Annex A > Chapter 7 - Supra Regional Services > The SRS system in operation > Continued designation of NICS
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Continued designation of NICS
166 On 19 May 1988 the Executive Committee of the SCS met and, amongst other things, it was reported by the then President, Sir Keith Ross, that the DHSS had requested the SCS to `consider whether it was in the best interests of all concerned' for NICS to remain in the SRS.
167 The SCS concluded that the SRCs should remain but that the situation should be kept under review. A questionnaire that the DHSS wished to circulate to the SRCs was also tabled:
`This was agreed, but it was noted that the questionnaire was extremely superficial.' [163]
168 In September 1988 the SCS set up a small sub-committee chaired by Professor David Hamilton, Department of Clinical Surgery, Edinburgh University, to liaise with the RCP and the British Cardiac Society (BCS), both of which were already looking into the future of paediatric cardiac surgery. [164]
169 On 22 February 1989 there was a visit on behalf of the Specialist Advisory Committee (SAC) in Cardiothoracic Surgery to the BRI and to Frenchay Hospital. [165] The Report concluded that:
`The visitors were impressed by the quantity and quality of work performed at both hospitals and particularly by the training offered.' [166]
170 On 12 May 1989 the Executive Committee of the SCS met and received a report from the sub-committee whose Chairman, Professor Hamilton, explained that it had been `extremely difficult' to obtain the necessary data and that staffing levels and facilities had not yet been assessed. The sub-committee found that, of the ten centres surveyed, `3 of them were considered good; 4 of them fair; one inadequate and one irrelevant and one had not submitted a return (Leeds)'. Professor Hamilton was concerned that confidentiality would be breached if a report were submitted to the Department. However, the meeting concluded, `after discussion', that `the DHSS would have the figures anyway and thus the confidentiality was not a concern in their case.' [167]
171 It was noted that Departmental funding was `based upon population and there was general approval for the continuance of supra regional designation of such centres.' [168]
172 On 28 July 1989 the SCS delivered its interim report on NICS units in England and Wales to Dr Halliday. [169] The report contained this passage: `Annual audit of work performed (including hospital survival), in this age range should continue to be carried out by the Department of Health.' [170]
173 Sir Terence English commented on the assumption that the Department was undertaking such an audit:
`A. Certainly, it was our belief that the Department had access to the UK Cardiac Surgical Register [UKCSR] data which each unit would have filled in, and could have provided to the Department if asked. I believe they were asked about it.
`Q. So your understanding was that, if you like, if you put yourself in Dr Halliday's shoes, you would have had the Cardiac Surgical Registry returns for each individual unit?
`Q. So putting yourself in, as you thought, leaving aside whether it is right or wrong, but as you thought Dr Halliday's position was, you would have been able to see how one unit compared against another?
`A. Yes, and also, if one unit seemed to be doing rather badly ...' [171]
174 In fact, the SRSAG did not obtain each unit's return to the UKCSR until the internal market was introduced in 1991.
175 The 1989 SCS report contained data showing mortality for under-1s after open-heart surgery. [172] Two units (one of which was Bristol) were shown as having statistically significantly higher mortality than the others. Sir Terence agreed that this was the sort of data he would expect questions to be asked about and that it was disquieting. [173] He also agreed that had he looked at this data in any detail, he would have concluded that it required some serious explanation. He acknowledged that, as a member of the SRSAG at the time, he should probably `have taken more account' of this data. [174]
176 The report was discussed at the SRSAG meeting on 28 September 1989. It was noted that:
`Bristol, Newcastle and Guy's Hospital were operating at sub-optimal levels; this had previously been identified in the 1986 report.' [175]
177 The de-designation of those units that were `non-viable' and operating at `sub-optimal' levels was discussed. Dr Halliday was asked about this in evidence to the Inquiry:
`Q ... the non-viable units which are referred to in the second paragraph, is that a reference back to Bristol, Newcastle and Guy's, because they were operating at sub-optimal levels?
`Q. So "sub-optimal" might refer to numbers; it might refer to success rates, and the report itself makes the point that the two tend to go together and the point you have just been emphasising?
`Q. So the idea was, was it, in the Group, "We really ought to de-designate those units"?
`A. That we ought to consider de-designating those units.' [176]
178 Dr Halliday explained that he was reassured by the conclusions of the 1989 `Interim Report of the Working Party', which recommended that Bristol, `should be encouraged to increase their numbers annually'. [177] Dr Halliday told the Inquiry that this was `very reassuring' to him, `that the problem remained one of non-referral, rather than outcome.' [178]
179 In a subsequent written statement to the Inquiry, Dr Halliday said that the:
`relatively high mortality figures naturally raised questions but I personally was reassured by the conclusion of the experts in this field namely that "Two centres (Newcastle and Bristol) have a less than average turnover of work and should be encouraged to increase their numbers annually".' [179]
180 Dr Halliday visited Bristol, and the two other units in the report `singled out ... as requiring review', in early 1990. [180] The report of the visit, recorded in SRS (90)6, concluded that:
`... although officials found the Bristol centre to be soundly based and giving every sign that the centre would be a viable designated unit, and despite the fact that geographical spread of the designated centres is desirable, there remains a question mark over the centre's long-term viability in supra regional terms.' [181]
It also stated, in more general terms, that the profession's advice was `that about seven centres are required to cover the caseload of England and Wales'. [182]
181 At the SRSAG meeting on 26 July 1990 the report of Dr Halliday's visit was considered:
`The Chairman invited Mr English [Sir Terence English] to give members the views of the [RCSE] on this service. Mr English considered that this service should remain designated, but with no more than 9 units. It would be helpful to have surgical data from each unit'. [183]
182 As to Bristol in particular, Sir Terence is recorded in the minutes as saying:
`... this unit should retain designation but [the RCSE] recommended [it] should be pressed to increase the workload.' [184]
Mr McGlinn attended the meeting as an observer from the Welsh Office and he assured the meeting that:
`... the Welsh Office had no plans to support a neonatal and infant cardiac surgery unit and would continue to look to Bristol to provide a service for Wales.' [185]
183 By September 1990 it was reported that, although outside the SRS system, Cardiff, Oxford and Leicester were all performing NICS. [186] In October 1990 Dr Halliday reported to the SRSAG that Professor Tynan at Guy's Hospital was arguing that the whole NICS service should be de-designated. [187]
184 At the meeting on 3 October 1990, the SRSAG agreed that the NICS should `ideally be concentrated in no more than six or seven centres and that proliferation occurred to the detriment of patients'. [188] This meeting considered SRSAG Paper (90)15, a discussion document on the units at Bristol, Newcastle, Guy's and Harefield. [189] At the meeting the view in favour of a reduced number of centres was generally accepted, but no clinician was willing for his or her unit to be de-designated. As Dr Halliday put it:
`The only difficulty is, I met with all the clinicians involved in this, and every single clinician I met in the designated units and the non-designated units would endorse what is in the minute, that we only need 6 or 7 units. It is the usual thing: "As long as it is not my unit that is closed". So everyone I spoke to endorsed our policy whole-heartedly: "As long as it is not my unit". They did not say that, but that was the connotation'. [190]
185 As regards Bristol, the Inquiry heard evidence that by 1991 Bristol was pleased to be a university teaching hospital designated as an SRS centre for NICS and hoped that it would become a heart transplant centre within two years (it had applied for such designation in May 1991). [191]
186 Mr Wisheart's evidence included this exchange with Professor Jarman:
`Q. I wondered if it would give you a bit of kudos, being identified as a supra regional service, a feather in your cap, as it were?
`A. I suppose there was an element of that but there was also kudos in doing the adult work well. I think cardiac surgery brings its own satisfactions and rewards as well as its disappointments at times.
`Q. I wonder also whether there had been any thought at that time of becoming a heart transplant centre?
`A. We had done in approximately 1990. It was either 1990 or 1991 when we appointed a new consultant, Mr Hutter in fact, who had as part of his training a time with Sir Terence English at Papworth and he himself therefore was trained and skilled and competent in this area.' [192]
187 A Report and Statement of Need dated 27 July 1990, `Paediatric Cardiology and Paediatric Cardiac Surgery in Bristol - The Case for a New, Integrated Unit', was written by Dr Jordan. It stated:
`Bristol is now recognised as a supra regional centre which takes patients, not only from the South West Region, but also from parts of Wessex and South Wales ... Bristol will almost certainly become a centre for heart and heart-lung transplants within the next year or two. Initially we expect to start with adult patients, but with the developments in this field which are now occurring, such transplantation in children will follow.' [193]
188 On 24 July 1991 Dame Deirdre Hine, then Chief Medical Officer (Wales), wrote to Dr Halliday on behalf of the Welsh Office. Amongst other things, she said:
`Within perhaps the next 3-5 years, I expect to see the University Hospital of Wales in a position to offer fully comprehensive paediatric cardiology and cardiac surgery for children of all ages. Within this period a step by step build up of neonatal and infant cardiac surgery will occur. All of this has very clear implications for the current Supra Regional Services Advisory Group strategy governing the pattern of services in the field of neonatal and infant cardiac surgery. It may be that de-designation of the supra regional status of existing units is very much closer than any of us would have anticipated just a year or two ago.' [194]
189 The SRSAG met again on 30 July 1991. On 31 July Dr Halliday wrote to Sir Terence English, who had been absent from the meeting:
`The Advisory Group at its meeting yesterday considered ways in which the cardiac surgical service for neonates and infants might be rationalised in order to ensure the continued designation of this service. It was suggested that it would be possible to define within the existing designated service those complex cardiac surgical procedures which should continue to be designated and to identify the units where this service could be effectively provided. If this were possible it would mean that some units presently designated under the existing arrangements could then be de-designated thus bringing about a rationalisation of the service.' [195]
190 Sir Terence replied on 19 September 1991, stating that in his view it would be very difficult to try to relate designation to specific categories of operative procedures. [196] His letter also referred to the possibility:
`... of some of the smaller or less effective units ... being de-designated in order that the good and responsible units could continue to provide a valuable service.'
Sir Terence identified Bristol, Newcastle, Harefield and Guy's as the units that there were `questions marks over in my mind'. [197]
191 Dr Halliday wrote to Mr Wisheart on 17 October 1991, indicating that the Department, in conjunction with the SRSAG, had commissioned a management consultancy study of the costs of the SRS. [198]
192 Dr Halliday wrote to Sir Terence on 20 December 1991, [199] enclosing the draft paper SRS (91). [200] In the letter Dr Halliday commented:
`... it is difficult to refute the logic of the conclusions, given the problems of remaining within the supra regional criteria and continuing the designation of the service.'
193 In draft paper SRS (91) it was stated that:
`Members had previously considered a paper, SRS (90)15 [201] which had provided more information on the units at risk. Bristol and Newcastle were considered to be essential on geographical grounds ...' [202]
194 It was also noted that `officials were asked to discuss with both units ways in which the activity might be increased'. [203] This comment seems to confirm Sir Terence's view that supporting the units was a matter for the SRSAG and the local units themselves, rather than for the Royal Colleges. [204]
195 Sir Michael Carlisle in his oral evidence agreed that the reason for Bristol's continued designation was its location. His evidence included this:
`Q ... It appears to be suggested ... that the only claim that Bristol had for continued designation was what is called "geography". Broadly, does that correspond with your recollection?
`A. It does. I seem to recollect that Newcastle and Bristol were two places that were regarded, certainly for a considerable time that I recall, as necessary for geographic reasons.' [205]
196 Sir Terence had no input into the drafting of SRSAG Paper SRS (91). He did not agree with its conclusion:
`... I think it was exceptional because I suspect, and I put it no stronger than that, that Dr Halliday may have seen the Royal College of Surgeons in particular, had consistently advocated that the service continue to be designated and I believe that, round about 1990-1991, the Department began to feel uncomfortable with designation of the service and probably wanted to see it de-designated, and I think that in that circumstance there may have been an exceptional lack of communication which might not have taken place in another setting.' [206]
197 On 8 January 1992 Sir Terence replied to Dr Halliday, stating, among other points: `I do not believe that Bristol and Newcastle should be considered essential on geographical grounds', [207] although he acknowledged that geography `was an important factor to be considered ...'. [208]
198 In questioning, it was suggested to Sir Terence that, if geography were discounted, the continuation of Bristol's designation on the basis of `potential' was misplaced:
`Q. That may seem to have the danger in it that it amounts to continued designation, as it were, on a "wing and a prayer"; that although there is no geographical reason strong enough on its own, although there never has been a sufficient track record of numbers, one can hope that the service will develop even though there has been no sufficient development up until now. Would you care to comment on that way of looking at the issue?
`A. Yes. I think one could look at it in that way.' [209]
199 On 24 January 1992 Professor Hamilton wrote to Sir Terence indicating that Dr Halliday was sending him `the figures for the last five years from the designated units' carrying out NICS. Dr Halliday had also agreed to attend a meeting with a small working party from the RCSE. [210]
200 Paper SRS 92(2), `Designation Issues. Neonatal and Infant Cardiac Surgery', [211] was considered by the SRSAG at its meeting on 4 February 1992. The paper stated that the number of units in England undertaking NICS was thirteen, whereas the epidemiological evidence suggested that the number of units required to provide the service was no more than seven and probably nearer five. [212] The paper also stated, amongst other things, that:
`Members accepted the conclusions set out in the paper SRS (90)15 that in general terms, all other factors being equal, there is a strong case for Bristol and Newcastle in terms of geographical spread. [213] They agreed that it would be difficult if not invidious to de-designate the centres in question on the basis of surgical expertise, and doubted whether it was possible to do so on the basis of referral pattern.' [214]
201 Dr Halliday emphasised that the SRSAG alone was not in a position to recommend to Ministers that a unit be de-designated on grounds of surgical expertise. He was asked about the paragraph from the paper SRS 92(2), `Designation Issues. Neonatal and Infant Cardiac Surgery', set out above:
`Q. Again, help me with the wording of it. It may or may not be yours, but what was meant in that paragraph: actually surgical expertise in the general sense, or was it the outcomes of particular procedures?
`A. Well, I think the two go together. I think we were talking about outcomes of particular procedures. I think the difficulty we are in here is all the documents that we considered this morning highlight that almost from day 1 we were facing a situation where we might have to de-designate this service, or units within the service.
`The problem was that however much we tried, and however much advice we got from the various medical organisations, no-one recommended de-designating particular units, so we were faced with the situation where the only option was to de-designate the service. That is why we talk about the importance of geography, the problems about de-designating on expertise, or referral problems. Unless someone could provide us with the evidence which would allow us to take that decision, we had no alternative but to de-designate the service.' [215]
202 At a meeting of the SRSAG on 4 February 1992, Sir Terence offered to set up a working party to look at the question of designation of NICS. He told the meeting that:
`... the most recent reports concluded that keeping 90-95 per cent of neonatal and infant cardiac surgery work concentrated in 6 or 8 centres was most beneficial to patient care.' [216]
203 Dr Halliday, on behalf of the SRSAG, formally accepted the offer on 6 February. [217] It was agreed that the Working Party would report by 1 July to be in time for the SRSAG meeting later that month.
204 Mr Steven Owen, then Administrative Secretary of the SRSAG, visited Bristol on 6 February 1992. He recalled receiving some mortality data during his visit, which he said he passed to Dr Halliday. A note of the meeting sets out this data. [218] Dr Halliday was asked about this in evidence:
`Q. ... Yesterday we were told by Mr Owen that he visited Bristol in February 1992. When he visited Bristol then, he was passed mortality figures which did not mean a lot to him, so he passed them on to you. First of all, do you recollect that?
`A. Yes. I mean, I was getting data fairly regularly, yes.
`Q. The second question: do you recollect what, if anything, you did with those figures?
`A. The difficulty is, as I have said, having figures in isolation, without the machinery to analyse it, is of no particular value. It would have been strange for me to be given - I mean, I was not given any figures with the suggestion that there was a problem here. I was given figures as I was on many visits. Sometimes my administrative colleagues would visit the units with the object of dealing with financial matters, and would be handed data. They would come back to me, or Dr Prophet, [219] and would hand us that data.
`If, however, we were given the data and told that there was a problem with that data, that would be a different matter.
`I have no recollection of any data being presented to me from Bristol with the caveat that there was a problem.
`If there had been a problem, I would have clearly gone to the College for advice, but to be given data without the suggestion that there was a problem, would not have given me the opportunity to raise this with the College. I mean, it would be pointless me giving them the data from one year and saying, "What do you think of this?".' [220]
205 On 12 February 1992 Sir Terence wrote to Professor Hamilton asking him to be the Chairman of the Working Party [221] and he accepted. Professor Hamilton wrote to Mr Wisheart on 10 March, asking him for relevant data. [222]
206 Professor Hamilton delivered the `Working Party Report' to Sir Terence, with his covering letter, on 19 June 1992. [223] In relation to the number of centres it was recommended that:
`... 9 centres now be recognised for supra regional designation and funding ... [They] are: Great Ormond Street, Birmingham, Liverpool, Leeds, Wessex, the Royal National and Brompton Hospital, Bristol, Newcastle and Leicester.' [224]
207 The effect of the advice was that Harefield and Guy's should be de-designated, and that Leicester should be designated. Thus, there would be a net reduction of one in the number of SRCs, from ten to nine.
208 Sir Terence was asked by Counsel to the Inquiry for his initial reaction to the recommendation that Bristol continue to be designated:
`Q. What argument would you derive from the data and from what you have already told us as to your knowledge of Bristol, which would justify its continued designation as a centre for the neonates and infants?
`A. That it was functioning at a lowish level, certainly not the lowest; and that it was still regarded as being an important centre.
`Q. In terms of your own reasons for supporting it earlier, geography was not essential, and potential appears to be belied by the trend downwards?
`A. Potential still has not been realised, I agree.
`Q. Is it not the case that if you were to apply your own approach to it, you would have said: "Well, this trend really argues against there ever being a realisable potential here, now."
`A. I certainly did not think that at the time that I received this report.
`Q. If you had the benefit of hindsight, do you think you might have taken that view?
`A. I think that I should have initially given a more critical analysis, or given more critical analysis to Table 1 of the report, but I had asked a group of very responsible clinicians to look at this. They had accepted the terms of reference; they had collected a lot of data, come up with a report that I could understand their reasoning for wishing to continue to advise that the service be designated and how this could be achieved. And the recommendations to ask Guy's to either amalgamate with another London unit or fail to continue to get funding, and similarly, to ask Harefield to amalgamate with the Brompton or face withdrawal of funding, and to recognise that Leicester was doing good work, these all struck me as being perfectly reasonable at the time.' [225]
209 On 2 July 1992 Sir Terence (as President of the RCSE) wrote a letter to Dr Halliday, enclosing the `Working Party Report', of which at this stage he was fully supportive. His letter concluded:
`The working party collected a lot of data on which to base their recommendations and should ... be congratulated on a report which has the full support of the Royal College of Surgeons.' [226]
210 Sir Terence also wrote to Professor Hamilton on 2 July 1992, thanking him for a `balanced and authoritative report' that had the full support of the RCSE. [227]
211 In a letter to the Inquiry received after the conclusion of the hearing of oral evidence, however, Professor Hamilton related that, although mortality was quoted in one of the Tables, `... it is possible that insufficient attention was given to these figures by the working party'. [228]
212 On 15 July 1992 Dr John Zorab, Medical Director of Frenchay Hospital, Bristol and a consultant anaesthetist, wrote to Sir Terence. [229] He enclosed an article from the `MD' column in `Private Eye'. [230] His letter stated, inter alia:
`Sometime last autumn, I made one or two efforts to get to see you in order to discuss the delicate and serious problem of mortality and morbidity following paediatric cardiac surgery in Bristol. I have no vested interest in this and the problem is outside my immediate sphere of influence but great anxieties were being expressed by some of my colleagues at the Royal Infirmary. In the event, I never made contact with you and the matter passed from the forefront of my mind.
`Matters have come to a head once again and the enclosed piece from `Private Eye', whilst possibly having some inaccuracies, quotes some statistics which have been confirmed elsewhere. One of the newer consultant cardiac anaesthetists feels that the mortality rate is too distressing to be tolerated and is job-hunting elsewhere.' [231]
213 At its meeting on 28 July 1992, from which Sir Terence was absent, the SRSAG:
`... noted the Royal College of Surgeons Working Group Report which recommended that the service should continue to be designated and the number of designated units should be reduced from the current 10 to 9.' [232]
214 Sir Michael Carlisle told the Inquiry that by 1992, NICS was consuming `nearly 25 per cent' of the SRSAG budget. [233] He said there was evidence that NICS was beginning to have completed its early developmental stage. It `was a mature service that was taking rather more of the supra regional services finances than it should.' He continued: `I mean, it [de-designation of NICS] was not a financial decision.' [234]
215 The minutes of the July meeting continued:
`Dr Halliday reported that since receiving the Royal College of Surgeons' report, he had been approached by Sir Terence English, who indicated that since submitting the report he now had reservations about the continued designation of the Bristol unit.
`The Advisory Group discussed the issue at length but concluded that it was unrealistic to expect to restrict the delivery of the service to those units for which the Royal College of Surgeons' report recommended continued designation ...' [235]
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Footnotes
[163] SCS 0004 0004. The Bristol questionnaire, completed by Mr Wisheart, is at UBHT 0193 0016. It contains mortality figures for 1985-1987 inclusive, for both open and closed operations on under-1s (UBHT 0193 0017)
[164] SCS 0004 0007; minute dated 21 September 1988
[165] RCSE 0002 0213 - 0220 ; SAC Report, 22 February 1988
[166] RCSE 0002 0219; SAC Report, 22 February 1988
[167] SCS 0004 0015; SCS meeting, 12 May 1989
[168] SCS 0004 0015 - 0016 ; SCS meeting, 12 May 1989
[169] DOH 0002 0223 - 0237 ; SCS Interim Report
[170] RCSE 0002 0028; SCS Interim Report
[171] T17 p.117 Sir Terence English
[172] DOH 0002 0233; `The Interim Report of the Working Party on NICS Units in England and Wales'
[173] T17 p.121-2 Sir Terence English
[174] T17 p.123 Sir Terence English
[175] DOH 0002 0214; SCS Interim Report
[177] DOH 0002 0230; Interim Report, T13 p.57 Dr Halliday
[179] WIT 0049 0024 - 0025 Dr Halliday, quoting from UBHT 0061 0204
[180] DOH 0002 0200; Paper SRS (90)6
[181] DOH 0002 0200; Paper SRS (90)6
[182] DOH 0002 0202; Paper SRS (90)6
[183] DOH 0002 0196; Paper SRS (90)6
[184] DOH 0002 0196; Paper SRS (90)6
[185] DOH 0002 0196; Paper SRS (90)6
[186] SCS 0004 0026; minute dated 21 September 1988
[187] DOH 0002 0168; Professor Tynan would again write a report to this effect in June 1992 - see DOH 0002 0126
[188] DOH 0002 0168; minutes of SRSAG meeting, 3 October 1990
[189] DOH 0002 0053; Paper SRS (90)15
[193] WIT 0097 0024 - 0025 Dr Joffe
[194] RCSE 0002 0063 - 0064 ; letter from Dame Deirdre Hine to Dr Halliday dated 24 July 1991
[195] RCSE 0002 0066; letter from Dr Halliday to Sir Terence English dated 31 July 1991
[196] DOH 0003 0003; letter from Sir Terence to Dr Halliday dated 19 September 1991
[197] T17 p.148 Sir Terence English
[198] UBHT 0277 0141; letter from Dr Halliday to Mr Wisheart dated 17 October 1991
[199] DOH 0003 0004; letter from Dr Halliday to Sir Terence English dated 20 December 1991
[200] DOH 0003 0005; SRS (91) `Report on Supra Regional Designation'
[201] DOH 0002 0173; SRS (90) 15 `Report on Supra Regional Designation'
[202] DOH 0003 0005; SRS (91) `Report on Supra Regional Designation'
[203] DOH 0002 0173; SRS (91) `Report on Supra Regional Designation'
[205] T15 p.48 Sir Michael Carlisle
[206] T18 p.105 Sir Terence English; Dr Halliday called this suggestion `quite absurd' WIT 0049 0026
[207] RCSE 0002 0081; letter from Sir Terence to Dr Halliday dated 8 January 1992
[208] T17 p.137 Sir Terence English
[209] T17 p.140 Sir Terence English
[210] RCSE 0002 0085; letter from Professor Hamilton to Dr Halliday dated 24 January 1992
[211] DOH 0002 0044; SRS(92)2 `Report on Designation of NICS'
[212] DOH 0002 0047; SRS(92)2 `Report on Designation of NICS'
[213] A change from the wording of SRS (91) at DOH 0003 0005 of `essential on geographical grounds'
[214] DOH 0002 0044; Paper SRS (92)2
[216] DOH 0002 0033 - 0036 ; minutes of SRSAG meeting, 4 February 1992
[217] DOH 0003 0012; letter dated 6 February 1992
[218] DOH 0004 0045; note of meeting, 6 February 1992
[219] Senior Medical Officer in Dr Halliday's division who had the policy resonsibility for paediatric cardiac surgery
[220] T13 p.113-14 Dr Halliday
[221] RCSE 0002 0146; letter from Sir Terence English to Professor Hamilton dated 12 February 1992
[222] UBHT 0061 0241; letter from Professor Hamilton to Mr Wisheart dated 10 March 1992
[223] RCSE 0002 0162; letter from Professor Hamilton to Sir Terence English dated 19 June 1992
[224] RCSE 0002 0167; `Working Party Report'
[225] T18 p.126-7 Sir Terence English
[226] DOH 0003 0013; letter from Sir Terence to Dr Halliday dated 2 July 1992
[227] RCSE 0002 0179; letter from Sir Terence to Professor Hamilton dated 2 July 1992
[228] WIT 0044 0004 Professor Hamilton
[229] RCSE 0002 0188; letter from Dr Zorab to Sir Terence English dated 15 July 1992
[230] SLD 0002 0005; `Private Eye'
[231] A full description of the events resulting from this letter is set out in Chapter 27
[232] DOH 0002 0099; minutes of meeting of SRSAG, 28 July 1992
[233] T15 p.41 Sir Michael Carlisle
[234] T15 p.41 Sir Michael Carlisle
[235] DOH 0002 0099; minutes of meeting, July 1992