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8th September 1999

Oral Hearings continued in Bristol today with evidence from Reverend Helena Cermakova, Hospital Chaplain at St Michael’s Hospital and Bristol Children’s 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 Children’s 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?
  25             Examined by MISS GREY:
   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
   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
   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.
   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
   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
   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.
   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
   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.
   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
   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
   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
   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
   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
   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?
   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
   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
   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.
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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.
   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
   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.
   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)
   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?
  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
   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?
   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?
   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
   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
   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.
   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.
   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.
   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?
   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
   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
   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
   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.
   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,
   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
   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
   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
   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.
   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.
   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
   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
   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
   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
   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.
   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
   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:
   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
   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.
   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
   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
   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.
   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
   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
   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
   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.
   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.
   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
   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
   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
   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.
   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?
   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
   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
   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,
   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?
   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?
   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?
   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
   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
   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?
   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
   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
   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
   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
   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?
   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.
   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
   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
   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
   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?
   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
   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
   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
   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
   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
   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
   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
   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?
   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?
   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
   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
   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",
   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,
   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?
   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.
   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.
   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?
   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
   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
   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.
   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
   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
   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".
   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
   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
   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."
   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.
   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
   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
   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,
   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
   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
   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
   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.
   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
   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
   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
   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
   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"?
   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
   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
   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
   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?
   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."
   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
   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
   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,
   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
   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
   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
   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
   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
   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
   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.
   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
   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
   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
   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
   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?
   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
   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"?
   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
   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
   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
   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.
   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
   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
   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?
   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
   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
   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
   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
   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
   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,
   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
   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
   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
   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"!
   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.
   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
   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.
   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.
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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.
   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?
   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,
   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
   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.
   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?
   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
   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?
   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
   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
   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
   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)
   2                I N D E X
   6        Examined by MISS GREY......................  1
   7        Examined by MRS MANDELSON ................. 28
   8        Examined by THE PANEL...................... 29
  10     MISS HELEN STRATTON (Sworn)
  11        Examined by MR LANGSTAFF .................. 34
  12        Examined by MRS MANDELSON ................. 162
  13        Examined by THE PANEL ..................... 164
  15     MRS JANET HAWKINS (Sworn)
  16        Examined by MISS GREY ..................... 173
  17        Re-examined by MR SCRASE .................. 195

Published by the Bristol Royal Infirmary Inquiry, July 2001
Crown Copyright 2001