8th September 1999
Oral Hearings continued in Bristol today with evidence from Reverend Helena Cermakova, Hospital Chaplain at St Michaels Hospital and Bristol Childrens Hospital (BCH). She discussed the role of the Hospital Chaplain and chaplaincy services, also commenting on the role of trained chaplaincy volunteers and a parents organisation "Friends to Parents", which offers practical support for parents attending hospitals in Bristol. She discussed training for the volunteers and said that there was also a bereavement training course accessible to hospital staff.
Hearings continued with evidence from Helen Stratton, former Cardiac Liaison Nurse at the Bristol Royal Infirmary (BRI). She described her perception of her role when she became the first Cardiac Liaison Nurse in 1990. She explained that her post was funded by the Bristol and South West Heart Circle, a local charity, and that she was based on Ward 5 at the BRI. She explained that when she took up her post she visited other paediatric cardiac centres including Great Ormond Street and Birmingham Childrens Hospital to compare practice and share ideas. She described her professional relationship with Helen Vegoda, Counsellor in Paediatric Cardiology, BCH. She then went on to discuss her own support mechanisms, highlighting the advice she received from Dr Freda Gardner. Mrs Stratton then talked about the culture within the BRI and explained to what extent she had been able to make suggestions for changes in practice and ultimately to raise concerns, commenting on the reaction she received from clinical and managerial staff.
The hearings concluded today with evidence from Mrs Janet Hawkins, mother of Paul born in 1982 (now 16 years of age) with bowel and bladder problems, who underwent cardiac surgery at BCH in 1991. Mrs Hawkins explained her experience of services at BCH focussing specifically on communication with clinical staff.
1 Day 46, 8th September 1999 2 (9.30 am) 3 MISS GREY: Good morning. Sir, our first witness this 4 morning is the Reverend Helena Cermakova, who is going 5 to assist us on services provided by way of support for 6 parents for families by the chaplaincy at the Bristol 7 Children's Hospital and also St Michael's. 8 I should say perhaps by way of introduction that 9 because she took up her post in 1995, and also because 10 her role does not cover the Bristol Royal Infirmary, it 11 is envisaged that the Inquiry may wish to hear further 12 from other witnesses who can help us more directly on 13 the Bristol Royal Infirmary. You will understand, sir, 14 that the Reverend's evidence this morning does not cover 15 that part of the hospital. 16 THE CHAIRMAN: Thank you, good morning. That would be 17 helpful. I think we would like to in due course hear 18 from others as I have indicated. 19 MISS GREY: Could I ask you please, Reverend Cermakova, to 20 come forward? 21 We have been taking evidence on oath throughout 22 the Inquiry, so perhaps you would stand and take the 23 oath? 24 REVEREND HELENA CERMAKOVA (SWORN): 25 Examined by MISS GREY: 0001 1 Q. Your name is the Reverend Helena Cermakova? 2 A. Yes. 3 Q. You are currently the Chaplain to the Bristol Royal 4 Hospital for Sick Children, and also to St Michael's 5 Hospital? 6 A. Yes, I am. 7 Q. If I could ask you, please, to look at WIT 272/1, which 8 should come up on the screen in front of you, that is 9 the first page of a witness statement which you have 10 kindly provided to the Inquiry. If I could ask you, 11 please, to turn to page 15, that is the last page, and 12 your signature appears on the bottom? 13 A. Yes, that is right. 14 Q. Just for the sake of the record, are the contents of 15 that statement true to the best of your knowledge and 16 belief? 17 A. Yes, they are true to the best of my knowledge and 18 belief. 19 Q. If we turn back to page 1, we can see there in the first 20 paragraph that your statement covers your own knowledge 21 of events and services since taking up your post on 22 6th February 1995, as a UBHT Chaplain with special 23 responsibility for the Hospital for Sick Children, and 24 also St Michael's Hospital. You are not, as I think 25 I said earlier, someone who has any direct involvement 0002 1 with the Bristol Royal Infirmary? 2 A. No, only when I am on call at night. 3 Q. Can you tell us as to the balance of your 4 responsibilities between the Hospital for Sick Children 5 and St Michael's? 6 A. Well, there should be an equal balance between the two 7 hospitals. On a daily basis, that may not be the case, 8 depending on what situations occur in the two hospitals, 9 and which one is a priority. 10 Q. I just wondered whether or not you spent more of your 11 time looking at it overall at St Michael's or at the 12 Children's Hospital? 13 A. I do not think that is the case, but I have not -- no, 14 it is not the case. It is just that on a daily basis, 15 it would maybe seem the case sometimes, because I may 16 need to spend a whole day in St Michael's Hospital for 17 some reason, or either a whole day in the Children's 18 Hospital. 19 Q. At St Michael's you would do a lot of work I understand 20 with mothers who have lost children either in or shortly 21 after pregnancy, or also possibly as a result of social 22 terminations; is that correct? 23 A. Yes, and terminations for abnormality. 24 Q. Paragraph 11 of your statement, if we turn on to that, 25 please, it is at page 7 of the statement. Paragraph 11 0003 1 implies that in general, contact with parents was 2 initiated or tended to be initiated when you were 3 contacted at a point when a child was either very ill or 4 dying; is that right? 5 A. Yes, that is right. I mean, I do have a print-out of 6 the different religions and I may have -- I have not put 7 it in my statement, I forgot to do so, but I may have 8 had a commendation from local clergy, but that is very 9 rare. No, it usually comes from nursing staff or one of 10 the councils or services. 11 Q. So you are saying generally you would not have an 12 opportunity to visit families on the ward before you 13 were contacted by staff because of a particular need? 14 A. I would not say that. I do make regular visits on 15 a ward, but it does very much depend on how much I am 16 working in the St Michael's Hospital and I am often 17 contacted by bleeper or by telephone. 18 Q. But if you are called in at the point at which a child 19 is either very ill or dying, does that reflect any 20 expectation or belief as to the role of the Chaplain? 21 A. Yes, I think it does. I think I am envisaged as being 22 the person that "when there is nothing else to be done, 23 we need to call in a Chaplain", but that is the 24 perception of Chaplains throughout the NHS; it is not 25 specifically at the Children's Hospital. 0004 1 Q. Could I ask you, please, to try and speak up a little, 2 both for the benefit -- I do not think that pulling in 3 the microphone will help, it is quite sensitive, but if 4 you could raise your voice a little bit both for the 5 sake of the Panel and also for the sake of the 6 stenographers. 7 If perhaps either because of the point at which 8 you are called in or because of pressures of time, you 9 yourself have a lot to cover, you might tend to be 10 called in at situations where things have reached 11 something of a crisis point, are there other people who 12 work with you who have a role in befriending and 13 assisting parents at an earlier stage? 14 A. Yes. I mean, we have our volunteer visitors, and 15 Friends to Parents. Is that what you are asking? 16 Q. Yes. I think you mention in your statement two 17 organisations in effect, or groups. The first being the 18 Friends for Parents, and would I be right in picking up 19 from your statement the fact that this is an 20 organisation which fulfills predominantly a practical 21 role? 22 A. Yes, they have got a listening role, a visiting and 23 listening role, but they are looking particularly to 24 helping patients or parents with practical needs, 25 especially those who have come from a distance. But 0005 1 they do have listening skills and they have been trained 2 in recent years in listening skills. 3 Q. But those who provide the greater part of the listening 4 or supporting services would be perhaps better described 5 as the chaplaincy volunteers; is that right? 6 A. Yes. 7 Q. And if we look at paragraph 17 at page 8 of your 8 statement, you describe there that volunteers are 9 members of the public who are recruited by the 10 chaplaincy service and then appropriately trained in 11 listening skills. 12 Then you also refer to the fact that you have 13 given us a little bit more detail at paragraph 26, which 14 is at page 11. 15 There you tell us that you have expanded the 16 volunteers service, the chaplaincy volunteers, 17 throughout the period of your term of office at the 18 hospital? 19 A. Yes, I have. 20 Q. Can you just tell us a little as to the training or 21 selection or support that is given to these volunteers? 22 How does the system work? 23 A. I can only tell you what -- the recruitment and the 24 training of volunteers is centralised at the BRI and 25 come under the Reverend Rob Yeomans and at present 0006 1 Mrs Joanna Abecassis. They have the full details of the 2 training scheme. As I understand it, they are recruited 3 and selected initially for their ability to listen and 4 to be sensitive to the situation, and then they attend 5 an eight week course and then again have an interview 6 and are selected or told that perhaps this is not the 7 right thing for them to volunteer for. 8 So it is fairly rigorous. I may then be in the 9 interview process if they are expressing an interest in 10 the Children's Hospital or St Michael's, but I am only 11 involved in that and then, when they come up to me, 12 I may give them more training in the specific sort of 13 ministry or volunteer visiting that we need at the 14 Children's Hospital or St Michael's it is very specific. 15 Q. What are the specific needs that you would see yourself 16 as having to train people for at those two hospitals? 17 A. I think the great sensitivity -- I am not suggesting 18 there is not sensitivity at the BRI, but the sensitivity 19 when you are dealing with children or parents or dealing 20 with patients who may have come in for terminations at 21 St Michael's, these volunteers may meet that sort of 22 event. 23 So we will talk about that and I will teach them 24 from my own experience what not to do and what to be 25 careful of. 0007 1 So, yes. There are just things like, you know, 2 when you are talking to the parents, you actually always 3 include the child in it, or you are sensitive to the 4 child; you do not just go barging in; and recognise that 5 the child actually has had a million people -- that is 6 an exaggeration, but a lot of people come to see them, 7 and you again, are another person, they may be aware of 8 you, so you have to approach it very, very sensitively, 9 especially very young children, and keep maybe a slight 10 distance from them so they get used to you, and things 11 like that. 12 Q. Once these volunteers start work after the training and 13 induction process you have described, would you have any 14 continuing contact or supervision of their role? 15 A. Yes, they come back at 4 o'clock on the day that they do 16 their visiting and we debrief. It is a two-way thing. 17 It is for me to be listening to what is happening in the 18 hospital in areas that perhaps I cannot get to on that 19 particular day or in that particular week, but also to 20 make sure that -- and then for me to become aware of 21 what needs to be done or visited, but also, to support 22 them and to help them perhaps cope with situations that 23 they may have become involved in that have raised issues 24 for them. 25 Q. Do you find there is a real need for support for these 0008 1 volunteers? 2 A. Yes. I think there is a need for anybody who is in that 3 sort of ministry, or volunteer. I think Chaplains 4 themselves have to have supervision. So I think that 5 anybody in that position should have supervision. 6 Q. Just one point of detail. This is a service which is 7 being organised by the chaplaincy? 8 A. Yes. 9 Q. Is it a specifically religious service in any way? 10 A. Well, it is specifically -- the chaplaincy volunteer 11 visiting comes within the remit of volunteer visiting in 12 the UBHT, but it is specifically chaplaincy because of 13 its particular dimension, if you like. We are not 14 allowed to proselytise, not even chaplains are allowed 15 to proselytise, so they have a very firm brief that they 16 are not allowed to go and bash people over the head with 17 a bible, sort of thing, so it is more spiritual than 18 religious. They tap into the spiritual dimension of 19 patients and if that patient wishes to express their 20 concerns in religious terms, then they will report that 21 back to me or maybe pray themselves with them, but it is 22 really hidden, really, in this ministry. They wait, 23 really, until the person themselves, the patient, 24 actually raises the issue of faith, you know: Why am 25 I here? Is there a God? We do not raise that. 0009 1 Q. Does it follow from the service that you have been 2 describing and your involvement in it that you think 3 that there is a legitimate role and a proper role for 4 non-professional, that is lay, support services within 5 a hospital? 6 A. Yes, I do. I think there is a whole raft of people out 7 there in the community that have tremendous gifts and 8 life experience which is a great benefit to parents and 9 patients who come into hospital. They can get alongside 10 them and help and support them. So as long as they are 11 recruited, selected, trained and continued with their 12 supervision and debriefing, I think that is of paramount 13 importance. But I see no reason why lay volunteers 14 cannot be involved in hospital work. 15 Q. Taking the services of the chaplaincy fairly broadly so 16 as to include both the volunteers and your own work and 17 that of your colleagues, how many patients do you think 18 would be aware of the services that were on offer, the 19 support that was on offer, through those routes? 20 A. The Friends to Parents have established themselves 21 enormously over the last approximately 11 years, so 22 their services are very much used and ward staff often 23 ring up individual Friends to Parents or the 24 co-ordinator, Dorothy Willis, to say they need this, 25 that or whatever, to look after siblings, say in bone 0010 1 marrow transplant when a parent cannot take the sibling 2 in because of isolation. That is a particular role that 3 Friends to Parents have done quite successfully. But 4 also, a birthday cake for a sibling may be produced and 5 just a whole raft of things, toiletries, I cannot think 6 of it all. Staff know that Friends to Parents have this 7 resource so they ring them up. 8 The volunteer visitors are, how can I put it, 9 a new sort of raft of people who have come in from 10 chaplaincy. But I always contact the ward and ask if 11 they would like a volunteer visitor before they come on 12 to the ward, obviously. And we have a discussion about 13 that. They are introduced to the ward, usually the ward 14 manager tells them about the ward, and then when they 15 visit on the day, they go to the nurse's station and ask 16 if there is anybody in particular that needs to be 17 visited. Other than that, they will do a ward round 18 quietly, from bed to bed, remaining sensitive to those 19 who do not want anybody to visit them. 20 For myself, we try and promote the work of the 21 chaplaincy through leaflets, through continual 22 noticeboard notices. I am on a rota with all the 23 Chaplains throughout the UBHT and that rota, which is 24 a monthly rota, goes to the key areas in the Children's 25 Hospital like ITU, special care, bone marrow transplant 0011 1 unit, so that the staff know who is on call, who is 2 available all through the night. 3 And I try to have a presence in the hospital and 4 be available and the people know that I am around. 5 Q. You obviously try very hard to have that presence, to be 6 around, but are you able to form any impression of those 7 parents who might have said, if they had left the BCH, 8 "Well, I wish I had known because I still did not know 9 about either the volunteers or the fact that a Chaplain 10 would have been available if I felt able to call upon 11 them". 12 Is there any way of measuring that, or testing 13 it? 14 A. I do not know that. I cannot answer that question. 15 I think the only way you could answer that question is 16 to do an audit and ask the parents. We did an audit at 17 St Michael's Hospital and one of the questions was "Did 18 you see a Chaplain?", "Was a Chaplain offered?" 19 Of course, usually -- a Chaplain is always offered. 20 In fact that audit came out very well in terms of our 21 bereavement services. 22 Q. That was an audit specifically directed at those who 23 lost children, was it? 24 A. Lost babies or in pregnancy. It was not only including 25 Chaplains, obviously, it was including nursing care, the 0012 1 Social Services, the bereavement officer and the 2 Chaplains, and whoever was involved in the care of the 3 bereaved parents. 4 So it was through that audit that I saw whether we 5 were doing okay or not, or whether our services were 6 being highlighted or not. 7 Q. At least at St Michael's Hospital where that was 8 examined, the overall verdict appears to have been 9 positive? 10 A. Yes, it was very positive, yes. 11 Q. If we turn then to the issue of staff training on 12 bereavement issues or generally handling with 13 sensitivity the difficulties of parents who have 14 children who are in extreme distress or illness, I think 15 you have had some involvement in the issue of 16 bereavement training for staff, but perhaps not 17 a central role; is that correct? 18 A. No, I have not had a central role. 19 Q. What has been the extent of your role there? 20 A. In St Michael's Hospital, I have been invited to give 21 talks on the care of the carers in their one-day 22 bereavement courses run by the training officer. That 23 really is certainly focused on staff in the hospital. 24 I have not really been desperately involved in the 25 training of staff in the Children's Hospital, partly 0013 1 because I think that Mike Pullan my colleague who is 2 a Free Church Chaplain has, and partly because 3 I personally do not consider myself to be a teacher. 4 Mike is a qualified teacher. So I felt that he would be 5 better at it. I teach more on a one-to-one basis. I am 6 better teaching at that level. I do not think that is 7 one of my skills, although I have given a talk, 8 I remember now, at a one-day seminar on bereavement on 9 caring for the carers. 10 Q. Some of the papers in the possession of the Inquiry look 11 at the bereavement courses that have been run, certainly 12 from 1996 onwards, and comment that the content of the 13 courses is extremely good but that attendance can be 14 patchy, sometimes poor, and in fact some sessions have 15 had to be cancelled because of lack of attendance. 16 Are you able to comment on either the accuracy of 17 that perception or the reasons that might lie behind 18 it? 19 A. I think that is an accurate perception. I think that 20 the reasons may lie in the fact that we are understaffed 21 and may not be able to release staff to those sessions. 22 Q. Because they have -- 23 A. The whole bereavement issue anyway is a very emotive 24 one. It may be a difficult -- there may be an 25 element -- I am just surmising now really, but there may 0014 1 be an element that it is difficult to attend a course. 2 Q. So it may be partly a management difficulty in so far as 3 staff have to be released from their duties on the ward 4 to attend a course? 5 A. Yes, they do, yes. 6 Q. Partly also possibly that there may be some reluctance 7 to face the difficult issues that may be brought to the 8 fore? 9 A. There may be. I am just making this supposition. 10 Q. If we look at the statement we have had from Reverend 11 Yeomans, this is witness 274/7, he comments there on the 12 training of staff in specifically the Bristol Royal 13 Infirmary. It is paragraph 22. If I look at the third 14 line down there, he says that training for staff in 15 death is good in parts. He goes on to explain that by 16 saying that there may be a problem with bank nurses or 17 young inexperienced staff who are not able to explain 18 what needs to be done in a straightforward way, for 19 example, the arrangements which need to be made in 20 viewing. 21 That is not a comment or observation that is 22 specifically directed at the Children's Hospital. Can 23 you tell us what your experience has been of staff 24 handling of these matters within the Children's 25 Hospital? 0015 1 A. For viewing arrangements, you mean? 2 Q. I mean more generally the handling of staff of that very 3 difficult moment of death and both the practical and the 4 emotional arrangements and needs which arise out of it? 5 A. I think they handle it extraordinarily well. They are 6 extremely sensitive. They spend a good deal of their 7 time, the nurse attached to the family spends as much 8 time as the parents wish to have. They are extremely 9 sensitive. They accompany them to the viewing room. 10 They deal with all the practical issues in terms of 11 their clothes and they allow the parents to wash the 12 baby. I cannot say more highly than that. In my 13 experience, the staff are extremely good. 14 Q. If we look at the administrative side to some degree of 15 the arrangements arising out of death, that would be 16 co-ordinated at the Children's Hospital, at least until 17 recently by Mr Milkins; is that right? 18 A. That is right, yes. 19 Q. When you arrived at the Children's Hospital and at 20 St Michael's, you undertook a review of this side of the 21 care and support of the families, and you refer at 22 paragraph 18 of your statement -- this is back to 23 WIT 272/8, please, at the very bottom, you talk there 24 about feeling that there was a confusion of roles in the 25 bereavement services offered at St Michael's and you 0016 1 undertook a review and redefined responsibilities. 2 What was the position at the Children's Hospital, 3 because you speak only of St Michael's there? 4 A. I found no difficulties. Graham Milkins seemed to be -- 5 I had no concerns for the Children's Hospital. The 6 concern at St Michael's was the duplicating of the 7 different roles and the confusion that arose from that. 8 But I did not find that at the Children's Hospital. 9 Q. It is now the case, if we look on from 1996 to today, 10 that a review is taking place within the Trust of 11 bereavement services subsequently and the Inquiry has 12 been given evidence on that. 13 Can I ask you, however, to comment on generally 14 the priority which you feel has been accorded within the 15 Trust to the issue of bereavement services specifically, 16 but also more generally to the whole area of support for 17 families who have children in hospitals? 18 A. Are you asking me that from the present time, or just an 19 overall view? 20 Q. An overall view really from the date of your arrival at 21 the Children's Hospital, if you feel that there has been 22 any change in attitude over that period of time? 23 A. I think there has been a change, but I have to say on 24 a much wider basis there has been a huge change in 25 bereavement care throughout the country, really in the 0017 1 NHS -- 2 Q. Could you try and speak up a little more? 3 A. There has been a great change in bereavement care in the 4 last ten years, really. It has been a developing and 5 evolving -- meeting the issue of how we help bereaved 6 parents or patients or whatever, deal with their loss. 7 Certainly in the Children's Hospital, there has been 8 a movement along the same lines as there has been 9 movement in all other hospitals up and down the 10 country. There has been a heightened awareness of the 11 fact that we need to pay more attention to bereavement 12 services. 13 That has brought about the beginning of 14 a bereavement group which I think was in 1997 -- I have 15 put it in my statement somewhere -- which looks at 16 issues around bereavement at the Children's Hospital 17 which meets on a monthly basis. 18 And particularly, I think, arose out of the need 19 to look at a protocol around the death of a child, the 20 death of a patient. 21 Q. If it would help, if we turn on to the next page of your 22 statement, page 9, we see there paragraphs 19 and 20, 23 you discuss two bereavement groups in the Children's 24 Hospital and St Michael's? 25 A. Yes. 0018 1 Q. Are those the groups that you were referring to? 2 A. Yes. 3 Q. So they are reviewing the provision of bereavement 4 services on quite a general basis? 5 A. With our audit at St Michael's Hospital, we reviewed the 6 bereavement services there and, as I say, it was a very 7 positive outcome. I believe that under Lindsay Scott, 8 then there is a review of the bereavement services in 9 all the directorates in process at the moment. 10 Q. If we look for instance at the statement of 11 Mrs Jean Pratten, WIT 269/11, please, if we go down to 12 the bottom of the page, she is talking generally about 13 involvement in the support services for parents over 14 a long period of time, which I recognise pre-dates, by 15 a considerable extent, your appointment at the BCH, but 16 she comments that the finance of the support and 17 counselling services was inadequate and that there was 18 generally a low priority afforded to support and 19 counselling work by the Trust management generally, in 20 her perception. 21 If we turn over the page to paragraph 43, can 22 I ask you, from your perspective, and based on your 23 appointment in 1995, how true or otherwise would you 24 feel that those comments were? 25 A. I think that with the appointment of a Chaplain anywhere 0019 1 specifically for the Children's Hospital, St Michael's, 2 it actually bears out the fact that the management, 3 UBHT, the Children's Hospital actually did believe that 4 there needed to be a support service in the role of say 5 a Chaplain, but certainly, when I came into post, there 6 was Helen Vegoda, who was the cardiac liaison support 7 worker. I may have got her title wrong. She appeared 8 to be doing an excellent job and from the moment I was 9 appointed, she and I worked very closely together. 10 Then of course there was the Social Services too, 11 which was separate, but, yes. So I did not feel at that 12 moment, at that time, that there was not enough support. 13 Then subsequently, we have had cardiac liaison 14 nurses appointed. 15 So I can only really comment at that sort of date, 16 1995. 17 Q. Can you help us a little bit more, then, as to what you 18 say about the general changes in the perception of the 19 importance of this sort of function for a hospital that 20 had been taking place over the last decade, or possibly 21 longer? 22 A. I do not think I understand your question. Do you 23 mean -- 24 Q. I am sorry. You mentioned earlier that you had seen 25 a change in attitudes to the importance of support 0020 1 services and also their content, and I wondered if you 2 were able to help us a little bit further on that, 3 because it may be that witnesses' comments arise out of 4 that change in the priority for these sorts of support 5 services? 6 A. I think we have become more aware that we need to put in 7 place adequate bereavement services while people are 8 still experiencing their loss in the hospital, we need 9 to make sure that we address and are supportive in that 10 time and to a certain extent, beyond, when they go home, 11 which is another whole raft of things. We have just 12 become more aware, society has become more aware, or 13 shall I say the Health Service has become more aware 14 that we need to put that service in place. It has been 15 a growing understanding throughout the NHS. 16 But, you know, I suppose it could arise from the 17 fact that we are now hopefully considering a person, 18 patients, parents, relatives in a more holistic way and 19 when death occurs, then we should be addressing that as 20 well. 21 Q. Are there moves afoot to strengthen the involvement of 22 Chaplains within the NHS at the moment? 23 A. Can you repeat that? 24 Q. I was wondering whether, arising out of that change that 25 you have described, there were, to your knowledge, any 0021 1 moves being made nationally to increase the involvement 2 of Chaplains within the NHS? 3 A. Yes. The C of E appointments which still, I am afraid, 4 are the majority of hospital chaplains, although it is 5 becoming more ecumenical, are usually advertised in what 6 is called the Church Times and every week without fail, 7 there are at least two adverts for hospital chaplains, 8 so there is an increasing number of hospital chaplains, 9 and we have, in the last five or six years, formed the 10 College of Healthcare Chaplains which is my professional 11 body and which is linked to MSF so it is a huge 12 undertaking of the Health Service, the role of the 13 Chaplain. We thought -- the Church I suppose thought 14 that when hospitals went to Trust, that maybe chaplains 15 would not be as involved but in fact it has been the 16 very opposite; there is an increasing number of hospital 17 chaplains. 18 THE CHAIRMAN: May I interrupt, Miss Grey, with one 19 question? Just for my own clarification, who pays you? 20 A. UBHT. And that is the case for all hospital chaplains. 21 I am accountable to the Trust. My line managers and 22 I am paid by the Trust, but I have to hold the Bishop's 23 licence to the diocese. When I am short-listed or 24 anybody is short-listed, the name goes from the Trust to 25 the Bishop and the Bishop or whatever the religious body 0022 1 is, they have to approve of the appointment as well. 2 MISS GREY: I wonder if you could help the Inquiry on this: 3 if the Inquiry hears evidence from parents or from other 4 people who have been involved in children's services and 5 they express a general dissatisfaction, or perhaps 6 a more specific example of an instance in which they 7 feel they have been badly let down by the staff involved 8 in the management of their child's care at that time, 9 how does one judge the response to the evidence of 10 parents at that point? If we look for instance at the 11 statement from Reverend Yeomans again, WIT 274/9, he 12 speaks there of the difficulties that staff have in 13 dealing with this situation and how difficult it can be 14 to anticipate and give what bereaved parents want in 15 their grief, distress, anger, when at that moment of 16 time they may be inconsolable. 17 So to what extent do you think that evidence of 18 these sorts of situations reflects inadequate provision 19 or inadequate responses from staff, or may be a comment 20 on the impossibility or extreme difficulty of meeting 21 the needs of people who, as Reverend Yeoman describes, 22 may be inconsolable at that point in time? 23 A. I must say that I think the staff at the Children's 24 Hospital are very much trained in that. It is very 25 specific, is it not, their role with children and 0023 1 parents. Of course they get upset, but I have not 2 noticed that they are so upset that they cannot help the 3 parents in their grief. 4 Certainly, as chaplains, we offer support to the 5 staff as well, so we look for that as the situation 6 evolves and certainly, after the parents have been 7 helped and perhaps helped to go home and whatever, then 8 we will look again at the staff to see if they are okay 9 and whether they wish to talk about it. They have 10 a tremendous support system within their own specialty. 11 They support each other very well. So I personally have 12 not -- obviously, it always raises your own grief or 13 your own loss, but -- and when it has happened, on one 14 or two occasions, then, you know, I give them the space 15 to come and see me and we talk through that. But it is 16 very rare they seem to. 17 Q. Could I just ask you to turn to one further matter, 18 which is the question of how you co-ordinate your 19 services with the services in the community, and the 20 extent or the point at which care on the part of the 21 hospital or from the hospital should be transferred to 22 services within the community. 23 How do you co-ordinate your liaison with 24 community-based services? 25 A. We do that in various ways. I mean, we have various 0024 1 people like Helen Vegoda and Ann Dent who have 2 tremendous resources out there in the community who can 3 key us into the right bereavement groups, whatever, and 4 for my part, if the parents want it, then we can link 5 them with the local vicar, religious minister, whatever, 6 if that is appropriate. 7 So we use that -- I mean, I feel very strongly 8 that we need to help people move back into their lives 9 and into the community and to begin the process of 10 healing, really, and although the door is always open 11 for them to come back to the hospital and to spend time 12 at the hospital in any way they wish, I think the 13 ultimate and ideal goal, in their time -- and that is 14 very important, their time -- they should be helped to 15 move out and back into their lives and to be supported 16 by their family, their community and whatever other 17 agency in the community is available to them. We need 18 to facilitate that work. I feel very strongly about 19 that. 20 Q. When you have identified a need for support within the 21 community, and you have mentioned there community-based 22 agencies for providing such support, is it your 23 experience that these agencies exist and are able to 24 meet that need, or are there issues of funding or 25 coverage that are an obstacle to providing support in 0025 1 the community? 2 A. It is the latter, really. I think that unfortunately 3 there is not enough availability out there. There are 4 long waiting lists and I do believe that the local 5 health authorities should in some way try and support 6 financially these agencies in order to provide the right 7 bereavement services in the community for parents and 8 relatives. 9 Q. You have talked about agencies generally and also 10 waiting lists for these agencies. Can you be a bit more 11 specific on the types of agencies we are talking about? 12 A. I am thinking of CRUSE in particular. 13 Q. That would be a service offering ... 14 A. Bereavement counselling, and I think that the Rainbow 15 Centre, which is a child centre, also has waiting 16 lists. 17 Q. Again, you talked about the need to facilitate parents 18 to move back into their lives and to cope or to adjust 19 to the extent that it is possible within that setting. 20 In the papers we have some discussion of the possibility 21 of a bereavement care service and an integrated service 22 that would be based at the hospital. Do you have any 23 comments upon the advantages or possible limitations of 24 centering such a service within hospitals? 25 A. I do not actually agree with that principle, because 0026 1 I think that we could quite -- there are limitations in 2 so far as you could create a culture of dependency. 3 I know that the proposal is that it is over a five-year 4 period. Well, I am very -- I feel very strongly that we 5 are not there. We need to help people to re-enter their 6 lives and you need a great deal of sensitivity about 7 it. It is on an individual basis. I still believe that 8 as with other health care issues, that should happen in 9 the community ultimately. I am not saying that we do 10 not have a brief -- I have been with a family for four 11 and a half years because of the nature of their 12 bereavement, part of the Public Inquiry, and it is 13 a very raw bereavement because it keeps being exposed by 14 the media. So I have stayed with them and I believe in 15 that, I think that is right, but I do not think normally 16 that that should happen. I do not agree with that 17 principle. I think that the bereavement services in the 18 community should be developed and supported financially 19 for the hospital to use. 20 MISS GREY: Thank you. Reverend Cermakova, we have today 21 the benefit of the attendance of Miss Valerie Mandelson, 22 who is the Manager and Senior Counsellor at the Alder 23 Hey centre. We have attempted to allow a discussion 24 between witnesses such as yourself and herself in order 25 to give the Inquiry the benefit of that dialogue, so 0027 1 I think there may be one or two issues that she would 2 like to raise with you, if that is acceptable. 3 Examined by MRS MANDELSON: 4 Q. Thank you. If I may, if I could just take you back to 5 some points on the volunteer visiting scheme, other 6 members of the Inquiry might already be aware of this 7 information, but for my benefit, you talked about the 8 visitors, the volunteers undergoing an eight-week 9 course? 10 A. Yes. 11 Q. Is that one session a week, or two hours a week? 12 A. I have to say to you that it is once a week and I think 13 it is an afternoon, but I think you need to ask the 14 Reverend Rob Yeomans and Mrs Joanna Abecassis, who run 15 that course. 16 Q. Having completed the course and been selected, how often 17 are the volunteers then on duty? 18 A. They are on duty once a week, for two hours. At the 19 moment, on a Wednesday. 20 Q. So if they were to visit a family and they may not be 21 back on duty for another week, the chance of building 22 a relationship with a family and offering support to 23 a family might be quite limited in that sense? 24 A. It is. In a sense, health care in the less critical 25 cases, they do go in and out of hospital anyway, but we 0028 1 have not -- I mean, we are hoping to up the volunteer 2 visitors in the Children's Hospital and St Michael's, 3 but it has just not happened. In fact in the next raft 4 of training there are one or two people interested in 5 coming up to the Children's Hospital, so we will be 6 hopefully increasing the numbers. 7 Q. One of the witnesses on Monday did talk about the 8 difficulty in a person being there consistently to 9 relate to and in fact that would be the case here. They 10 may not see that person again during their stay in the 11 hospital? 12 A. They may not, but in a debriefing session, if I am 13 picking up a particular person or whatever, then I will 14 go and visit them as well and then they will have 15 a consistent presence with me in this, yes, if it is 16 appropriate. 17 MRS MANDELSON: Thank you. 18 MISS GREY: I do not know whether or not the Panel have any 19 questions? 20 THE CHAIRMAN: Mrs Howard? 21 Examined by THE PANEL: 22 MRS HOWARD: Good morning. I would just like to ask your 23 views on how you feel the chaplaincy service is involved 24 within the clinical team, specifically in respect of 25 ongoing discussions with perhaps surgeons about the 0029 1 long-term care needs of children and how you could 2 support the clinical management of the family? 3 A. Well, I have been involved in one or two cases, but 4 I must say that I was really disappointed to see that in 5 some of the statements I have read, the chaplaincy has 6 hardly been mentioned, especially in the Jean Pratten 7 statement. I know that she worked very closely with Rob 8 Yeomans, but my own feeling is, what I would have liked 9 to have worked for, is that chaplaincies should become 10 much more integrated in a multidisciplinary team, 11 especially in that sort of discussion, and I would hope 12 in the future that becomes more and more the case. 13 Q. Perhaps just to follow on from that, do you have any 14 views or comments to express as to why the chaplaincy 15 service does not appear to be part of or acknowledged as 16 part of the clinical team? 17 A. I think the perception of chaplains has still not 18 widened enough to realise that they actually have a huge 19 amount to contribute, especially in the area of ethics. 20 I have sat on the ethics board of the UBHT for the last 21 three years, but not everybody is aware of that, that we 22 have a lot of training in ethical issues, in counselling 23 skills; we have a much wider brief than just being 24 seemingly at the end of life, dealing with death and 25 funerals. 0030 1 To raise that perception is extremely difficult. 2 We are also considered probably by some of the medical 3 staff as being "bible-bashers", and many times I do not 4 wear my collar around the hospital in order to convince 5 people that I am an ordinary human being with lots of 6 other skills apart from dealing with death. 7 So I think it is the education of clinicians and 8 medical staff that chaplains have a much wider brief, 9 and the only way chaplains can do that is to try and 10 highlight that by constantly saying "Should we not have 11 an ethics forum", which I have tried to do in my time. 12 In a sense, in St Michael's I have succeeded in doing 13 that a little bit more so than in the Children's 14 Hospital, but it is difficult to break tradition down. 15 That perception, I have to say, is generally 16 experienced by all the hospital chaplains throughout the 17 UK, because when we go to our annual conference, we sit 18 and talk about it: how do we get into the system and 19 acknowledge that -- because I think a lot of people 20 actually believe that we are paid by the Church and the 21 Church has actually put us there. They do not actually 22 realise we are members of the UBHT staff, or members of 23 the Trust staff and that we actually are being paid by 24 them. 25 So it is a very difficult one. It is a matter of 0031 1 education, I think, on both our parts, mine and the 2 clinical staff. But I am sure we should be there, 3 I agree with that. 4 THE CHAIRMAN: We have no further questions from the Panel. 5 MISS GREY: I think there may be some further questions or 6 a question from Mr Chambers. 7 THE CHAIRMAN: I was about to ask Mr Chambers whether he had 8 any questions. 9 MR CHAMBERS: I did have, but the question was raised by 10 Mrs Howard so I am saved a long journey across the room. 11 THE CHAIRMAN: I am very grateful to you. Mrs Mandelson? 12 MRS MANDELSON: If I go back a little bit, you talk about 13 the Bereavement Working Group being set up to deal with 14 issues. Are you saying there was really a lack of 15 co-ordination of any of the bereavement services before 16 this working group? There was no centre, if you like, 17 for the different parties involved to relate to? 18 A. Yes, I think that is true, but that is true of all 19 hospitals that I know of. The Children's Hospital has 20 very specialist areas and within those areas, they set 21 up their own specialist protocols. It is bringing all 22 those together and making sure that we do not reinvent 23 the wheel all the time. I think it was for that reason. 24 Q. So then there was no protocol? 25 A. Yes, there were protocols. 0032 1 Q. But separate? 2 A. There were certainly protocols, but I think it would be 3 difficult for me to comment on that, because I know that 4 it was particularly about protocols and I know there was 5 an ITU protocol, but I think that you need to ask 6 someone else that question. I know there was a feeling 7 that we needed to be in touch with all the different 8 areas of the hospital that were looking at bereavement 9 services. That is really basically what it was about, 10 without going into the detail of that. 11 MRS MANDELSON: Thank you. 12 THE CHAIRMAN: Mr Chambers, do you wish to follow up on 13 that? 14 MR CHAMBERS: No, sir, thank you. 15 THE CHAIRMAN: Thank you very much indeed for giving us your 16 time. It has been very helpful to us. You have painted 17 a broad picture for us, and we have learned quite 18 a lot. I am very grateful to you for finding the time 19 to come to see us. 20 If there is anything else that comes to your mind 21 that you would like to tell us about, then please know 22 that we will be happy to hear from you for the duration 23 of the Inquiry. Thank you. 24 REVEREND CERMAKOVIC: Thank you. 25 (The witness withdrew) 0033 1 MISS GREY: Sir, the next witness this morning is Miss Helen 2 Stratton. I think, however, it would be appropriate if 3 I could ask you for a quarter of an hour's break at this 4 point, and we will perhaps resume with her at a quarter 5 to 11? 6 THE CHAIRMAN: Yes. Shall we adjourn, therefore, for 15 7 minutes and reconvene at 10.45? 8 (10.30 am) 9 (A short break) 10 (10.45 am) 11 MR LANGSTAFF: Sir, our next witness is Helen Stratton. 12 Miss Stratton, would you kindly stand to take the oath? 13 MISS HELEN STRATTON (SWORN): 14 Examined by MR LANGSTAFF: 15 Q. If you look to the screen in front of you, can we have 16 on that screen WIT 256/1? 17 Is that the first page of a statement which you 18 made for the purposes of this Inquiry? 19 A. Yes, it is. 20 Q. If you go to page 14, that is your signature at the end? 21 A. That is correct. 22 Q. And it is dated 21st July? 23 A. Yes. 24 Q. Since then, you have seen, but only I think as a matter 25 of fact recently, a number of comments which others have 0034 1 made upon your statement? 2 A. That is correct. 3 Q. If at any stage during the questions which I ask you 4 you would like time to consider in greater detail what 5 they have said, just ask for it. 6 A. Thank you. 7 Q. We will take your statement as read, so the questions 8 I ask will be ones which arise from and expand upon your 9 statement, and deal with a number of other references 10 that have been made to you and your role in the course 11 of the evidence which we have already heard. 12 A. Yes. 13 Q. Sir, I should say that Miss Stratton is represented by 14 Mr Paul Rose who sits behind me. 15 THE CHAIRMAN: Thank you. 16 MR LANGSTAFF: Miss Stratton, when you were appointed, did 17 you have any qualification in dealing with bereavement? 18 A. Not a professional qualification. I had experience as 19 a nurse of dealing with bereaved relatives, but no 20 professional qualifications. 21 Q. Had you had any training in counselling? 22 A. Not official, formal training, no. My understanding was 23 that it was not part of the criteria for this particular 24 job. 25 Q. Had you had any detailed knowledge of cardiac surgery? 0035 1 A. Yes, I had. I had done cardiac surgery when I was in 2 Australia as a Sister, and I had also done cardiac 3 surgery at the Bristol Royal Infirmary while I was doing 4 the intensive care course. 5 Q. So you had experience of intensive care? 6 A. Yes, I did. 7 Q. You had experience of cardiac surgery? 8 A. Yes. 9 Q. Of paediatric cardiac surgery? 10 A. Not directly, no, but again, that was not a prerequisite 11 for this particular role. 12 Q. In general terms, as I understand it, Helen Vegoda 13 looked after counselling of parents at the Children's 14 Hospital. You were a cardiac liaison nurse, or support 15 nurse, at the Royal Infirmary? 16 A. That is correct. I think that the term was "liaison", 17 based on a role that I think Mary Goodwin had begun at 18 Great Ormond Street. That is my understanding of the 19 role. 20 Q. You say that was your understanding of the role. Did 21 you ever have a formal job description? 22 A. I believe I did, but I am afraid I neither have it nor 23 can recall exactly what it had on it. 24 Q. When you applied for the post, what sort of role did you 25 envisage doing? 0036 1 A. The role I envisaged doing was one of communication 2 between the GP, the health visitor and the parents, and 3 also acting as an information source for parents who 4 were often travelling from Devon and Cornwall to 5 Bristol, and making the transition from the Children's 6 Hospital where they had the initial diagnosis and 7 investigations, to the transition to the Bristol Royal 8 Infirmary, smoother and more informed. That was my 9 understanding. So essentially it was an 10 information-giving, communicating, co-ordinating role. 11 Q. You described yourself in a number of letters written to 12 parents as a "support nurse". First of all: that is 13 right? I think that is how you described yourself? 14 Why did you describe yourself as a support nurse 15 if in fact your role was communication, information, 16 liaison? 17 A. I cannot recall the letters, but obviously if I have 18 written it in a letter, then I have. Because I was 19 there to support parents with information regarding what 20 was happening with their child, so I can think of no 21 other reason why I would write that. As I say, I cannot 22 recall actually writing that I was a support nurse. 23 Q. Perhaps we can find an example. I had not imagined it 24 would be in issue so you will have to give me a moment 25 while I put my finger on it, perhaps. I will come back 0037 1 to it and show you the letter and take up that issue in 2 a moment or two. 3 So far as you were concerned, to whom were you 4 answerable for the work that you did? Who was your 5 boss? 6 A. I perceived that Jean Pratten, the Chairman of the Heart 7 Circle, was my boss, as the Heart Circle were paying my 8 salary, or funding the post, so I saw her as someone to 9 refer to as a reference. 10 I do remember having a discussion with her that 11 she did not feel it was appropriate for me to have the 12 senior nurse on the cardiac unit as my direct report 13 because I was not actually nursing patients or children, 14 I was not clinical hands-on. So that might have been 15 inappropriate. But I think, suffice to say, it was 16 quite unclear, apart from my perception of it being 17 Jean Pratten because the Heart Circle were paying my 18 salary and for day-to-day things going on the unit, 19 I would probably refer to Fiona Thomas, or Julia Thomas 20 in the beginning of my job, but I cannot remember that 21 ever being formalised. That was just something that 22 I did. 23 Q. Jean Pratten tells us, you have seen her statement, that 24 she did not regard herself as being in any formal 25 management role so far as you were concerned, and it 0038 1 appears that her view is that you were an employee of 2 the Trust. 3 A. Yes, I have read that. 4 Q. Who appointed you? 5 A. Jean Pratten did, at an interview. 6 Q. Was she the only person at the interview? 7 A. No, Julia Thomas, who was then the Senior Sister on the 8 unit, and there may have been one other person, a member 9 of the Heart Circle, I cannot recall. 10 Q. Who paid your salary cheque as such? Leave aside who 11 funded it, who actually paid the cheque? 12 A. The money actually went into the bank and I received 13 a payment slip via the UBHT salary office. 14 Q. So you were paid through the UBHT? 15 A. Yes, and my perception was that that was for PAYE and 16 the more formal -- 17 Q. For administrative purposes? 18 A. Yes. It would not have been right if the Heart Circle 19 just gave me a cheque every month. Obviously 20 Jean Pratten wanted it more formalised than that. So 21 that was my perception. 22 Q. At some stage you must have had a written contract of 23 employment, a written statement of the terms of your 24 employment? 25 A. I cannot recall having any terms and conditions. 0039 1 Q. So throughout, what you are telling us is that you 2 regarded yourself as an employee of who? 3 A. The Heart Circle. 4 Q. Although you were actually working at the hospital? 5 A. For some of the time when I was not working in the 6 community or working with Jean Pratten giving talks at 7 the Heart Circle and things like that, the majority of 8 my time was spent in the hospital, yes, that is correct. 9 Q. So it follows that so far as the hospital is concerned, 10 you saw yourself as occupying an independent position? 11 A. Yes. I think so. 12 Q. Were you, so far as the BRI was concerned, on your own? 13 A. In what respect? 14 Q. You were carrying out the communication, information, 15 liaison, perhaps support, whatever that may mean. Was 16 anyone helping you to do that? 17 A. No. Well, apart from Jean Pratten, who was very 18 supportive, but as she said, she was supportive in as 19 much as she guided me in what she felt the Heart Circle 20 wanted me to do in fulfilling the role. 21 But there was nobody -- if you are asking me if 22 there was anyone immediately at the BRI whom I was 23 referring to or guiding, then no. 24 Q. You began your work, you tell us, in October 1992? 25 A. Yes, I think so. 0040 1 Q. I am sorry, 1990, my fault, I am sorry. I did not mean 2 to mislead you. You ended in early 1994? 3 A. That is correct. 4 Q. Just clear this up for me: you say in your statement you 5 finished in February 1994? 6 A. Yes. 7 Q. I think there is a reference to your being copied in to 8 a meeting -- let me just find it for you. It is 9 UBHT 135/37. It is the minutes of the Paediatric 10 Interest Group of 6th April 1994. 11 A. Yes. By that time I was probably in my first or second 12 week at BUPA in London. 13 Q. We see that your apology is given to the meeting. The 14 very first item on the agenda, just scroll down to it, 15 deals with Helen's post? 16 A. That refers to me. 17 Q. Because there are a lot of Helens? 18 A. Yes, unfortunately there are, yes. 19 Q. You had prepared it seems a job summary. Just read the 20 first paragraph. 21 A. All I can see is "2. Paediatric care". 22 Q. It is underneath "1". Let me read it through and then 23 ask you the question so you follow it. You are 24 absolutely right, you should stop me if you do not 25 understand the question you are being asked. 0041 1 A. I have read the first paragraph. 2 Q. What it says, the last sentence: 3 "Freda will read the job summary which Helen has 4 prepared to ensure that developments made will be 5 maintained." 6 A. Right. 7 Q. That suggests to me that before you left, probably 8 because somebody had asked you, you had summarised what 9 your job involved doing. 10 A. Yes. My understanding was that once the Heart Circle 11 had finished funding my post, which was for three years, 12 the Trust would take on the post, so I cannot recall the 13 job summary or writing it, but I would imagine that that 14 was the case: that Jean Pratten probably wanted me to 15 put down the learnings from the three years there and my 16 recommendations, probably, for the future of that 17 particular role, which I had understood was in the job 18 summary. But without seeing it, I cannot really say. 19 Q. It appears again from this paragraph that if you did do 20 the job summary, which it suggests you did, and you 21 cannot remember, you would have passed it to Freda 22 Gardner? 23 A. Dr Gardner, yes. 24 Q. Why not Jean Pratten, if you felt you were answerable to 25 Jean Pratten? 0042 1 A. I would imagine I gave it to both of them. I cannot 2 remember. I cannot be more specific than that. 3 Q. So there you are at the BRI -- 4 A. I am sorry: actually, can I come back to that point? 5 Dr Gardner was actually tasked by the Heart Circle to 6 write a supportive paper to continue the funding for my 7 post, so if I did give it to her, the reason was because 8 of that, because I knew she had been tasked by the Heart 9 Circle to prepare a paper in support of this job. So 10 whilst I cannot remember, that may have been what 11 I did. 12 Q. Stepping back a moment to the question I was asking you, 13 you were at the BRI. You had some support from 14 Jean Pratten in the work you were doing? 15 A. Yes. 16 Q. You saw yourself as answerable to no-one very much 17 within the BRI, but to Jean Pratten, because she was the 18 source of your funding, and you had, do I take it, no 19 other person supporting you in your role during the 20 three and a half years that you were there? 21 A. Not supporting me, but suffice to say, I did have 22 a regular dialogue with the Sister, well -- Fiona Thomas 23 (Julia Thomas before then) regarding ward issues, you 24 know, whether it was things that I felt could be done 25 better, or why we were not having any children in that 0043 1 week, or day-to-day issues. There was a dialogue which 2 was very good with the senior Sisters, but they were not 3 there to support me, if that is what you are asking me. 4 Q. So you got to know the individuals at the BRI, those who 5 were there regularly, such as the Sisters you have 6 mentioned? 7 A. Yes. 8 Q. You got to know them well, did you? 9 A. Some of them I knew because I had worked in the Bristol 10 Royal Infirmary in other departments, I knew to say 11 hello to. I did not really know them terribly well when 12 I started. I think some of them I got to know more well 13 while I was working there. 14 Q. And you also got to know Helen Vegoda? 15 A. I met Helen Vegoda when I commenced my job, yes. 16 Q. Did you get on with her? 17 A. I think the problem was, because I had in my mind the 18 perception of the job that Jean Pratten had asked me to 19 do, but I think the problem was, I do not know whether 20 that had been communicated down through other people 21 I would interact with. So I think that when I met Helen 22 Vegoda, she probably did not have an accurate 23 understanding of what my role was going to be, and 24 I perhaps had a misperception of what her role was at 25 the time. I was told there was a counsellor at the 0044 1 Children's Hospital who looked after the parents before 2 I commenced the job, and so I made it my point to go and 3 see what Helen did, so I could see how the jobs 4 dovetailed, really. 5 Q. You began that answer by saying "the problem was", and 6 then you gave an explanation for it. 7 How did the problem manifest itself? 8 A. I decided to go to Great Ormond Street and latterly the 9 Birmingham Children's Hospital, where this role of 10 liaison had been established, certainly at Great Ormond 11 Street, to find out exactly what the nurse there, who at 12 the time was Mary Goodwin, did, so that I could mirror 13 that at the Royal Infirmary. I think one of the first 14 things I found out was that she felt the role of the 15 liaison nurse was very important at the diagnosis time 16 when perhaps the cardiac catheter had been done, or even 17 before. Clearly, at Great Ormond Street that was what 18 happened. 19 I suggested that that would be a very large part 20 of my role and a very valuable part, but I got the 21 impression that Helen Vegoda felt that my role was based 22 at the Bristol Royal Infirmary and was not to be at the 23 Bristol Children's Hospital at all, and that was 24 a problem. 25 Q. So essentially, do I read it right in thinking that you 0045 1 and she disagreed as to what your respective roles 2 should be? 3 A. I think so. I mean, we never discussed it in detail. 4 I did put it to her that I had been to Great Ormond 5 Street, I had found out that part of the liaison role 6 was to be at the Children's Hospital when the child was 7 being diagnosed and the sort of dovetailing with 8 cardiologists, and then the transfer of the parents and 9 the child down to the Bristol Royal Infirmary, which 10 would allow the liaison nurse to start to have 11 a relationship with parents, to talk to the GP and the 12 health visitor, and then there would be continuity of 13 care. 14 Helen Vegoda felt quite strongly that it was her 15 role to look after the parents at the Children's 16 Hospital, and my role was at the Bristol Royal 17 Infirmary. 18 So that was a problem, yes. 19 Q. So if I can go back to the question I asked you about 20 three before last: how did you get on with her? 21 A. I got on with her on a day-to-day basis. We were always 22 very professional. We always had a dialogue, but I do 23 not think we would ever be good friends, if that is what 24 you are asking me. It never affected our professional 25 relationship that we had differences. 0046 1 Q. So if I were to summarise what you are saying in these 2 terms, tell me how accurate or not it is: that your 3 relationship was professional but cool? 4 A. Yes. That is my perception. You would have to ask 5 Helen Vegoda hers. 6 Q. It is only your perception you can tell us of, I think. 7 You put that down to an unfortunate start in working out 8 who was to do what? 9 A. Yes. I think so. And also, that I had a feeling that 10 because I wanted to become involved with the children 11 and the parents at the Children's Hospital, with 12 discussing perhaps some of the medical aspects, clinical 13 aspects of the child's care in outpatients, Helen Vegoda 14 went to outpatients and felt that was part of her role, 15 so that was difficult. 16 Q. Can we have up on the screen, please, UBHT 167/74? 17 This is the annual report for 1989, therefore 18 published in 1990, of the BRI and the Sick Children's 19 Hospital. 20 If we go over two pages to 76, we can see I think 21 it must have been published some time late in 1990 22 because it says under "Staff": 23 "The working team on Ward 5 now includes about 75 24 nurses ... supported by Mrs Helen Vegoda, counsellor to 25 the families of the children, and Miss Helen Stratton, 0047 1 who has a similar but wider counselling role supporting 2 any families in need and also of the staff." 3 It describes how "both the latter appointments 4 have been made possible by the farsighted leadership and 5 generosity of the Bristol and South West Children's 6 Heart Circle under the leadership of Mrs Pratten". 7 The official summary of the year's work appears to 8 see your role as a similar but wider counselling role to 9 that of Helen Vegoda; but you did not? 10 A. No, not at all. (a) I have not seen this document and 11 I am very surprised by that. I saw my role as a cardiac 12 liaison nurse based on the role that Mary Goodwin had 13 done at Great Ormond Street. 14 Q. When the annual reports were produced for Bristol 15 cardiac surgery, did the staff, so far as you recollect, 16 actually see them? 17 A. No. 18 Q. So this was something talking about you and what you did 19 but, as you recall, not shown to you at all? 20 A. Yes. 21 Q. If you had seen this at the time, what would you have 22 said about it? 23 A. I would have clarified my role. 24 Q. Because it does look on the face of it that those who, 25 if they did not employ you, were responsible in one 0048 1 sense for you, that is the hospital, had a different 2 view of what you were there to do than you had? 3 A. Yes. 4 Q. So far as Mary Godwin is concerned, communicating, 5 providing information, liaising, would that have 6 involved her, did it involve her, as you understood it, 7 in talking to parents after surgery, if for instance the 8 surgery finished during the evening? 9 A. I think, well, when I spoke with Mary, she was involved 10 with parents and children when the nurses on the unit 11 felt it was appropriate, so she was not always involved 12 with parents and children unless the staff on the ward 13 or a particular consultant felt it was appropriate. 14 Q. So she was a resource summonsed in by the nurses? 15 A. Yes, and I think so because it was a dedicated 16 paediatric unit, then the nurses were more comfortable 17 dealing with parents and children at Great Ormond Street 18 and there may have been less demand on her post for some 19 of the more counselling aspects of the job, but there 20 was also at Great Ormond Street at the time 21 a professional counsellor who Mary could call on if 22 parents wanted more than Mary sitting and going through 23 the child's condition and aspects of intensive care. 24 Q. So, so far as you understood the position, is it then 25 that she did not, as a rule, make herself available for 0049 1 parents during and after the surgery of their children, 2 unless a nurse made a specific request that she should 3 do so? 4 A. I do not think there was a hard and fast rule, but 5 I think when I asked her about how she managed her time 6 and how she saw parents, was it in a structured way or 7 was it she went round the unit and chatted to people, 8 she said "I do go into the intensive care unit and I do 9 say hello to people, and I do make sure they know I am 10 around, but I do not see parents for long periods of 11 time unless I am asked to by the nurses or the 12 consultant in charge". 13 Q. In your case, you did see parents? 14 A. Yes. 15 Q. As a general rule, before their children went for 16 surgery? 17 A. Yes, I did. I think with any new role it is evolving 18 and I think -- I did have a job description, I am afraid 19 I cannot remember exactly what it had on it, so I was 20 evolving a job given what was happening at Great Ormond 21 Street, but I think in a typical nursing fashion, I was 22 trying to fill gaps where I thought there were gaps in 23 the provision of looking after parents and children at 24 the Royal Infirmary. So if I felt it was appropriate to 25 talk to parents on the unit, I would do that. So it was 0050 1 rather unstructured to start with, because I did not 2 have an awful lot of guidance, apart from what I was 3 learning at Great Ormond Street, to go on. 4 Q. You were regularly, were you, there while children were 5 undergoing surgery? You were there for the parents as 6 a liaison between what was happening in theatre and the 7 parents? 8 A. Yes, as a rule I tried to -- parents would have the 9 option of going down to theatre with the child, which 10 was something that I fought quite hard for, because that 11 certainly did not happen when I first arrived; that was 12 discouraged, which I thought was wrong; I thought 13 parents should have the choice, if that was what they 14 wanted. So I would take them down to theatre. We would 15 normally suggest that they did something during the day 16 because time would go very slowly, and that they would 17 ring in at certain times, and I would try and be 18 available when they rang in -- I could not always be 19 there to answer the phone because they rang the main 20 part of the unit, I did not have a telephone dedicated 21 to me. I would make it my job to go down to theatre, 22 find out how the operation was going, and either tell 23 them personally or make sure the nurses on the intensive 24 care unit were able to have that conversation with them 25 on the phone. 0051 1 So that was a liaison, information-giving. 2 Q. Did that involve you as you expanded the role in being 3 present when surgery was over, even though that might be 4 late in the evening? 5 A. I did try to, but towards the end of my job I was 6 finding that it was getting increasingly difficult to 7 work those types of hours and make those huge emotional 8 investments. 9 Q. It was the latter I was going to ask you about. So far 10 as Mary Goodwin was concerned, do I understand from what 11 you say in your statement that she did not, as a general 12 rule, make herself as a matter of course available at 13 the end of surgery? 14 A. No, she did not. 15 Q. So her role was strictly speaking information, 16 communication, liaison? 17 A. Yes. I believe her role was a cardiac liaison role. 18 Q. You found, did you, that you were required to go beyond 19 the information -- 20 A. I think what happened is that whilst I tried incredibly 21 hard to do the liaison job, the job that I had been 22 tasked with doing, I found that I was filling gaps and 23 doing things that Mary Goodwin did not do, but just 24 because there was a need and someone had to meet that 25 need. 0052 1 So I did that, yes. 2 Q. The need that you are describing: the one that you 3 perceived on a human or nursing level, or both? 4 A. I think both. 5 Q. Essentially, was the role that you were pushed into 6 doing by these pressures in the nature of a counsellor, 7 a shoulder to cry on, somebody to be there, something of 8 that sort? 9 A. I think increasingly, it did become that, but as I think 10 I said in my statement, as the need to counsel, and 11 I think you have to be very careful on your definition 12 of counselling. My personal definition of counselling 13 is someone who has a professional qualification to carry 14 that out. I recognised I did not have that 15 qualification. That is when I sought advice and help 16 from Dr Gardner as to how I should support, counsel 17 these parents, given that I did have not a mental health 18 background or counselling, and I took advice from her. 19 Q. So if one looks and charts the development of your role, 20 you are appointed to a new role, a role which you 21 understand to be communication, information, liaison. 22 You found that by filling the gaps, because of your 23 nursing background you find it necessary to be the 24 shoulder to cry on, and you develop a counselling side 25 to your role, even though you had no formal 0053 1 qualifications as such? 2 A. I think unintentionally the job drifted into that. 3 I think also I felt that the nurses on the unit were 4 doing an incredibly difficult job in very difficult 5 circumstances, and if I could alleviate that by giving 6 them one less thing to do, which was to perhaps spend 7 some time with the parents, et cetera, I thought that 8 would be time well spent. 9 Q. At any stage, did you stop and stand back and say to 10 yourself, "Well, I am not really doing the job that 11 I was appointed to do; I am doing a counselling job I am 12 not fitted for because I have no training; that is what 13 I am doing, in fact and I am not really, therefore, just 14 concentrating on doing the job I was appointed to do"? 15 A. I think I did probably at the end of the second year, 16 and I spoke to Dr Gardner about this, but there was 17 nobody else to do it, I felt I could not just walk away 18 from that role. 19 Q. You spoke to Dr Gardner, then, what, about October 20 1992? 21 A. Yes, I think. I cannot be clear about the date. 22 Q. You mention in your statement years and again, just so 23 I know roughly what time various events happened, you 24 begin in October 1990. The first year ends at the end 25 of September 1991; the second year, October 1991 to end 0054 1 of September 1992; the third year, October 1992 to the 2 end of September 1993, and so on. 3 That is about right, is it? 4 A. I cannot be clear about the dates, but I know that 5 probably about year or 18 months into my role was when 6 I did ask the question that you have just posed as to, 7 was I actually deviating from the liaison role into 8 something which was just plugging gaps where necessary, 9 and I did speak to Dr Gardner about that. That, 10 I think, is around the same time as I asked for 11 supervision from her. 12 Q. So the date you are putting it at is some time between 13 about April 1992 and October 1992, that sort of time? 14 A. From what I can recall, but it is vague, I am afraid. 15 Q. Why Freda Gardner? 16 A. I had met Dr Gardner when she came to Bristol because 17 she was doing a PhD into the psychological impact of 18 having a child with congenital cardiac disease. She 19 contacted Jean Pratten when she came to Bristol to do 20 her PhD because of Jean's role in the Heart Circle, and 21 Jean introduced me to her so that I would be able to 22 approach parents and if they were agreeable, meet 23 Dr Gardner so she could discuss with them the 24 psychological impact of having a child with congenital 25 cardiac disease and video them. I mean, this was all 0055 1 done under the Ethical Committee and Research and all 2 the rest of it. So I acted as a liaison with Dr Gardner 3 for her PhD thesis, so I had got to know her then. 4 So without any other mental health support that 5 I knew of in the hospital, she was clearly the first 6 port of call. 7 Q. Was there any other port of call to which you turned? 8 A. I spoke to Jean Pratten about it. 9 Q. Anybody else? 10 A. Well, latterly, as I got to know Dr Bolsin, because he 11 was working on the unit, and I knew his wife because she 12 worked in the accident department where I had previously 13 worked and we had friends in common, and also they lived 14 next-door to me, so we started as friends socially and 15 then I raised the subject to him that I was finding it 16 very difficult. 17 Q. Doing a job you were not essentially trained for? 18 A. Yes. 19 Q. And without anyone else helping you to do that 20 particular job? 21 A. Yes. 22 Q. Just picking up on the last point, the absence of any 23 other support, you tell us that so far as Mary Godwin 24 was concerned -- paragraph 29 of your statement, 25 page 11 -- that she and indeed Susie Hutchinson from 0056 1 Birmingham -- it is the last sentence of paragraph 29, 2 could call on a strong multidisciplinary team for 3 support? 4 A. Yes. 5 Q. Including a dedicated accommodation officer, a social 6 worker and psychiatric support if necessary? 7 A. Yes. 8 Q. So far as the dedicated accommodation officer was 9 concerned, was there one at Bristol? 10 A. No. 11 Q. So far as a social worker was concerned, was there one 12 at Bristol? 13 A. There was a social worker called Sarah Appleton who was 14 allocated I think five hours a week to the cardiac unit, 15 but that was for children and adults. She and I had 16 a very good working relationship and she helped a number 17 of parents on the unit, but I would not say that was 18 dedicated. 19 Q. Because it was too short in time? 20 A. Yes, it was too short a time. 21 Q. Was there psychiatric support? 22 A. No, not that I was aware of, no. From what I can 23 remember of the Bristol Royal Infirmary, psychiatry was 24 not based at the Bristol Royal Infirmary, but I cannot 25 be clear about that, I am afraid. 0057 1 Q. Did you ever ask anyone for the support of an 2 accommodation officer? 3 A. Again, I talked to Jean about it, and she said that 4 there had been somebody who dealt with hospital doctors' 5 and nurses' accommodation, who had helped them out in 6 the past, but apart from that, there was nobody. 7 Q. So far as psychiatric support was concerned, you spoke 8 to her as you told us, but not to anyone else apart from 9 her or Dr Gardner? 10 A. No, I did not, no. 11 Q. So far as social work provision was concerned, did you 12 speak to anyone about the absence of sufficient social 13 work support? 14 A. I did express my concerns to Fiona Thomas, who was also 15 very concerned that the social worker was given 16 five hours for the unit. I do not know what she did 17 about that, but I did express it to her. I know for 18 Sarah, that she was incredibly stretched and I certainly 19 would not have asked her for more hours because she just 20 did not have that time to give me. 21 Q. Apart from agreeing with you, what was Fiona Thomas's 22 reaction, as you recall it? 23 A. She agreed with me, but I think she felt that there was 24 not an awful lot she could do about it. 25 Q. When was it, do you think, that you raised that with 0058 1 her? 2 A. Again, I think it was probably 18 months or two years 3 into the job. 4 Q. So at the stage when you were beginning to feel the 5 pressures of having to do counselling? 6 A. Yes. I think probably it was one of the informal 7 conversations we had on a daily basis in our office 8 regarding things on the unit and the state of play of 9 things that were going on. 10 Q. So was it a complaint that you made an emphasis of, or 11 was it one of those things you happened to mention 12 perhaps in passing? 13 A. I think I expressed a concern. I did not put it in 14 writing, if that is what you are asking me. 15 Q. Do you think it was, "Look here, Fiona, this is 16 a definite and detailed concern", or do you think it was 17 something you passed off more as a grumble? 18 A. No, I was quite serious about it. 19 Q. You contrast, in your statement, the approach which you 20 understood to operate in Great Ormond Street, the 21 multidisciplinary team approach, with that which you 22 found at the Bristol hospitals. 23 What complaint, if any, do you make about the 24 approach at the BRI -- it is 256/4, the second sentence 25 of paragraph 12 at the foot of the page: 0059 1 "The teamwork approach which existed at Great 2 Ormond Street didn't exist within cardiac services in 3 Bristol." 4 What sort of approach did you expect and hope for 5 that was not there? 6 A. I think, as I have said in my statement, my only 7 benchmark for what should happen in a multidisciplinary 8 service was from the renal unit at Southmead Hospital 9 where I had worked as a transplant co-ordinator, where 10 I worked closely with nephrologists, transplant 11 surgeons, intensivists, anaesthetists, the nurses on the 12 transplant unit and dialysis unit. It was very much 13 a team effort and there was transparency in 14 communication. People were clear about their roles, and 15 I suppose I expected to find those, given that that was 16 my only experience, given what I was told by people 17 working at other centres, that I would find that in the 18 cardiac unit. 19 Q. At the renal unit you were co-ordinating between staff, 20 were you? 21 A. I am sorry, at which unit? 22 Q. The renal unit. 23 A. I was a transplant co-ordinator, which entailed going to 24 the intensive care units in the South West, where 25 somebody had unfortunately died on the intensive care 0060 1 unit and had become an organ donor, and I would talk to 2 relatives there about the aspects of organ donation, 3 I would talk to the staff, I would talk to the 4 anaesthetist and I would liaise with the transplant 5 teams at the different areas in the country, organise 6 the retrieval, and once the organs had been received by 7 the particular patients, I would make it my job that 8 they could write anonymously to the donor family. So 9 that again was a sort of liaison communication role 10 which was why I thought I was a suitable candidate. 11 Q. How did the approach then differ in the cardiac 12 services? 13 A. There was a lot more communication between the different 14 clinical disciplines, nephrology and transplant surgery 15 and anaesthetists. There were very good working 16 relations and communication and no one person owned the 17 patient, particularly when they were having the 18 transplant. It was a multidisciplinary approach. 19 There were regular meetings which involved all 20 levels of staff, junior doctors, dieticians, and where 21 patients would be discussed and their suitability for 22 transplantation, and I assumed that that was the correct 23 approach to delivering a service like that. 24 Q. So how did it differ in cardiac services? 25 A. None of it happened. 0061 1 Q. So you mean cardiologists did not talk to surgeons? 2 A. They may have done, but I was unaware of any cardiac 3 surgeons and cardiologists and nurses and dieticians and 4 people like that, all meeting together to discuss issues 5 about parents and children. I was unaware of that sort 6 of meeting taking place. I certainly did not see any 7 meetings, informal or otherwise, between cardiologists 8 and cardiac surgeons on the unit at the Bristol Royal 9 Infirmary. 10 Q. Were there meetings between the surgeons and the nurses? 11 A. Not that I was aware of, no. 12 Q. Were there meetings of the nurses? 13 A. I think the Sisters had a meeting, the senior Sisters on 14 the cardiac unit, possibly once a month. 15 Q. But not a meeting that involved you, is what you are 16 saying? 17 A. I was involved sometimes when I knew about them, but not 18 on an official basis. It was really to discuss ward 19 issues, you know, fairly practical issues and nursing 20 policy issues, but that is not saying that it would have 21 been helpful for me to be there. 22 Q. What about the anaesthetists? 23 A. They were not at the Sisters' meeting, but I do not 24 recall or believe there were regular meetings between 25 the anaesthetists and the surgeons and the 0062 1 cardiologists, but I may be wrong. I just was not aware 2 of them. 3 Q. If there had been, let us suppose, a meeting once each 4 week to review the cases coming up for surgery the 5 following week, a meeting involving cardiologists, 6 cardiac surgeons, possibly anaesthetists, is that 7 something you would have been aware of? 8 A. I hope so, yes. I mean, my ideal would have been that 9 there would have been a meeting with the referring 10 cardiologist, the cardiac surgeon, and at least 11 a representative from the anaesthetic department who was 12 involved with paediatric cardiac anaesthesia, some 13 nurses from the unit, to discuss future operations, 14 patients that were on the ward at the moment. That, 15 I believe, would have been the ideal. But I am not 16 aware that that ever happened. 17 Q. Would you forgive me for one moment? There is what we 18 call a technical glitch. Sometimes when a "not" is 19 said twice in a sentence, as you did, it can be missed. 20 Let me just correct it at this stage. Can I take you 21 back to what you said and just ask if this is what you 22 meant to say. 23 The question I asked you about the meeting of the 24 sisters in the cardiac unit was: 25 "That was not a meeting that involved you, is that 0063 1 what you are saying?" 2 Your answer was: "I was involved sometimes when 3 I knew about them, but not on an official basis. It was 4 really to discuss ward issues, you know, fairly 5 practical issues and nursing policy issues. That is not 6 saying that it would have been helpful for me to be 7 there." 8 A. Yes, that is what I said. 9 Q. That is what you meant? 10 A. Yes, it is. 11 Q. So you did not mean to say -- it is not saying it would 12 not have been helpful for you to be there? 13 A. No, it would have been, because I think it would have 14 been helpful if we had had an opportunity to discuss 15 particular children and parents on the unit, and an 16 opportunity for me to say, you know, how I thought 17 things could be improved in a formal setting, rather 18 than talking in a corridor or going to Fiona Thomas's 19 office and saying "I think this is a good idea, why 20 don't we do this". So I had supported a more formal 21 approach of assessing how parents and children were on 22 the unit at the moment on particular issues. 23 Q. I am sorry to take you back to that, but thank you. You 24 have clarified the answer. That is what we need, to 25 make sure we got your evidence as you meant to give it. 0064 1 Going back to where we were, I was talking to you 2 about whether, if there had been meetings, pre-surgery 3 meetings between referring cardiologists, cardiac 4 surgeons and possibly anaesthetists, you would have 5 known? 6 A. I would like to think I would have done, but the climate 7 on the cardiac unit was not one that encouraged, I felt, 8 nurses to be involved with meetings with consultants and 9 anaesthetists. I felt there was very much a, nurses 10 were nurses and consultants were consultants, and 11 I personally felt that the nurses were -- the more 12 senior nurses were perhaps not valued in being able to 13 contribute to a meeting where cardiologists and cardiac 14 surgeons were. I got that perception. 15 Q. What gave you that perception? 16 A. I think when I asked nurses about specific issues on the 17 unit, nursing issues on the whole, organisational 18 issues, it was always said, well, we would have to ask 19 the surgeons, or we would have to ask Mr Wisheart. And 20 I got the impression there was very much a strong hold, 21 a sort of command and control on the unit by the senior 22 surgeons. 23 Q. That approach might suggest that what you were saying, 24 the useful suggestion, or whatever it was, would 25 actually have gone up the tree, if that is the right way 0065 1 of putting it, to Mr Wisheart, and he would then have 2 had a recommendation from one of the nurses as to what 3 might be done and would say "Yes" or "No". Is that the 4 way that it worked as you saw it? 5 A. Yes. I am aware from talking to nurses on the unit that 6 if they wanted to change dressings or the type of drain 7 bottles they used or some nursing issues, then that 8 would have to go to the surgeons to be discussed before 9 any consent was given for a change of practice, even if 10 that was essentially probably a nursing issue. 11 So I had some reservations about whether, if I had 12 made a suggestion that we had a multidisciplinary team 13 meeting, that would have been embraced or whether that 14 would have been felt unnecessary. I think because I was 15 working on my own, I got the distinct impression that 16 I was quite a weak player in trying to get things to 17 change. 18 Q. Does it follow from what you said that you do not 19 actually know what would have happened, because you 20 never actually made the proposal? 21 A. I did not make that proposal, no. 22 Q. So it follows, I think, that all you may have is 23 reservations about what might have happened? 24 A. Yes. I think once I had been, after the initial time 25 when I had gone to Mr Wisheart about the importance of 0066 1 the liaison role being someone who was involved from the 2 time of diagnosis, and from what I can remember his lack 3 of support for me in doing that, I just became 4 increasingly aware that any other suggestions would 5 probably be met with the same sort of disinterest. 6 Q. I will come back to that in a moment, if I may. 7 So far as you perceived other people's 8 relationships on the unit -- I will come back to 9 yours -- is it the case, from what you said, that nurses 10 would actually have felt able to raise matters with 11 Mr Dhasmana or Mr Wisheart, even although they could 12 only propose and the surgeons would dispose? 13 A. My understanding is that if a nurse on the unit wanted 14 to suggest a change in something, they went through the 15 senior nurse on the unit, and my understanding was, she 16 would bring that up with Mr Wisheart, or, you know, the 17 senior clinician. 18 Q. So you understood there to be a channel of 19 communication? 20 A. Yes. 21 Q. So far as you were concerned personally, how easy did 22 you find Mr Dhasmana to talk to? 23 A. I think it changed from day to day, depending on how 24 busy and sort of under pressure he was, obviously. He 25 was always very pleasant to me, always very nice, but 0067 1 I did not find him particularly easy to approach and 2 I did not find him particularly easy to make suggestions 3 of changes in care, because I think it was perceived as 4 a criticism. 5 Q. Two things. How did he differ -- it may be obvious but 6 tell us -- when you felt he was under pressure compared 7 to those times when he was not? 8 A. He could be quite short with you. 9 Q. On the occasions when he was not under pressure, then 10 there were occasions when he would be pleasant and 11 polite to you? 12 A. Yes. 13 Q. So what was the difficulty in approaching him? 14 A. I think because I never had an opportunity whilst I was 15 on the unit, you know, that the surgeons were in theatre 16 or they were in a hurry to get down to theatre. There 17 was never time to catch him when he was not under stress 18 to have that type of dialogue with him. I saw him 19 either as he was rushing down to theatre or when he was 20 coming back, or when he was rushing around the unit 21 prior to going down to theatre, and I suppose if we had 22 had a formal way of communicating, a dialogue through 23 a meeting, that would have been appropriate. But it was 24 actually quite difficult to find a time when he would 25 have had the time to sit down and speak to me. 0068 1 Q. So you are describing really a time problem rather than 2 a personality problem, is it? 3 A. Yes. I think if I had caught him when he was not 4 stressed and we were able to sit down and have some sort 5 of dialogue, then I am sure we could have done that. 6 Whether those suggestions would have got any further 7 than Mr Dhasmana, I am not sure. 8 Q. Mr Wisheart, the same questions: was he an easy man, as 9 you saw it, to approach? 10 A. Putting the time constraints aside, he was an easy man 11 to approach. He had a very easy manner. But when 12 I dealt with him in the latter part of my job, not at 13 the beginning, I did feel he was slightly patronising 14 and rather dismissive of me and the role. 15 Q. In the earlier days, when he was not patronising and 16 dismissive, what then? Easy enough to approach, or not? 17 A. Yes, he was. 18 Q. Did you in fact approach him on any issues? 19 A. I did approach him on the issue regarding the liaison 20 work at Great Ormond Street and the importance I felt of 21 that role being somebody going to the Children's 22 Hospital, being with parents and cardiologists and 23 cardiac surgeons at the time of diagnosis. 24 Q. You had a meeting about that which I will come to in 25 a moment. 0069 1 A. Yes. 2 Q. On any other issue, did you approach him? 3 A. Not that I can recall. 4 Q. Later on you tell us -- I am looking ahead for 5 a moment -- you became concerned about the length of 6 time that children spent in theatre? 7 A. Yes. 8 Q. And as a generalised concern, from what you had heard 9 from others, and from what you had noted down yourself 10 in your notebook, I think. Have I got it right? 11 A. It was from talking to the nurses at Great Ormond 12 Street; also latterly talking to Susie Hutchinson at 13 Birmingham, and, yes, my own concerns that there did 14 seem to be a number of children who were not surviving. 15 When I spoke to my colleagues at Great Ormond Street and 16 Birmingham, they expressed surprise and concern, which 17 obviously I came away thinking, "Well, perhaps there is 18 something wrong". 19 Q. Did you ever raise any concern about the length of time 20 the children spent in surgery, or ask for any 21 explanation of the length of time they spent in surgery 22 from Mr Wisheart? 23 A. I did not, no. 24 Q. Or from Mr Dhasmana? 25 A. I did not, no. I did not approach either of them about 0070 1 it, because the climate was not such that I felt it was 2 appropriate. 3 Q. Again, climate is sometimes very elusive to define, even 4 though it may be easy enough to recognise. So far, what 5 you have told us about the climate is that nurses on the 6 unit felt that they had to refer upward, as they saw it, 7 to the surgeons for decisions about any matter relating 8 to practice? 9 A. Yes. 10 Q. You have told us that there was a channel of 11 communication through Sister Thomas, and your 12 understanding was that matters raised with her were 13 raised with the surgeons. 14 You have told us that in general terms, although 15 not perhaps when Mr Dhasmana was under pressure, both 16 surgeons were relatively approachable. 17 What, then, created the climate? Was there 18 anything else which created the climate to which you 19 have referred? 20 A. I just had a perception that you would make yourself 21 unpopular if you made any suggestion that things that 22 were being done at Bristol were perhaps not being done 23 as well as they were being done at Great Ormond Street 24 and Birmingham. I mean, I did come back from both those 25 places and I had some ideas and initiatives to do with 0071 1 parents and I was allowed to implement them, but there 2 was a disinterest in that, and I think that some people 3 felt that by coming back with suggestions that were "At 4 Great Ormond Street they do this and I think it is 5 a great idea and I think we should think about doing it 6 here", was taken as a personal criticism rather than 7 being embraced as a good idea. People were quite 8 defensive. 9 Q. Can you put flesh on it for me and give me a "for 10 instance" of a particular proposal, a particular 11 practice at Great Ormond Street which you said to 12 someone in Bristol "Let us do that here, it is a good 13 idea" and how that someone let it be known to you that 14 that was really criticising them personally for the way 15 that things were done? 16 A. I think when I came back and suggested that we might do 17 foot or hand prints of the children when they had died, 18 and put them in a card, and that would be quite nice, 19 and, you know, parents had the option of having that if 20 they wanted, some people dismissed it, some people said 21 it was in bad taste, and some people said "Don't expect 22 me to be the person doing that". But I went ahead and 23 did it because I thought it was important that people 24 had that choice and if parents thought that it was 25 inappropriate, then they could just say, "No, that is 0072 1 not what I want". But I felt they should have the 2 choice. It was clearly something that had worked very 3 well at Great Ormond Street. 4 Q. There may legitimately on occasions be two views about 5 what is the best approach? 6 A. Yes. 7 Q. Take, for example, the Moses basket provided by the 8 Heart Circle. 9 A. Yes. 10 Q. You regarded that as a useful development and something 11 which was helpful? 12 A. I did, yes. 13 Q. So the dead child could be placed in the Moses basket 14 and that would be appropriate and acceptable? 15 A. Yes. 16 Q. We heard earlier this week in evidence that every death 17 is different and people react to every death in 18 a different way. 19 A. Yes. 20 Q. Parents are individual. Do you accept that for some 21 parents, seeing their child in a basket which was not 22 his or her own, in which the child had never been 23 before, in which the child was presented to them in 24 death, could be disturbing? 25 A. Yes, I do accept that. 0073 1 Q. So there are two views that one might take as to the 2 appropriateness of something like that? 3 A. Yes, I accept that. 4 Q. And might the same possibly be said of hand and foot 5 prints? 6 A. Yes. 7 Q. What you are saying is, "Let us give people the choice", 8 so it is not a decision that you would make, not 9 something you would do, but you would give them the 10 choice? 11 A. Yes. 12 Q. So far as the reaction that you got in respect of that 13 issue, why do you classify it as opposition and 14 disinterest, rather than a genuine expression of, "Well, 15 this might not actually be appropriate"? 16 A. Because the reaction I would have hoped for would have 17 been, "Well, I personally think that that is not a good 18 idea, or it is tasteless, but I agree that you should 19 give people the option". I think that was the answer or 20 the approach I was looking for, rather than a dismissive 21 and defensive reaction. 22 Q. And the dismissive and defensive reaction that you have 23 described comes from your contact with the nurses? 24 A. Yes, on the whole, yes. 25 Q. At the BRI? 0074 1 A. Yes. 2 Q. Was it the nurse in charge, Fiona Thomas or not? Did 3 you discuss that with her? 4 A. No, I cannot recall who it was. 5 Q. Because I understand from what you have said that you 6 have a respect for Fiona Thomas's professionalism? 7 A. Yes, I do, yes. 8 Q. And does it follow from what you have said that the 9 culture as you saw it was not something which, from that 10 example, related to the surgeons? 11 A. I think it did in as much as any change was seen as 12 a threat to the status quo or the stability of the 13 unit. I just had the impression that if you wanted to 14 change anything, whether it was to implement something 15 or to approach the death of a baby in a different way, 16 or the parents' option to go down to the theatre, there 17 was a reluctance to change. 18 Q. Did you ever ask the surgeons about the particular 19 example you have given: the foot prints -- 20 A. I did not ask the surgeons about it, no. 21 Q. You went ahead and did it? 22 A. I did, yes. 23 Q. You felt free enough to do that? 24 A. Yes, I did. I discussed it with Jean Pratten and I did 25 discuss it with the nurses. Although they were not 0075 1 particularly keen, they did not prevent me doing it. 2 Q. Did you have any feedback which would attribute as 3 having come originally from the surgeons, even though 4 they may not have spoken to you personally about it? 5 A. On that issue? 6 Q. On that issue. 7 A. No. 8 Q. So again, trying to put flesh on the culture and what 9 caused it and who had it, what other example can you 10 think of that might enable the Panel to get a handle on 11 what was happening between people at the time that you 12 were at the BRI? 13 A. What exactly do you mean by "what was happening between 14 people"? 15 Q. Well, the culture. 16 A. I just think that going back to the multidisciplinary 17 approach, I was surprised that the surgeons would come 18 around and do a ward round or walk around the unit, and 19 then the anaesthetist would come around later and then 20 somebody else may pop in and see the patient as well, 21 and it was all at different times, and I never visibly 22 saw a more team approach to the care of the children or 23 the parents. It seems a bit split. It seemed to be 24 that the surgeons came round, gave these instructions; 25 the anaesthetist came round, gave different 0076 1 instructions, possibly, and I personally felt that that 2 perhaps was not the best way to approach the delivery of 3 care. 4 But then, I was a nurse on the unit and it would 5 have been difficult for me to have started suggesting 6 that the consultants changed their practices; it would 7 have been unacceptable. 8 Q. In so far as the culture is concerned, you have told us 9 of what you might describe as the resistance or lack of 10 interest to your new ideas from the nurses. You have 11 told us of the fragmentation of care in the sense that 12 different people had responsibility or appeared to have 13 responsibility at different times. 14 What was it about either of those that made you 15 think that to make a suggestion would actually be so 16 unwelcome that it would, as it were, rebound upon you? 17 A. It is difficult to describe a culture or a climate when 18 you feel it personally yourself and you become aware 19 that other people feel that, but I think there were 20 mixed feelings and possibly an indifference to my role 21 which made me quite a weak player in the framework of 22 everything. And I just got the distinct impression that 23 if I had voiced a view or an opinion, then even if -- as 24 I did with Julia Thomas and Lesley Salmon, any view or 25 expression would end up at the senior clinician's door, 0077 1 possibly Mr Wisheart at that time, and would be treated 2 with some indifference or, after my experience of trying 3 to get to go to the Children's Hospital, where I felt 4 quite strongly, I was "put back in my box", for want of 5 another expression, I was not keen to go down that road 6 again. 7 Q. So is it or is it not right that the only occasion when 8 you had a direct rebuff from one of the surgeons was in 9 respect of that early meeting about how your role and 10 Helen Vegoda's interacted? 11 A. Yes, but that was sufficient. 12 Q. That was sufficient to put you off trying again? 13 A. Yes. I felt that I was not given a good enough reason 14 why, if we wanted to follow a model that was at Great 15 Ormond Street, and we wanted to have a liaison service, 16 that seeing the parents and children at the Children's 17 Hospital was fundamentally a very, very important part 18 of the role. I was extremely saddened, and I felt let 19 down that Mr Wisheart and the others did not feel that. 20 I did feel that it was "We have been working here 21 for a long time and it has been done like this; 22 therefore it will continue to be done like that." 23 That is how I felt. 24 Q. It is part of the nurse's professional duty, is it, to 25 be the advocate for the patient? 0078 1 A. Yes, it is. 2 Q. In terms of the early meeting that you had in respect of 3 Helen Vegoda, when was it? 4 A. I cannot be clear exactly. I would imagine, given that 5 it was after some of my first visits to Great Ormond 6 Street, it was probably in the first year at some stage. 7 Q. Can you be more helpful? 8 A. No, I cannot, I am afraid. 9 Q. Can you put it towards the beginning or towards the end? 10 A. No, I really cannot. 11 Q. Almost one of the first things you would have to do when 12 you came to the Royal Infirmary was to sort out what you 13 were doing, what Helen Vegoda was doing? 14 A. Yes. 15 Q. Was it much more than a simple geographical split: she 16 was at the Children's Hospital and you were at the BRI? 17 A. What, our roles were different? 18 Q. Your roles were different, you have told us that, but in 19 terms of how you divided it up, was there more to the 20 division of what you actually took responsibility for 21 across the whole of cardiac care than her saying or her 22 acting within the BCH and you taking on whatever had to 23 be done under your job description as you saw it at the 24 BRI? 25 Have I made the question clear? 0079 1 A. No, I am afraid I do not understand the question. 2 Q. Do not worry, it is my fault, not yours. You came into 3 a situation in which Helen Vegoda was already at work. 4 A. Yes. 5 Q. You knew she was at work. 6 A. Yes. 7 Q. Did you know that she was a Heart Circle funded post? 8 A. Well, I did after I had been in post for a while, yes. 9 Q. Did you see her, in fact, before you came into post in 10 October 1990? 11 A. Not before I started the job, no. 12 Q. She, I think you saw this morning for the first time. 13 She recalls meeting you in July and September, before 14 your taking up post in October 1990? 15 A. Well, I cannot recall that, I am afraid. 16 Q. Can we have on the screen WIT 256/16? This is her diary 17 for 20th July 1990, before you took up post. 18 A. Right. 19 Q. The number that is there, 505050, extension 3782. Your 20 number? 21 A. Southmead Hospital's number. 22 Q. You were there at the time? 23 A. I was transplant co-ordinator there. 24 Q. "11.30, Helen Stratton" and the number. Did you speak 25 to her by phone before you took that appointment? 0080 1 A. I cannot recall meeting her, and I cannot recall a phone 2 call. 3 Q. She says it happened. Is that probably right? 4 A. I cannot comment. I cannot remember it. 5 Q. The next diary extract that she gives us, she tells us 6 that she spoke to you or saw you before October. Her 7 recollection, I think, is at fault in saying you began 8 in November because you began in October, did you not? 9 A. I think so, yes, if that is what I have put. 10 Q. WIT 256/17. "1 pm, Helen S in room." 11 "Helen S" is probably you? 12 A. Yes. 13 Q. There were lots of Helens, but no other Helen S, was 14 there? 15 A. Not that I am aware of. 16 Q. So very shortly after, if you began on the Monday, which 17 you might have done, two days later, did you, do you 18 think, meet Helen Vegoda? 19 A. Yes, probably, because I probably thought it was 20 important that we had an opportunity to discuss our 21 roles. 22 Q. What she recalls is, the way she puts it -- WIT 256/15, 23 item (1), five lines down -- that you would have been, 24 she says, from meeting her, fully aware of her role in 25 the BCH and BRI with cardiac children and their 0081 1 families? 2 A. I was aware that she worked there. My initial 3 impression was that she was a counsellor for children at 4 the Children's Hospital. She did later clarify that for 5 me, but I was not aware of exactly the details of her 6 role in as much as, for instance, when I said I would 7 consider coming up to the Children's Hospital to talk to 8 parents about their child's condition to relay or 9 clarify medical information, I distinctly remember her 10 saying that "That is part of my role. I go to 11 outpatients to see the parents." 12 So I know that she saw the parents in 13 outpatients. I am not quite sure of the support and 14 help she gave. I am not sure what format that took. 15 Q. Are you sure that Jean Pratten did not tell you at some 16 stage prior to your appointment -- because you saw her 17 quite a bit, did you not? 18 A. Jean Pratten? Yes, probably, I cannot recall. 19 Q. -- that Helen Vegoda was the only other funded post by 20 the Heart Circle at the Bristol Hospital? 21 A. I was told by Jean that her funding had been taken over 22 by the Children's Hospital; the Heart Circle had 23 initially funded her post, but it had been taken over by 24 the Trust. 25 Q. If the Heart Circle had originally funded her post, did 0082 1 you not put two and two together and say "If it is the 2 Heart Circle, it must have been cardiac"? 3 A. At the time I obviously did not, no. 4 MR LANGSTAFF: It has just gone 12, sir. That perhaps might 5 be an appropriate moment for a short break. 6 THE CHAIRMAN: Yes. I would suggest we have a break for 7 half an hour, 12 to 12.30. Would that be suitable? 8 MR LANGSTAFF: Certainly. 9 THE CHAIRMAN: Thank you very much. We reconvene, 10 therefore, at 12.30. 11 (12.05 pm) 12 (A short break) 13 (12.40 pm) 14 MR LANGSTAFF: I said this morning that I would track down 15 where you described yourself as "support nurse 16 specialist". Can I have WIT 74/589 on the screen, 17 please? Can we just look at the date? This is 18 10th October 1990, so immediately after your 19 appointment. It is obviously a standard letter. Let us 20 go down to the bottom and see your signature. That is 21 your signature? 22 A. Yes. 23 Q. So you have not only had this put out in your name, but 24 you actually signed it, so you would have read it at the 25 time? 0083 1 A. Yes. 2 Q. Did you draft it? 3 A. I think I probably did and the background to that is, we 4 had not yet decided, because of salary and funding 5 reasons, whether I should have the title "cardiac 6 liaison nurse" or whether I should be "support nurse 7 specialist". 8 At the beginning of my job I was support nurse 9 specialist, and by the time I had been there a few a few 10 months, it was decided, because of the grading of the 11 post and things, that I should be called Cardiac Liaison 12 Sister. 13 Q. So you describe your job in terms of "giving any support 14 and advice you may need regarding your child's operation 15 and your stay in Ward 5", that is the second paragraph. 16 A. Yes. 17 Q. On the face of it, "support" is an imprecise word, but 18 it might lead the recipient to believe there was 19 a shoulder to cry on, counselling, that type of role, 20 might it not? 21 A. I can only give you my perception of the word "support" 22 which was to help parents when they were on the 23 intensive care unit with accommodation, someone to sit 24 with and talk to about, you know, the ventilator and why 25 certain things had happened that day and those sorts of 0084 1 things. I would not have used the word "counselling" 2 because I do not have the appropriate qualifications. 3 But if people perceived support to be professional 4 counselling, then, you know, I cannot say that they did 5 not. 6 Q. The way you describe Helen Vegoda's role in the next 7 paragraph is as a "family support worker"? 8 A. Yes. At the beginning of my job, I thought that was her 9 title. Then she was called the "paediatric counsellor", 10 I think. I have to say, there was a lot of looseness 11 around titles, and I did have some difficulty getting to 12 grips with, you know, formal titles of people. 13 Q. So to an extent I think you are answering the next 14 question, which was that throughout at least the early 15 stage of your involvement, and to an extent perhaps your 16 later stage, there was a vagueness, uncertainty, lack of 17 definition in the role that you were to do? 18 A. Yes. I clearly had a perception and I had my brief from 19 Jean Pratten of what she wanted. But, you know, in 20 hindsight, I would say that the hospital, the Bristol 21 Royal Infirmary and the staff there, did not have the 22 same perception. Whether that was a communication 23 issue, I cannot be sure. 24 Q. Very shortly after that, I think, you had the 25 discussions, the interaction with Helen Vegoda which led 0085 1 to the rebuff, as you saw it, that you had at the 2 meeting with Mr Wisheart and Julia Thomas? 3 A. Yes. 4 Q. Was it Dr Joffe as well? 5 A. Yes, he was there, yes. 6 Q. So there were five of you there, were there? Helen 7 Vegoda was there too, was she? 8 A. Yes, she was. 9 Q. And perhaps to focus this part of your evidence, let us 10 look at WIT 192/110. 11 This is a copy of a letter in fact sent to Helen 12 Vegoda, because her name is underlined at the top, but 13 it appears that it was sent to her and to you. No doubt 14 your copy would have had your name underlined. Just 15 take a moment and look at it and see if you recollect 16 it? 17 A. I do not recall the letter, no. 18 Q. Let me then take a little care in going through it since 19 you do not recall it, although it should, from the 20 heading, have been sent to you? 21 A. I also note I am called a "family support worker" here. 22 Q. Yes, which again adds to your evidence about the lack of 23 clarity that others may have had as to your role. 24 If you had had a letter which said "family support 25 worker" at the top, would you simply have ignored it as 0086 1 one of those things, somebody else's misdescription, or 2 would you have raised it? 3 A. I would have raised it because I did think it was a very 4 important issue because I was not a family support 5 worker. I felt that quite strongly. 6 Q. The author of the letter, if we turn over the page to 7 111, it is Julie Crowley, the General Manager. Back 8 now, please, to 110. 9 The author appears to have given you and Helen 10 Vegoda exactly the same job description, job title, 11 which might imply the same job, which of course you were 12 not doing? 13 A. Yes. 14 Q. But the second paragraph: 15 "To recap on our discussions to date, the team 16 covering both Ward 5 and the Bristol Royal Hospital for 17 Sick Children [that is medical and nursing staff and 18 yourselves] have been aware of a difficulty in achieving 19 smooth, free flow communications and in generally 20 understanding and accepting each other's roles." 21 A. Yes. 22 Q. That is accurate, is it? 23 A. Yes. 24 Q. It refers to "discussions to date": so this had been 25 a running sore, had it, for a matter of months? Those 0087 1 are my words. Feel free to depart from them. 2 A. Yes, well, I did express concerns that I had a problem 3 accepting that Helen Vegoda, who had a very different 4 role to mine in my perception, was doing a job at the 5 Children's Hospital which, for some reason, did not 6 allow her to come and do that job at the Bristol Royal 7 Infirmary. 8 I mean I had this slightly idealistic view that 9 both our roles, in my perception of what they were, 10 could have worked very well together if she had carried 11 out her role at the Children's Hospital and at the 12 Bristol Royal Infirmary, and I had carried out my 13 liaison role at the Bristol Royal Infirmary and the 14 Children's Hospital. 15 But because of the strong feeling that I could not 16 go to the Children's Hospital and Helen Vegoda could 17 come to the BRI but I think, as it says here, only to 18 visit families she already was involved with, I found 19 that was an issue. I did not understand why there was 20 not the ability to be more flexible. 21 Q. So, again, so that I understand it, the issue was 22 whether you had such different roles to perform that you 23 could both do each of those roles at both hospitals? 24 A. I believed -- 25 Q. That was your perception? 0088 1 A. Yes, that was my perception. 2 Q. The other point of view was that you had such similar 3 roles, even though there were differences, that it was 4 economic in terms of time and so on for one of you to do 5 the job at the Children's Hospital and the other at the 6 Royal Infirmary? 7 A. I think there was a perception and I obviously feel 8 wrongly, that I would do the same role that Helen Vegoda 9 did at the Children's Hospital at the Bristol Royal 10 Infirmary. This was an underlying perception that 11 I gradually over months and years realised that people 12 had. 13 Q. It was the concept between those two perceptions that 14 gave rise at this meeting to the trouble there had been? 15 A. Yes, because I think on that one occasion I mentioned it 16 to Mr Wisheart -- I mean, I think it is important to 17 point out that I started this job with a lot of 18 enthusiasm and a lot of -- I really wanted to make 19 a difference. I had gone off to Great Ormond Street 20 and Birmingham Children's Hospital to find out how 21 I could come back and incorporate these 22 liaison/information-giving aspects of the role, and 23 I was keen to make changes. So I did express, both to 24 Mr Wisheart, that I really wanted to replicate what was 25 going on at some of these other centres. 0089 1 I think my, you know, voicing these opinions, made 2 it that people felt uncomfortable for quite a while, 3 because I was actually challenging that we should not 4 have this split, we should not have Helen Vegoda working 5 at the Children's Hospital and me working at the BRI 6 doing what people obviously perceived as similar roles. 7 Q. The third paragraph I think can be summed up by saying, 8 can it -- have a read through it -- that each of you 9 should stick essentially to your own "patch"? 10 A. Yes, that is correct. 11 Q. And the fourth paragraph says that what applies to Helen 12 Vegoda so far as the Children's Hospital is concerned 13 applies to you so far as the Royal Infirmary is 14 concerned. That seems to be the approach? 15 A. Yes. 16 Q. Looking at the foot of the page, it talks about how 17 Helen Vegoda has reviewed her job description -- we are 18 going to hear from her tomorrow -- and adjusted her 19 objectives, now in the process of considering some 20 research. Likewise you have defined your job 21 description and research has been a major part in your 22 role since coming to post. 23 A. I am sorry; research has been a major part in my role? 24 Q. That is what it says. 25 A. I did not undertake any research when I was in that 0090 1 post. 2 Q. Did you understand it was part of your job to do so? 3 A. No. The only research I did was to assist Dr Gardner in 4 her PhD thesis. Maybe that is what people are 5 suggesting in that, but my role was not research. 6 Q. Had you, over the months leading up to January 1992, 7 defined your job description? 8 A. I cannot recall changing it or altering it, no. 9 Q. Looking at the last paragraph, had you agreed as the 10 letter suggests you had, that the roles that you and 11 Helen Vegoda occupied were, in quotes, "similar but 12 extremely different". It is a lovely paradox, is it 13 not? 14 A. I am sorry, what are you asking me? I am sorry. 15 Q. Had it been agreed that the roles are, in that memorable 16 phrase, "similar but extremely different"? 17 A. I would not have used those words, for obvious reasons, 18 but I think there had been, in order to create some 19 stability, and I think in order to, as I described to 20 you, put me "back in my box", people said, "Well, Helen, 21 let us just agree that your job is different", because 22 they knew that would keep me happy, if I knew it was 23 different, "but you have to realise that it will be 24 similar". Obviously there were one or two -- it is 25 similar in as much as we were both dealing with parents 0091 1 and children, but, you know, I share your view about 2 that statement, really. 3 Q. Do you recall such memorable words being used? They 4 are in quotes. 5 A. I do not remember those particular ones, but there was, 6 as I said, in order to create a, you know, "let us not 7 rock the boat and let us just keep some status quo here, 8 let us just placate Helen and say, 'Yes, your job is 9 different and we recognise that, but it has some 10 similarities to Helen Vegoda's'" which, as I said, it 11 did have some similarities. 12 So although I cannot recall those words, I can 13 recall and know that as part of the overall sort of "let 14 us just keep things as they are", then that would have 15 been a way of doing that. 16 Q. If we turn overleaf: the plan of action, communication 17 must be obtained, you felt this could only improve by 18 maintaining weekly meetings, even if there are no 19 families to discuss. Did you in fact have such 20 meetings? 21 A. Yes, we did meet weekly. We alternated, I went to the 22 Children's Hospital and Helen came down to me. We 23 alternated. 24 Q. One matter which Helen Vegoda is likely to be asked 25 about, which it is therefore important to have your own 0092 1 comments on if you can give them, is what emerges from 2 her review. It is WIT 192/112. This is in relation to 3 her. It is signed, if we scroll down a bit, by her at 4 the bottom, and dated. It is dated 21st October, even 5 though it purports to be actually written 6 months 6 earlier. 7 A. I am sorry, is this something I should have seen? 8 Q. I am taking you through it slowly because you probably 9 have not seen it. What I am going to ask you about is 10 what arises from it, and if you are not able to comment, 11 then you are not able to comment, but if you can help, 12 I would appreciate it. 13 A. All right. 14 Q. If we go down to the very last paragraph: 15 "Helen has had difficulty", Helen Vegoda, not you, 16 "but has managed to maintain working relationships with 17 Ward 5 at the BRI." 18 This obviously relates to what has been said or 19 what has arisen or been perceived by those reviewing 20 Helen Vegoda's role. That presents, perhaps, a rather 21 gloomier picture than "professional but cool" as you 22 described it earlier this morning in terms of 23 relationships between yourself and her. 24 From your perspective, what do you think lies 25 behind that statement, if you can comment? 0093 1 A. I can only reiterate that our relationship was always 2 professional, and I never did not communicate or have 3 any dialogue with her for professional reasons, but it 4 was cool, as I suggested this morning. 5 The only comment I could make on that statement 6 would be that my perception and concerns that I had, 7 once I had been in the role for a while, was that Helen 8 Vegoda felt I was in some way encroaching or threatening 9 her role at the Children's Hospital. 10 So that is the only comment I can make on that. 11 Q. The difficulty that is referred to there: is that 12 probably the difficulty between you and her, or did you 13 perceive a more general difficulty between her and 14 Ward 5? 15 A. I cannot speak for the nurses on Ward 5, but they had 16 some I think concerns about Helen Vegoda's involvement 17 with the parents and children in as much as they did not 18 believe that she had the appropriate nursing background 19 to deal with some of the issues that the parents would 20 be asking. 21 So, whilst I understand she was always made 22 welcome at the Royal Infirmary, I think that the nurses 23 did sometimes feel, and perhaps part of the evolvement 24 of the job I did was, that they would have welcomed 25 somebody who could talk to the parents about the 0094 1 different aspects of the intensive care unit, and they 2 could have more of a rapport with than someone who did 3 not come from a clinical background. 4 Q. But you spent much more of your time at the Royal 5 Infirmary than you did at the Children's Hospital? 6 A. I did not spend any time at the Children's Hospital. 7 Q. You say -- 8 A. Well, if you are asking me, did I go to the outpatients 9 on a regular basis, then I did not, because of the 10 request not to. 11 Q. Help me, then, if you would, with this. You tell us 12 that -- this is page 13 of your statement, paragraph 37, 13 about three lines down: 14 "The nurses at BCH were always receptive to my 15 role and ideas throughout my time as a liaison nurse. 16 They were more receptive to change and new ideas than 17 the nurses at the BRI." 18 A. Yes. 19 Q. We have dealt with the question of change being 20 a personal criticism this morning but what you seem to 21 be saying there is that the nurses at the BRI really 22 resented or put difficulties in or were resistant to you 23 and your ideas, whereas those at the BCH were not? 24 A. That is correct. When I said I did not attend the 25 Children's Hospital, I meant on a formal basis to do 0095 1 sessions there in the outpatients. However, what I did 2 do was, because they were friends and I had worked with 3 them before, Linda Bailey and Bridget O'Reilly, I would 4 visit the intensive care unit at the Children's Hospital 5 to discuss ideas and issues with them, mainly because 6 they were experienced paediatric nurses, I wanted their 7 input, and I wanted to build some kind of better 8 relationship between the paediatric nurses on the 9 intensive care unit at the Children's Hospital and the 10 nurses looking after the children at the BRI. 11 So I would describe those sorts of visits as more 12 informal. They were often made after work, and they 13 were a sort of information-gathering, ideas-sharing 14 format, rather than I was going to the Children's 15 Hospital to see children and parents in outpatients. 16 Q. They were people you felt easy with, they were friends? 17 A. Yes, and naturally, you are going to want to talk to 18 people who are going to be more receptive to your ideas 19 than people who are not, so that was a natural -- and 20 also, you know, when I brought back ideas from Great 21 Ormond Street, I wanted to discuss it with them as well, 22 because they often had good ideas themselves. But I was 23 also aware that there was this cavern between the nurses 24 at the BRI and the nurses at the Children's Hospital and 25 I wanted in some small way to see how that could be 0096 1 improved, whether that was through communication, 2 whether that was through going to the Children's 3 Hospital and speaking with people informally, and 4 setting up the Paediatric Cardiac Nurses' Association, 5 which I did whilst I was there as well. 6 Q. Two things arising out of that: firstly, the "cavern" 7 that you say existed between the BCH and the BRI: that 8 is an emphatic word. What is the justification for it? 9 A. I think there were territorial issues in as much as if 10 I suggested that perhaps somebody came down to Ward 5 11 from the Children's Hospital to spend some time down 12 there with the nurses, there was a sort of, "Oh, no, you 13 have got adults down there" and, you know, "No, we do 14 not want to go down there". And vice versa, the 15 children's nurses on the BRI unit did not want to go up 16 to the Children's Hospital because "No, they do not 17 understand what we are doing down here". 18 So I thought that was quite sad, really, and there 19 was very much, "This is my territory. Why would I want 20 to go up to the Children's Hospital to find out what 21 they were doing up there?" 22 Q. So a reflection, really, of the child/adult split? 23 A. Yes. I know a lot of the nurses at the Children's 24 Hospital felt quite strongly, because they were trained 25 paediatric nurses, that the children should not be 0097 1 having surgery on an adult unit. Their views were 2 obviously shared amongst a number of people. 3 Q. It is a view we have heard a number of times already in 4 this Inquiry. 5 So far as your comparison of the culture of the 6 two units -- 7 MRS HOWARD: Mr Langstaff, just for my clarity, could I just 8 refer you back to something Miss Stratton said? It is 9 98/5. You said "and vice versa, the children's nurses 10 on the BRI unit did not want to go to the Children's 11 Hospital." 12 Did you mean children's nurses or did you mean 13 nurses who were caring for children at the BRI? 14 A. Yes, nurses who were caring for children at the BRI, 15 I am sorry. 16 MR LANGSTAFF: You have described then the "cavern" really 17 between the adult nurses, as it were, or nurses in the 18 adult environment, and the children's nurses in the 19 children's environment. 20 So far as the culture is concerned, the second 21 question that arises out of your earlier answer: am 22 I right in thinking that your perception of the approach 23 to the culture in the BCH really came from your contact 24 with Linda Bailey and Bridget O'Reilly? 25 A. Yes. That is the only experience and knowledge that 0098 1 I could base the view on. 2 Q. It might be said that those with whom you worked at the 3 BRI and spent your time with at the BRI were resistant 4 to your ideas. Those with whom you did not work, where 5 you had a couple of friends at the BCH, you say were 6 not. The cynic might say, this is perhaps a reflection 7 of where you were and what you were doing and it might 8 have been the same at the BCH had you been there. 9 What would you say about that? 10 A. I would say that I got the distinct impression that that 11 would not have been the case, and I know there were 12 occasions that I sought advice from Linda Bailey and 13 Bridget O'Reilly and I said, "if I suggested you did 14 this up here", and they did in fact take on some of the 15 ideas that I had brought back from Great Ormond Street 16 and other centres, at the Children's Hospital, they took 17 them on very willingly. I said "If I came to you and 18 said, 'I have found out that this is something they do 19 at Birmingham', do you think that is a good idea?" then 20 they were very receptive. 21 When I suggested to them that I could meet with 22 them to discuss and support them, the nurses at the 23 Children's Hospital, in talking about issues, just 24 a sort of information-gathering, supportive meeting, 25 they said "That would be marvellous, we would like that 0099 1 very much. We would like you to come up and we can 2 discuss all the issues around looking after parents and 3 children", and I would be a facilitator for that. Some 4 would argue that was really outside my remit, but I saw 5 it as being a relationship and communication part of my 6 job. 7 Q. The same surgeons and the same cardiologists covered 8 paediatric heart patients in both the Children's 9 Hospital and the BRI? 10 A. Yes. 11 Q. Resistance to new ideas is not unknown amongst societies 12 and cultures. Was it, do you think, simply at the BRI 13 a natural resistance to new ideas because people were 14 familiar and happy with the old? 15 A. Yes, I do. 16 Q. It was that, was it, rather than a fear of, "Well, this 17 is a good idea but we are going to get shot down in 18 flames if we take it upstairs"? 19 A. I think it was mainly the former, but I think also, 20 where nurses had tried to change things and they had 21 been rebuffed or told that that was not appropriate or 22 whatever, they did not bother after a while. So I think 23 there was an element of -- I mean, I can think of 24 perhaps one or two staff nurses who did try and bring in 25 some different nursing issues, or different ways of 0100 1 approaching things. And it was "No, we do not think 2 that is appropriate and we will continue doing this", or 3 "using these drains" or whatever. 4 So I think after a while, the nurses were 5 reluctant to come up with new ideas and systems. 6 Q. Can I turn to something perhaps a little different? 7 Towards the end of your period of time at the BRI 8 you tell us in your statement a number of things about 9 yourself. You tell us, as I note them, that you were 10 finding your time difficult to manage? 11 A. Yes. 12 Q. And indeed, so difficult that you sought help with how 13 best to manage your time? 14 A. I sought supervision from Dr Gardner, in essence 15 because, without a counselling qualification, I felt 16 that I was dealing with often situations that I was 17 unqualified to deal with, and whilst there was nobody 18 else to do it, I went to her for advice and support. 19 I felt, along with trying to support the theatre nurses 20 and the nurses on the unit, I needed to have some 21 support myself. So I thought it was appropriate to ask 22 Dr Gardner for that, because to continue to do my job in 23 a professional manner, I would need to be supported in 24 that way. 25 Q. You tell us that you felt emotionally drained? 0101 1 A. On some occasions I did, yes. 2 Q. You tell us that you felt that you were out of your 3 depth? 4 A. On some occasions, yes. 5 Q. That you had what you describe as "extreme exposure" to 6 distressed patients and parents? 7 A. Yes. 8 Q. And this came to such a pitch that at some stage in the 9 middle of your third year, you felt unable to go down to 10 theatre with the patients? 11 A. Yes, I did. 12 Q. Can you help me to put a time on that? This is the 13 third year, as you describe it at the bottom of page 12 14 of your statement, paragraph 34, and Year 3 of course 15 begins, if it is chronological, if you intended it that 16 way, in October 1992. So Year 3, one takes to read 17 between October 1992 and the end of September 1993. 18 You describe your cardiac study day and raising 19 money for the Heart Circle, and it was at this stage 20 that you felt unable to go down to theatre because you 21 were emotionally drained. You ensured that one of the 22 other nurses in the nursery was able to carry out this 23 task. 24 What do you mean by "it was at this stage"? 25 When? 0102 1 A. I think it was a combination of, by then I did have 2 concerns about the surgery there, the length of stay in 3 intensive care and the number of patients who were 4 dying, and having expressed my concerns to Dr Bolsin, as 5 I said, we spent a great deal of time, him and his wife 6 and myself, at his house discussing how we could change 7 things and how we could improve things and how we could 8 get people to realise that there was something seriously 9 wrong. 10 I said to Dr Bolsin that I was finding it 11 increasingly difficult to go down to theatre with 12 parents when I had these concerns in the back of my 13 mind. I was not only dealing with parents who were 14 understandably very, very upset and it was a very 15 emotional time for them, it was a very difficult time 16 going down to theatre, but I also had in the back of my 17 mind the fact that I did not know whether this was 18 actually the right thing. 19 So I felt the best thing to do, the most 20 professional thing to do, was to withdraw from going 21 down to theatre, but to make sure that there was 22 somebody else to do that. 23 Q. What I was hoping to get from you was when did you cease 24 going down to theatre, roughly? 25 A. I do not know. March, April? I am not sure. I cannot 0103 1 be sure. 2 Q. So you think March/April 1993? 3 A. I think so. 4 Q. You appeared on Panorama? 5 A. I did. 6 Q. You were asked, I think, about an operation which took 7 place on 12th October 1993 -- 8 A. No, I was never asked specifically -- 9 Q. Let me tell you what the voice-over said. The 10 voice-over said: 11 "The child's operation took place on 12th October 12 1993. By now one of the nurses had begun to wonder how 13 much longer she could go on handing babies over to the 14 surgeons". 15 A. Yes. 16 Q. Then your bit: 17 "We would get a call from theatre to say they were 18 ready and we would go down. It was a very, very 19 emotional, difficult time for parents, incredibly 20 difficult. We would go down to the theatre. They would 21 normally go into the anaesthetic room. They would have 22 an opportunity to give the baby a kiss and say a few 23 words." 24 You go on to say: 25 "I think you have to understand", because you 0104 1 were asked, why you did not say something, "that the 2 situation was so emotionally charged like that, for 3 people to put their trust, faith and hope in the 4 surgeons there, that if I had in that situation actually 5 said 'I think actually we should go back upstairs and 6 take the baby back upstairs'". 7 The question: "Is that what you wanted to say?" 8 and your answer: "Of course it was what I wanted to 9 say. I wanted to pick the baby up and run out of the 10 operating theatre, bundle it in the car with the parents 11 and take them anywhere else." 12 That is what you said, was it? 13 A. That is what I said. I said it in an interview where 14 I had no idea of what would lead into my interview. 15 I did an interview where I was asked generically, not 16 with dates or specific families, what it was like to go 17 down to the operating theatre and how difficult it was. 18 I was not aware, and I was not allowed, to see that the 19 introduction to my piece was going to refer to a family 20 which I cannot remember, and at a time when I do 21 remember that I had withdrawn from doing that. 22 Q. Looking at what you said -- and accepting what you say 23 about the introduction which was not your responsibility 24 and you may not have been aware that it was going to be 25 said -- you did say you "wanted to pick the baby up", 0105 1 that is the "baby" generically I think, "run out of the 2 operating theatre, bundle it in the car with the parents 3 and take them anywhere else." 4 That, you said in general terms, did you? 5 A. Yes. I mean, I think when I spent time thinking about 6 how I could possibly change this, or I could make 7 a difference to it, I did think about -- 8 Q. Can we take it stage by stage? I am sorry to cut you 9 short. If there is something you want to say later on 10 to complete the answer, by all means. But the first 11 step of the questions I have to ask is: you said it, and 12 did you mean it? 13 A. I did at times feel that I just wanted to say to the 14 parents, "Let us go back upstairs and go back to your GP 15 and discuss going somewhere else". Yes, I did think 16 that. I did think that. I think the fact that I said 17 I wanted to pick the baby up and run out of theatre, 18 I think -- I would never have done that, obviously. 19 I think that is probably me just thinking, "Gosh", you 20 know, "wouldn't that be wonderful if I could do that". 21 But I did really think, many times, why can I not just, 22 you know, say "Look, let us just go back upstairs, 23 I think you need to reconsider this". 24 Q. So that is the way you felt many times? 25 A. Yes, towards the end of my time in the job, it was, 0106 1 yes. 2 Q. It would have to be before the end of your time going 3 down to the theatre with children? 4 A. Yes. 5 Q. Which your best recollection now is spring of 1993? 6 A. My best recollection, yes. 7 Q. So it would be a number of times in, what, late 1992, 8 early 1993? 9 A. 1993, I think probably, yes, where I think I spent a lot 10 of time, as I said, with Dr Bolsin and his wife, 11 discussing what we could possibly do to change things, 12 and when I thought about ringing the health visitor or 13 the GP, when I thought that through, and I thought it 14 through with Dr Bolsin, at best the parents may have 15 taken notice of that, although it is difficult for them 16 to remember now, they were very trusting of Mr Wisheart, 17 and I think if it had gone back to the GP and they had 18 gone home and that would be discussed with the 19 cardiologist, and then we would be back at square 1 and 20 I would have been dismissed for libel. I thought many 21 times about what I could do within my professional 22 capacity to change things. And I discussed those 23 possibilities with Dr Bolsin regularly. 24 Q. Your duty to be an advocate for the patient, you accept 25 as part of the nurse's role? 0107 1 A. Yes, I do. 2 Q. That necessarily involves speaking up, whatever the 3 situation, whatever the consequences? 4 A. Yes. 5 Q. Would you take a look at WIT 142/7, the statement of 6 Mr Gibbons? 7 Can we go down to paragraph 17? This is in 8 relation to an operation which took place on 9 3rd November 1992. What is recollected by the parents 10 is that you showed them around the ward, took them to 11 the intensive care ward where Jessica would be staying 12 after the operation, introduced them to the nurses 13 involved in Jessica's care. You see the next two 14 sentences: 15 "She told us how lucky we were to have Mr Dhasmana 16 operating on our daughter. According to her he was an 17 eminent surgeon and Bristol was a centre of excellence 18 in paediatric heart surgery." 19 Has Mr Gibbons got it right? 20 A. I do not remember the family. I certainly do not 21 remember saying that. Suffice to say, although 22 "eminent" is within my vocabulary, it is not a word 23 I use, and I certainly was not in a position to give 24 parents my own opinion on a surgeon, whether they were 25 eminent or not. 0108 1 Whilst I may have been able to say they have done 2 this operation before, I certainly would never have 3 described Bristol as a "centre of excellence". 4 Q. So he -- we have not heard from him in oral evidence, 5 but it follows from what you say, he would have no 6 proper basis for saying that in his statement? 7 A. Well, I cannot recall the family, but they are not words 8 or a description I would have used at any stage in 9 talking to the family. 10 Q. Did you try to reassure parents when they came to 11 Bristol? 12 A. In respect to ... 13 Q. To the ordeal which faces any parent? 14 A. Yes, I did try and reassure them. 15 Q. Was part of that reassurance to say to parents, "Do not 16 worry, he is in good hands", or something of that sort? 17 A. I would not have said that, because I would not have 18 given my own personal opinion as a consultant. I would 19 have, at best, said "Mr Wisheart/Mr Dhasmana, have done 20 this operation before", but I would not have said, "and 21 he is really good", or "and he is the best", because 22 I would not have felt comfortable saying that. 23 Certainly, latterly I would not have felt comfortable 24 saying that. I do not think it was appropriate for me 25 to give an opinion. 0109 1 Q. In November 1992 you certainly should not have felt 2 comfortable, from what you have being saying a moment or 3 two ago, because at that stage you thought it was the 4 opposite? 5 A. Yes, so I would certainly not have said the opposite of 6 what I was thinking. 7 Q. If what Mr Gibbons says is right, whatever you may have 8 said to Mr Gibbons, you did not give him the impression 9 that you had concerns and worries about Bristol? 10 A. No. It would not have been ethical or professional, in 11 my opinion, for a nurse to give a view to parents, their 12 personal view, on what they thought about the level of 13 care or surgery at that centre. 14 Q. In May 1993, you dealt with Mrs Willis. Am I right in 15 thinking that you said nothing to her about your 16 reservations and your worries and your concerns about 17 the standard of surgery at Bristol? 18 A. I cannot recall the Willis family. All I can say is 19 that I never expressed to any parents my own personal 20 views on the cardiac surgeons or the care at the 21 hospital. 22 Q. So by that stage, which is taking it on six months from 23 the Gibbons, you either had given up or were just about 24 to give up going down to surgery with parents because 25 you could not face it and you thought it was so awful? 0110 1 A. Well, I think I felt that I was personally finding it 2 difficult to be part of something that I no longer felt 3 I wanted to be part of. 4 Q. Apart from Dr Bolsin, to whom did you speak? 5 A. Dr Gardner, and to Jean Pratten. I only spoke to Jean, 6 I think, maybe once or twice about it, because I knew 7 that she felt that clinical issues were not something 8 that the Heart Circle wanted to get involved with. 9 Q. You were a nurse, and there was a senior nurse in the 10 ward. Did you speak to her? 11 A. I did speak to Julia Thomas and Lesley Salmon who were 12 both sitting in the office at the same time. I did not 13 put that in writing. They accepted my expressions of 14 concern and they told me that they would be bringing 15 that up at the next directorate meeting. 16 Q. You have given, I think, two accounts of that 17 conversation with Julia Thomas and Lesley Salmon. 18 A. It was Fiona Thomas. 19 Q. I am sorry, you actually said Julia Thomas, but I think 20 you meant Fiona, did you not? 21 The first that I want to take you to is at page 11 22 of your statement. It is paragraph 31. 23 "For my part, I expressed my concerns to Fiona 24 Thomas and to Lesley Salmon". You went to see Fiona in 25 her office. Lesley happened to be there. You explained 0111 1 the concerns that you had developed talking to others, 2 and you say this: 3 "They both listened and did not dismiss what I was 4 saying." 5 That is the way you put it? 6 A. Yes. 7 Q. They said they would bring your concerns up at the next 8 cardiac directorate meeting? 9 A. Yes. 10 Q. "They both listened and did not dismiss what I was 11 saying". 12 Does that mean they simply listened but expressed 13 no opinion? 14 A. They did not express an opinion themselves, but they 15 acknowledged what I was saying and they told me they 16 would be bringing it up at the next directorate meeting. 17 Q. So by "acknowledge", what you were saying, a sort of nod 18 of the head to note you had made the point, without 19 expressing any view on it? 20 A. Yes. Suffice to say at this time I was already aware, 21 because we had discussed it, of Dr Bolsin's efforts to 22 get these points raised. It is important to remember 23 I was quite a weak member on the team, whereas he was 24 having difficulty as a very strong player on the team. 25 Q. Do you recall anything else about the conversation with 0112 1 Fiona Thomas and Lesley Salmon? 2 A. No. It was a discussion in an office. 3 Q. So a business-like discussion, they note your point and 4 they say they will raise it? 5 A. Yes. 6 Q. Can we have on the screen, please, GMC 14/150? It is 7 the second paragraph. This is your statement to the 8 GMC: 9 "I expressed my concerns about the high mortality 10 and morbidity with Fiona Thomas, the senior sister at 11 Bristol Royal Infirmary, and Leslie Salmon, the General 12 Manager of the cardiac unit. They both appeared to 13 agree with my sentiments ..." 14 That is wrong, is it not? 15 A. I think what I was saying was, because they did not 16 dispute them, I took that to be an agreement, and that 17 is obviously how I have written that in this statement. 18 But my remembrance, when I wrote this statement, was 19 obviously that they took on board what I had said and 20 I had read that as agreement and that is obviously how 21 I perceived it at the time of writing this statement. 22 There had been an attitude of, "Well, this is what 23 it is like here. We deal with very sick babies". That 24 certainly is what I was told for quite some time when 25 I was there. 0113 1 Q. What you say about the meeting in your statement to the 2 GMC is that actually at that meeting they say, "Well, it 3 has always been like that at Bristol"? 4 A. Well, I cannot say that they -- I mean, I cannot recall 5 this very well. When I made this statement, I was 6 relying on things that I could remember at the time. 7 But there was a feeling that, "Well, this is because we 8 have more difficult babies to deal with". 9 Q. So what you say in your evidence to the GMC that they 10 said to you at that meeting is, as you now recall it to 11 the best of your ability, in fact the general impression 12 which you had from dealing with them and others at the 13 BRI? 14 A. Yes, I think so. 15 Q. You say at the very end of your statement to us, 16 paragraph 39, page 14, it is the second last sentence: 17 "In my opinion, the standard of paediatric nursing 18 on the unit under the circumstances was good." 19 A. Yes. 20 Q. It is part of being a nurse to be the advocate for the 21 patient, is it not? 22 A. Yes. 23 Q. So here, as you saw it, were either Sister Thomas and 24 Lesley Salmon, saying, "Well, one of those things", 25 shrug of the shoulders, "that is what happens at 0114 1 Bristol", or there being a general atmosphere, "Yes, of 2 course there is high mortality, high morbidity, but that 3 is what it has always been like here", neither of which 4 would be really being a proper advocate for the patient? 5 A. I am sorry, what -- 6 Q. How can you say that the standard of paediatric nursing 7 was in the circumstances good -- 8 A. It was good. 9 Q. -- if in fact nurses were falling down on their 10 responsibility to raise issues of concern such as this? 11 A. I would say the standard of paediatric nursing on the 12 unit was good under the circumstances, which were very, 13 very difficult, very stressful. I would support that by 14 saying, if the nurses did have concerns, it was very, 15 very difficult for them to express them. 16 Q. Coming back to your statement to us earlier on, leading 17 up to that passage where you deal with expressing your 18 concerns to Fiona Thomas and Lesley Salmon -- it is 19 page 11 -- in fact, let us go back to page 10. The very 20 last paragraph : 21 "About halfway through the second year", that is 22 about April 1992, on the basis that it starts in October 23 and ends at the end of September, "I began feeling 24 concerned about the time the children spent in theatre 25 and also the time that they spent in the intensive care 0115 1 unit." 2 Those are the two concerns which you identify. If 3 you just read through there, the top of page 11, please, 4 and scan on down to paragraph 31, what you have been 5 talking about in terms of your concerns were concerns 6 about the time in surgery and the time in intensive 7 care? 8 A. Yes. 9 Q. When you say, in paragraph 31, you expressed your 10 concerns -- and the way you write that it relates back 11 to your concerns about time in surgery and time in 12 intensive care? 13 A. Yes. 14 Q. Is that the way you meant it to read? 15 A. Yes, it is, because by implication. The time spent in 16 theatre and the time spent in intensive care I felt 17 equated to, you know, an issue with the surgery which 18 was reflected in longer time in theatre and longer time 19 in intensive care than at other centres I have been to. 20 Q. Was that both surgeons, or just one? 21 A. I think it was both. 22 Q. When you gave your statement to the GMC -- let us go 23 back to it, GMC 14/150 -- what you say you were raising 24 with Fiona Thomas and Lesley Salmon were your concerns 25 about the "high mortality and morbidity". 0116 1 So to the GMC you mention your concerns about 2 death and illness; to us, you mention your concerns 3 about time in surgery and time on ITU. And you 4 confirmed that a moment ago in evidence. 5 What is the position, then, so far as mortality 6 and morbidity is concerned? Were you actually raising 7 those as concerns with Fiona Thomas and Lesley Salmon or 8 not? 9 A. Yes, but I think the high mortality and morbidity, 10 I probably explained that, and also the fact that that 11 ties in with patients or children spending a long time 12 in theatre and intensive care, which relates to my 13 mortality and morbidity, and I do not know why I chose 14 to use those words, but the expression in my view was 15 the same. 16 Q. There might seem to others, might there not, to be a big 17 difference between saying "There is an awful lot of 18 deaths happening" on the one hand? 19 A. Yes. 20 Q. And on the other hand, saying "Are not children spending 21 a bit long on the table?" 22 A. I did not distinguish. I personally did not -- maybe it 23 was because I was not expressing myself very well, or 24 I was having problems remembering, but I did not 25 distinguish the difference between length of theatre and 0117 1 length in intensive care and mortality. To me they 2 meant the same. 3 Q. What Lesley Salmon recalls, let us have it at 4 WIT 256/107, it is four lines down: 5 "I do recall Helen coming into the office one day 6 and talking about the time children were spending in 7 theatre. I recall us talking in general terms about her 8 concerns." 9 She does not recall saying she would take it any 10 further. 11 Would there, do you think, possibly have been some 12 difference in the way she would have seen what you were 13 saying between on the one hand saying "Lesley, too many 14 children are dying, it just does not compare with Great 15 Ormond Street, it just does not compare with Birmingham, 16 something is going wrong", words to that effect on the 17 one hand, or saying, "Don't children spend a bit longer 18 here in surgery than they do at Great Ormond Street or 19 Birmingham and is there perhaps a reason for it?" 20 A. I cannot recall the conversation, but I would imagine 21 what I said was that, having been to other centres, 22 Great Ormond Street and Birmingham, and met with people 23 who were doing similar posts to myself, I was struck by 24 the difference of the time that the children spent in 25 theatre, the time they spent on intensive care and the 0118 1 number of children who were dying. That is how I would 2 have expressed my concern to her. 3 But I cannot recall my exact words to her because 4 I cannot recall the conversation. 5 Q. You have told us really how the job was draining you and 6 how, in essence, you were not able to cope with going on 7 and being as it were complicit in a system which you 8 thought was harming children rather than helping them. 9 That is the flavour of what you have been saying. Have 10 I got it right? 11 A. Yes. 12 Q. When you were first funded, was it for two years or 13 three years? 14 A. Three years. 15 Q. So your three years expired in October 1993? 16 A. That is correct. 17 Q. Can we perhaps have a look at UBHT 213/14? Heart Circle 18 meeting, 1st March 1993. Jean Pratten was there, Fiona 19 Thomas was there, Lesley Salmon is there. 20 Your post is dealt with at the middle of the 21 page. Let us scroll down to it. 22 "Helen has taken on more responsibility for the 23 Heart Circle and her job is developing well. She wishes 24 to remain in post after her contract runs out in 25 October." 0119 1 That is March 1993. 2 Is that the case? 3 A. I do not know who said that, but in March -- I mean, 4 I think I made the decision that I would not want to 5 continue with the post around the summer of 1993, so in 6 March, despite my concerns and other issues surrounding 7 the post, I probably had not said to Jean that I would 8 not continue, but then in July, I did say to her that 9 I would not want to be continuing with the post. 10 Q. It is actually the reverse of what they have put you 11 down for saying. These are all people you knew well or 12 worked with, alongside. Fiona Thomas. You saw 13 Jean Pratten and treated her as the person to whom you 14 were responsible. They had the idea that you wanted to 15 stay there. 16 Is that an idea that you had actually expressed to 17 them round about March 1993? 18 A. No. 19 Q. It will be suggested, no doubt, by others that if it was 20 the case, there is obviously a contradiction between 21 what they understood your wishes to be and what you 22 yourself were feeling at the time, which was basically 23 you are soldiering on because of your feelings of duty 24 to the charity, the Heart Circle? 25 A. I think that came a little bit later than March. 0120 1 I think that was July sort of time. 2 Q. You talk in your statement, just going back to that, it 3 is page 12, paragraph 33, about needing help to cope 4 with the extreme exposure to distressed parents. 5 The reason you could not cope was because of your 6 concerns about the surgery, was it? 7 A. Not initially, I do not think. I think the reason was 8 that I felt I was supporting the parents and the 9 children while they were on the unit, the nurses, and 10 also trying to be effective in my job, and I was finding 11 that difficult because I did not have a mental health 12 training to be able to counsel these people at a level 13 I would have felt comfortable or appropriate. 14 Q. Not initially; so latterly? 15 A. Latterly I felt that, yes. 16 Q. So here you were, with your concerns, the concerns 17 having an effect upon you and your health, no doubt, 18 wishing to tell parents that they really should get in 19 a car and go somewhere else, but not doing so because 20 that would be unprofessional, as you saw it, and raising 21 your concerns once in the meeting in the way we have 22 been through with Fiona Thomas and Lesley Salmon, and 23 otherwise in informal talks with Dr Bolsin. 24 Did you raise those concerns anywhere else? 25 A. Not as directly as that. I did obviously, when I went 0121 1 to Great Ormond Street and I met with other paediatric 2 cardiac nurses as part of the Paediatric Cardiac Nurses' 3 Association. I did express to them concern that, again, 4 the time in theatre and intensive care and the death of 5 the children seemed to be far more frequent than at the 6 centres they were working at. 7 Q. You were Secretary of the Paediatric Cardiac Nurses' 8 Association, so you had an association behind you, had 9 you wished to say something? 10 A. It was an association which I formed with some nurses at 11 the Great Ormond Street Hospital as well as at the 12 Brompton and other cardiac centres, and it was really 13 not to be a large lobbying body but to be an exchange of 14 information and ideas, and it was primarily nurses. 15 Q. But you knew they shared your views, because that is 16 where they had come from? 17 A. They shared my views -- 18 Q. As to the length of time children should stay in 19 theatre? 20 A. They expressed surprise, concern, when I would say, 21 "Well, you know, this is happening and I am not sure 22 whether it is correct or appropriate". 23 Q. Why did you not raise your concerns with someone in 24 management in the BRI? 25 A. I think because my perception of the management in the 0122 1 BRI was they were very distant from certainly the nurses 2 on the ward. A lot of them were just names to me. 3 I did not have any association with these people. And 4 certainly, latterly, when through Dr Bolsin I was aware 5 of his efforts to get various members of the management 6 to make a stand about the issues, I did not see that 7 there would be any benefit from me approaching these 8 people who would not know who I was, I did not know who 9 they were, and I had a feeling of, I would not be 10 listened to or taken seriously. 11 Q. So let me just unpick that for a moment. These were 12 people that you knew by name but not otherwise, and what 13 I think is implicit in your answer is, you could have 14 spoken to them? 15 A. I could have arranged, if I had known who they were and 16 their role and whether it was appropriate to see them, 17 then I suppose I could have done, yes. 18 Q. And I understand from your answer, you chose not to? 19 A. I chose not to because I felt there was very little 20 point, as I was aware of the huge amounts of work 21 Dr Bolsin was doing with those very same people, and as 22 I said, as I was a weak player on the units in 23 comparison to someone like Dr Bolsin, I saw very little 24 point. I was also aware that I was funded by the Heart 25 Circle, and because I was funded by the Heart Circle, 0123 1 I did not want to take on this role of banging on the 2 door of the Chief Executive or whatever, because I would 3 be seen as representing the Heart Circle and I did not 4 have, you know, Jean's authority or permission to do 5 that. 6 Q. You are a member of the RCN? 7 A. Yes, I am. 8 Q. You were at the time, a member of the RCN? 9 A. I am now. 10 Q. Were you then? 11 A. Yes, I was. 12 Q. Did anything prevent you going to your union and raising 13 the issue with them as to how best to proceed with what 14 were obviously serious concerns? 15 A. When I did think about that, I thought, "Well, I do not 16 have enough substantive evidence, apart from, well, 17 I have talked to people at Great Ormond Street and it 18 does not happen there". I did not have sophisticated 19 audit or any of the tools that Dr Bolsin had, and I also 20 had this feeling that if I went to the RCN, the first 21 port of call may be that they would come and speak to 22 Fiona Thomas or they would come and see Mr Wisheart, and 23 they would be told that "No, everything was all right, 24 we have some very difficult children here, we have had 25 some deaths". Because there was this overriding 0124 1 attitude of, "Well, we do have difficult cases here and 2 that is why we have a number of children that die". 3 I felt that if I had gone down that road, all roads 4 seemed to lead back to the one or two people on the unit 5 whom I did not have faith in, in actually taking the 6 cause forward. 7 Q. Who were they? 8 A. Mainly Mr Wisheart, I think, in his role as the senior 9 surgeon on the unit, and I think the Clinical Director 10 at that time. 11 Q. You were a nurse. There was a Nurse Adviser, a Nurse 12 Manager. Did you think of talking to her? 13 A. Who was the nurse -- the RCN? 14 Q. No, Margaret Maisey at the hospital? 15 A. I thought she was Director of Operations. 16 Q. That as well. 17 A. I did not know she had a nursing ... 18 Q. Apart from talking to Dr Bolsin, did you make any 19 enquiries as to whom you might refer your concerns to? 20 A. Enquiries of -- 21 Q. Enquiries of others? 22 A. I did frequently, as I said, talk to Dr Bolsin and in 23 supervision Dr Gardner about what could I do within my 24 professional capacity, which was ethical, to raise these 25 concerns? We felt we were rather powerless to actually 0125 1 do that. 2 Q. Despite the fact that concerns had already been raised 3 in Private Eye in the middle of 1992 -- you knew about 4 that, I take it? 5 A. I only knew about it because Dr Bolsin mentioned it to 6 me, and people obviously talked about it on the unit. 7 Q. So there had been talk about Private Eye on the unit. 8 There had been something in the public domain. 9 Dr Bolsin was concerned. You felt that every time you 10 took the child down to theatre you were betraying the 11 parents. There were people you could have spoken to, 12 and you have told us that you did not and you have 13 explained why you did not. 14 Part of that explanation was, as I understand it, 15 that you felt that you might be wrong. You were saying, 16 "How do I know, because all I have is this information 17 to go on and -- 18 A. I did not feel I was wrong. I just did not feel I had 19 substantive evidence to show that my gut feeling and my 20 comparison of talking to other nurses at other units 21 would be sufficient to substantiate that kind of claim, 22 and I think, as I said in the background, whilst I spent 23 a long time talking to Dr Bolsin frequently, I felt that 24 it was more appropriate, in his position as a consultant 25 anaesthetist and his ability to produce audit, he was 0126 1 a far more appropriate way to do it. 2 Q. So am I right in thinking that apart from raising it on 3 the one occasion that you did with Fiona Thomas in the 4 way you have described, and talking to Dr Bolsin and 5 Freda Gardner, and I think you mentioned in your 6 statement, you mentioned it to Jean Pratten, I will come 7 to that in a moment -- you left it all to Dr Bolsin? 8 A. Dr Bolsin and I spoke about it and in fact we spoke 9 about it very recently, and he said I was not in 10 a position -- if he was having problems trying to get 11 people to take notice, that, you know, there was very 12 little point in me trying to do anything. That is how 13 I felt at the time. I felt if people were not listening 14 to somebody of his status and somebody who had 15 substantive evidence, then why would they listen to me? 16 Q. Can we have a look at UBHT 154/195? 17 It is a letter from you, as we will see when we 18 get to the bottom of the page, 18th August 1992, to 19 Mr Dhasmana. Let us scroll down and see the text. It 20 is support groups held with the nurses, yourself and 21 Julia Thomas, certain aspects of long-term patient care 22 and communication with relatives have been highlighted 23 as being problematic. You welcomed the opportunity to 24 discuss those issues with Mr Janardan and his 25 colleagues. 0127 1 So these are the nurses proposing a meeting with 2 the surgeons, is it? 3 A. Yes. The Support Groups were support groups 4 I facilitated along with occasionally the social worker 5 when she had the time and the Chaplain to give the 6 nurses the opportunity to express their concerns, their 7 views. It was a supportive mechanism for them because 8 things were very stressful. 9 One of the things they found particularly 10 stressful was looking after -- I mean, I do not know 11 whether we are talking about paediatrics here 12 specifically. I do not think it says, does it? 13 Q. No. 14 A. But, yes, the views that came out were that they wanted 15 to discuss the care of these patients. 16 Q. If we turn over two pages to 197. It is 17 11th September. The meeting which you proposed you 18 now say is going to be on 2nd October. That is 1992. 19 Can we go to UBHT 135/118? 23rd August 1993. So this 20 is at a stage when, whenever it was that you stopped 21 going down to surgery with parents, this is on any date 22 you have given us so far, after the time you have 23 stopped, you have withdrawn from it. It is a letter 24 from Jean Pratten to Freda Gardner, talking about 25 a meeting to discuss, in the second paragraph, the 0128 1 issues involved in the management of paediatric 2 patients: 3 "We will then have a regular weekly meeting to 4 discuss the ongoing management of all patients on the 5 cardiac unit." 6 A. Yes. 7 Q. So such meetings were held, were they? 8 A. Yes. I can remember two or three, not more than that. 9 Q. The next one I want to take you to is UBHT 135/110. It 10 is a memo, and you see the list of names there. 11 Mr Dhasmana is there, Mr Wisheart is there, you are 12 there, Fiona Thomas. "Re: Paediatric meeting": 13 "The next meeting will be on ... 16th February 14 1994". 15 That may have been about the time you were 16 leaving? 17 A. Yes. 18 Q. The point is, this appears to be an organised meeting of 19 nurses and surgeons, those involved in paediatric 20 care. Am I right? 21 A. Yes. 22 Q. So there were such meetings? 23 A. No. I think following my conversations with Dr Gardner 24 and my concerns that there were not these type of 25 meetings, I think she took on the role to organise 0129 1 these. I think she carried more weight than I did in 2 the unit to be able to orchestrate this, based on the 3 concerns that I expressed to her, but these did not 4 happen until late 1993. 5 Q. Page 135/97: what is described as the Paediatric 6 Interest Group. It shows the attendees and the 7 apologies. The first of the apologies is Mr Wisheart 8 himself. You were an attendee. This is 8th December 9 1993. 10 To scroll it down and show the headings, what was 11 discussed: the management of paediatric care. Overleaf, 12 please: developments, and it is obvious from 13 developments that the idea is to involve cardiologists 14 as well. And the date of the next meeting. 15 So that meeting undoubtedly took place. What you 16 say to the suggestion that at any one of the meetings, 17 in any one of these fora, you might have raised the 18 concerns and sought an explanation from those who knew 19 if there was an explanation, or some action if there was 20 no proper explanation? 21 A. Are you asking me why I did not raise my concerns at 22 this particular meeting? 23 Q. Yes, at any of them. 24 A. I think I only attended probably the one, because they 25 did not start until later in 1993 and I did not raise 0130 1 it, I suppose, because I had already raised it with 2 Dr Gardner, she knew my views, and I did not think it 3 was an appropriate platform to raise it. And also, 4 I had made it clear by then that I would be leaving my 5 post at the end of the three-year term. 6 Q. The fact of your leaving the post did not alter your 7 feelings as needing to do something about the conditions 8 you saw? 9 A. No, but I think it is fair to say that on advice from 10 Dr Gardner, I had withdrawn my input to a level where 11 I was not enthusiastic and ambitious any longer, and 12 would not have felt I wanted to raise that concern. 13 Q. We heard evidence from the parents of Oliver 14 Darbyshire. You have seen, this morning it may be, 15 a transcript of what was said? 16 A. I saw it briefly this morning for the first time. 17 Q. Although the statement has been available for some time, 18 you may not have seen the statement until this morning, 19 or at least, until fairly recently. 20 You appreciate that what is said by the 21 Darbyshires -- let me just take you to it. The 22 transcript is at INQ 4/44. 23 If we keep the top right and the bottom right, 24 please, and just focus in on that, can we go down the 25 next page, the same page but the part below, the bottom 0131 1 right-hand corner? It is page 144 of the transcript. 2 The top of the page: 3 "Question: Was there a Heart Circle office?" 4 The answer that Susan Darbyshire gave us was: 5 "Yes, Oliver's cot, his little space was situated 6 right opposite the Heart Circle office and we saw a lady 7 during the course of the afternoon coming and going, 8 appeared to be extremely busy. We assumed she was a 9 Heart Circle counsellor [that is the way they put it] 10 for the parents and the last we saw of her was about 11 5 o'clock when she locked the office door and went 12 home. She did not introduce herself to us. We assume 13 that is who it was. She did not introduce herself to 14 us, so we were left literally stranded. 15 Question: You knew there was going to be 16 a counsellor there? 17 Answer: Yes, we were told that by Helen Vegoda at 18 the Children's Hospital, that there was a paediatric 19 cardiac counsellor situated at the BRI." 20 Leave aside the precision of the description: it 21 was you that plainly was being referred to. You would 22 accept that, I take it? 23 A. Well, a lot of people used my office, but -- 24 Q. Nobody else would be described as a "paediatric cardiac 25 counsellor"? 0132 1 A. No. 2 Q. And the Heart Circle office might have been used by 3 others, then? 4 A. Yes, it was. 5 Q. It has been pointed out to me entirely rightly that they 6 assumed that the person they saw coming and going was 7 the counsellor. 8 Can we go overleaf? The top left, and then there 9 is a complaint about not being met. The next page, 146, 10 the bottom left, Susan Darbyshire described the contact 11 with the doctor. Top right, please? And bottom right, 12 I am sorry. They describe from lines 8 to 25 how they 13 were spoken to by a nurse about Oliver's operation, and 14 how the nurse told them that matters were put off. Thus 15 far they were describing contact made with the doctor, 16 with the nurses, and not with the lady, whoever it was, 17 going in and out of the Heart Circle room. 18 Your office was the Heart Circle office, was it? 19 A. There was a linen cupboard on Ward 5, which, when 20 I started my post, I managed to persuade them that 21 I needed facilities where parents could sit if they 22 wanted to be quiet and just to take people who wanted to 23 be away from the main rest-room. So the Heart Circle 24 and myself converted the linen cupboard into an office. 25 The nursery at that time was opposite that. It then 0133 1 later moved further down the unit. 2 Inside that office, there were a number of books 3 which were for reference for nurses on the unit. 4 I cannot recall the office ever being locked 5 because nurses used to use it for private study and for 6 sitting in, there were two chairs in there. There was 7 also a very large cupboard in there which kept, amongst 8 other things, Heart Circle stickers, sweatshirts, those 9 sorts of things, as well as Christmas decorations and 10 other things which are kept on the ward, so I was not 11 the only person to be using that office, but primarily, 12 that was my office, I suppose. 13 Q. The only thing you did not have that you might have 14 found particularly useful you have already told us was 15 a phone? 16 A. Yes. 17 Q. Can we go overleaf, please? It is top right, please. 18 It is line 17: 19 "Roundabout mid-morning, Helen Stratton, the 20 counsellor, came over and she introduced herself to us 21 and I just tried to be really polite to her. I was 22 really embarrassed, I felt really uncomfortable. She 23 came over and neither of us said a word. She just 24 looked at my husband and basically she said 'I know you 25 don't like me. I don't really care what you think of 0134 1 me. A lot of parents have not liked me in the past. It 2 really does not bother me'. Then she walked away, then 3 she came back..." 4 Just dropping for a moment to line 13, you can see 5 that I asked whether she was a person that Susan 6 Darbyshire had seen the day before, and she said it was, 7 so the link was made at least in her recollection 8 between the person going in and out of the Heart Circle 9 office and you. She says how you came back, whether you 10 had second thoughts, "really do not know", 11 "... came back and invited us into her office for 12 a chat. My husband did not want to go, he did not want 13 to come but I asked him to. I said this is really 14 embarrassing, let us go in and hear what she has to 15 say". 16 She described the damage had been done "because 17 she should have approached us the day before", and it 18 confirms there the account given that was put in her 19 witness statement to us. 20 There are a number of questions to ask you about 21 that. First of all, do you recollect the conversation? 22 A. No, I do not. 23 Q. Secondly, at this time -- this was 15th July 1993 -- 24 this will be at a time when you told us you had probably 25 given up going down to theatre because you were very 0135 1 concerned. It is a time you told us that you were under 2 pressure, which you found at times extreme? 3 A. Yes. 4 Q. That you were forced to do a counselling role which you 5 were not fitted for doing, and you only did, really, 6 because people needed it, although you were not 7 technically a counsellor? 8 A. Yes. 9 Q. Might it be the case that you reacted in the way 10 described because you may have been feeling some of the 11 pressures and embarrassment and difficulties of the job? 12 A. No. I would never have behaved or said any of those 13 things, because it would be wholly unprofessional, and 14 anyone who knows me personally or professionally knows 15 that I would never say anything like that in 16 a professional or personal capacity. Whilst I accept 17 that I was having problems coping with the emotional 18 demands made on my time, I took appropriate action to 19 have supervision with Dr Gardner to ensure that when 20 I was working on the ward in the unit, I always behaved 21 in a very professional and appropriate manner. 22 Q. You say "supervision" from Dr Gardner. She was 23 a clinical psychologist, was she not? 24 A. Yes, she was. 25 Q. Did she give you psychological help? 0136 1 A. She helped me in coping with -- both by giving me advice 2 on how to deal with parents who were extremely 3 distressed, but also advice and help on how to deal with 4 my own feelings, and part of that was to remain always 5 very professional, always to do my job to the best of my 6 ability, and if I thought for one minute that I was 7 unable to do that, I was to withdraw from the ward and 8 the situation, which is what I did. 9 Q. Did it get to the stage when you took any medication to 10 help? 11 A. No. 12 Q. This incident was something which it appears in the 13 recollection of the Darbyshires, that they complained 14 about, and certainly, we have a report in the medical 15 records -- let us look at it. It is MR 1840/554, 16 19th July 1993, the fourth line down: 17 "Spoken to by Helen Stratton. Dad very upset and 18 complaining about care and support given to them over 19 the weekend". 20 It goes on to say that no complaints were made at 21 the weekend about the standard of support and care. 22 Parents did not ask to see senior members of staff re 23 this. Helen Stratton had a long chat with parents, who 24 are still not happy. Mr Dhasmana informed of the 25 situation." 0137 1 Later on Lesley Salmon spoke to the parents about 2 their complaints. 3 Do you remember an incident in which the 4 Darbyshires were complaining about care, you spoke to 5 them and you could not satisfy them? Does that help? 6 A. No, I really cannot recall the situation at all, I am 7 afraid. 8 Q. Because there is certainly contemporaneous record of 9 complaints which appeared to be directed at you. Have 10 we to leave it simply that you have no recollection of 11 it? 12 A. No. I am afraid when I left Bristol, I made a conscious 13 effort to forget what I considered to be a very 14 distressing and difficult time in my life. 15 Q. Sometimes, even those matters we exclude from our minds, 16 we can later on recall and recollect. If it is the case 17 that you recollect what actually happened at some later 18 time -- I appreciate, leave aside the reason for it, 19 that you have only seen the statement and documents 20 recently -- feel free, please, to write to the Panel and 21 tell them. 22 I mention that particularly because if no other 23 side of the story is to be given about this incident, 24 the evidence that the Darbyshires have given remains 25 essentially uncontradicted. That is something you may 0138 1 want to think about. I do not want to push you or press 2 you further on that now, just to mention it. 3 We heard from a number of parents, may I say, 4 about how marvellous you were. We heard from 5 Mr Wagstaff, and perhaps we ought to have a look at 6 that, to ensure there is a balance: INQ 4/7. Can we 7 please highlight the top right-hand side? 8 Here Mr Wagstaff describes how "Helen Strachan 9 [I suspect you get used to be calling all sorts of 10 things] showed us around". 11 "Question: Was that a helpful exercise, being 12 shown around the ITU? 13 Answer: Yes, it was. 14 Question: Why? 15 Answer: I think it really prepared us for the 16 shock of seeing Amy with all the tubes and pipes and 17 everything coming out of her, so at least we knew what 18 to expect the following day. 19 Question: So the following day was when the 20 operation took place? 21 Answer: Yes." 22 He then goes on to describe, on the next page, 23 page 28, lines 11 and 15, how you sat with the Wagstaffs 24 and helped them through that particular period. 25 So that is a compliment for you, as is Paula 0139 1 Jordan. It is INQ 4/31, she is discussing the care of 2 her son Joe. The bottom right-hand corner, please: 3 Cardiac Liaison Nurse. This is dealing with an earlier 4 stage of your career at the BRI than the episode with 5 the Darbyshires that we have been talking about. She is 6 talking about your role: 7 "Basically a go-between so if there was anything 8 you did not know or understand she would ask her. If 9 she did not know or could not understand, she would find 10 out for you". 11 That is a pretty good description of your role? 12 A. Yes. 13 Q. "Question: Was that helpful? 14 Answer: Absolutely wonderful. 15 Question: How good were the medical staff? 16 Answer: They were marvellous as well." 17 Could I mention those so there is a balance here, 18 because you appreciate that what I have to do is to put 19 to you what we have been told by others so you have 20 a chance of dealing with it. I do not want the 21 transcript or the wider public to get an unbalanced 22 reflection of what has been said about you by others. 23 Do you remember dealing with a Mrs Helen Rickard? 24 A. No, I do not. 25 Q. She has a recollection that when you showed her the ITU, 0140 1 she asked whether you felt she could get used to it, 2 words to that effect. 3 Is that something which you sometimes said to 4 parents? 5 A. I never used those precise words. 6 Q. But something to that effect? 7 A. I would often say to parents, "This is a very difficult 8 environment but parents do find it gets easier the 9 longer they stay in the intensive care", and by "easier" 10 I meant they became more familiar with the machinery and 11 the noises. I never indicated that it became less 12 stressful; it is just that people and parents have told 13 me that obviously the more times they were in there and 14 they were exposed to it, the more relaxed and 15 comfortable they became. 16 Q. If you had said something along the lines, "You get used 17 to it", you can see why that might cause distress, can 18 you? 19 A. If I had said that, yes. 20 Q. If what you said was taken that way, it would have been 21 unintentional, would it? 22 A. Absolutely. 23 Q. We have heard from a number of parents -- I want to take 24 it compendiously -- that following the surgery and the 25 sad death of their child, you were particularly 0141 1 concerned that they should leave the hospital. 2 First of all, in general terms, did you find the 3 bereavement of parents easy or difficult to cope with 4 yourself, personally? 5 A. I do not think anyone in that supportive role finds it 6 easy. As I have said, it became increasingly difficult 7 for the reasons we have already described. What I would 8 say is that one of the first things I did when I got to 9 the post was to ensure that I built up a relationship 10 with the Patient Affairs Officer, who dealt with parents 11 once the child or adult in the BRI had died. 12 We did a lot of very good work together, which 13 ensured parents had the necessary information to 14 register the death, et cetera, which had not been 15 available before. 16 I think supporting parents in a bereavement is 17 never easy. It was never beyond my professional 18 capacity. I never let it become like that. 19 Q. What I am asking you about is whether, when there had 20 been a death, you feel that you may have given the 21 impression to parents that the best thing that they 22 could do for themselves, perhaps for the hospital, was 23 to leave and to take their grief elsewhere? 24 A. No, not at all. A number of these bereavements were 25 late in the evening, perhaps following the surgery, if 0142 1 the child had died in theatre. These parents lived in 2 Cornwall, Devon. It was a very long drive. I often 3 said to parents "You are very welcome to stay, and you 4 still have the room and you can meet Diane, the Patient 5 Affairs Officer in the morning, or you can go home". 6 A number of parents felt that, however late it was, they 7 wanted to get out of the hospital and they wanted to be 8 surrounded by their home and their family. There was 9 never an incident where they were pushed into making 10 a decision to leave against their wishes. 11 Q. What Mick Parsons told us was said in INQ 4/13,INQ 4/14 the 12 bottom right: 13 "Helen Strachan [again, he gives you the Scottish 14 surname, as it were] was waiting outside and she then 15 led to us a small boxroom which was full of all sorts of 16 stuff and had a small settee, effectively a junk room." 17 What is that a description of? 18 A. I don't think you ought to describe it like that to Jean 19 Pratten! It had been a junk room and the Heart Circle 20 paid for it to-- 21 Q. Is this the laundry room? 22 A. No, we have moved on from the laundry room. We now have 23 a storeroom which the Heart Circle -- there was nowhere 24 essentially for adult relatives or parents on the unit, 25 so Jean asked if we could have a "junk room", as it is 0143 1 described here, and the Heart Circle furnished it with 2 a pay phone which they paid, you did not have to put 3 money in, the Heart Circle took up the money for that, 4 a settee and a table, and probably a small decoration or 5 something. 6 It was a very small room, but it was the only room 7 that the Heart Circle was allowed to make any 8 improvements to, on the Cardiac Unit. 9 Q. Just going on: 10 "Helen asked us whether we would like to see Mia 11 to say our goodbyes. I said no but Leen said that she 12 wanted to say goodbye. Helen explained it would be good 13 to see Mia and say goodbye and it would help us to come 14 to terms with her death." 15 That is something you might have said, I take it? 16 A. I think what I used to say was "Some parents have found 17 it helpful to see their child". 18 Q. By using that expression, "some parents have found it 19 helpful", you were indicating what they might perhaps 20 like to do? 21 A. I was giving them the option, yes, but it was always 22 a choice. 23 Q. Is it an option or is it a steer, do you think? 24 A. I think it is an option, because a number of parents had 25 told me that whilst they did not immediately feel that 0144 1 that was something they wanted to do, they were glad 2 that they had done it, and I know that some parents who 3 did not see their children when they had died, did 4 regret that. 5 Q. Just going on: 6 "I therefore reluctantly agreed to see her, but 7 Mia was brought in wearing a white baby-grow which was 8 not hers. She was in a Moses basket. Leen was upset 9 with the baby-grow because it was not hers and she did 10 not like white on Mia. In any event, we picked her up 11 and cuddled her. Helen took a photograph. She then 12 left us with Mia. After a short time, she returned and 13 said that it was best if we went home. We actually said 14 we preferred to stay in the little room at the hospital, 15 and I think in all honesty it was because we did not 16 want to leave Mia." 17 He goes on to describe -- it is INQ 4/15, the 18 bottom left: 19 "In any event, Helen insisted we would disrupt the 20 ward if we stayed; getting back to our home environment 21 was the best thing we could do. At this stage I became 22 extremely stubborn. The whole sequence of events that 23 transpired since we had been told about Mia's death was 24 deeply upsetting. There was firstly the fact that 25 another lady and her young child were present in the 0145 1 room". 2 He says that you broke the news in front of 3 somebody else who had a child awaiting surgery, and that 4 that was inappropriate. 5 Might you have done that? 6 A. No. He is right, it would have been completely 7 inappropriate, and it is something I would never ever 8 have done. 9 Q. "There was the incident in the corridor; basically 10 placed in a junk room where we were expected to say 11 goodbye to Mia; and finally I got the distinct 12 impression we were being rushed out of the hospital 13 before we were ready to go." He goes on to say about 14 how he lives in Swansea. 15 He describes a bit of an argument and a fuss about 16 his not wanting to go and your wanting him to go. Do 17 you recollect it? 18 A. No, I do not. 19 Q. We have heard from I think it is approaching double 20 figures of the parents who say that the "cardiac liaison 21 nurse", and some of them identify you by name, gave them 22 the impression that it would be better for them, 23 sometimes the expression used, "some parents find it 24 helpful to leave straightaway", words to that effect, 25 gave them the impression that they should leave the 0146 1 hospital straightaway. 2 I can put specific instances to you. From what 3 you said earlier it may be that you do not precisely 4 recall the particular parents in the way they will 5 inevitably recall what happened? 6 A. No, I do not. 7 Q. But in general terms, might you, do you think, have said 8 to a number of parents words to the effect: some parents 9 do find it useful to go home, to leave the hospital and 10 come back later, or see the doctors later, words to that 11 effect? 12 A. No. I think, again, many of these incidents happened 13 late in the evening and I was acutely aware that these 14 people lived a long way away, and they would have been 15 allocated a bedroom for that night anyway, and I always 16 gave them the choice. I had absolutely no reason to 17 want to rush them out of the hospital or to make the 18 decision for them. It was up to them whether they 19 wanted to say and deal with things with the Patient 20 Affairs Officer in the morning, or whether, as some 21 parents did, they wanted to get in their cars and drive, 22 you know, extremely long distances in the middle of the 23 night, to be at home. 24 But it was always their choice. I did not make 25 that decision for them. 0147 1 Q. Is there anything about the way in which you might have 2 approached those parents which may, albeit unwittingly, 3 have given them the impression that you wanted them, 4 really, to go? 5 A. No. 6 THE CHAIRMAN: Mr Langstaff, that might be an appropriate 7 moment to take a break for, shall we say, 15 minutes? 8 MR LANGSTAFF: Certainly. 9 THE CHAIRMAN: We will reconvene, therefore, at 2.45. 10 (2.30 pm) 11 (A short break) 12 (2.50 pm) 13 MR LANGSTAFF: Miss Stratton, I think I finished asking you 14 about the feeling that a number of parents say that they 15 had, that they were being pushed out or hurried out, 16 save for one matter. 17 Accommodation for parents, I think, was limited in 18 the BRI? 19 A. Yes. On the intensive care unit, Jean Pratten and the 20 Heart Circle had again persuaded the unit to turn two 21 junk rooms into bedrooms, and had furnished and painted 22 those. The two bedrooms were intended for parents prior 23 to their child going into theatre, and for a few days 24 afterwards, but such was the demand for these rooms when 25 we had more than two children on the intensive care unit 0148 1 or awaiting surgery, parents would then be taken to 2 a hospital house which the Heart Circle -- I think you 3 would have to ask June Pratten for clarification, but 4 I think the Heart Circle paid some rent for, and these 5 were furnished by the Heart Circle, but obviously they 6 were not as ideal because they were a walking distance 7 from the hospital. 8 Q. I think Jean Pratten actually says they did not rent 9 them, they managed them? 10 A. Yes, well, she would know. 11 Q. There may have been occasions, might there, when the 12 room was needed in any practical sense by parents whose 13 children were actually on or coming into ICU? 14 A. Yes. 15 Q. And the parents who were there might have needed to go 16 elsewhere? 17 A. Yes. I think it is important to recognise that when you 18 have parents in the rooms on the unit which were very 19 convenient, and in an ideal world you would have had 20 enough rooms on the unit for all the parents at all 21 stages of the time they were there, but I am aware that 22 it was difficult for parents when they were asked to 23 move to the accommodation outside the hospital, albeit 24 five minutes away, but it was outside and it was, you 25 know, not in the hospital, which was significant, to 0149 1 make way for parents who were coming in to use that 2 room. I think Jean Pratten and certainly myself felt 3 that every family should at least have the opportunity 4 to have use of that room, and in that respect, you could 5 not have parents staying in that room for long periods 6 of time when there were other parents coming in, to be 7 fair to everybody. 8 Q. I do not know, but perhaps one of the problems of seeing 9 parents at the BRI for a day or two, because it would 10 normally be the next day after admission for surgery 11 would take place, I think: might it be that you did not 12 have much of an opportunity to build up a relationship 13 with the parent before, if the worst did happen, it 14 happened? 15 A. I think that is true and that is why I felt quite upset 16 and saddened that I was not given the opportunity to go 17 to the Children's Hospital and meet them at the earliest 18 possible time and build up a relationship with them 19 whilst they were waiting to come to the Royal Infirmary, 20 either through the health visitor or through the Heart 21 Circle representative. 22 When they arrived at the hospital they were often 23 bombard with a variety of people who wanted to see them, 24 whether it was the physiotherapist, the nursery nurse, 25 the people who wanted to take the blood, there were 0150 1 a variety of tests the children had to have. There was 2 a limited time for me to see the parents, and it is 3 difficult to build up a rapport or understanding of 4 their needs in that short time. 5 Q. When they had a echocardiogram or a catheter, that might 6 have been done at the BCH? 7 A. The catheter and echo would have been done at the BCH. 8 Q. The parents would, in that context, have regarded Helen 9 Vegoda as their support? 10 A. Yes. 11 Q. Using the word "support" neutrally? 12 A. Yes. 13 Q. So they would have faced a change from someone they knew 14 and had time to relate to, suddenly to the emergency of 15 the operation, the stresses put on them, they have you 16 instead of her? 17 A. Yes, and that again comes back to the fact that I was 18 very keen that whilst we both had important roles to 19 play, those roles should cross the boundary of "your job 20 is at the Children's Hospital" and "your job is at the 21 Bristol Royal Infirmary" to have worked in the most 22 effective way. 23 Q. So quite apart from the lack of any dedicated support -- 24 we have been through that in terms of other staff and in 25 terms even of a telephone -- you had this additional 0151 1 handicap that your job in terms of giving information as 2 a nurse, as someone who knew, was hampered because you 3 were not "in on the ground floor", as it were? 4 A. Yes. I cannot emphasise strongly enough how important 5 I thought that role was, not only because I witnessed it 6 at Great Ormond Street, but because I could see from 7 what Mary Godwin had told me that that was really the 8 beginning of the liaison and communication and 9 a building up of some rapport with parents, rather than 10 as described, them turning up the day before, meeting 11 someone new and being thrown into this, you know, very 12 emotional, difficult time. So, yes. 13 Q. Jean Pratten has responded to your statement, as I know 14 you know and have seen. Can we have on the screen 15 WIT 256/106? Paragraph 2. Her view which she states, 16 she says, with emphasis, is that you were not employed 17 by the Heart Circle, nor regarded as an employee of the 18 Heart Circle, even though you were funded by the Heart 19 Circle. 20 That is a difference of understanding or lack of 21 clarification? 22 A. Yes, a difference of understanding. 23 Q. We saw earlier on the assessment which Helen Vegoda went 24 through, the appraisal. Did you ever have any similar 25 appraisal, or not? 0152 1 A. Not in a formal way. I often sat down with Jean Pratten 2 and we went through things that I had done, things that 3 I wanted to do in the future, you know, how my job was 4 going, and latterly, that would also involve Dr Gardner 5 talking to me about how she felt I was dealing with 6 bereaved parents and guiding and steering me, giving me 7 advice on how I could improve my practice in that area. 8 Q. In paragraph 32, just switching back from Jean Pratten's 9 statement for the moment, page 12 of your statement 10 (WIT 256/12), you spoke about raising the concern you 11 have spoken about with Jean Pratten. 12 You make, I think, two points. One is that you 13 realised that the questions you raised were clinical 14 issues and were not really something for the Heart 15 Circle as such? 16 A. Yes. 17 Q. Is that because the Heart Circle was a fund-raising 18 organisation? 19 A. Again, you would have to clarify with Jean Pratten, but 20 my understanding is that they were not primarily 21 a fund-raising organisation. They were there for the 22 interests of the parents. If that involved raising 23 money through fetes and things to improve accommodation, 24 buy medical equipment, things for the nursery, that is 25 what they did. But Jean understandably was reluctant to 0153 1 get involved with any issues, clinical issues or 2 otherwise in the Bristol Royal Infirmary. 3 Q. Just for your impression, was it your impression that 4 the Heart Circle were concerned equally for the living 5 and the bereaved, or was there any imbalance? 6 A. I think they were concerned about both. Very concerned 7 and very supportive of both. 8 Q. In that paragraph, paragraph 32, you ascribe to Jean the 9 view that first of all it was not part of your job to 10 raise the concerns that you had, and secondly, you give 11 her a motive for saying that, which is that she was on 12 friendly terms and thought a lot of Mr Dhasmana and 13 Mr Wisheart? 14 A. Yes, that is correct. 15 Q. So far as job is concerned, if you just go back to what 16 she says at 256/106 paragraph 5, about six lines down: 17 "The Heart Circle was a charity providing support 18 to families and it was important that we focused on that 19 role. Whereas there were many occasions on which Helen 20 Stratton and I chatted in an altogether informal way 21 about the stresses and problems of her job ..." 22 Stopping there, were the chats you had with her 23 formal or informal? 24 A. They were informal. 25 Q. Is it right to describe them as "altogether informal"? 0154 1 A. I am not quite sure what you mean by that. 2 Q. Just her use of language "in an altogether informal 3 way": it sounds like a casual friendly type of 4 conversation? 5 A. It was not said in passing. I used to meet with her 6 two or three times a week at her house and we would sit 7 and discuss issues, but we never had minutes or a formal 8 agenda, so that is informal, in my view. 9 Q. She talks about the stresses and problems of your job. 10 Were there more than you have already told us of? 11 A. I think she recognised the stresses of implementing 12 a number of initiatives which the Heart Circle and 13 I wanted, against a background which was very resistant 14 to change, very resistant to taking on new initiatives, 15 and two management structures, both at the BRI and the 16 Children's Hospital, which were not particularly 17 cohesive, making any kind of change very difficult. 18 I know that on practical issues where she tried to sort 19 out accommodation and things, she had experienced this. 20 Q. She says in the very last sentence, just read it through 21 for the moment. (Pause) Having read that through, 22 I will take you back to what you say in your statement 23 at 256, page 12. 24 What you say there is that Jean gave you, these 25 are your words, the "distinct impression that it wasn't 0155 1 part of my job to raise this type of concern." 2 The words "distinct impression" may suggest that 3 she did not actually say anything in those terms to 4 you. One may have an impression as to what someone 5 thinks without them saying it? 6 A. I cannot recall her saying "That is not part of your 7 job", but I cannot recall her saying, "Well, you know, 8 that is why you are there and that is why your role is 9 important". She understandably did not want to get into 10 discussing any sort of clinical concerns. 11 Q. So the impression came really because, whenever she 12 mentioned how important the job was, it was in terms of 13 supporting the families? 14 A. Yes. 15 Q. And it was not because she said, "It is not part of your 16 job to raise concerns", just that she did not mention it 17 was part of your job to do so? 18 A. No, but I think when you raise a concern with someone 19 and they then hastily go on to say, "Well, that is why 20 your job is very important", it is an indication, and it 21 was to me, that she did not want to discuss clinical 22 issues. 23 Q. She has the view, as you have just read to yourself, in 24 the last sentence of 32, that she said what she said 25 dismissively. The way you have just put it in your last 0156 1 answer was that when you talked about the number of 2 bereaved parents you had to deal with, she used it as 3 an opportunity to say, "That is why your job is 4 important. That is why we value the work you do"? 5 A. She was trying to be supportive, but I perhaps 6 unrealistically wanted her to say "Well, that is really 7 important, Helen, what can we do about it?" I was 8 looking for support or a colleague to strengthen my 9 case. I was perhaps being unrealistic in expecting 10 somebody running a charity to play that role. 11 So it is not an indication of her lack of 12 interest; it was just my expectation that she may 13 support me in my concerns. 14 Q. So she obviously thought, and you got the sense that she 15 thought she was being supportive in saying, "Dealing 16 with bereaved parents, the number that you have to deal 17 with, is important. That is the very important role you 18 are fulfilling". 19 Did you actually go further and say "Look, I am 20 really worried about the numbers which I think are too 21 many. To whom should I go to make a complaint or 22 enquiry about this?" Did you ever put in it those 23 terms? 24 A. No, I did not, no. 25 Q. There is nothing else I think I need ask you arising out 0157 1 of what she has had to say by way of comment. Let us 2 look at what Mr Dhasmana says in paragraph 1, 3 WIT 256/104. It is about seven lines up from the 4 bottom: 5 "The system improved in the early to mid-1990s 6 when more anaesthetists were appointed. Intensivists 7 were organised. The intensive care management was 8 streamlined. Miss Stratton compares the system with 9 Great Ormond Street and Birmingham, both of which are 10 dedicated paediatric centres with every member of staff 11 well versed in looking after children, and 12 a well-established system of intensivists, especially at 13 Great Ormond Street. I am not surprised that she and 14 new nurses noticed the difference." 15 If what he was saying there was that Bristol was 16 not a dedicated paediatric centre, it was likely to 17 compare unfavourably with Great Ormond Street and 18 Birmingham because Bristol did not have every member of 19 staff well versed in looking after children and did not 20 have a well-established system of intensivists, do 21 I take it you would agree? 22 A. No, I do not think that is an acceptable reason for not 23 having good practice. 24 Q. That was not the question, but you answered the next one 25 I was going to ask, and I am grateful. 0158 1 The only other matter arising from his further 2 statement is -- I need not actually take you to it, but 3 he says that he is sure that you knew that he was always 4 working to improve himself, analysing his work to the 5 extent of being self critical. 6 Did you know that? 7 A. I did not know that, no. 8 Q. I have kept you there for some time answering my 9 questions. I have nothing further which I am going to 10 ask you. In a moment there may be a question from 11 Valerie Mandelson. She is an expert on counselling. 12 Although counselling was not your role, as you told us, 13 she would like to clarify something, because we are 14 addressing it in the part of the evidence what we call 15 Issue I, which relates to counselling and support for 16 parents. 17 Before she does that, is there anything you would 18 like to say, either to emphasise a point which you have 19 made which you feel may not have got across properly, or 20 anything which you would like to add which you have not 21 been asked about but would like to tell us about at this 22 stage? 23 A. Yes, thank you for that opportunity. I think what 24 I would like to clarify is something which you 25 concentrated on for some while, the nurse being an 0159 1 advocate for the patient, and whilst that is true, my 2 understanding and clarification with the RCN and the 3 UKCC is that the nurse is an advocate for the patient, 4 but is an advocate and channel to take parents' concerns 5 to the medical staff involved, and act in that way, but 6 it would not have been appropriate, as a nurse and an 7 advocate for the patient, according to UKCC to start 8 expressing opinions about consultants and their surgical 9 performance. 10 I would just like to emphasise that I went over 11 every possible reason and action I could possibly think 12 of taking to bring this to people's attention, and it 13 was extremely difficult. I think people need to 14 understand, if they do not already, that as a weak 15 player and a nurse on a unit where the management 16 structure is fairly aloof, there is a sort of 17 established "membership club", sort of "inner sanctum" 18 structure. It is incredibly difficult, whoever you are, 19 and particularly a member of the nursing staff in that 20 instance, to make any headway when voicing very 21 difficult issues like that. I did try all possible 22 avenues that were open to me to make a difference, some 23 of which we have discussed. And I discussed it with 24 Dr Bolsin, and we went over all the possible things that 25 we could do to make a difference and assure myself that 0160 1 I did do everything within my professional role to try 2 and change things. 3 Q. One of the things I think that you did -- it may have 4 been right from the beginning, it may have been later 5 on -- was keep a book? 6 A. Yes, I kept a red book with patients' names and 7 addresses, the name of the health visitor, how often 8 I had spoken to the health visitor, the name of the GP 9 and other information like whether I had referred the 10 family to the social worker. It was really a record 11 that I could see: had I contacted the health visitor, 12 when did I last contact them, had the parents received 13 any support from the social worker and had they received 14 any financial support from the Heart Circle, which was 15 by the giving of a grant. 16 Q. Did it have any details of surgery and outcome? 17 A. It had the date of the operation, the date the child was 18 extubated or taken off the ventilator, the date they 19 were moved through to the nursery, the date they went 20 home and the date they died, if they had died. 21 Q. Do you still have that book? 22 A. I do. 23 Q. Do you think that at a convenient moment you might send 24 it to the Inquiry, so that we can see whether it would 25 be useful to the Inquiry to consider it? 0161 1 A. Yes. I lent it to Dr Bolsin when he was collecting his 2 audit, as he was finding it quite difficult to find 3 accurate information, data, dates of birth, dates of 4 operations, and I lent it to him and Andy Black and one 5 of his assistants when they were collecting their 6 audit. I then took it back and then the GMC had it. 7 I now have it in my possession. 8 Q. In turn, after that distinguished company, I wonder if 9 we might have it, as I say, at a convenient stage? 10 Is there anything else you want to add or say 11 before Miss Mandelson asks what she has to ask? 12 A. I do not think so. 13 Examined by MRS MANDELSON: 14 Q. Just two questions, really. If I may go back to the 15 beginning, and I know there has been a lot of debate and 16 confusion over job titles, but you did say that when you 17 first started in this role, it was your understanding 18 that Helen Vegoda was actually a counsellor for 19 children? 20 A. Yes, it was. 21 Q. I am just wondering how you thought that? 22 A. Just through talking to people, I was aware that there 23 was this counsellor, as she was described when I talked 24 to people, at the Children's Hospital, and I accepted 25 that, you know. If I had thought about it, I would have 0162 1 realised because she had been funded by the Heart 2 Circle, she was obviously a heart counsellor, a Heart 3 Circle counsellor. Obviously after I met with her she 4 clarified that she only dealt with children with cardiac 5 conditions. 6 Q. But not actually seeing the children; she was not like 7 a paediatric counsellor in terms of actually -- 8 A. No, I am sorry, I misinterpreted your question. My 9 understanding -- you would have to clarify with her -- 10 was that she counselled the parents and not the 11 children. 12 Q. There is just some confusion there. I think 13 I misunderstood actually what you said earlier on. 14 The other thing was, we talked about territorial 15 issues almost as if there was a demarcation line drawn 16 up about who did what. I am just wondering how was the 17 handover of families facilitated and if families went 18 back to the Children's Hospital, how did you know what 19 support they were going to get? 20 A. If they were going back to the Children's Hospital, 21 I would liaise with Helen Vegoda, we had weekly 22 meetings, and I would say, you know, "This family are 23 coming back", and she may or may not have met them 24 before. I would say to her "The social worker at the 25 Bristol Royal Infirmary is involved and she will be 0163 1 handing the care over to the appropriate professional at 2 the Children's Hospital", and I think the nurses did the 3 appropriate handover as far as the child's condition is 4 concerned. 5 But I think part of our weekly meetings was to 6 ensure that when patients transferred, or parents and 7 children, from one unit to another, there was this -- 8 people did know about it and that is why Helen and 9 I spoke on a weekly basis about that. 10 MR LANGSTAFF: There will be some questions from the Panel, 11 and then some from Mr Rose. 12 THE CHAIRMAN: Mrs Maclean? 13 Examined by THE PANEL: 14 MRS MACLEAN: I have a very simple question. It arises from 15 this question of confusion about roles. Did you wear 16 nursing uniform? 17 A. No, I did not, no. 18 THE CHAIRMAN: Mrs Howard? 19 MRS HOWARD: Thank you. Just one question. We have spent 20 a good deal of time talking about the split roles and 21 where there appeared to be tension in respect of that. 22 Can you offer us any specifics that in your view 23 actually compromised children's care as a direct result 24 of that split and perhaps unclarified role situation? 25 A. I think the split site meant that there was 0164 1 a communication problem, I mean, not between Helen 2 Vegoda and I in as much as we met on a regular basis, 3 but I think with the nursing staff, just because they 4 were not both in the same hospital, there were 5 inevitably communication problems. I am not aware of 6 any particular instance where I thought, "Gosh, you 7 know, if people had communicated that or the children 8 had been nursed in the Children's Hospital all the time, 9 that would not have happened". I cannot specify 10 instances, although I am sure people will be able to do 11 that, but I cannot. 12 Q. Can I just take you a little further in terms of your 13 role and Helen Vegoda's role. You have expressed very 14 eloquently your personal belief that you needed to be 15 involved at a much earlier stage, but again, do you have 16 any specifics in your nursing career that perhaps did 17 cause some compromise to children's care, because you or 18 your role, the person who would have been doing that, 19 were not involved at the very early stage? 20 A. I do not have particular instances, but I think if you 21 asked parents whether, at the times of diagnosis they 22 would have benefited from having a nurse there who could 23 explain the condition to them, could explain what the 24 surgery would involve, could start to prepare them for 25 intensive care and what that meant, I think most parents 0165 1 would say yes. I mean, I cannot recall specific 2 situations where parents said -- specifically names, but 3 I know parents did say to me, "Gosh, it would have been 4 useful if you had been there when Simon had his 5 catheter", or whatever, and that is where I felt there 6 was this desperate need to have a liaison nurse, not to 7 do the same role as Helen Vegoda, but to do an 8 information-giving and liaison with the community and 9 health visitors, and, yes, I think that would have been 10 very, very beneficial. 11 I think one of the reasons I was so saddened and 12 so rebuffed by what I am sure probably appears like one 13 meeting where I was told "you are not going to be able 14 to do that", the reason I felt so saddened about that 15 was because I saw this as being a very large, intrinsic 16 part of the role. 17 MRS HOWARD: Thank you. 18 THE CHAIRMAN: Professor Jarman? 19 PROFESSOR JARMAN: On page 9 of your statement, at the very 20 bottom, you said that medical equipment funded by the 21 Heart Circle included syringe pumps or specific pieces 22 of equipment requested by the nursing or medical staff. 23 Do you know why the Heart Circle had to fund such 24 basic equipment as syringe pumps? 25 A. I think often when parents had either taken their baby 0166 1 home or wanted to make an expression of their gratitude, 2 they wanted to buy something for the unit, and they 3 asked what was needed on the unit, and I would ask some 4 of the medical staff and the nurses, and, you know, they 5 would often say, "We desperately need two, three, more 6 pulse oximeters or syringe pumps" and often parents 7 would like to have a small plaque put on that. I think 8 for the parents, but they would have to speak for 9 themselves, that is "We have made a real difference and 10 given something back to the unit that has helped or 11 supported us". 12 Q. The other question is, on Day 32, the nurses Fiona 13 Thomas and Sheena Disley, they were describing your work 14 and at one stage they say: 15 "She probably did have a role in supporting some 16 staff at a later stage". 17 Did you actually have a role in supporting staff? 18 A. I suppose quite early on when I was evolving the post, 19 I thought it would be helpful, given the high levels of 20 stress that the nurses were experiencing on the unit, to 21 give them an opportunity to have half an hour or 45 22 minutes where they could discuss those concerns and 23 although it was never, although I cannot recall, but 24 I cannot remember it ever being pointed out as a large 25 part of the job, I felt that by supporting the nurses, 0167 1 they in turn would be able to support the parents more 2 effectively, and some would argue that I took on a role 3 that, you know, was not part of my initial job, but it 4 was important because I had empathy with the nurses who 5 were giving extremely good care in sometimes almost 6 impossible conditions. 7 Q. Did you at any time during those talks to the nurses or 8 the staff express any of the concerns you have discussed 9 today? 10 A. I was very careful in as much as it was my view, and 11 I was not going to express it to people who would be 12 influenced to take my view, so with junior staff I would 13 not have expressed that view. I think with some of the 14 sisters who came to the group, although it was mainly 15 the more junior staff, I did say, you know, "Do you feel 16 that we are dealing with more bereaved parents than 17 anywhere else?" and I think you have to understand that 18 a lot of these nurses on the cardiac unit were very 19 junior. They had only done perhaps 6 months of nursing, 20 they had done no intensive care and they were exposed to 21 extreme levels of emotion and stress and although they 22 were not looking after the children, they were exposed 23 to it, and I could not see the benefit of saying to 24 those people, "Well, actually, you know, it is really 25 bad here" and things. It would not have been 0168 1 appropriate, because they were too junior. 2 Q. But you did with the more senior levels? 3 A. Yes. They did not come to the support groups as 4 a whole, but a few of the nurses joined the Paediatric 5 Nurses' Association which I was involved with, and I did 6 express my concern to them. They said, I think, you 7 know, "We do get very difficult children here". There 8 was an acceptance. I did not feel that I wanted to 9 really push it. 10 PROFESSOR JARMAN: Thank you. 11 THE CHAIRMAN: I had a question but it may be that you have 12 just answered it, Miss Stratton. You were asked by 13 Mr Langstaff about whether you raised your concerns 14 elsewhere. It is at 122/17 in the transcript, for those 15 who wish to find it. You said that you raised it with 16 other paediatric cardiac nurses as part of the 17 Association. 18 Were you referring to nurses outside Bristol or 19 only colleagues in Bristol? 20 A. No, I think probably on an individual basis, because 21 I was always aware that what I was saying could be 22 libellous or very sensitive, so I think that on 23 individual occasions I spoke to a couple of the Sisters 24 at Great Ormond Street to sort of say, "I do have 25 concern" and I said "I am trying to express concerns 0169 1 through the professional channels that are available to 2 me". Having said that, there were not very many. 3 Q. That really prompts the question I was going to ask. 4 I wonder whether you could remember the names of the 5 nurses to whom you did express concerns, the names from 6 Great Ormond Street? 7 A. I cannot remember the name of the Sister on the unit, 8 but I can remember having a discussion with Adelaide 9 Tunstill, and I believe she was the cardiac manager at 10 Great Ormond Street. I cannot be sure of her title. 11 I can remember saying to her, "I am not sure whether 12 what is happening on my unit is right, or whether there 13 is something that is very wrong". I mean, I did not 14 have substantial evidence, I did not have audit or 15 figures, I just knew that what I was experiencing was 16 very different to what they were experiencing. 17 Q. Thank you for that. If you remember the other name 18 perhaps you could let us know? 19 A. Yes. 20 THE CHAIRMAN: I have no more questions. Mr Rose? Please 21 come forward. 22 MR ROSE: There were two matters I was going to re-examine 23 Miss Stratton on. When Mr Langstaff asked at the end of 24 her evidence to the Inquiry whether there was anything 25 she would like to add, she in fact dealt with those two 0170 1 points. 2 There is a third matter perhaps I could mention to 3 the Inquiry? 4 THE CHAIRMAN: Yes. May I invite you to please sit down? 5 MR ROSE: In relation to a number of the witness statements 6 that we saw, which Miss Stratton saw for the first time 7 this morning, which Mr Langstaff has referred to, with 8 that caveat in this introduction, I think Miss Stratton 9 would like the opportunity to comment on those witness 10 statements when she has read them in detail, and indeed 11 the transcripts, when she has read those in detail. 12 I think she would like the opportunity to put in a short 13 supplemental witness statement dealing with particular 14 areas of personal criticism. It may be she cannot 15 recollect the specific parents concerned, but I think 16 she would like to put on the record what her practice 17 has been historically and why she thinks it is likely, 18 or whatever the position may be, that the account given 19 in some of those transcripts may not be entirely 20 correct. 21 THE CHAIRMAN: Mr Langstaff? 22 MR LANGSTAFF: Sir, yes. I would hope she would do that. 23 What we say to every witness is I think what the 24 Chairman says to every witness, which is, I can almost 25 quote his words, "we will be here for a long time"! 0171 1 MR ROSE: I can see that! 2 MR LANGSTAFF: While we are, we are receptive to evidence 3 and I am saying this really for the wider audience: that 4 any witness who has given evidence or who has given us 5 a written statement, which is of course evidence to us, 6 should feel free to add to it if they think that there 7 is something useful to add or something they would wish 8 to add and it is certainly the case that anyone who is 9 criticised in any way in any statement should not feel 10 that they have lost the opportunity to comment because 11 they have actually come and given oral evidence. In 12 their own interests and in our interests and in the 13 public interests, which we represent, they should put 14 the regard straight as far as they can. 15 MR ROSE: That is most helpful. 16 THE CHAIRMAN: I am grateful to you for raising that, 17 Mr Rose, thank you very much indeed. 18 Miss Stratton, you have heard what has just been 19 said: if you do have anything further you would wish to 20 put in, do please know that you may do so through your 21 advisers or yourself, or whoever you think most 22 appropriate. 23 For today, thank you very much for coming. We 24 have covered a large area of evidence and we are very 25 grateful to you. 0172 1 MISS STRATTON: Thank you. 2 (The witness withdrew) 3 MR LANGSTAFF: Sir, we now have Mrs Hawkins to give her 4 evidence, and Miss Grey will take her evidence. 5 MISS GREY: Mrs Hawkins is represented today by Mr Rupert 6 Scrase, her solicitor, who is here. 7 With that introduction, could I ask that 8 Mrs Hawkins stands to take the oath, please? 9 MRS JANET HAWKINS (SWORN): 10 Examined by MISS GREY: 11 Q. Mrs Hawkins, can you give us your name? 12 A. My name is Janet Hawkins. 13 Q. If we could turn, please, to WIT 130/1, this is the 14 first page of a statement which you provided to the 15 Inquiry. If we turn, please, to page 8, we should see 16 there your signature; is that right? 17 A. Yes. 18 Q. This is the statement you have given to the Inquiry. 19 Are its contents true to the best of your knowledge, 20 information and belief? 21 A. Yes, to the best of my memory, yes. 22 Q. Because you say at paragraph 1 of the statement, page 1, 23 that you have made the statement not only to the best of 24 your recollection, but without having access to the 25 medical records so as to confirm particular dates or 0173 1 medical details? 2 A. Yes, that is correct. 3 Q. And also, Mrs Hawkins, just to complete your statement, 4 if we turn to page 9, we also see there, do we, 5 a statement from your son, Paul Hawkins? 6 A. Yes. 7 Q. Who was the patient concerned in the operations you are 8 talking to us about today? 9 A. Yes. 10 Q. We can turn back then to page 1 of the statement. You 11 say at paragraph 2 that Paul was born at the Bristol 12 Maternity Hospital on 7th April 1982. 13 At that time, the medical problems which he had 14 were not known to include any heart problems? 15 A. No, they were not picked up until he was eight years 16 old. 17 Q. However, he did have initial surgery for the other 18 problems he had at the Bristol Children's Hospital? 19 A. Yes. 20 Q. And you give us there paragraph 2, and then going on to 21 paragraph 3, the details of the operations that he had, 22 firstly when he was very young, just a day old, then 23 when he was 9 months old, another one when he was 13 24 months old, 2 years old and when aged 4 or thereabouts? 25 A. Yes. 0174 1 Q. Then we come over the page and there were other day 2 attendances. So is the result of that that by the time 3 the heart problem came to be diagnosed at the age of 8, 4 you were something of a repeat customer, as it were, of 5 the services of the Children's Hospital? 6 A. Yes, we were. We were used to the surgical procedures 7 and in fact, we almost went on the same ward, obviously 8 once Paul went in as a patient to the Children's 9 Hospital, not when he went to the Maternity Hospital, 10 but obviously it was still a great shock to find he had 11 cardiac problems as well. But, yes, we were used to the 12 Children's Hospital procedures. 13 Q. You say you always went to the same ward? 14 A. Yes. 15 Q. Which ward was that? 16 A. Ward 33 of the Children's Hospital. 17 Q. So by the time you had been there a few times, did you 18 know, for instance, some of the nursing staff? 19 A. Yes, some of the nursing staff were there. When Paul 20 was a patient for cardiac surgery, some of the nursing 21 staff were the ones that had been there before when we 22 were there, yes. 23 Q. Did you get an impression, therefore, of the experience 24 which they had in handling children? 25 A. Yes. 0175 1 Q. Were they trained paediatric nurses? 2 A. They were trained, most of them were trained paediatric 3 nurses, yes, who were very good with the children and 4 also very good with the parents. 5 Q. It may be that it is too difficult to remember this now, 6 but are you able to cast your mind back to the first 7 time that Paul was admitted to the Children's Hospital 8 and when you first came into contact with the staff at 9 the Children's Hospital, so as to recollect your 10 experience of the hospital as a first time user, as it 11 were? 12 A. Well, yes. I think the first occasion, like anything, 13 it was strange because you do not know the procedures 14 and do not know where things are and do not know what 15 you ought to be doing and you are not exactly sure, but 16 the staff were certainly very supportive, right from the 17 beginning, and it was very evident that they were very 18 caring, to make sure that the parents were put as much 19 at ease as possible. 20 Q. Can you remember any formal introduction or planned 21 introduction to the ward, or was it a matter of you 22 asking for information as and when you needed it? 23 A. No, there was no formal -- subsequent visits to the 24 Children's Hospital, I know afterwards they set up an 25 arrangement where children who were due to be admitted 0176 1 would often come and look round the ward and hospital 2 before. But I think at that time when Paul was first 3 admitted there was no such procedure anyway. 4 Q. Because then we could be looking right back to 1982? 5 A. Yes. 6 Q. So you are describing a development of the services or 7 procedures as time went on? 8 A. Yes. 9 Q. If we could go on, then, to paragraph 4 of your 10 statement, you there describe the moment when an SHO 11 first detected that there might be a heart problem and 12 called in the Cardiac Registrar. At that stage there 13 was a diagnosis of a heart murmur. Then further 14 investigations were conducted by Dr Joffe, who diagnosed 15 the problem as a coarctation of the aorta. 16 He then, as I understand it from your statement, 17 explained what the problem was to you? 18 A. Yes. 19 Q. Was there anyone else present at that meeting? 20 A. No. 21 Q. So neither your husband nor a nurse? 22 A. No. It was unfortunate. On most hospital visits, my 23 husband would attend, but he was not there, nor a nurse 24 there. 25 Q. How did the process of giving you the explanation of the 0177 1 diagnosis proceed? 2 A. He explained what the problem was. He drew a diagram, 3 he went into great depths, explanation of what would 4 happen if Paul did not have the surgery, that he 5 probably would only live to about 13 and suffer spells 6 of breathlessness, turning blue, and then what the 7 surgery would entail and what would happen. 8 Q. You say he explained it very well to you? 9 A. Yes. 10 Q. You were assisted by the fact that he drew a diagram; 11 is that right? 12 A. Yes. 13 Q. Was there any other written information that was 14 provided to you? 15 A. No. 16 Q. Any suggestions as to where you might go for further 17 information if you needed it? 18 A. No. 19 Q. Do you think that might have been helpful? 20 A. Yes, looking back, it probably would have been, yes. 21 Q. You say that Dr Joffe explained it very well to you. 22 Can you just tell us what it was about his manner and 23 the information that he was giving to you that made it 24 a good explanation as opposed to a poorer one? 25 A. He did not hurry. He took his time. He gave me time to 0178 1 think about it and gave me time to ask questions so 2 I did not feel I was pressurised. I felt I was given 3 time to understand the implications. 4 Q. After that time did you feel you needed to go back for 5 further explanation at any time, or had you got what you 6 needed from that encounter? 7 A. I was one of the parents who felt they never had enough 8 information, so when I did get home I got a couple of 9 books to look it up, but that was probably me. I like 10 to have -- I cannot recall finding out anything extra 11 I had been told, but there was a possibility I may have 12 done, so I had to look in the books just in case. 13 Q. If he had given you suggestions as to further reading 14 you would have probably followed them up? 15 A. Yes. 16 Q. But as it is, you found your own information? 17 A. Yes. 18 Q. We have been hearing discussion today of the role of 19 nurses or potential role of nurses at such diagnosis and 20 discussion meetings. Would it have helped you, do you 21 think, to have had a nurse present who could have 22 explained matters further to you, or were your questions 23 and your ability to go and look at books more than 24 enough, or enough for you? 25 A. I do not think having a nurse present would have given 0179 1 me any further information. The questions I asked 2 Dr Joffe he answered. I think it is always difficult 3 anyway, because when you are in a situation like that 4 and you suddenly are told something, often questions 5 would arise afterwards anyway, so I think having anybody 6 present at that time would not have been of any help. 7 Q. I think the idea might have been that that person might 8 have been a resource you could have gone back to for 9 further assistance? 10 A. Yes. 11 Q. But at that point you would have been an outpatient in 12 any event, so it may be a nurse would not have been 13 a particularly easy liaison for you? 14 A. No. 15 Q. Dr Joffe said they would arrange for Paul to see 16 a cardiac surgeon to arrange for corrective surgery, and 17 you tell us at the bottom of page 2, going on to the top 18 of page 3, that in fact an initial appointment was made 19 with Mr Dhasmana, but that somebody your husband knew 20 gave you a very strong recommendation for Mr Wisheart 21 instead. 22 Can you just tell us who that person was? 23 A. Yes, my husband at the time was Deputy or Assistant 24 Finance Officer for the Bristol and Weston Health 25 Authority. He did not know Mr Wisheart and he did not 0180 1 know Mr Dhasmana personally, but the Director of Finance 2 did know them both and told my husband that whilst both 3 of them were, to his knowledge, perfectly competent 4 surgeons, if he had to choose one to operate on one of 5 his children, he would choose Mr Wisheart. So he said 6 to my husband, "If I was having an operation on one of 7 my children, I would prefer Mr Wisheart to operate", not 8 to say because of anything surgically or anything, just 9 because he knew Mr Wisheart, knew his manner and he was 10 a caring and approachable person. 11 Q. So at that time your husband was working for the Bristol 12 and Weston District Health Authority? 13 A. Yes. 14 Q. I think he would have subsequently worked for the Trust; 15 is that right, after its creation? 16 A. Yes. 17 Q. As the Deputy Director of Finance? 18 A. Yes. 19 Q. So when you first had the recommendation for 20 Mr Wisheart, you have just told us, I think, you did not 21 know him socially? 22 A. No. 23 Q. Did you ever meet him socially on later occasions? 24 A. Yes. 25 Q. On a number of occasions, once or twice? Can you just 0181 1 tell us the extent of your contact? 2 A. It was either two or three. I certainly met him, they 3 had a Board Christmas thing, the Christmas after Paul 4 had been operated on, and he remembered me and he 5 remembered Paul and asked how Paul was. I think the 6 year after that I met him, possibly on one other 7 occasion. 8 Q. You think you met him once or twice socially at Trust 9 functions? 10 A. Yes, after, yes. 11 Q. You go on at paragraph 8 of your statement to the first 12 meeting with Mr Wisheart. You describe an explanation 13 that you have called "painstaking". Can you tell us 14 what you mean by that? 15 A. Well, it is not meant to be a criticism. When we had 16 dealings with other consultants and Paul had had 17 operations, it was never explained in such minute detail 18 as Mr Wisheart explained. I know this was cardiac 19 surgery, so possibly that would have given an 20 explanation of why it was so different, but Mr Wisheart 21 was so exact in what he told me, he drew diagrams and he 22 was really, really thorough. The impression I had 23 overall, more than anything else, was how it was very 24 unhurried. You certainly were not given the impression 25 there was anybody else waiting for his attention or 0182 1 anybody else he was waiting to see, which there 2 obviously must have been. But there was certainly no 3 pressure, you could have taken as much time as you 4 liked. 5 Q. You speak at paragraph 9 of the risks of the surgery 6 being outlined to you. They are described as a 10 per 7 cent chance of Paul either not surviving the surgery or 8 being paralysed because of the process of stopping the 9 blood supply around the body. 10 That is a discussion of the risk of physical 11 paralysis; is that right? 12 A. Yes. 13 Q. Was there any discussion of the risk of brain damage? 14 A. Not that I can recall. 15 Q. At the bottom of the paragraph, you say it was put in 16 a way that seemed "very fair and balanced and with all 17 the necessary detail". 18 How do you judge that, Mrs Hawkins? 19 A. I can only judge it from a personal view. It was told 20 very factually and that, unless Paul had the operation, 21 we were told what would happen to him, he would probably 22 only live to his early 30s and have more and more 23 problems with breathing, turning blue, sort of thing. 24 We were told the risks but there was no -- if we had 25 said "No, we do not want the surgery", I had the 0183 1 impression that would have been accepted, there would 2 have been no pressure for us to go either way. 3 Q. It was not, though, that you went back to the books and 4 found that there was nothing further that needed to be 5 added, or -- 6 A. I do not remember going back to the books. 7 Q. Not at that stage? You mention also at paragraph 8 of 8 the statement that Mr Wisheart took the trouble to 9 involve Paul at this meeting? 10 A. Yes. 11 Q. Can you tell us what you mean by that? 12 A. He just talked to him. There is always a tendency for 13 consultants, especially with younger children, for them 14 to talk to the parents and the children may as well not 15 be there, but he did talk to Paul as well. He was 16 generally friendly towards him. He included him. 17 Q. Did he try and explain the operation to Paul as well, to 18 a degree at least? 19 A. To a degree, yes. 20 Q. In terms you thought were appropriate to Paul's 21 understanding? 22 A. Yes. 23 Q. But there must have come a point at which he needed to 24 show Paul out of the room in order to discuss the risks 25 of surgery rather more bluntly perhaps, because you 0184 1 mention in paragraph 9 that this part of the discussion 2 was not discussed in Paul's presence? 3 A. Yes. 4 Q. How did he handle that? 5 A. As far as I can remember, there was a nurse outside, 6 I think. I think Paul went outside with the nurse, 7 briefly. 8 Q. You then go on to discuss the timing of the surgery 9 itself, looking at page 4 of your statement. The 10 surgery was undertaken reasonably shortly after the 11 initial discussion with Mr Wisheart. He had a cardiac 12 catheter test in June 1990, the surgery was set for 13 October 1990 and it took place then, did it not? 14 A. Yes. 15 Q. You talk at paragraph 12 of consents. After admission 16 to the Children's Hospital, you saw Mr Wisheart again, 17 is that right? 18 A. Yes, before the operation, yes. 19 Q. Did he have anything to add to what had been said on the 20 previous occasion? 21 A. No. It was basically -- no, basically we went over the 22 operation procedures again, stressed the risks again. 23 No, I think it was basically the same as had been said 24 before. 25 Q. You also met the consultant anaesthetist, Dr Hughes, who 0185 1 also talked about the procedures and risks? 2 A. Yes. 3 Q. Again, was anything further added by him? 4 A. Only that when Paul returned -- he just talked about the 5 drips and things and the things that Paul would have, 6 the medication Paul would have when he came back from 7 surgery, chest drains and those sort of things. 8 Q. I think if we were to look at your medical notes, we 9 would discover that the consent form that you signed for 10 the operation shows that the process of taking that 11 formal consent for the operation and the explanation for 12 that purpose was taken by a Dr Hayes? 13 A. Yes. 14 Q. Do you remember her? 15 A. Yes, Senior House Officer, yes. 16 Q. Can you recollect what part she had to play in this 17 process? 18 A. She had again said what would happen during the surgery, 19 and then just asked me if I was prepared to sign the 20 consent form. 21 Q. Did she give as full an explanation as Mr Wisheart had, 22 or a shorter one? 23 A. As I remember, she said "Mr Wisheart has explained to 24 you in detail", so, no, she gave a shorter one, as 25 I remember. 0186 1 Q. So she was referring back to the discussions you had had 2 already with Mr Wisheart? 3 A. Yes. 4 Q. So all in all, three people were explaining to you the 5 process before the last stage, the consent was taken; 6 is that right? 7 A. Yes. If anything, I cannot remember what I said in my 8 statement -- yes, I do say it. If anything, it was 9 petrifying, because I just kept being told about these 10 risks and when Paul had had other surgery, obviously 11 there was risk because there is always risk with 12 anaesthetic and things, but it had never been clarified 13 in quite the same way. All these people just kept 14 telling me about the risks, so I thought, "My God, 15 what am I doing?" 16 Q. You mention in your statement you remember thinking 17 that, if anything, the risks were being over-emphasised? 18 A. I do not suppose it is possible to over-emphasise risk 19 because if something does go wrong -- certainly it was 20 quite frightening. 21 Q. Turning over the page, page 5, the surgery was performed 22 at the Children's Hospital, where Paul was familiar with 23 that and that suited him. You say that it took a little 24 longer than you had been expecting. Where were you 25 whilst the surgery was being performed? 0187 1 A. We were told to leave the hospital and come back. 2 Q. Why were you given that advice? Was it explained to you 3 why that was thought to be a good idea? 4 A. I cannot remember whether it was explained or I just 5 concluded it would make the waiting time shorter if 6 I was at home doing something rather than hanging around 7 in a hospital ward. 8 Q. Did you live near enough to go home? 9 A. Yes. 10 Q. So did it on balance seem a sensible suggestion? 11 A. Yes, especially having not been home and spending the 12 night before, it was sensible to go home and have 13 a shower and try to make myself feel a bit more 14 presentable for the day, and ready to -- 15 Q. You had been staying with Paul, had you? 16 A. Yes, I had stayed there. Yes, I had, yes. 17 Q. You then described the process by which Paul came back 18 to you and the post-operative recovery. If I turn to 19 paragraph 18 of your statement, page 6, you say that you 20 continued to see Mr Wisheart on almost a daily basis; is 21 that right? 22 A. Yes, that is correct. 23 Q. When you saw him, was that in the context of formal ward 24 rounds or on more informal visits to the ward? 25 A. A mixture. Sometimes it was formal ward rounds, 0188 1 sometimes he would wander into the ward on his own. 2 Q. Can you tell us how the formal ward rounds were 3 conducted? First of all, were you present at the time? 4 A. Yes. 5 Q. Was that something that you suggested or was it a normal 6 part of the routine that you would stay during ward 7 rounds? 8 A. It was part of the normal routine, but if it had not 9 been, I would have asked if I could have been present. 10 Q. You think it would have been appropriate for you to have 11 been present a during ward round? 12 A. Certainly. 13 Q. We have heard evidence from some parents that they were 14 asked to leave during ward rounds -- this was evidence 15 relating to the Royal Infirmary rather than the 16 Children's Hospital -- presumably on the basis that it 17 would have been a frightening, distressing or difficult 18 experience to hear difficult issues relating to their 19 children's care discussed when possibly their children 20 were in a situation of illness from which they might not 21 recover. How do you feel you might have coped with 22 that? 23 A. Even if I was in a situation where Paul may not have 24 recovered, I would rather have been there to know the 25 situation. I would rather have known exactly what the 0189 1 situation was and how he was. I would have felt as 2 though I had been kept in the dark if I had been 3 excluded. Even if things were not good, I would rather 4 have known. 5 Q. Does it follow from what you have been saying, and the 6 tone in which you have been saying it, that you would 7 have felt patronised if somebody had suggested you 8 should not stay to hear these discussions? 9 A. Yes, I would. 10 Q. So you remained whilst the ward rounds were being 11 conducted. Who would be included in such a ward round? 12 Who would be there? 13 A. Mr Wisheart, sometimes together with Mr Dhasmana; the 14 cardiac team, so Dr Joffe and the other cardiologist; 15 anaesthetists; some students; dietician; the staff nurse 16 or sister. 17 Q. You are describing a multidisciplinary team; is that 18 fair? 19 A. Yes, which had ward rounds. Certainly once a week they 20 had ward rounds like that. 21 Q. Once a week? 22 A. At least, they had a ward round like that. On other 23 occasions just the cardiologist would come round, 24 sometimes with Mr Wisheart. But they had one big ward 25 round at least every week, as I remember. 0190 1 Q. During the process of the ward rounds discussion, were 2 you included in the discussion, or not? 3 A. Yes. I was usually asked how Paul was and if there was 4 anything I wanted to ask. 5 Q. And you felt able to ask, I think it is implicit again 6 from your answers: if you had questions, you were able 7 to raise them? 8 A. Yes. 9 Q. Did you generally feel that you had been given enough 10 information about Paul's condition? 11 A. Yes, generally. 12 Q. How did that contrast, if at all, with your experience 13 on other occasions when Paul had been admitted for 14 surgery? 15 A. There were certainly occasions in the past when Paul was 16 younger where I felt I was not given enough 17 information. There was one occasion in particular, 18 I actually tackled the surgical team because I was not 19 happy with the information I was being given. 20 Q. So when you felt you were not being given enough 21 information, you actually tackled the medical staff 22 direct? 23 A. Yes. 24 Q. On this occasion, talking with the team involved in 25 Paul's care, the need did not arise? 0191 1 A. No. If there had been anything -- I had no doubt when 2 I asked questions I felt able to do so and they were 3 answered, yes. I did not feel as though I was being 4 kept in the dark. 5 Q. Generally, turning over the page to page 7 of your 6 statement, you speak about the nursing care and that you 7 give praise to the nurses in the care that was given, 8 and you talk about your general experience of the 9 hospital. Can I ask, did you have any involvement with 10 any other people who might have offered you support or 11 assistance whilst you were at the Children's Hospital? 12 A. Helen Vegoda. Before Paul had his operation, Helen 13 Vegoda came and introduced herself to me and said that 14 she was available if I needed someone to talk to, and 15 told me where her office was if I wanted to go down to 16 her office and have a cup of coffee or anything, and she 17 also, on occasions after the operation, just in passing 18 asked how Paul was. It was not taken any further on my 19 part because, for one thing, I was aware of hospital 20 procedures so I was not quite so fazed by it all and the 21 other thing, because we lived nearer anyway, my husband 22 was available so I was able to discuss things with my 23 husband, so I did not feel the need for support. 24 Q. In any event, it follows from what you were saying that 25 you were aware that she was there if you would felt the 0192 1 need? 2 A. Yes. 3 Q. What about any other support services in the hospital, 4 either for yourself or for the family generally? 5 A. There was a play scheme for Paul's brother which ran 6 during the day and at weekends, which on some occasions 7 when my other son visited he was able to avail himself 8 of. There was also the Radio Lollipop which was in the 9 evenings, which my other son went to. 10 Q. You came into the hospital for surgery for other 11 reasons. When you came in for Paul's bowel and bladder 12 problems for surgery, had there been any other person 13 comparable to Helen Vegoda to offer comparable 14 assistance? 15 A. No. 16 Q. If we look at paragraph 22 of your statement, you talk 17 again there about the fact that Mr Wisheart explained 18 things very fully to you and also, as you have been 19 saying, he always seemed to have time to deal with you 20 and was very aware that, as a parent, when you are first 21 told something about your child's health, it is a shock 22 and does not sink in and some of the questions you 23 wished to ask may only occur to you later, and you say 24 Mr Wisheart always allowed for this. 25 How did he allow for that? 0193 1 A. At the time, he always said, "Have you got anything you 2 want to ask?" and then he would say "Well, if there is 3 anything, you can always ask me next time I come 4 round". He said that on a couple of occasions, 5 certainly. Obviously when he explained the operation to 6 us, there was no occasion after that, until we were 7 actually admitted to the hospital. But he always seemed 8 approachable. 9 Q. So if there had been further questions arising out of 10 the diagnosis and the recommendation for surgery that 11 you had wanted to have answered, what would you have 12 done about them? 13 A. That is difficult. I mean, now I would say I would have 14 phoned up and tried to speak to somebody, but whether 15 I actually would have done, if there had been anything 16 I wanted to know, I do not know. It is a hypothetical 17 question. 18 Q. But why now as opposed to in 1990? What do you think 19 might have changed? 20 A. Only that I never thought of any questions there to ask, 21 and I have never thought until now what I would have 22 done if there had been any questions. I think if I had 23 wanted to find out something, if I had questions, 24 I think I would have felt quite happy to phone up and 25 ask. I do not think I would have thought about "Why is 0194 1 this parent continuing to ask questions?" I think 2 I would have felt happy to do so. 3 MISS GREY: Thank you very much. 4 The Panel may have some questions for you. 5 THE CHAIRMAN: We do not have any questions. Mr Scrase? 6 MR SCRASE: Just one very brief question, please. 7 THE CHAIRMAN: Please come forward. May I invite you to do 8 so? 9 RE-EXAMINED BY MR SCRASE: 10 Q. Mrs Hawkins, we have heard in your evidence in quite 11 a lot of detail about the difference between the way 12 Mr Wisheart advised you of the risks in the previous 13 operations and in particular at paragraph 22, you state 14 that it was definitely explained to you. 15 The initial operations that Paul had when he was 16 a day old and then various operations until he was 4: do 17 you actually recall the advice you were given when he 18 was a day old? 19 A. You mean the operation procedures? 20 Q. Yes, in terms of risk and things. 21 A. I do not remember being told any risks. Possibly, 22 I have thought about this, because there is always 23 a risk with an operation anyway, with an anaesthetic 24 anyway, but I do not recall any risk then. But it did 25 occur to me when Paul was a day old it could have been 0195 1 just that I could not remember because it was all such 2 a shock and all so new. But on occasions after that 3 when Paul had various surgery, some of it major surgery, 4 I cannot ever remember any mention of risks. 5 Q. And as far as you were concerned, you had all your 6 faculties about you? 7 A. I admit I may not have done when he was a day old, but 8 certainly I would have done at later dates. When Paul 9 was a day old I may just only remember some things from 10 it, because I was still in the shock of having a baby 11 born who had problems, but I am sure afterwards I would 12 have remembered, and actually Paul has had surgery since 13 this cardiac surgery that Paul had when he was 8, Paul 14 has had further surgery. I still cannot remember any 15 risks, which, as I say, there must be, because there 16 always is. 17 MR SCRASE: That is my only question. 18 THE CHAIRMAN: I am very grateful to you. Miss Grey has not 19 said, because I am as it were interrupting and 20 pre-empting her by saying that not only are we very 21 grateful to you for coming to talk to us, but if, of 22 course, you have other things that you would wish to 23 bring to our attention, things that you remember or you 24 would like to add, you should know that we would be very 25 glad to receive them at any time through Mr Scrase or 0196 1 whatever. We will be here for a little while, so if 2 there are other matters we should know, please tell us. 3 Unless Miss Grey has anything else for you, may 4 I on behalf of the Panel thank you very much for coming 5 and spending this afternoon with us. I am sorry we kept 6 you so late. 7 You may like to sit there for two seconds more 8 while Mr Langstaff tells you about tomorrow. 9 MR LANGSTAFF: In two seconds: 9.30, Mrs Pratten followed by 10 Helen Vegoda, and we may have the benefit of Valerie 11 Mandelson saying a few words at the end. 12 THE CHAIRMAN: I am very grateful. We will now adjourn and 13 reconvene at 9.30 tomorrow morning. Thank you. 14 (4.10 pm) 15 (Adjourned until 9.30 on Thursday, 9th September, 1999) 16 17 18 19 20 21 22 23 24 25 0197 1 2 I N D E X 3 4 5 REVEREND HELENA CERMAKOVA (Sworn) 6 Examined by MISS GREY...................... 1 7 Examined by MRS MANDELSON ................. 28 8 Examined by THE PANEL...................... 29 9 10 MISS HELEN STRATTON (Sworn) 11 Examined by MR LANGSTAFF .................. 34 12 Examined by MRS MANDELSON ................. 162 13 Examined by THE PANEL ..................... 164 14 15 MRS JANET HAWKINS (Sworn) 16 Examined by MISS GREY ..................... 173 17 Re-examined by MR SCRASE .................. 195 18 19 20 21 22 23 24 25 0198