roylance as to what he had done about them. |
| 12 May 1994 | The Cardiac Expansion Working Party of the UBHT reported a perception that the quality of paediatric cardiac services at Bristol did not match that of `competitors'. |
| June 1994 | Anaesthetists discussed a letter expressing concerns about the Switch operation, and decided to address it to Dr Monk, for him to take forward with Dr Roylance. |
| 21 June 1994 | Letter signed by six anaesthetists at the UBHT expressing concern about the Arterial Switch programme being undertaken at the BRI. |
| 30 June 1994 | Dr Underwood anaesthetised a patient undergoing a non-neonatal Switch operation. |
| 1 (or 12) July 1994 | Dr Monk spoke to Dr Roylance and informed him that there was a problem in PCS regarding outcomes. He says that he offered Dr Roylance a copy of the anaesthetists' letter, but that Dr Roylance refused to accept it since it was addressed to Dr Monk. Dr Roylance denies being shown the letter at all. |
| July 1994 | The anaesthetists' concerns about the Arterial Switch programme were brought to Mr Dhasmana's attention by Dr Monk. |
| 19 July 1994 | Dr Peter Doyle attended a meeting in Bristol. Dr Bolsin accompanied him back to the station. During the journey, he handed Dr Doyle a copy of his data in an envelope (which Dr Doyle subsequently did not read), and outlined concerns. |
| 21 July 1994 | Dr Doyle wrote to Professor Angelini, and stated that concerns over mortality rates in NICS at the BRI had been brought to his attention. |
| 19 August 1994 | Professor Angelini replied to Dr Doyle's letter. |
| 30 August 1994 | Dr Doyle replied to Professor Angelini's letter. |
| 4 September 1994 | Mr Wisheart wrote to Dr Roylance, commenting on Professor Angelini's letter of 19 August 1994 and referring to `the limited nature of the problem'. |
| 12 September 1994 | Dr Roylance wrote to Dr Doyle, having been made aware that correspondence had passed between Dr Doyle and Professor Angelini stating that the Trust Board were `aware of the problem'. (There was no evidence to this effect given to the Inquiry.) |
| September 1994 | Professor Farndon, Mr McKinlay and Professor Angelini had a meeting to ensure there would be no administrative problems associated with the appointment of the new paediatric cardiac surgeon. |
| 22 September 1994 | Dr Roylance wrote to Dr Doyle to inform him that a new paediatric cardiac surgeon had been appointed and of the progress in moving PCS to the BRHSC. |
| 3 October 1994 | Dr Doyle replied, thanking Dr Roylance for keeping him up to date. |
| October 1994 | Mr McKinlay began to hear for the first time from Dr Roylance about Dr Bolsin and Dr Doyle. |
| 10 November 1994 | A consultants' meeting was held, attended by Mr Dhasmana, Mr Hutter, Mr Bryan and Professor Angelini, immediately after the monthly audit meeting. The meeting ended in acrimony, with Mr Dhasmana accusing Professor Angelini of raising concerns about his clinical performance outside Bristol, and the Professor seeking to rationalise the paediatric cardiac service. |
| 17 November 1994 | Professor Farndon discussed the concerns being expressed about PCS with Mr Wisheart. The latter agreed that the outcomes of some procedures were `not good'. |
| 18 November 1994 | Professor Farndon set out the previous day's discussion and the agreed way forward in a letter to Mr Wisheart. |
| 21 November 1994 | At one of his clinics, Dr Martin saw Joshua Loveday for the last time before his operation on 12 January 1995. |
| 8 December 1994 | A meeting of the `Paediatric Heart Club' took place in the evening at Dr Joffe's house to discuss Mr Dhasmana performing non-neonatal Switch operations. |
| 15 December 1994 | Professor Vann Jones wrote to Mr Wisheart acknowledging receipt of data Mr Wisheart had sent him. |
| By Christmas 1994 | Mr McKinlay said he had reached the point where he told Dr Roylance that he wanted an independent inquiry and Dr Roylance agreed to it. Dr Roylance said that this decision was not reached until after the Loveday operation. |
| After Christmas 1994 | Joshua Loveday's parents received a letter from the BRI advising them that if they wished the operation to go ahead Joshua could be admitted to the BRI on 10 January 1995. |
| December 1994 | Dr Bolsin contacted Dr Doyle at the Department of Health in the light of the proposed operation. |
| 1994 | Figures submitted to the UKCSR showed that there had been 50 open-heart operations in those under 1 year of age, with 14 deaths. |
| January 1995 | Mrs Herborn pointed out the listing of Joshua Loveday to Dr Bolsin, who told her the operation would not take place. By 11 January she said she had spoken to Dr Bolsin again and also to Professor Angelini. |
| 6 January 1995 | Professor Angelini went to see Mr Wisheart to persuade him that the Loveday operation should not proceed. |
| 6 January 1995 | Immediately after the meeting with Professor Angelini, Mr Wisheart telephoned Dr Bolsin and agreed that data was to be urgently gathered and that there would be a meeting of the whole Paediatric Group on 11 January 1995 to review the decision to operate on Joshua Loveday. |
| 10 January 1995 | Professor Angelini wrote to Mr Wisheart in order to put his concern in writing. |
| 10 January 1995 | Joshua Loveday was admitted to the BRI. Dr Martin did not see Joshua upon admission. |
| 11 January 1995 | Dr Doyle telephoned Dr Roylance to advise him of the fact that concerns over the operation had been expressed to him by Professor Angelini. |
| 11 January 1995 | Dr Monk spoke to Mr Wisheart expressing his view of the risks of going ahead with the proposed operation. |
| 11 January 1995 | At 5.30 pm a meeting of clinicians was held in the Catheter Laboratory at the BRHSC to discuss the outcomes at Bristol of Arterial Switch surgery and whether to proceed with the planned surgery on Joshua Loveday. Dr Martin, Mr Wisheart and Mr Dhasmana convened a side-meeting, which took place after the discussions in the main clinicians' meeting. The need for the operation was expressed as urgent. The decision of the meeting was to proceed. That of the side-meeting was to the effect that Mr Dhasmana felt able to do so. |
| 11 January 1995 | Joshua's parents gave consent to the operation. They had not been told of the (extraordinary) meeting which had just been held to discuss the advisability of the operation. |
| 12 January 1995 | Mr Wisheart telephoned Dr Doyle to inform him that the outcome of the meeting had been to proceed with the planned operation. |
| 12 January 1995 | Operation on, and death of, Joshua Loveday. |
| 12 January 1995 | Dr Doyle spoke to Dr Roylance and Mr Wisheart and advised that an outside independent inquiry into the PCS service was now essential. |
| 13 January 1995 | A coroner's post-mortem was carried out on Joshua Loveday. |
| 16 January 1995 | Professor Angelini wrote to Dr Roylance stating that an inquiry should be held on the paediatric work carried out in the Department of Cardiac Surgery. |
| 19 January 1995 | Professor Vann Jones wrote to all the cardiac surgeons, stating that Dr Roylance had requested him to call a meeting between all the cardiac surgeons, himself and Dr Roylance to discuss the situation with regard to the Switch operations. |
| 23 January 1995 | Professor Vann Jones wrote to the members of the cardiac surgery associate directorate expressing his dismay at how divided and acrimonious the atmosphere was in cardiac surgery at the most recent meeting. |
| 24 January 1995 | Dr Doyle wrote an internal memorandum addressed to Dr Winyard and Dr Scally, updating his colleagues on the situation developing in Bristol. |
| 25 January 1995 | Dr Doyle wrote to Dr Roylance saying that it would be extremely inadvisable to undertake any further neonatal or infant cardiac surgery. |
| 26 January 1995 | Dr Roylance replied to Dr Doyle's letter, confirming that the UBHT had ceased to perform complex neonatal and infant cardiac surgery. |
| 3 February 1995 | Dr Doyle wrote to Dr Roylance confirming the way forward for the inquiry. |
| 10 February 1995 | Professor de Leval and Dr Hunter visited the UBHT. |
| 24 February 1995 | Dr Roylance told the UBHT Board that Mr Wisheart would review the contents of the report together with Professor Vann Jones and Dr Joffe. |
| 24 February 1995 | Dr Roylance went on annual leave. |
| During the week of 27 February 1995 | The faxed report became known to Mr Nix following press interest. Mr Nix stated that he consulted Mr McKinlay about the appropriate response to be made by the UBHT. |
| 3 March 1995 | Mr McKinlay wrote to Ms Rennie Fritchie that he had requested Mr Wisheart not to deal with the media queries and to leave the internal action in the hands of Dr Laszlo. |
| 3 March 1995 | The report was considered by Dr Laszlo, Dr Joffe, Dr Monk and Professor Vann Jones. This led to a report of their combined views, which was produced to assist Mr McKinlay and Mr Nix. |
| 3 March 1995 | Mr McKinlay wrote to Ms Rennie Fritchie confirming the UBHT's intention to act on the report's recommendations. |
| 6 March 1995 | The UBHT's first press statement in relation to the performance of the PCS team was made. |
| 6 March 1995 | NHS Executive arranged a meeting between the Regional Health Authority, the UBHT and NHS Executive representatives. |
| 9 March 1995 | The above meeting took place and the report was considered. It was agreed at the meeting that the approach would be as set out in Dr Roylance's letter to Dr Doyle of 26 January 1995. |
| 13 and 14 March 1995 | Two meetings were held of all relevant consultants to discuss the report. |
| 15 March 1995 | Mr Nix and Mr McKinlay set out what they believed was the consensus view of the way forward in the department in a draft protocol. |
| 15 March 1995 | The draft protocol was circulated to the clinicians and to Professor de Leval and Dr Hunter for their approval. A copy of the protocol was sent to Ms Fritchie inviting comment. |
| 21 March 1995 | Professor de Leval indicated his satisfaction in a letter. |
| 27 March 1995 | Dr Hunter indicated his satisfaction in a letter. |
| 4 April 1995 | The media broadcast the story surrounding the UBHT. A helpline was set up by the Trust. |
| 5 April 1995 | `Daily Telegraph' article was published. |
| 6 April 1995 | Dr Bolsin appeared on the BBC regional news programme. |
| 16 April 1995 | A letter written on behalf of Dr Joffe, Dr Martin, Dr Hayes, Mr Wisheart and Mr Dhasmana was addressed to the medical staff, setting out the UBHT's position. |
| 1995 | Meeting between Dr Bolsin and Dr Roylance in respect of the investigation in relation to an incompatible blood transfusion. Dr Bolsin described being threatened with the sack. Dr Roylance denied that this was what was intended by an analogy he used in conversation. |
| April 1995 | A similar analogy was used to Dr Bolsin's union representative, and was similarly interpreted. |
| April 1995 | Dr Bolsin's anaesthetising rota was altered. |
| 24 April 1995 | Dr Bolsin wrote to Dr Monk expressing his concerns about the unofficial change to his contract that had occurred in the previous two weeks. |
| 25 April 1995 | At a clinic, Dr Martin met Mrs Peacock, mother of Andrew. |
| 25 April 1995 | A meeting was held to discuss changes in Dr Bolsin's cardiac commitments, attended by Dr Bolsin, Dr Monk, Dr Trevor Thomas and Professor Prys-Roberts. |
| 26 April 1995 | Dr Monk replied to Dr Bolsin's letter, asking him to agree to flexibility in his work pattern, in order to avoid interpersonal conflict. |
| 1 May 1995 | Mr Pawade took up his position as paediatric cardiac surgeon at the BRI. |
| 1 May 1995 | Surgery took place on Andrew Peacock, performed by Mr Wisheart. |
| 6 May 1995 | Dr Joffe's reply to the article of 15 April was published in the `British Medical Journal' concerning the audit figures. |
| 23 May 1995 | Dr Black responded to Dr Joffe by letter. |
| 25 May 1995 | A letter was written by Dr Bolsin to the `British Medical Journal'. |
| 30 May 1995 | Andrew Peacock died. |
| June 1995 | A meeting took place to discuss the audit figures involving Dr Joffe, Mr Wisheart, Mr Dhasmana, Dr Bolsin and Dr Black, chaired by Dr Roylance. |
| June-August 1995 | Arrangements for counselling were made by the UBHT to mediate between the cardiac surgeons and Dr Bolsin. |
| Autumn 1995 | Dr Bolsin withdrew from the counselling process. |
| 1 September 1995 | Professor Vann Jones wrote to Dr Roylance to express his dismay that the recommendation that all the operations on children should be done by Mr Pawade had not been implemented. |
| 13 September 1995 | Professor de Leval wrote to Dr Roylance concerning the quality of Mr Dhasmana's work and his withdrawal from PCS. |
| September 1995 | Dr Bolsin wrote to Dr Roylance indicating that he and Dr Black were dismayed to have made a mistake in relation to the VSD operations. |
| 12 October 1995 | Professor de Leval sent another letter to Dr Roylance reiterating the points made in his first letter. |
| 17 October 1995 | Dr Roylance responded to Professor de Leval. |
| November 1995 | Professor de Leval was invited to write a report on the updated PCS results of the UBHT. |
| 23 January 1996 | Mr Ross sent the second de Leval report to the Regional Director of the NHSE. |
| 26 January 1996 | The UBHT's final report on PCS was presented to, and approved by, the UBHT Board. |
| 31 January 1996 | The UBHT's final report was presented at a public meeting. |
| February 1996 | Dr Bolsin left the Trust's employment to take up an appointment in Australia. |
| 27 March 1996 | Sir Terence English commented on the mortality levels at Bristol as having been disturbingly high during an interview for the television programme `Dispatches'. |
| 3 June 1996 | Mr Wisheart prepared a statement for the Clinical Directors, in which he sought to answer questions or allegations raised against him. |
| June-July 1996 | The Hospital Medical Committee passed a motion of support for Mr Wisheart. |
| 24 July 1996 | Professor Farndon wrote to Dr Black expressing his attitude towards the concerns over PCS. |
