THE MEDICAL COUNCIL FITNESS TO PRACTISE COMMITTEE UNDER PART 8 OF THE MEDICAL PRACTITIONERS ACT 2007 PROF. P. CORBALLY & DR. SRI PARAN THAMBIPILLAI

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1 THE MEDICAL COUNCIL FITNESS TO PRACTISE COMMITTEE UNDER PART OF THE MEDICAL PRACTITIONERS ACT 00 PROF. P. CORBALLY & DR. SRI PARAN THAMBIPILLAI TRANSCRIPT OF HEARING HEARD ON FRIDAY, RD SEPTEMBER 00 - DAY AT KINGRAM HOUSE KINGRAM PLACE DUBLIN Gwen Malone Stenography Services certify the following to be a true and accurate transcript of the shorthand notes of the evidence in the above-named action.

2 APPEARANCES COMMITTEE: DR. J. MONAGHAN (CHAIRMAN) MS. A. DURKAN MR. T. O'NEILL LEGAL ASSESSOR: MR. K. CROSS SC FOR THE CEO: INSTRUCTED BY: MR. P. LEONARD BL MR. JP McDOWELL MS. A. RYAN McDOWELL PURCELL SOLICITORS THE CAPEL BUILDING ST. MARY'S ABBEY DUBLIN. FOR PROF. CORBALLY: INSTRUCTED BY: FOR DR. SRI PARAN: MS. E. BARRINGTON BL MATHESON ORMSBY PRENTICE SOLICITORS MR. C. MEENAN SC MR. C. BURKE BL INSTRUCTED BY: O'CONNOR SOLICITORS COPYRIGHT: Transcripts are the work of Gwen Malone Stenography Services and they must not be photocopied or reproduced in any manner or supplied or loaned by an appellant to a respondent or to any other party without written permission of Gwen Malone Stenography Services

3 INDEX WITNESS EXAMINATION PAGE NO'S MR. SRI PARAN THAMBIPILLAI DIRECT - MR. MEENAN - CROSS - MS. LEONARD - CROSS - MS. BARRINGTON - QUESTIONED - THE COMMITTEE - 0 RE-DIRECT - MR. MEENAN -

4 THE HEARING RESUMED, AS FOLLOWS, ON FRIDAY, RD SEPTEMBER 00 CHAIRMAN: Good morning everybody. Welcome to day four of this 0: inquiry. I think at the close yesterday Ms. Barrington had finished her case and I think Mr. Meenan was about to begin his case. MR. MEENAN: That's correct. That is 0 what I propose to do then. 0: CHAIRMAN: So we will go ahead then. MR. MEENAN: Very well. Mr. Paran, please. MR. SRI PARAN THAMBIPILLAI, HAVING AFFIRMED, WAS 0: EXAMINED, AS FOLLOWS, BY MR. MEENAN Q. MR. MEENAN: Now good morning, Mr. Paran? 0 A. Good morning. 0: Q. Firstly, can I circulate to the Committee and my Friends a copy of your Curriculum Vitae, please. CHAIRMAN: This will be Exhibit. (SAME HANDED). Q. MR. MEENAN: Very well, Mr. Paran. I 0: propose to look through your Curriculum Vitae so that the Committee can be familiar with your background and your qualifications. Mr. Paran, you were born in Sri Lanka, isn't that

5 correct? A. That's correct. Q. You did your primary and part of your secondary education in Sri Lanka? A. That's correct. 0: Q. Completed your secondary education in England, is that correct? A. That's correct. Q. Then you went to University College Galway in to 0 study medicine, isn't that correct? 0: A. That is right. Q. Very good. So you took your primary degree in is that right? A. That is right. Q. All right. Then I think on the following page there 0: are further qualifications which I think you have taken. First of all you are -- if I can just try and do this in order -- you became an FRCSI of the Royal College of Surgeons of Ireland in, is that 0 correct? 0: A. That is right. Q. You also became a Fellow of European Board of Paediatrician Surgeons in 00, is that right? A. That is right. 0 Q. You obtained an MD from University College Dublin in 0: June 00, that is this year, is that right? Q. Right. Okay. You have also set out other qualifications there. Then on the following page you

6 detail awards and honours. The following page membership of medical and scientific societies. On page, you set out you are regular reviewer of the following journals: Paediatrician Surgery International, Journal of Paediatric Surgery, Journal 0: of Medical Case Reports. I take it those are all peer reviewed? A. Yes, they are. Q. Yes. You just might briefly indicate to the Committee 0 what is entailed in being a reviewer of these journals? 0: A. If some authors send their paper to you...(interjection). Q. Maybe if you might speak towards the Committee rather than me. Thank you, Mr. Paran. A. An article is written by some authors and it is sent 0: down for recognition, whether it is qualified for printing or not, and it is sent out to two reviewers, and I will be one of them. What I do is that I research on the topic that they have written the 0 article on and find out whether it is relevant for 0: publication. Secondly then go through the, scrutinise their methodology and conclusion and see whether it is all valid before either correcting it or saying that, yes, it is worthwhile publishing it or not. Q. You have also listed there that you are an examiner, 0: firstly in Final Medical Examination in RCSI and UCD, and the Diploma in Childhood Health in the RCSI? Q. Could I just briefly again ask you, you are examiner in

7 respect of what in the final medical examination in the College of Surgeon and UCD? A. The clinical part of paediatric examination include a section towards paediatrician surgery, and that could be how they examine a child, or how they identify a 0: condition or how they treat a condition. So I would be manning that particular station on paediatrician surgery. Q. All right. In the Diploma in Childhood Health? 0 A. Very similar. 0: Q. Very good. Then if I might turn over, pages and pages set out your Postgraduate training? Q. If I can just possibly start in the -- you were appointed a Registrar in January, is that correct? 0: A. That's correct. Q. You were a Paediatric Surgical Registrar to Mr. Prem Puri in Harcourt Street/Tallaght Hospital? A. That is right. 0 0 Q. All right. Then in January to December 000, you were 0: a Paediatric Surgical Registrar to Prof. Fitzgerald in Crumlin? Q. June 00, you were a Paediatric Surgical Registrar Mr. Martin Corbally in Crumlin? 0: Q. And June '0 to June '0, Paediatric Surgical Registrar to Mr. Fergal Quinn? A. Correct.

8 0 0 Q. I think in truth you say Mr. Corbally and Mr. Quinn, those were their titles at their time, I think both have moved on to become Professors, is that correct? A. Prof. Corbally has. I think Mr. Quinn is still...(interjection). Q. All right. All right. Okay. That might explain why it is Mr. Corbally as opposed to Prof. Corbally. Then July '0 to June '0, you were Specialist Paediatric Surgery Registrar to Prof. Puri? A. That's correct. Q. Okay. Now, just you might explain to the Committee how you have come from being a Surgical Registrar to a Specialist Surgical Registrar? A. The training has been streamlined. You spend two to three years in general surgery and then once you choose your speciality you spend some time in that speciality. What you are hoping to do is become a Specialist Registrar where you get into a recognised training programme that is run over a period of six years, and at the end of which your training is complete. It is a structured training programme. That is why it is called Specialist Paediatric Surgery. Q. All right. Then you were a Research Fellow for Prof. Puri for July '0 to June '0. Is that a position in addition to acting as Surgical Registrar? If you want to double up the academic side of your career, it is advisable to spend two years purely doing laboratory based research, and that is why I took those two years to do that type of research. 0: 0:0 0:0 0:0 0:0

9 Q. All right. Then from July '0 to June '0, you were a Clinical Fellow in the Memorial Sloan-Kettering Cancer Centre in New York, is that correct? A. That's correct. Q. You just might indicate to the Committee what that 0: position entailed? A. It was discussed yesterday about the Memorial Sloan-Kettering Cancer Centre. It is purely dedicated to cancer surgery. They have a Paediatric side to 0 that. Prof. Michael La Quaglia is the Chief of 0: Paediatric Surgery there. They absorb cancer from all over Europe. So some place like Crumlin Hospital will go through about thirty or thirty five solid tumours surgery in a year. A place like Memorial Sloan-Kettering Cancer Centre will go through nearly 0: 00/00. So it is a concentrated training. Q. I suppose it is what has come to be described as a Centre of Excellence, is that correct? 0 0 Q. In any event, at the end of June '0 and July '0, you 0: were back in Our Lady's Hospital in Crumlin, isn't that correct? A. That is right. Q. You were now Specialist Paediatric Surgery Registrar to Prof. Martin Corbally? 0: Still continuing on my, that six year plan. Q. Yes. A. So as you can see I only have completed two to two and a half years before I left, so I am joining back into.

10 The research will only count as one year. So I am here back to finish my structured training programme. Q. Very good. Then January '0 to December '0, and the events which are the subject of this inquiry occurred in that period, you were Specialist Paediatric Surgery 0: Registrar to Prof. Puri, is that correct? A. That's correct. Q. Then January '0 to December '0 you were Specialist Paediatric Registrar to Mr. Fergal Quinn, is that 0 correct? 0: A. That's correct. Q. Okay. January of this year to June of this year, you were back to Prof. Prem Puri, isn't that correct? A. That's correct. Q. Then in May 00, is it the case that you were 0: recommended for appointment as a Consultant Paediatric Surgeon between Crumlin and Tallaght? A. Yes, that's correct. Q. That is a matter which I am going to come back to in 0 due course. But your present status is that you are in 0: a position of having been recommended for appointment as a Consultant Paediatric Surgeon, is that correct? A. That's correct. Q. The following two pages, I believe, deal with chapters in books which you have written. I don't propose to go 0: through these, but I take it these are textbooks, is that correct? Paediatric Surgery textbooks. Q. Very good. Then on pages through to, you have 0

11 0 0 0 set out various articles which you have written in peer review journals? A. That's correct. Q. Very good. Is there anything, without going through those articles, is there anything in particular that you have a particular interest in or specialise in? A. Well the two year research was in bowel related development. Gastrointestinal development. Prof. Puri has a huge interest in that. So, I was developing...(interjection). Q. It is an interest that you share with Prof. Puri, is that right? A. That is right. Q. Okay. Then on pages through to, you list presentations at international scientific meetings. Again I don't propose to go through those. Are these, clearly international scientific meetings are self-explanatory. Presentations? Are these papers you presented or how does the system work? A. It is usually whatever the research that you are doing, you send them abstract, and if they accept it it will be three or five minutes, ten minutes oral presentations followed by questioning, and hopefully if you do a good presentation, then you can move on to publishing that work in a peer reviewed journal. Q. Would some of the articles which you have already listed in the peer reviewed journals have, as it were, begun life as presentations? A. More than likely, yes. Most of them. 0: 0: 0: 0: 0:

12 Q. Yes. Okay. Then if I can just do -- I should put this together. and 0, these are actually papers you have presented at National Scientific Meetings, is that correct? A. Yes, that's correct. 0: Q. All right. Then on page you set out: "Specialised Training and Interests: Research. Paediatric Oncology Surgery. Teaching." 0 0: Over the following pages then you give some detail on that, is that correct? Q. All right. I don't propose to go through that, but I think it is, I think you would agree that that would be 0: consistent with your qualifications, the articles you have written and the various hospitals in which you have practiced, is that right? A. That's correct. 0 Q. All right. So that is your Curriculum Vitae, 0: Mr. Paran. In March 00, you were a Specialist Surgical Registrar in Paediatric Surgery, isn't that correct? A. That's correct. Q. So could you just indicate to the Committee the duties 0: which fell on you in March 00 holding that position? A. There are four consultants and four registrars. Two of them are recognised for specialist training and the other two are not. I was one of the recognised trainee

13 working for Prof. Puri. My duties, normal duties will be I that do whatever, that I cover Prof. Puri, and Prof. Puri has two theatre lists, one Out-Patients clinic, and he does on-calls, and I would have been doing -- that is my set out duty. 0: Q. Yes. Approximately, I mean how many hours a week do you have to work to do all those duties? A. The hours, we normally start at :00 o'clock in the morning and finish whatever the time, the emergencies, 0 or the set out duty is finished which with Prof. Puri 0: it is not too bad, usually you finish by :00, :0, :00. But then you have the on-call duties, which is, there are four Registrars, we had to cover /. Usually with the annual leave, study leave, other absences, there is one person on holiday, so it a one 0: in three rota effectively. It averages around 0/ hours per week, but some weeks it will be 0 hours plus, other weeks it will be hours, but it averages around about 0 hours plus. 0 0 Q. When you say "on-call" what in fact does that mean? 0: A. On-call means that any emergency work becomes, you are responsible for it. So the emergency work can come through the Accident & Emergency Department, whatever comes through there. Emergency work can come through phone calls you receive from peripheral hospitals. It 0: can come from neonatal units where a newborn baby with an normality, and they are asking for you to receive the patient and take care of the patient. It also means that Crumlin is not just a surgical unit, so it

14 is a medical unit as well. So there is a lot of medical patients, and suddenly if they develop a surgical component to their illness, then you will have to address that. Q. So I mean is there ever a quiet time when you are 0: on-call? A. Normally day and evening are extremely busy, but when it comes to midnight and after, you can hope for, I mean we have a policy that we don't bring anything, 0 unless absolute emergency, to operate on them after 0: midnight. Q. After midnight. A. That helps. So once you have caught up with all the work after midnight, unless a newborn child arrives, or a transfer arrives, or casualty, someone comes, it is 0: usually not too bad. Q. So you can be operating up until midnight on non-emergency? A. Even after midnight, yes. But as I said, after 0 midnight is absolute emergency. So you won't be doing 0: routine, not routine, an appendix or something like that, you tend to delay it until the following morning. Q. Can I come now to the morning of the st March 00. Q. Could you, on that day, indicate to the Committee what 0: your specific duties were? A. Usually Prof. Puri has Out-Patients clinic on Friday morning, and he also runs a small theatre list the same morning. We would decide, if Prof. Puri had a meeting

15 or something like that, he will say "you go start the list at half eight and carry on with it. I will go straight to the clinic". Sometimes he comes in early and he will say "look, why don't you have a cup of tea and go down to the clinic and I will finish in theatre 0:00 and come down to the clinic." That is what we normally have on a Friday morning. But Prof. Puri took a flight out of the country on Thursday afternoon, Thursday evening, for a meeting. He is very academically 0 involved. 0:00 Q. Can I just stop you there. I think that this particular week was Holy Week? A. Yes, it is a Good Friday. So there is no routine work scheduled. Q. Yes. 0:00 A. So there was no clinic. There was nothing planned. Q. Right. A. But I was on-call for that day. Q. Yes. 0 A. I arrived at the Hospital at :00 o'clock, and I knew 0:00 that Prof. Puri has no scheduled work, and he is also out of the country. So my routine responsibility would have been looking after his in-patients, which is not normally a great number, about four or five in-patients. 0:0 0 Q. Yes. A. Then taking over my on-call duties. When I arrived into the doctor's mess I met my other two colleagues, one was on annual leave, that is Farhan Tareen,

16 Prof. Corbally's Registrar, he was away. Dr. Reshma and Mr. Mortell were there, and I met them, and more or less trying to find out what is the overall workload for that day. That is when I found out that Prof. Corbally had a scheduled list, which was 0:0 unexpected, and there were two or three emergencies, which you normally expect. I also found out that Mr. Mortell, who has been on-call on Thursday night, had a cold, and he said to me very early in the morning 0 that "Sri, I would like to go home early", and I knew 0:0 Reshma's consultant had one or two very small cases, semi-urgent cases that he wanted to do, and she said she will be busy with that. So within about five or ten minutes it became evident that there is only one person who can cover the scheduled list, that was me, 0:0 and I said "okay, if I have to I have to". Q. So the position was that your consultant was away and Prof. Corbally's Registrar was away, is that right? 0 Q. So you, as it were, subbed up as Prof. Corbally's 0:0 Registrar, is that correct? Yes, that's correct. Q. You didn't know that until the day, is that right? A. No, because the whole week, because Prof. Puri was there I was with him. I didn't put my head out of that 0:0 zone to see what is going on. I have helped Prof. Corbally's team out with a couple of emergencies on Wednesday, but Thursday I went home half day because all the Specialist Registrars have one half day where

17 they are supposed to academic work. Q. Okay. A. I went home around about :00 o'clock. So I wasn't aware of what is being planned for Friday up until that morning. 0:0 Q. Right. So anyway, the first, at :00 o'clock on Friday you do a ward round, isn't that correct, with Mr. Badrul, who is SHO to Prof. Corbally, isn't that correct? 0 :0, once I realise there is a scheduled list, I 0:0 also realise that Prof. Corbally normally has two House Officers, and one of them was on holiday. That left just Badrul as his only team member. Q. Yes. A. I asked him; "do we have many in-patients?", and he 0:0 said; "yes, we have loads of them and four in ICU as well", and I said; "okay. Why don't we do a quick ward round to pick out anything that has to be addressed urgently?". 0 Q. Yes. 0:0 A. Having worked with Prof. Corbally I know how the theatre list system works. Usually they kick off around about half eight, a quarter to nine, sending for the patient. There is two theatres. They both will send for one patient each. 0:0 Q. Yes. I am going to come to all that in a minute, but I just want to go back now to the ward round? Q. I think in the course, in the course of the ward round,

18 0 0 0 in the course of the ward round, included in that round would have been Master Conroy, is that correct? A. Yes, that's correct. Q. Would you just tell the Committee the ward round, as you recollect it, as it affected Master Conroy? A. The ward round between :0 and :0, you have twenty minutes. So it is a prioritising ward round where you are more concerned about any sick patients, and I was taking guidance from Badrul, who knew all the patients. As we were walking through the ward, we came to, we have to try and see all the patients under Prof. Corbally which is listed on each ward, there is a list with Prof. Corbally's patient's names. So we were going through one after the other, and when we came to Master Conroy's room I said "what is this patient here for?", and he says it an elective, it is a child for nephrectomy, and I said; "is everything set up?", and he said, yes. So I said; "okay, do I have to see?" No. So we moved on further. We did not enter the room, because I was more concerned about getting through all the patients and trying to pick out anyone who is seriously ill, especially the ICU patients, and since this patient has been admitted the night before and everything has been set up, according to Dr. Badrul, I just moved on. Q. When you talk about everything set up, was there any discussion over x-ray films? I mean when a House Officer says to you "yes, everything is sorted", you ask very quick questions. I 0:0 0:0 0:0 0:0 0:0

19 said; "is he consented?", and he said "yes". I looked at the consent. I said "is it the left side?", and he said "yes", and he showed me the theatre list, which he has printed out, and I had the consent in front of me, and I quickly flicked the child's chart to see Prof. 0:0 Corbally's handwritten notes indicating it is for left nephrectomy. I was satisfied at this stage, and I said; "do we have the x-rays?", and he said; "no, we don't hold the x-rays in ward any more. It will come 0 to the theatre", and I said "fine". 0:0 At this stage, looking through the theatre list, we picked out two major cases, and in my mind, because I am more or less stand in, I felt like those two will be for the boss, and I said...(interjection) 0:0 Q. The boss being? A. The consultant. Q. Very good. A. And I moved on. 0 Q. Did you regard the nephrectomy operation as being the 0:0 more, a serious operation on the list? I mean my level of training, it is a big deal. Q. Okay. We will come to all that in due course. In any event that, well it didn't conclude your ward round, but it concluded, as it were, the first time you had 0:0 come across this particular patient, is that correct? A. That's correct. Q. All right. Can I move then on now to the theatre and the list.

20 Q. There were two operating theatres running; Theatre and Theatre, is that correct? A. That's correct. Q. You were operating in Theatre, is that correct? 0:0 I went to Theatre by choice. Q. Yes. A. Because I had already made up my mind that there are so much expected of me so I have to limit what I take on. 0 So I have decided, in my mind, I am going to stick to 0:0 the day cases. 0 Q. Yes. A. So I went into Theatre, introduced myself to the theatre coordinator, who is Michelle Cullinane, and I said; "I am with you. You can start sending for the 0:0 patients". Q. Okay. Prof. Corbally was in Theatre, is that right? A. I assumed, yes, somebody was going. Q. Yes. Was it the case that, as it were, you were 0 dealing with the minor cases in Theatre, and the more 0:0 serious matters would go to Theatre. Is that the way it was to work? A. It is again, as Prof. Corbally explained yesterday, it is a very fluid system, but Theatre is a small theatre and usually it takes on the day cases because 0:0 it is right next to the day ward as well. Theatre is a much larger area. Any major cases are usually sent towards Theatre. But it is completely at the decision of the consultant. He can change the 0

21 decisions at any stage. Q. I see. All right. Now if I can now just turn to the operation which you were doing, which I understand is a Hickman/Broviac removal? 0:0 Q. It has been referred to yesterday? Q. You just might again remind the Committee, you were doing that operation in, isn't that correct? 0 A. That's correct. 0:0 Q. You just might again remind the Committee, in two or three sentences, what that operation consisted of? A. It is very similar to a central line, which is placed through a tunnel under the skin. The purpose being it has less infection and it can last up to several 0:0 months, enables chemotherapy and all the rest, but once the treatment is finished, you are removing it, it is, there are no stitches holding it. What is holding it is a cuff, a piece under the skin, which is stuck to 0 the skin. So you have to isolate the cuff and then 0:0 pull it out. Effectively it is about five, seven minutes procedure. Q. Okay. A. The anaesthetic time...(interjection). Q. Did anything happen in the course of that procedure? 0:0 I was in theatre while the child is being anaesthetised, because the anaesthesia literally is a mask, holding a mask, and it doesn't take too much time. So I was waiting there for the anaesthetists to

22 0 0 0 say go ahead. At that point in time one of the nurses in Theatre said; "Prof. Corbally is looking for you in ". I said "okay". I registered that. But I was prepared to do this case, I had my gloves on. So I waited and moved on with the case, and while I was isolating the cuff, Senior Nurse Arial came into the theatre, and he was standing there and said; "Sri, Prof is waiting for you". Q. "Prof is waiting for you". That is Prof. Corbally? Q. Okay. So what did you do then? A. I finished the procedure and asked them to keep pressure to make sure it doesn't cause any bleeding, because usually at the end of the procedure you hold the vein for about three minutes to stop further bleeding, and then you move on to writing the operative notes. Q. Right. A. But I dropped all that and I delegated it to one of the staff nurses and I went to Theatre. Q. Had you any idea what Prof. Corbally wanted? A. Absolutely not. Q. All right. Anyway you went over to Theatre, is that right? A. Yes, that's correct. Q. Can I just ask you there; if a Professor calls you when you are operating, do you drop everything and go? A. As long as -- if you haven't started, you drop everything and go, but if you are in the middle of the 0:0 0:0 0:0 0:0 0:

23 case you send a message back "look I am scrubbed". Q. All right. Anyway, you go to Theatre. Q. Would you just tell now the Committee what happened in Theatre? A. Prof. Corbally was scrubbed, and the child is fully draped, and I didn't even know what the case is, and I went up to him and I said; "Prof, you called for me?", and he said; "yes, have a look at this. I want your opinion". I said, I looked at it, it is hypospadias, it is an orifice in the phallus of a child. Q. Could I just stop you there. That is the operation which was referred to yesterday as the hypospadias fistula repair. A. That's correct. Q. It is the third operation on the second page of this sheet which was handed in yesterday. It is operation number 0. I will put a copy of that before Mr. Paran to identify it. (SAME HANDED TO WITNESS). Q. It is that operation there, 0, hypospadias fistula repair? That's correct. Q. Okay. Sorry, you were telling the Committee what the Professor had asked you, your advice on something, isn't that correct? A. My opinion on what he was seeing on the child, and I said, he told me that the original hypospadias has been repaired and it is a recurrent fistula, so it is 0: 0: 0: 0: 0:

24 probably the second time. What happens is on the phallus, the opening is lower down, and you do a surgery to bring it to the normal point, but sometimes the original opening keeps opening up again and again, and I think that is what the problem was. Q. That is what happened here. In any event, you just might just carry on as to what you recall the Professor said to you and what you said to him? A. The question was where sometimes when you put the skin fold you cannot really see where exactly the opening has reopened. Q. Yes. A. I think the doubt was, there were two or three skin folds that looks like opening, which is the real opening. I suggest him a technique that I have learned from Prof. Puri. When I described that to him and he says; "why don't you scrub in?" Q. He said; "why don't you scrub in?", which in layman terms, is that in other words get involved in the operation? A. Yes, getting involved in the operation. Q. Yes. All right. Did you scrub in? Q. All right. You got involved in the operation? Q. Did Prof. Corbally say to you any reason why he was seeking your advice or opinion? A. I think when I scrubbed in and came back and I was helping him along, and he said; "this is a recurrent 0: 0: 0: 0: 0:

25 problem and the father is a doctor", and I said, I understood that he wanted to give the best to the child, so he was trying to get a second opinion and do the right thing this time. 0 Q. A second opinion? Okay. 0: 0 Q. In any event you scrubbed in, you got involved? 0 Q. Did you remain to the end of that operation? 0 A. No, because the operation involves finding where 0: exactly the opening is, but once the original opening is closed. 0 Q. Yes. A. Then there is a cosmetic end to the surgery. Q. I see. So you didn't remain there? 0: A. I think I remained for the crucial part. Q. Yes. A. Once that stage is reached, because Theatre was of the opinion that I am there to do the cases one after 0 the other. 0: Q. Okay. A. Which is what my discussion with the theatre coordinator is. Q. All right. So you didn't remain there. So you left Theatre, is that correct? 0: A. Yes, I mean I didn't write the operative notes for that child, or wasn't there for the dressing or any of that. No. Q. All right. Okay. Where did you go to after Theatre?

26 A. Straight to Theatre. Q. When you went back to Theatre, first of all at that stage when you were leaving Theatre, had you had any other discussions with Prof. Corbally about doing a nephrectomy? 0: A. Absolutely none. Q. Okay. In any event, you went back to Theatre, is that right? A. Yes, that's correct. 0 Q. All right. Why did you go back to Theatre? 0: A. Because that is where I am working. The children were being sent for for the next case and the next case. Q. All right. When you went back to Theatre, what did you find? A. Obviously whatever the time lapsed between me being 0: called into Theatre, there must have been a twenty or thirty minute lapse. So the next patient has already arrived in Theatre. 0 Q. Yes. 0 A. And in the absence of Prof. Corbally and me, they have 0: went for the third in line, which was Badrul Yeap, the House Officer. Q. Yes. Just to explain that, what seems to have happened; whilst you were away another patient had come and had been dealt with, is that right? 0: A. Is being dealt with, yes. Q. Is being dealt with. Yes. Okay. Did you say anything to the ward coordinator, Michelle Cullinane? A. Because when I looked over Badrul's shoulder, he is

27 nearly finished the case. Q. Yes. A. So I came into the theatre, and adjoining that is the anaesthetic room where the phone is. Q. Yes. 0: A. The theatre coordinators are usually beside the phone. I went up to Michelle and said; "what are we sending for next?" She said; "okay. What do you want?", and I said "whoever is ready". 0 Q. Whoever is ready? 0: Q. Okay. So you sent for the next patient, whoever was ready? Q. Michelle Cullinane, she is the theatre coordinator, is 0: that correct? A. Yes, theatre coordinator for. Q. All right. So, clearly your next patient had not arrived, isn't that correct? 0 A. No. 0: Q. Did you saying anything about that you want the next patient to be a short easy operation, or a long operation, or did it matter? A. We have already decided that only the day cases are being done. 0: 0 Q. Okay. A. We haven't heard anything otherwise from the Professor. So, we were continuing on that path. Q. So you are in, and you told Ms. Cullinane to send for

28 the next patient, is that correct? A. Yes, that's correct. Q. Would you then just tell the Committee what happened then? A. The discussion with Michelle was in the anaesthetic 0: room, and somewhere along that point Mr. Mortell came down, because it has reached nearly the half ten mark, and he has already indicated to me that he will look after his patients that are in-patients, sort them out. 0 Q. His in-patients, yes. 0: A. His in-patients. Then he was going to head home. Q. Yes. A. Having done the ward round, he has come down to give me a hand over. Q. A hand over of what? 0: A. A hand over of all his in-patients; what they are in for, what is happening. So that I am on-call for that day and if he is leaving at half ten, from that moment onwards all of Mr. Quinn's patients will be my 0 responsibility as well. So he wanted me to give a 0: heads up on all those patients. Q. I see. So you are in the anaesthetic room. I think you had indicated that Mr. Mortell was feeling a little under the weather, is that right? A. Yes, yes. 0: Q. And wished to go early? Q. So he handed over to you at that stage all Mr. Quinn's patients, is that correct?

29 A. Yeah, he was handing over the patients one by one. Q. All right. Can you recall how many of his patients were involved? A. No. 0 Q. All right. 0: A. I mean probably about -- Mr. Quinn usually on average has about eight to ten patients. Q. Eight to ten. Mr. Mortell is handing over. So at this stage now you have sent for your next surgical patient, 0 isn't that correct? 0: A. Yes, that's correct. Q. Mr. Mortell is handing over to you now Mr. Quinn's patient, is that right? A. That's correct. Q. All right. When you say "giving you a heads up", is 0: he, is part of the hand over telling you what the patients are in for and what the problems are? A. The hand over, because we don't sit down and have the luxury of handing over one by one by one, it is mainly; 0 who are the real sickies? What the plan? If there is 0: any investigation, has he ordered them or not, or his SHO is doing it, and what did I need to check and at what times to make sure that -- the continuity of care is...(interjection). Q. This is all done verbally, is it? A. Verbally. Q. Yes. A. If there is -- verbally, but if there is too many information then I will write it down on a piece of

30 paper and keep it with me for the day. Q. So anyway, Mr. Mortell has now handed over all the patients to you? Q. What happened then? 0: A. He was still handing over the patients to me, and somebody put their head in through the anaesthetic door and said; "the patient for nephrectomy is at the reception. There is some query". 0 Q. Yes. 0: A. Because I was in the middle of hand over, all I registered was; there is a patient in for nephrectomy at the reception and there is some query. Q. Yes. A. I said okay, and we were still talking, and we decided 0: to walk towards the patient. 0 Q. Yes. A. And we moved up. Q. I think it is obviously well known that that patient 0 was now Master Conroy, isn't that correct? 0:0 A. Yes, that's correct. Q. Yes. Can you just tell the Committee in your -- first of all, have you got a good recollection of these events? A. Yes, absolutely. 0:0 Q. All right. Would you just tell the Committee now who said what to whom? A. Well once -- the walk from Theatre to the reception is thirty seconds to a minute, and we were leisurely 0

31 0 0 still talking about the patients and walking towards there. Once I got there only I realised, I know that there is some query, I don't know exactly what the query is. So I asked the nurse who was with the patient; "what exactly is the query?". Q. Yes. A. They said; "there is some query about the side". I said okay. What I did was, I moved up to the patient. Now part of my mind registered that I have already seen the left sided nephrectomy scheduled on the theater list. I have already seen the consent. I also noted a quick glance of Prof. Corbally's handwritten notes on the chart earlier on during the ward round. So what I did was I looked on the trolley and there the chart was there. So I went, I picked up the chart. Q. Now the child clearly is on the trolley. Were the child's parents present? Q. You just might indicate where they were? A. The theatre reception is a two large double door, and outside is the trolley and the parents. I was coming from inside the theatre area. Q. Yes. A. The mother was with the boy at the head of the boy, and the father was standing more towards the end of the trolley. Q. Right. A. The chart was at the end of the trolley. Q. Yes. 0:0 0:0 0: 0: 0:

32 0 0 0 A. So I went, I picked up the chart and moved back about four or five steps with the nurse who told me what the query is about the side. Q. Yes. A. I quickly glanced through the chart. Q. Yes. A. And confirmed to myself it all looks left side. So I came out and said -- what I did was, I opened the page of Prof. Corbally's handwritten notes and showed Mr. Conroy and said, so and so is scheduled for left nephrectomy, and this is Prof. Corbally's handwriting, and here it says left % and left nephrectomy. When a query like that arises, most of the time you are looking, you are talking, but also looking at the parent's face and the body language to see how much of a concern is this? Is it an enormous concern or not? And father said, yes. Then I turned towards the consent form and pointed out it is written left nephrectomy, and turned the part where he, the parent has to sign, and I said; "is this your signature?", and he said yes. So I said; "he is scheduled for left nephrectomy", and the father said yes. Then once I finished with that conversation, father said; "would the x-rays be there, doctor?" Even before I opened my mouth Olive Delaney, who is the theatre coordinator for Theatre, who was beside me, asked the nurse who brought the child from Our Lady's Ward that; "where are the x-rays?". Q. Yes. 0: 0: 0: 0: 0:

33 A. So this conversation was taking place openly in front of all of us. Q. Yes. A. Anna Davey said, I don't know where the x-rays are. Q. Was it the case that the x-rays were not present when 0: this conversation was taking place? A. No, the x-rays were not there. Q. Yes. Okay. A. So, Olive Delaney asked Anna "where are the x-rays?", 0 and Anna said "we don't keep it in the ward". 0: Q. Yes. A. Then Mr. Mortell, who was following me and talking to me and just standing there, just did this to me (indicating), because he could see that I am caught between one thing and the other, and he did this to me 0: (indicating) and started walking towards the X-ray Department. So I knew Alan Mortell is going to get the x-rays. Q. Okay. 0 A. When a senior like that heads off, you are more or less 0: guaranteed the x-rays will be found. Q. Okay. Did you have a discussion with the child's mother? I mean then I said to -- at that point in time I said to father "we will make sure that the x-rays are 0: in theatre". Q. Yes. A. I looked across the area and I saw Mrs. Conroy standing there, and she looked upset, and I wanted to kind of

34 0 0 0 have a chat and to make sure that everything is all right. So I walked up to the head of the patient and said "has anyone marked the child?", and she said no. Although there was no strict site marking policies, protocols, or anything like that, I think retrospectively I, more than anything just wanted to create a conversation, and I went up and I opened the gown of the little boy and I said "it will the left side", and I had a marker pen, which I always carry, and I marked it on the left side and I said, when I marked, the mother said "would the cut be that high?", and I said "yes, the scar will be somewhere here". That is the point, I noticed that he had a left iliac fossa scar as well. Now, I was not familiar with Master Conroy's, his past history, up until that point in time. So I said -- mother said this is the -- "can you utilize that scar?", and I said; "no, it is far too low town". I said; "is it a colostomy closure scar?", and she said "yes", and then I quickly copped it is, that he had a previous surgery. Q. Yes. A. And I said; "more than likely you cannot use this scar, but it will be Professor who will be doing the case and I will make sure that I will pass the message on to him". Now that is the conversation is in my memory. Q. Yes. A. But how much of -- it all happened so fast. We are talking about the whole thing lasting about three and a half/four minutes. 0: 0: 0: 0: 0:

35 Q. I think you were here when Nurse Anna Davey was giving evidence? Q. Nurse Davey, that is the witness who gave evidence over the telephone I think from Canada? 0: Q. She was the nurse who had brought the child down, isn't that right? A. That's correct. 0 Q. Okay. She recorded in her notes "patients" and the 0: name is given: "Parents seem satisfied after speaking with Dr. Paran." Yourself. Was that your impression? 0: A. At the end of that whole three or four minutes I felt whatever the query that was there seems to have been addressed. Q. Yes. 0 A. So, I moved back. 0: Q. So you felt the query which the parents had raised had been addressed? A. Addressed. Q. Okay. So you moved back anyway to the -- sorry, just before we just leave that particular matter, at that 0: stage did you know that you in fact would end up doing that nephrectomy? A. Absolutely not. Q. No.

36 A. No. 0 Q. Okay. So you moved back anyway. You moved back to what? A. I went back to Theatre. Q. Yes. 0: A. To find out whether Badrul has finished his case and how far away are the child from coming. Q. This is the one, the patient you had sent for? A. Sent for. 0 Q. Yes. 0: A. Michelle said; "yes, it is sent for, Sri". So normally if you send for a day case patient it takes about ten, fifteen minutes lapse before they actually are in the room, and then you have another five or ten minutes for them to go to sleep, depending on what type of surgery. 0: So I knew that I had about /0 minutes to spare. Q. Yes. So what did you do with that /0 minutes to spare? A. One of the, the bleep is always going off, and one of 0 the bleep was, I don't know whether it happened within 0: that twenty minutes or before, there were two things that was in my mind; one was a child who was about to be born with a congenital problem, and that child had to come to the intensive care unit. It is not always, ICU beds are not always available, so we have to make 0: sure that the ICU bed is available. If there is no availability, I have to inform the maternity ward that there are no beds in Crumlin, try Temple Street. So I wanted to verify that, but this child is not born yet,

37 0 0 so I had a few hours in my pocket. The second thing is that I received a phone call from casualty saying there is a child with abdominal pain that needs review. Q. Yes. A. So those two things are in my head, but I am also acutely aware that I have only done the third floor and second floor ward round, and I am on the first floor, which is theatre and the intensive care unit, and in the intensive care unit I knew there are four patients, I haven't even glanced at them yet. So I said; "okay, first things first, let's go have a quick look at these patients". Q. So you left the operating theatre area to go to the ICU, is that correct? Q. To see four patients? A. There were four patients. Q. Yes. A. My ambition would have been to see all four, but I don't know, I would have got around to one or two to see. Q. Yes. So you spent some time in the ICU, is that correct? A. I spent some time. I don't have clear recollection of exactly what I did. I definitely saw one or two patients, and I probably had a chat with the floor manager to see how the bed situation is, and that is all I did. Then as the time lapses you become conscious, okay, we have to get back to Theatre. So, 0: 0: 0: 0: 0:

38 once I knew I have reached my time limit, I automatically walk back to Theatre to see whether the patient is ready. 0 Q. Okay. So the position was; you are in the ICU, you knew you only had a certain period because the surgical 0: patient was on the way down to ; isn't that right? A. That's correct. Q. All right. Now you go back to. 0 Q. What happens then? 0:0 A. The patient wasn't there and we were all a little bit under pressure that day because there were quite a lot of workload to get through, and also what do you call, there was so much going on in my own head. So I actually confronted, not confronted, I went looking for 0:0 Michelle and said; "what exactly has happened? What is the delay?". Q. Yes. A. Normally if you have plenty of time you will say 0 'great, there is no patients I will go for a cup of 0:0 tea', but this day I wanted to get on with it. So I said; "where is the patient?", and then she apologised. She realised -- the patient was about to leave -- we realised the child needs a pre-med. That can happen, because a child looks very calm and 0:0 collected...(interjection). Q. So. I don't mean to cut you short. That patient wasn't there in Theatre, isn't that right? A. No, no. A pre-med, when you send for a patient and if

39 they suddenly realise the child needs a pre-med, then they won't bring the child in, they will give the pre-med and there is a /0 minute delay until the child calms down or falls asleep before they will move the child into the surgery. 0: Q. So they had given the pre-med. How long did you think you had to spare before you were going to have to actually operate on this child? A. She said; "the pre-med is given and the child is coming 0 to the reception". 0: Q. Yes. A. So now I knew I had another ten minutes. Q. You have now ten minutes to spare, is that right? A. Ten minutes to spare, yes. Q. Okay. Now you didn't go for a cup of coffee as it 0: turned out? A. No. Q. So you had ten minutes to spare. So what did you do with that ten minutes? 0 A. Because, just before I went off on my little journey to 0: ICU, I have already spoken to Mr. Conroy and Mrs. Conroy, and I knew Master Conroy was on his way into Theatre. 00 Q. Yes. A. And the time lapse I knew that he will be more or less 0: getting ready, from the anaesthetic point of view, for the surgeons to catheterise and position. Those are jobs for an SHO or Registrar. You don't expect the performing consultant to do those things.

40 0 Q. Yes. A. So I said I will go down and I will see what is happening. I didn't know exactly what I was going to do. I said I will just go down to Theatre and see what needs to be done. 0: 0 Q. Okay. So you went to Theatre, and you just might tell the Committee what happened then? A. When I entered Theatre, Dr. Mannion has already put the child to sleep. 0 0 Q. Dr. Mannion is the anaesthetist. 0: A. The anaesthetist. He has already had the epidural in, which is extremely quick, because epidurals can take up to minutes on their own, let alone anaesthesia, and he was standing there and said; "come on, Sri. Come on. Catheterise". I said okay. So as I walked in 0: said; "come on, catheterise the child", and I said okay, fine. Give me whatever size catheter that I chose. Normally one of the nurses will bring out a dressing pack and the catheter to you, and I was 0 catheterising. Just as I was catheterise, I was 0: looking around to see who is in the theatre, and I didn't see Professor, and especially I didn't see the SHO. 0 Q. Yes. A. Which was a little bit not what I expected. I expected 0: the SHO to be in Theatre the whole time. Very quickly I realised that he is a one man army on his own. He had to admit nearly / days cases and look after their discharges. So I said to myself, 'okay, he 0

41 is not here, probably he is caught up in day ward, let me do these things'. So I did the catheterisation and then when I was looking around I still didn't see anybody in there, and I said, okay, I will position the child. I started positioning the child, and even just as I was robing up I saw Prof. Corbally walking into the room. Q. Yes. Then what happened? A. Prof. Corbally walked into the room and went straight to the operative notes and the chart that was there on the side, and he was looking, flicking through the chart, and I knew that he is making sure of that. I just positioned and I realised that my job here is done, and I was more or less making an exit back to Theatre. Q. Yes. A. I was heading, halfway away from the child, when I heard Prof. Corbally...(INTERJECTION). Q. Before that, before you were making your exit, did the Professor say anything to you? A. No. The Professor came in and he was looking at the chart. Q. Okay. A. Then he turned around and says; "are you happy to go ahead with this?", and I was very much taken aback, because it simply means that I am suddenly going to do this case, and regardless of all the error and whatever that happened, it is going to suddenly bind me to that that theatre for an hour, hour and a half, and I have 0: 0: 0: 0: 0:

42 already sent for a patient in Theatre, I don't know who is going to do that. But at the same time when a consultant asks you, I normally don't say no. I just turned around and looked at him. 0 Q. Yes. You looked at him? 0: A. I looked at him, and he asked the question; "are you happy to get on?" 0 Q. So that is the second time he asked? A. The second time. 0 Q. Yes. 0: A. In the surgical world it is known there is only one correct answer. So within 0/0 seconds I said yes. Q. Did you feel you could say 'no, I have another patient in ', or 'I am not prepared for this operation', or whatever? 0: A. The consultant is in charge of the list. He knows everything that is happening everywhere under his care. If he says do something, you do something, and if somebody is out there, the child asleep, the nurses 0 will automatically go to the consultant and he will 0: either go and do it himself or he will send somebody else to do it. You don't dictate what happens where. Q. Okay. So you said yes? Q. You didn't feel you could say no, is that right? 0: A. No. Q. Well, I think in fact he has given that evidence in fairness, so I am not leading him on that. I am very conscious of that.

43 MR. LEONARD: Yes. Q. MR. MEENAN: You did commence the operation? Q. How many minutes had you got to prepare for that 0: operation? A. The child is anaesthetised and I have already positioned the child. The next thing that happens is if the surgeon is happy, he goes ahead and starts 0 scrubbing. When Professor said "are you happy to go 0: ahead?", and I yes, Professor came over to the child and had a look at the child's positioning. Q. Yes. A. He agreed with that. Q. Yes. 0: A. He indicated that make an incision, and he put his finger on the...(interjection). 0 Q. I am going to come to all that, but I just want to ask you; how long before the operation did you know that 0 you were going to be doing it? 0: A. Less than five minutes. Q. Less than five minutes? A. Literally as it starts. Q. All right. Now I am going to come to what happened after that in a moment, but I just want to deal with a 0: matter that arose in the evidence yesterday. You were here when Prof. Corbally gave evidence that you had at least thirty minutes notice that you were going to do that operation.

44 0 0 Q. I think you have heard that? Q. Okay. Is that correct? A. No, not according to my recollection, absolutely not. Q. Okay. His evidence was to the effect that at the conclusion of the hypospadias fistula repair he said words to the effect "would you like to do" or "will you do the nephrectomy?"? A. No. I mean not only I don't remember it, if somebody had said to me at that point in time, my entire actions following that would be completely something different. Q. Okay. Now if that had been said to you, you don't believe it was, how would your actions have been different? A. Basically at that point in time, I have to clear myself for the next two hours, because nephrectomy is a major surgery. Q. Well can I just stop you there. I think the Professor gave the impression yesterday that the nephrectomy is not a, and these are not the words he used, but isn't a complex operation. I think this would be a simple nephrectomy, is that right? A. It is the skill of the person. If I am asked to run ten mines miles, it is a big deal for me, but for a marathon runner it might be a simple thing. Q. Okay. A. For me, in 00, it is a big deal. Q. It is a big deal. Why is it a big deal? 0: 0: 0: 0: 0: