THE MEDICAL COUNCIL FITNESS TO PRACTISE COMMITTEE … · 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17...

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THE MEDICAL COUNCIL

FITNESS TO PRACTISE COMMITTEE UNDER PART 8 OF THE

MEDICAL PRACTITIONERS ACT 2007

PROF. P. CORBALLY & DR. SRI PARAN THAMBIPILLAI

TRANSCRIPT OF HEARING HEARD ON

THURSDAY, 2ND SEPTEMBER 2010 - DAY 3

AT KINGRAM HOUSE

KINGRAM PLACE

DUBLIN 2

Gwen Malone StenographyServices certify thefollowing to be a trueand accurate transcriptof the shorthand notesof the evidence in theabove-named action.

______________________

APPEARANCES

COMMITTEE: DR. J. MONAGHAN(CHAIRMAN)MS. A. DURKANMR. T. O'NEILL

LEGAL ASSESSOR: MR. K. CROSS SC

FOR THE CEO: MR. P. LEONARD BL

INSTRUCTED BY: MR. JP McDOWELLMS. A. RYAN

McDOWELL PURCELLSOLICITORSTHE CAPEL BUILDINGST. MARY'S ABBEYDUBLIN 7.

FOR PROF. CORBALLY: MS. E. BARRINGTON BL

INSTRUCTED BY: MATHESON ORMSBY PRENTICESOLICITORS

FOR DR. SRI PARAN: MR. C. MEENAN SCMR. C. BURKE BL

INSTRUCTED BY: O'CONNOR SOLICITORS

COPYRIGHT: Transcripts are the work of Gwen MaloneStenography Services and they must not be photocopied orreproduced in any manner or supplied or loaned by anappellant to a respondent or to any other party withoutwritten permission of Gwen Malone Stenography Services

INDEX

WITNESS EXAMINATION PAGE NO'S

PROF. M. CORBALLY

DIRECT - MS. BARRINGTON 4 - 80CROSS - MR. LEONARD 80 - 107CROSS - MR. MEENAN 108 - 170

QUESTIONED - THE COMMITTEE 171 - 177FURTHER CROSS - MR. LEONARD 177 - 178

RE-DIRECT - MS. BARRINGTON 179 - 185

MR. P. OSLIZLOK

DIRECT - MS. BARRINGTON 187 - 189

MR. F. BREATHNACH

DIRECT - MS. BARRINGTON 190 - 192CROSS - MR. MEENAN 193

MR. F. MURPHY

DIRECT - MS. BARRINGTON 196 - 205CROSS - MR. LEONARD 205 - 207CROSS - MR. MEENAN 207 - 211

QUESTIONED - THE COMMITTEE 211 - 214

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Gwen Malone Stenography Services Ltd.

4

THE HEARING RESUMED, AS FOLLOWS, ON THURSDAY, 2ND

SEPTEMBER 2010

CHAIRMAN: Good morning everybody.

You are welcome to the

third day of this inquiry. We stopped yesterday at the

point where Ms. Barrington had applied for a direction.

So would you like to resume?

MS. BARRINGTON: Thank you, Chairman.

CHAIRMAN: Well perhaps I will say,

the Committee considered

the matter of No. 7 on the inquiry, and we have looked

at the transcript this morning, so I think we would be

happy that No. 7 would be withdrawn along with the

other ones.

MS. BARRINGTON: Very good. Thank you,

Chairman

CHAIRMAN: So, that is all we have to

say about that.

MS. BARRINGTON: Yes. Well then I propose

proceeding to call

Prof. Corbally.

PROF. MARTIN CORBALLY, HAVING BEEN SWORN, WAS EXAMINED,

AS FOLLOWS, BY MS. BARRINGTON

Q. MS. BARRINGTON: Thank you, Professor. We1

are going to hand into the

Committee a copy of the Professor's CV. I am not sure

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what exhibit that is? (SAME HANDED). That is Exhibit

13. Thank you, Professor. The Committee has a copy of

your CV. I am not sure if you have it yourself there?

A. No, I do not. (SAME HANDED TO WITNESS)

Q. As the Committee will of course already have heard,2

Professor, you are a Consultant Paediatric Surgeon and

a Paediatric Surgical Oncologist in Crumlin Hospital.

You are also an Associate Professor in Paediatric

Surgery at the Royal College of Surgeons. How long

have you been working in Crumlin Hospital?

A. Since 1994, but I was appointed in 1993 and took a year

proleptic training in liver transplantation in Kings

College Hospital, London.

Q. I know you have a slight difficulty hearing with your3

right ear, Professor, but if you could, you might try

to keep your voice up and direct your answers to the

Committee.

A. Of course.

Q. Looking through your Undergraduate education,4

Professor, page 5 of the CV, I think you graduated from

University College Galway in 1978, is that right?

A. That's correct.

Q. Thereafter, you did your initial training at SHO level5

in Cork Hospital?

A. That's correct.

Q. I think you then took some time overseas, approximately6

a year in West Africa, is that right?

A. That's correct.

Q. You worked then in Temple Street Hospital for some time7

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as a Locum Registrar?

A. Yes, that's correct.

Q. Then you started in Crumlin as a Registrar in 1984?8

A. That's correct.

Q. You then went abroad again to Iraq for some time?9

A. For six months, yes.

Q. After that you did some training in the Sloan-Kettering10

Cancer Centre. Can you just outline for the Committee

the nature of that centre and its reputation globally?

A. Sloan-Kettering, Memorial Sloan-Kettering Cancer Centre

is one of the world's largest institution dealing

primarily with cancer, both in adults and paediatric

patients. I was fortunate to work there for tree years

in a research clinical fellowship where I gained

extensive experience in paediatric surgical oncology

in the last year of that fellowship.

Q. I think in fact Mr. Paran has also done a fellowship in11

the Sloan-Kettering, is that right?

A. That's correct. I have very good relations with the

staff in Sloan-Kettering and was very happy to organise

a rotation for Mr. Paran in Sloan-Kettering, where he

spent one year and was highly commended after his year

in that institution.

Q. On your return from the Sloan-Kettering, you worked12

again in Ireland for a while, and you then did a year

in the Great Ormond Street Hospital in London?

A. That's correct.

Q. Ultimately then, as you have indicated, after some13

visiting fellowships abroad, you took up your position

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as a Paediatric Surgeon in Crumlin in 1993/1994?

A. That's correct.

Q. Are you the longest serving, that is probably not the14

way to put it, but the most senior Paediatric Surgeon

in Crumlin?

A. As of last week, yes.

Q. Can you outline for the Committee your duties in15

Crumlin?

A. Well I have several duties to maintain in Crumlin.

There is a large service commitment to the generality

of paediatric surgery; neonatal surgery, oncological

surgery, and also paediatric hepatobiliary surgery. In

addition to an active clinical role I am responsible

for Undergraduate teaching and training in the College

of Surgeons and Post Graduate training of doctors who

rotate through the hospital to gain experience in

paediatric surgery.

Q. You deal with your teaching duties at page 11 of your16

CV?


Q. I understand, and it is set out at page 12, that you17

have also done a significant amount of humanitarian

work. What does that involve?

A. We work through the College of Surgeons in Ireland and

the Christina Noble Foundation to deliver a skills

based workshop platform to train our colleagues in

Vietnam in paediatric surgery, mostly in complexity,

complex paediatric surgical procedures. We have

recently been able to establish a cardiac, an open

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heart surgery in the same hospital, which is in its

first year at this point.

Q. You have listed the various learned articles you have18

authored. Then at page 30 of your CV, you outline the

courses you have attended, including a course you have

enrolled in for this September, is that right?

A. Yes, I am enrolled as a Graduate Student in the

University College Hospital Dublin, in a diploma course

on Health Care Risk Management and Quality.

Q. You also, in 2008 and 2010, attended courses in Safer19

Operative Surgery?

A. Yes, I attended one in London in May 2008, shortly

after this incident, and in February I think of this

year I attend a Safer Operative Course run by Professor

George Youngson in Crumlin.

Q. Thank you, Professor. Professor, I wonder would you20

just outline for the Committee, you did so very

briefly, but your working obligations as a surgeon

firstly?

A. Surgery involves many points of patient contact, not

only in theatre, but also in the out-patients and on

ward rounds.

Q. On how many days do you perform surgery in the working21

week?

A. My working list, operating list, is Monday, Wednesday,

and Friday.

Q. You operate every day yourself, do you?22

A. Every day on those three days, yes

Q. On the Monday, Wednesday, and Friday?23

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A. On those three days, yes.

Q. How many patients would your team operate on in a year?24

A. I think the average is about 1,200, but there could be

more or less than that in any given year.

Q. In addition to your surgical commitments, you have an25

on-call obligation, is that right?

A. Yes. Since 1994, I have been on-call ten to twelve

nights for emergency call every month. On-call for

oncological surgical problems on 24/7 since 2005 in

addition, yeah.

Q. So you have a significant on-call commitment in26

addition to your...(INTERJECTION)?

A. There is a very significant on-call rota. The problem

is that there are only two full-time paediatric

surgeons in Crumlin, and up to very recently two

part-time surgeons. We deliver a national paediatric

surgical service, both in terms of neonatal surgery,

oncological surgery, trauma surgery, hepatobiliary

surgery, and the generality of if paediatric surgery.

So it is quite an onerous commitment to have to

deliver. We have been trying to improve staff numbers

consistently over many years.

Q. Is that by way of looking for additional paediatric27

consultants?

A. Yes, exactly. We have, hopefully we will have four

part-time surgeons, two full-time surgeons, very soon.

I did address the College of Surgeons in, I think

2005/2006 at a surgical forum and pointed out that we

needed eight surgeons to be appointed in total. We

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have had difficulty, politically and institutionally,

in attempt to try and fill these positions over the

years.

Q. But in 2008, there two were two full-time Consultant28

Paediatric Surgeons, is that right?

A. Two full-time surgeons; myself and Mr. Quinn, and two

part-time surgeons. Yes.

Q. So you have your three days a week where you are29

operating yourself, you have your significant on-call

rota, and you also have an Out-Patients Department

commitment. Can you explain to the Committee how that

works?

A. Yes. At that time I, well I have, I still have two

out-patient sessions; Tuesday morning and Thursday

morning, and also at that time I had the spina bifida

clinic in the afternoon on a Tuesday as well. That

has, neurosurgical service have now transferred to

Temple Street so I no longer have that commitment.

Q. In the out-patients clinic that you do twice a week,30

how many patients would you see per clinic?

A. The booked numbers of patients would be at least 35,

sometimes 45 patients in a clinic. On a Thursday

morning there are two hours to see that number of

patients. My practice is to review all the charts and

to delegate appropriately to the SHOs and Registrars

assisting with the clinic the patients that I think

they feel competent and able to deal with.

Q. Because you couldn't possibly see all 35 yourself in a31

two hour period?

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A. Not in two hours, no.

Q. Professor, can I move on to your involvement in this32

case with Master Conroy. I note the Committee has a

Book of Extracts from the medical records, which is

Exhibit 2. I am not sure if you have that, Professor?

I am also going to hand into the Committee two very

small booklets of some additional extracts from the

chart. (SAME HANDED)

CHAIRMAN: We will call these Exhibits

14 and 15.

MS. BARRINGTON: Exhibit 14. If Exhibit 14

is the letter to Dr.

Sheridan, commencing with the letter to Dr. Sheridan.

Then Exhibit 15 is the other smaller booklet.

CHAIRMAN: Okay. 14 and 15 then.

Q. MS. BARRINGTON: Professor in the, I know it33

is a little confusing now

to have three booklets, but in the bigger of the three

booklets at page 5?

CHAIRMAN: Exhibit 2.

Q. MS. BARRINGTON: That is Exhibit 2. I hope34

you have the report of the

8th February 2002.

A. Yes.

Q. That is a report that recorded:35

"Minimal left sided Grade I reflux."

Can you explain to the Committee the significance of

that report?

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A. Well, clearly in retrospect the attributing left-sided

reflux was incorrect in this patient. Reflux, on

review by our radiology colleagues, confirmed that this

was an erroneous report in fact and that the reflux

occurred on the right side. Reflux is where urine,

rather than leaving in an antegrade direction from the

bladder actually passes retrogradely into the ureter.

If that urine has bacteria in a significant degree it

cause damage to the kidney on that side. So reflux in

association with the patient's ongoing anorectal

problems could be associated with a reflux nephropathy

on the side of the reflux.

Q. When was this error in the February 2002 report picked36

up?

A. Only after the incident. After.

Q. This error then was replicated in the chart on a number37

of occasions, is that correct?

A. That's correct.

Q. I think you have gone through the chart and have noted38

how many times the left sided reflux was noted. How

many times was that?

A. Eleven times in total. One of those times was at a

multi-disciplinary meeting x-ray conference, where the

images were in fact reviewed and wrongly assigned to

the left side.

Q. I am just going to ask you to look then at one of the39

smaller of the two booklets, it is Exhibit 14 for the

Committee, starting with the letter to Dr. Sheridan.

A. Yes.

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Q. That letter, back in March 2002, records in the third40

paragraph much the MCUG showing minimal reflux into the

left distal ureter. So that was one of the first

instances of the replication of the error in the

February 2002 report, isn't that right?

A. That's correct.

Q. If you turn over the page then, there is a letter of41

January 19th 2004. That is in fact a letter from

Mr. Paran, who at the time was the Surgical Registrar

to Prof. Fitzgerald, which again in the body of the

letter erroneously refers to left sided reflux, isn't

that right?

A. That's correct.

Q. Over the page again, a letter from April 2004, from a42

different Registrar to Prof. Fitzgerald. Half way

through the first paragraph:

"The original MCUG showed mild gradereflux on the left side."

A. That's correct.

Q. Again turning over the page, there is a letter from43

Dr. Mary Waldron who is a Consultant Paediatric

Nephrologist. I think she was asked to become involved

in the management of Master Conroy by Dr.White, who was

the Consultant Paediatrician Neonatologist in Crumlin

Hospital at that -- in the Coombe Hospital, is that

right?

A. Coombe and joint appointment at Crumlin, yes.

Q. Coombe and Crumlin. I see. Dr. Waldron also refers to44

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the left sided reflux?

A. That's correct.

Q. The next letter is one from Dr. White himself, which in45

the summary of diagnosis refers to "left sided VUR"?

A. That's correct.

Q. There is a further letter then in June 2006 from46

Dr. White, again referring, under the summary of

diagnosis, to "left-sided VUR". There is a letter next

of June 2007 from Dr. White. Again, recording

left-sided VUR. The next record is I think the x-ray

conference that you alluded, a note of the x-ray

conference you alluded to earlier. That is a very

early x-ray conference on 13th February 2002, at which,

it would appear, that the report was discussed but the

error wasn't picked up. Is that correct?

A. That's correct, yes.

Q. The Committee will see then that there are thereafter a47

number of extracts from notes made in the chart at

various stages referring to "left-sided VUR".

Unfortunately that error in the notes doesn't seem at

any stage to have been picked up prior to these events?

A. That's correct.

Q. Your initial involvement with Master Conroy I think at48

the outset related to bowel issues, is that right?


Q. Master Conroy was first referred to you, or to your49

team, in April 2006. I am going to ask you to turn

back, Prof. Corbally, to the main booklet, which is

Exhibit 2. You will find a note at page 15?

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A. That's correct, yes

Q. From your Out-Patients Department, is that right?50

A. That's correct.

Q. Dated 13th April 2006. That was the first time that51

your team became involved. I think it was your

Registrar, Dr. Mortell, who saw the patient at that

stage, is that right?

A. That's correct.

Q. Can you just outline for the Committee what the problem52

was in relation to bowel issues at that time?

A. The patient was at that time four years of age and had

been born with a high anorectal abnormality where the

rectum and anus had not formed. Prof. Fitzgerald, my

predecessor and senior colleague at the time, had

performed an operation to create a new anus and rectum.

That, in terms of producing a conduit or a channel, had

been very successful. However, as often happens with

these issues, especially when they are sacral

abnormalities, the continence issue had become a

serious problem. The patient at this time was four

years of age and was not continent of faeces. So he

was referred primarily to my clinic (inaudible due to

coughing) not because of urological issue or a renal

issue but primarily to sort out his continence issues.

At four years of age one would expect a child, a male,

to be toilet trained. This was not happening with this

patient at this time.

Q. I think the chart shows that he was seen again in your53

Out-Patients Department in June 2006. The notes

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related to that are in the third of the small booklets,

Exhibit 15. There is a record there of an attendance

in June. Over the page, page 690 in the pagination on

the bottom right-hand side, a further attendance in

August 2007. How did Master Conroy fair under your

management in relation to those incontinence and

soiling issues?

A. Well initially I had not seen him in the out-patients

and he had been seen by the SPRs or Surgical

Registrars. When I saw him ultimately it was apparent

that a variety of treatment measures had been tried,

and all of these were appropriate, first of all to try

and stimulate his bowel to empty, and then laterally to

try and slow him down a little bit, but none of these

were working, and he was still using at least ten

nappies per day. So he was still incontinent of

faeces. In that situation, and particularly with this

problem from the congenital aspect of his case, with a

high anorectal abnormality, the next step is to

introduce a technique called the Willis Washout

Programme. The Willis Washout Programme essentially is

a retrograde enema using fluid saline and a stimulant

laxative which is passed into the colon through a small

cone shaped nozzle, and that washes out the retained

faeces or faeces in the colon, so the colon is empty.

So effectively they become socially continent. They

are not in the true sense continent, but they become

socially continent, which is a fantastic achievement

considering that an anorectal abnormality results in

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poor muscle development around the anus. It is that

muscle that gives you continence.

So after the Willis Washout Programme was instituted,

which means roughly speaking washing his colon out

every two days, he became socially continent.

Q. So his situation improved considerably?54

A. Yes, exactly.

Q. Then ultimately in September 2007, he was, the55

Committee has seen already I think, referred by his

general practitioner, Dr. Kenny to you, to deal with a

discrete issue. The letter is, the referral letter is

at page 21 of the main booklet, Exhibit 2. Was that

the first time you became involved with Master Conroy

in relation to his urinary issues?

A. That was the first time I was aware of the urinary

problem, yes.

Q. She asked in her letter of September 10th 2007, that56

you would see Master Conroy as a matter of urgency. I

think he was seen in October 2007, and you arranged for

his admission, I think as a day case, in November of

2007. The record of his admission is at page 23 of the

book. Is that correct?

A. That's correct.

Q. What was the admission in November for?57

A. That was to perform a DMSA scan and a renal ultrasound

to establish a cause for his urinary tract infections,

which is why Dr. Kenny had sent him to me in the first

place.

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Q. Those scans then were performed in November, and you58

wrote a letter back to the GP on 22nd November, which

is to be found at page 22 of the book.

A. Yes.

Q. Can you just outline for the Committee the findings you59

had noted on the ultrasound and what you informed the

general practitioner of?

A. He had had quite significant and severe recurrent

urinary tract infections recently, but in the years

prior to that he had been relatively infection free.

But he was requiring antibiotics. He was an Augmentin

Antibiotic Prophylaxis. He was quite symptomatic with

fever, headache, and vomiting. I could find nothing

abnormal on the examination at that time. I considered

that he was managing well on his Willis Washout

Programme and was clean with this. I did not consider

that faecal contamination was contributing to his

urinary tract infections. I considered that he most

likely had a renal abnormality because of his previous

congenital abnormality. So, I organised and an

ultrasound to confirm this, and a DMSA scan to confirm

function, or any damage to function in either or both

kidneys.

Q. The scan was carried out, and we have seen, the results60

of the scan are at page 28 and at 29. The Committee

has seen that. That is the scan that recorded the 9%

function in the right kidney, isn't that correct?

A. That's correct. Can I just say too before I comment on

that? I did continue him on prophylactic antibiotics

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because I felt that we needed to keep his urine free of

infection. I also asked his parents to attempt, where

possible, to get him to empty his bladder in what is

called "double voiding" so that his bladder would not

be a source of infection. If there was any possibility

of stasis in his bladder.

Q. You saw Master Conroy again in the Out-Patients61

Department on January 17th, 2008. Was that with a view

to discussing the treatment subsequent to the scan

having been carried out?

A. That was to review the imaging primarily and to discuss

a treatment plan based on the imaging results.

Q. Yes. Were the scanned reports, which the Committee now62

has at page 28 and 29, available to you at that meeting

on January 17th?

A. These reports were not available. They were not in the

patient's chart. Nor were the x-rays available in the

Out-Patients Department. Normally a copy of the report

is kept in the patient's x-ray folder, and also a copy

of the report is kept in the patient's chart. Neither

of these reports, no official report was in the chart.

Q. Yes. Was that an unusual phenomenon at the time for63

the imaging reports not to be in the chart?

A. Well we had, we have had some difficulty with this

problem, in that the X-ray Department, two or three

years before this event, had unilaterally decided that

because of the high number of x-rays that were being

misplaced and lost that x-rays would no longer be

released at all points of the patient's transit or

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journey through the hospital.

Q. I wonder if I could ask you, Professor, just to slow it64

down a little bit for the Stenographer, please?

A. Sorry. Two or three years prior to this event, the

X-ray Department had decided that they would not

release the x-ray packet, the x-ray folders, to

accompany the patient at all points of the patient's

progress through hospital. We were assured that,

however, x-ray reports would always be available in the

chart, but regrettably that was not always the case,

and quite a common occurrence that x-rays would not be,

x-ray reports, would not be available in the chart.

X-rays occasionally going missing in a hospital system,

and the hospital does not have a computerised archive

retrieval system, or a PACS system, where x-rays can be

viewed on screen, so you don't need to have x-ray

copies. So theoretically at least the chances of

mislaying x-rays could be minimised if we had a PACS

system. We have been trying, and I think the Hospital

now has approval to put in a PACS system.

Q. So there were two pathways for images, and the results65

of the images, is that right, at that time? The x-rays

themselves, the images didn't go into the chart lest

they be lost, but went back to the Radiography

Department where they could be retrieved if necessary,

is that right?

A. The x-rays, the actual x-ray, the image, or the packet

of the images, are kept in a separate large folder call

the x-ray packet. Radiology had decided that x-ray

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packets would not follow the patient throughout his or

her course through hospital. The

reports...(INTERJECTION).

Q. The images, the packets themselves, were retained66

where?

A. In the X-ray Department.

Q. Yes.67

A. But even so, x-rays were still, from time to time

mislaid, even with that system in place. The x-ray

report is generated by the radiologist having reviewed

the imaging, and that report is duplicated. One of

those reports should go into the x-ray folder, the

packet with the x-rays, and the other report should go

into the patient's chart.

Q. In this case, when you are doing your Out-Patients68

Department Clinic, you had, if I have understood you

correctly, neither the packet of the images, and you

wouldn't normally have that in the Out-Patients

Department, but nor did you have on the chart a report

on the images, which in theory should turn up in the

chart at some stage?

A. Normally the x-rays would be available in the

Out-Patients Department.

Q. The x-rays themselves?69

A. They would be found for the clinic, but they weren't

available on that day. The report should also have

been in the chart, but was not in the chart.

Q. Yes.70

A. So I could not, I did not consult the official report,

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which was not available in the chart, and I did not

have the x-rays to review the x-rays in the

Out-Patients Clinic.

Q. Yes. Nor, if I have understood you correctly, did the71

hospital have this PACS system that some hospitals have

that allowed the images to be reviewed on computer?

A. That's correct. There is one computer between five

consulting rooms in Crumlin, and that is at the nurses'

station, but it is not a PACS system.

Q. Yes. Just before dealing with the detail of your72

interaction with Master Conroy's parents and the detail

of this meeting, I wonder could you outline for the

Committee what your working commitments had been that

week and how the Out-Patients Department operates in

this two hour period?

A. Well, can I take the last part of that first?

Q. Yes.73

A. The Out-Patients is a particularly busy place. It is a

very small antiquated archaic room. There is a couch,

a desk, a sink. There is barely enough room for one

parent and one child to sit in the clinic. There is an

adjoining door, which is another room a similar size to

this, where the Registrar, SPR, or SHO would sit, and

across the corridor there is another room where an SHO

or Registrar will also sit. It is a particularly busy

place. There is a lot of distractions. There are

people coming in and out asking for opinions, SHOs,

Registrars. There are nurses bringing results in and

what not. There are phone calls. It is a particularly

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busy place. When you are trying to see 35 to 45

patients in a two hour period, it can be quite a

demanding place. My duties that week had been, of the

seven day period, including that Thursday morning, that

Thursday, I had been on-call five of those seven days.

I had a particularly onerous week that week with busy

on-call demands and service commitments. For example,

on the day before the clinic, I had been involved in a

ten hour case of a chest wall tumour with chest wall

reconstruction.

Q. That was a surgery case?74

A. Surgery all day in that case with my orthopaedic

colleagues. That finished I think around 6:30/7:00

o'clock. I did rounds. I went home. I was called in

again around 9:30 or so to deal with a newborn neonate

who had congenital oesophageal atresia fistula, where

the oesophagus hadn't formed and where an abnormal

connection from the distal, from the far end of the

oesophagus into the airway existed. So, that is a

life-threatening condition. I finished that case at

about 1:30/2:00 o'clock in the morning. After I had

spoken to the parents and got home, probably about 3:30

in the morning, to return again for 8:00 o'clock, an

8:00 o'clock meeting, a surgical audit meeting at 8:00

a.m., to start to do rounds at 9:00 and to start the

clinic at 10:00 and to finish the clinic by 12:00 so I

could attend the tumour board, Tumour Oncology Board at

12:00. So quite a busy and demanding schedule on that

particular day.

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Q. Yes, but not in any way out of the norm of the type of75

days that you might have, having regard to your

obligations?

A. Well, I have an ongoing service commitment to deliver a

paediatric surgical services, which would see us

working, and my colleagues all work the same, I am not

exceptional in this, we would work typically a 75/80

hour week, which does not include the emergency call

outs that we have to deal with on a regular basis, and

also I think being on-call ten to twelve days of every

month since 1994 adds to that, and one has to find, it

is a balance, a juggling act at times to try and

incorporate emergency patients into your ongoing busy

list, which has become even more busy because of the

national tendency to refer paediatric patients to a

paediatric centre because our anaesthetic and surgical

colleagues in peripheral hospitals are increasingly,

and perhaps I would have to say no longer prepared, to

operate on children below 1, 2, or 3 years. So that

has resulted in a very significant referral pattern

increase to Crumlin to look after these patients. So

our workload has increased significantly, and the call

has remained significantly as before.

Q. Then on the 17th January, we have heard from Master76

Conroy's parents, they attended at the Out-Patients

Department and you met with them. Can you outline what

your recommendations were for Master Conroy's

treatment?

A. I believe that I recommended a nephrectomy. I believe

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that I recommended a right nephrectomy, but I

erroneously recorded a left nephrectomy.

Q. You are looking, I think, at the note you made at page77

30 of the booklet?

A. That's correct.

Q. You have clarified that the report, or reports I should78

say, of the scans weren't on the chart, but you noted a

9% function in the note that you made, albeit that you

noted it on the left hand side. What do you think,

what information do you think you did have that allowed

you to make that note?

A. Well in the absence of an official signed report from

radiology and/or the x-rays themselves, I clearly had

specific information as to differential function

between the right and the left kidney. So, I can only

surmise that I had an unofficial report of some form

handed to me that said a split function of 9% and 91%.

Q. When you say an unofficial report, can you elaborate79

for the Committee on the difference between an

unofficial report and an official report?

A. An official report is when the radiologist has reviewed

the images and signed off on the content of the images

and their result. An unofficial report is often, and

in very many cases issued, and unfortunately it is a

practice that persists, and I have tried my best to

stop availability of unofficial reports on screen in

Crumlin, which I believe that administration are taking

seriously now. Unofficial reports really state "this

is not an official report" on the top.

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Q. They haven't been signed off then by the Consultant80

Radiologist, is that right?

A. That's correct. I have many times witnessed unofficial

reports being changed in the light of the official

report. So typographical errors, or errors of

laterality are at risk in unofficial reports.

Q. In this case presumably you looked at the chart, you81

identified the fact that no reports were available on

the chart. Who would you have asked to try to

ascertain information in relation to the results of the

scans from?

A. Well generally nursing staff are most helpful in

Out-Patients, and they will go to the computer and

produce a report from the computer, but that report is

not an official report. It is an unofficial report.

Q. So you would have identified that there was no report82

in the chart. The parents were there, and you asked

the nurse to go to the one computer that the five rooms

share in order to print off what was, at that stage,

probably an unofficial report?

A. That's correct. I may have asked for that report

before the parents came into the room, as you would

normally go through the notes and have an idea of what

you are actually going to talk to the parents about.

Q. The nurse may have simply transcribed what she saw on83

the screen or...(INTERJECTION)?

A. Or printed off a report.

Q. Printed off a report. I see. The parents have84

indicated in their evidence that they had a

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recollection that you told them the nephrectomy was

going to be on the right hand side. Do you believe you

did say that to them?

A. I absolutely agree that I would have said that, yes.

Q. Which would suggest that the report, in whatever form85

you got it, was probably a correct report?

A. I agree with that too, yes.

Q. Then you made an error in noting down the contents of86

the report, is that the case?

A. Regrettably so, yes.

Q. You did indicate, I think, to the Great Ormond Street87

Review that you may have got an incorrect report.

Which do you think is the more likely scenario?

A. Well, what certain is that there was no official report

because at the time of the event there was no, in

theatre there was no official report in the chart, and

when I took the x-rays from the x-ray packet, there was

no official x-ray report, there was no report at all in

the x-ray packet. So it was one of those. It was an

unofficial report or a handwritten report off the

screen.

Q. You wrote in your note "for nephrectomy". What did you88

mean by that?

A. Well I have heard evidence that that may have been in

some way a temporising measure, but it wasn't a

temporising measure. It was in fact a clear management

plan that a nephrectomy was required. In looking at

this note, it was clear that I intended, I erroneously

intended a left nephrectomy, whereas I may have

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discussed a right nephrectomy with the parents, I may

have been distracted, and I presume I was distracted in

some form or other, and got the side wrong.

Q. If that is so, it was a human error on your part, is89

that right?

A. Yes.

Q. Mr. Wheeler has said that if you are faced with a90

situation where there was no report on the chart, you

had a number of options, one of which was to ask the

parents to come back another day. Do you agree that

that was one of your options, and if it was, why didn't

you do that?

A. I believe that that was certainly an option. These

parents have been up and down to hospital a lot. I

really wanted to have management plan in place for this

patient. I also considered that he was having

significant and severe infections, so we wished to

arrive at a management plan that would sort out his

infections and improve his quality of life. So, yes,

it was an option not to do anything. It was an option

not to see the patient at all. It was an option not to

write anything, to explain that I hadn't got the

imaging and that we would come back another day. But

in writing this note, I clearly intended to actually

review the imaging myself, and I clearly intended to do

this operation myself, because at that time the Senior

Registrar on my service would not have been able to do

this procedure.

Q. Who was that Senior Registrar on your team?91

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A. That would have been Mr. Farhan Tareen. So at that

stage in his career he would not be able to do an

nephrectomy unaided, or in any way. So, I could not

have possibly booked the procedure without considering

that I was doing the procedure myself, and in that

situation I would have realised that I would have had a

chance to review the imaging myself.

Q. When you say you would have had a chance to review the92

imaging, in what circumstances would the imaging have

been reviewed by you?

A. Well, I think hospital systems are in place because

they recognise that everyone is fallible and that

mistakes can happen. They are there to actually, there

should be a series of brakes, and the brakes should be

applied when the red flag goes up, and the red flag is

when the parents express concerns. It is a great pity

and sadness to me that the parent's concerns were not,

were not adhered to or not listened to in significant

detail. So, it would have been my intention to review

the imaging when the patient was in theatre, or before,

if I had had an opportunity to see him on the ward

round that morning, but unfortunately I did not have an

opportunity to do that.

Q. Yes. I am going to move on, Professor, if I may, to93

what happened when Master Conroy was admitted into

hospital. I think his surgery, Ms. Stewart said, was

brought forward from the original date?

A. Yes.

Q. Ultimately Master Conroy was admitted on the 20th. He94

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was seen subsequent to his admission, the Committee has

heard, by Dr. Ghallab. Would there be circumstances

where you yourself might see patients on their

admission, or is it, in Crumlin Hospital, always a

member of your team who sees patients on admission?

A. Generally on the morning of surgery, it is not possible

to do rounds at 8:00 o'clock because we have a nurses'

hand over. It is very difficult to do full ward

rounds, but generally the Registrar will do a ward

round on the patients who are not in ICU. I would do

my own ward round in ICU in the morning before surgery.

Q. The ward round, in this case a ward round did of course95

occur on the morning of the 21st. I think it was

Mr. Paran who did the ward round, isn't that right?

A. That's correct. Mr. Paran, at that time, I had no

knowledge as to who would be helping me with my list on

that day, because Mr. Farhan Tareen was on leave. When

I booked this patient for surgery, I had no idea that

Mr. Tareen would be on leave that week, or indeed that

Mr. Paran would be the helping SPR at that time?

Q. We have heard from Ms. Stewart and Mr. Conroy that they96

say they raised a concern on the evening of the 20th,

with Dr. Ghallab, when he was performing the consent,

although he doesn't appear to recall the question of

the laterality being raised. Assuming the parents did

raise this issue with Dr. Ghallab, who indicated that

he also was not able to find a report in the chart,

what in your view should he have done?

A. Firstly I would like to state that I totally believe

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that the parents raised this issue on admission. I

think Dr. Ghallab at that point should have alerted the

Senior Registrar on call, and if that was

unsatisfactory he should have alerted me. If there was

a question of laterality being raised at that point,

there is a ward based computer, and I believe that you

can access reports, although they may be unofficial

reports, on that computer. So some degree of

cross-checking would have been possible, and certainly

it would have been possible to communicate this problem

at that stage, before it escalated to the point to

which it did.

Q. That was, the parents say, the first occasion on which97

they raised a query in relation to laterality, but

subsequent to the consenting process with Dr. Ghallab,

they say they still had concerns and they raised the

issue on a second occasion with Nurse Hart. Nurse Hart

indicated that she indicate to Nurse Quinn to pass the

issue on, and that doesn't seem to have happened. Do

you think Nurse Hart should have taken any further

steps?

A. I think it is very difficult for nursing staff to go

outside the normal hierarchical system, so to speak.

She had, Dr. Ghallab had obtained consent, and he had

assured the parents, although they weren't completely

assured at that time. I think it would be very

difficult to be totally critical of the nursing staff

for not communicating it to anyone else but a senior

nurse at that time. However, I have written to the

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Director of Nursing in Crumlin and advised that in a

situation like this that it is most appropriate for a

nurse to feel that she has the right and authority to

contact any senior member of staff if there is an issue

of laterality with any patient.

Q. The following morning then, Dr. Paran conducted the98

ward round with the SHO, Dr. Yeap. Dr. Yeap was an SHO

in your team, is that right?

A. At that time he was an SHO, but he was a highly trained

Malaysian paediatrician surgeon who was with us for a

year, and has subsequently taken up a position in

Punang as a Consultant Paediatric Surgeon.

Q. But he was assigned to your team?99

A. He was.

Q. Yes. The parents again say they raised a query, a100

third query, on the morning, although I think they are

not clear who it was that they spoke to on the morning.

Again, neither the anaesthetic team, Dr. Zaidi, who

also would have seen Master Conroy, recalls that, nor

does it seem that Dr. Yeap recalls that. I think

Dr. Paran says he didn't speak with the parents at all

during that ward round, but he did ask for the x-rays

to be made available. Would that be standard practice

on the ward round?

A. That would be good practice to ensure that the x-rays

are available. Yes.

Q. Why would one, would Mr. Paran want to have ensured101

that the x-rays were available? For what purpose?

A. Well because we are dealing with a situation of

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laterality. There is disease on one side. It is

important to be paranoid about that and to ensure that

no errors have been made in booking process or

assignment of right to left. That is primarily the

reason. It is to confirm that that is the correct

case.

Q. So he was clearly and correctly conscious of the need,102

when conducting the ward round in the morning, to have

the images to ensure that the laterality could be

verified?

A. He was doing the absolute best thing at that time to

ensure that the x-rays were available. Yes.

Q. The parents, unfortunately, and their concerns had not103

been allayed, and they say that they raised the issue

for a fourth time with Nurse Davey in the lift when

they were going down to the theatre. Nurse Davey

appears to have appropriately passed the issue on to

the theatre nurse, Nurse Suska, who in turn, the

Committee has heard, passed it on to her superior,

Nurse Delaney, and the Committee has heard from Nurse

Delaney. She passed it on to Mr. Paran, on the basis

that Nurse Delaney understood that Mr. Paran, at that

time, was doing the surgery, although he says he didn't

believe that he was doing the surgery at that stage.

When were you made aware that this cascade of queries

had been made by the parents?

A. The first knowledge I had of this was after the event,

when I went to see the parents to inform them, and I

will never forget that meeting with the parents, that

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the wrong kidney had been removed, that I had attempted

to revascularise the kidney, but unfortunately that

that had been unsuccessful. I am not sure which parent

had said it, but they told me that they had informed

people along the line of their concerns re: laterality.

I was amazed that that had happened and that no-one had

communicated that concern or anxiety to me.

Q. What, in your view, should Mr. Paran have done when the104

issue of laterality, which he appears to accept now was

raised, when the issue was raised with him, what should

he have done?

A. Well it is always ease in retrospect to say what should

have been done. I think that it would have been better

to look at the x-rays, to confirm that the right side,

the correct side was being operated on, and to, if any

concern whatsoever remained after that, to discuss this

with me.

Q. Mr. Meenan yesterday put to Mr. Wheeler that in fact105

there was no need to escalate the concern to you,

because the parent's concerns had been allayed. Is it

your view that the parent's concerns could properly be

allayed in circumstances where the images were not

viewed?

MR. MEENAN: Chairman, it does sound

like a leading question. I

am sure my Friend would probably like to rephrase it.

Q. MS. BARRINGTON: I accept that. I accept106

that. Perhaps it is a

question you have already answered, Prof. Corbally, but

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how do you believe that the parent's concerns could

best have been allayed?

A. I think their concerns were perhaps allayed in that

they were assured that the correct side was the left

side. However, if a concern has been raised by parents

at any level, it is our standard guidance that parents

are always correct and that they should be listened to,

and in that situation it takes one or two minutes to

pull the x-ray out of the folder and look at the

imaging and confirm the side.

Q. Of course the parents say, although Mr. Paran denies107

this, that in fact they asked Mr. Paran to look at the

x-rays, isn't that correct?

A. I gather that is true.

Q. On the morning, you had a list of patients who were to108

be operated on, and to that extent it is your list,

isn't that right?

A. That's correct.

Q. But can you or do you operate on all of the patients in109

your list?

A. It is not physically possible to do that with the

service commitment that we have and the level of sick

and critically ill patients that we treat, to be

available for every single patient on the list. It is

not, just not possible to do that.

Q. To that extent, the service provided in Crumlin110

Hospital is not the consultant led service that

Mr. Wheeler described yesterday in his evidence, isn't

that right?

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A. Well I think it is consultant led, but it is not

necessarily consultant delivered.

Q. Yes.111

A. At all aspects.

Q. Well I think in fairness to Mr. Wheeler, when he was112

talking about consultant led service he meant that the

surgery is necessarily delivered by the consultant in

charge of the list?

A. That's correct.

Q. That is not what happens in Crumlin Hospital?113

A. Crumlin, or a lot of other hospitals in this country

with significant service commitments.

Q. We have heard from Emma Cooney how the list operates,114

and reference to the term "parallel lists". What is

your understanding of a parallel list?

A. I think there are certain academic details and

definitions of the parallel list. My understanding of

the parallel list is a list that, a list of patients

designated for surgery on a day and X number of

patients are identified to be operated on by the Senior

Registrar, and Y number of patients to be operated on

by the consultant, with very little if any interaction

between the two lists.

Q. Is that the way the list works in Crumlin?115

A. No, it isn't. It is not the way the list worked in the

Crumlin because a list is a fluid and dynamic entity.

Everyone's focus is to get the patient in to theatre,

minimise inconvenience to parents and patients alike,

and get the procedures done in the allocated time. So

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there is a cross over of patients. If a theatre

becomes available, then a patient will go into that

theatre. If that finishes and there is a slot in the

other theatre, then the patient will move to that

theatre. It is a fluid and dynamic process.

Q. But there are often occasions where two theatres are116

being used?

A. Simultaneously, yes.

Q. And some people, as we have heard from Emma Cooney,117

referred to that scenario as being a situation where

parallel lists are run, is that right?

A. That's correct. There has been great debate about how

appropriate parallel lists are, both in this country

and in the UK. My understanding is that it is

acceptable to have such an arrangement if the delegated

Senior Registrar in the other theatre is of a

sufficient standard and quality. I had no doubt that

Mr. Paran was, and is, of that standard and quality.

However, might I add that in light of this event, and

also because we were trying to appoint new surgeons,

and have appointed two new part-time surgeons, that I

no longer have a second theatre available to me. I

have one theatre all day on a Monday, one theatre on a

Wednesday, and one theatre on a Friday.

Q. But on this day there were two theaters in operation;118

Theatre 7 and Theatre 5?

A. Yes, that's correct. That also would apply to many of

my surgical colleagues in Crumlin.

Q. There has been, I hope I am not understating, but some119

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suggestion in Mr. Paran's observations that he was

assigned to Theatre 7. Olive Delaney didn't agree with

that, but what is your view in relation to Mr. Paran's

role. Was he assigned a particular theatre?

A. No, I mean it would be I think probably traditional

practice that Theatre 7, the SPR would tend to do his

cases in there, but equally so I could go into Theatre

7 to do a case after Mr. Paran. Mr. Paran has always

been extremely helpful and generous with his time, and

he would do that quite willingly.

Q. You have indicated that Mr. Farhan Tareen was your120

normal SPR. Had he been assigned to you, you would

have done this nephrectomy yourself?

A. That is absolutely correct.

Q. What were your feelings then when you realised that121

Dr. Paran was providing cross cover in the absence of

Mr. Tareen?

A. Well, I only discovered that on the Friday morning, and

I was absolutely delighted to know that Mr. Paran was

helping me with my list.

Q. Was that unusual for a different Registrar to be made122

available to you just on the morning?

A. Yes, it could have been any of the other three

Registrars or SPRs on that day. I considered myself

fortunate that Mr. Paran was helping me. He is an

extremely talented and accomplished surgeon.

Q. I am sorry, I was asking, Professor, was it unusual for123

you to find yourself with a Registrar who was providing

cross cover on a morning, when you didn't know in

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advance who that Registrar would be?

A. Sorry, no, that would be the norm. That would be the

normal arrangement, yes.

Q. So Mr. Paran was made available to you, and you were124

happy to have him. Why were you happy to have him?

A. Well, Mr. Paran was the senior of the Senior

Registrars, the most senior. He had recently been

approved for admission to the Irish Medical Council

Specialist Registrar Paediatric Surgery. He had

returned approximately six months before from a

fellowship in Memorial Sloan-Kettering, where I knew he

would have been exposed to multiple solid tumour

surgeries, and when I discussed his training with

Dr. Michael La Quaglia, who is the Chief of Paediatric

Surgical Oncology in Sloan-Kettering, Dr. La Quaglia

was extremely complementary about his performance

during that year.

Mr. Paran had sat and passed the exit fellowship of the

European Board of Paediatric Surgery. He had I think

more than eight years, maybe eight and a half years in

paediatric surgery at that point. I had worked with

him closely, he had been my SPR in the previous six

months. I knew Mr. Paran to be a dedicated and

conscientious surgeon, and I had no doubts whatsoever

about his ability to perform, what I regarded as a very

straightforward procedure.

Q. Where did he do his medical training?125

A. Mr. Paran, I understand, went to University College

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Galway to do medicine. I think he may have gone to

secondary school in Galway as well.

Q. You had previously worked with him?126

A. Yes.

Q. Although at that time he was the Registrar assigned to127

one of your colleagues, is that correct?

A. That's correct. When he returned from Sloan-Kettering,

I think in July or August of 2007, he spent that six

month period with me as my SPR. Then for the next six

months he was rotating through with Prof. Puri. This

was kind of, he was in his last year of training, and

he was eligible from that point, within six months of

that point, to apply for a consultants post. He did

apply for a consultant post in Temple Street initially,

was unsuccessful in that, but was successful in, I

think February of this year, in obtaining a post as a

Paediatrician Surgeon in Crumlin, a position that I

welcomed him to, as his experience in paediatric

surgery and oncology would augment my practice and take

some of the pressure off me, I felt.

Q. Had he previously performed nephrectomies?128

A. Yes, he had.

Q. Had he previously performed nephrectomies on patients129

who were patients on your list?

A. Yes, he had.

Q. I want to hand you in, Professor, if I may, the listing130

of the theatre procedures for 21st March. (SAME

HANDED)

CHAIRMAN: We will call this Exhibit

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16.

Q. MS. BARRINGTON: This has been redacted only131

to remove the patient name,

but you have a column with the chart number, the

patient's date of birth, the surgeon in charge/surgeon.

What is the difference between "surgeon in

charge/surgeon"?

A. Well the surgeon in charge is the consultant in overall

charge of the patients on the list. The surgeon would

be a delegated SPR or SHO.

Q. So, the surgeon in charge is the person on whose list132

the patient is, and the surgeon is the operating

surgeon. Is that right? That is the distinction

between the two?

A. Well in that column that distinction is not clear. One

would have to look at the operational note to actually

get that final distinction.

Q. The operation type is listed, and then the timing of133

the operation. There is the timing for the start of

the anaesthetic and the end of the anaesthetic. Does

the operation in fact end before the time given for the

end of the anaesthetic?

A. Yes, it takes approximately 10, 15, 20, sometimes

slightly longer, maybe 25 minutes for anaesthesia to

have anaesthetised the patient, put in an epidural

catheter for analgesia, inserted their IV lines, and

all of those procedures, before the surgeon can

actually start the procedure. So there is a hiatus of

at least 15, 20, 25 minutes before the surgeon will

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start the procedure.

Q. Yes. Timing is given here for the end of the134

anaesthesia, but I am asking you, Professor, has the

surgery stopped before this time, the end anaesthetic

time?

A. Yes. Sorry. The anaesthetic time is when the patient

is awoken from anaesthesia. The surgical time finishes

when the abdomen or the wound, wherever that wound may

be, is closed.

Q. So the surgery presumably will have finished some135

significant time before the time given for "end

anaesthesia" on this list, is that right?

A. Yes. It depends on the level of anaesthesia that has

been used. It depends on the medications they have

given, the drugs they have used to retain anaesthesia,

and that could be 10, 15 minutes after the surgical

time has...(INTERJECTION).

Q. Yes. Then the procedure is listed. If one looks at136

them in time order, it would seem that the first

operation conducted on the day was the second listed,

chart number 535492. That was an operation where

tongue tie division. You are listed as surgeon in

charge and surgeon. The start time of the anaesthetic

is 8:36 and the end anaesthetic 8:45. So that was a

short procedure?

A. That's correct.

Q. Who do you think did that procedure?137

A. I did that procedure.

Q. Then the next procedure, following the time line, it138

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seems to be three down, chart number 542878. Again,

you are the surgeon in charge. You are the operating

surgeon. That is a hernia repair. Anaesthetic start

time 8:54, end time 9:27. Then the next procedure is

again two down, chart number 481283, and there you are

listed as the surgeon in charge, but the operating

surgeon is Mr. Paran. The start time is 9:07 of the

anaesthetic. End time of anaesthetic 9:35. I think it

was put to Nurse Delaney that Mr. Paran had performed

two short procedures in the morning. Do you think this

was the first of those procedure?

A. I think that is correct, yes.

Q. The next procedure where yourself and Mr. Paran are139

listed is over the page, 483570. Here the start

anaesthetic time is 9:25. The end is 10:50. This is a

hypospadias. Do you recall that procedure?

A. Not in great detail, but I accept that that is the

patient on the list.

Q. I think again Mr. Burke, when cross-examining Nurse140

Delaney, accepted that Mr. Paran assisted you in that

procedure?

A. That's correct.

Q. You recall that?141

A. I recall him helping with the case. The details I

cannot remember in great detail.

Q. That was in Theatre 5?142

A. In Theatre 5. Yes.

Q. Yes. So, he had come to Theatre 5 to assist you with143

that case?

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A. Yes. He had worked in Theatre 7 and then he came into

Theatre 5 to assist.

Q. The end of the anaesthetic time there is given at144

10:50. When do you believe that operation would have

been concluded, from a surgical perspective?

A. Probably around 10:45, 10:40/10:45. A fistula repair,

it is quite a straightforward repair. It takes about

15 minutes to do.

Q. Oh yes, the hypospadias. That is a fistula repair?145

A. Yes.

Q. Yes. Then the next procedure is just above that146

515562. The start anaesthetic time is 9:55. The

surgeons listed are yourself, and as operating surgeon

Mr. Paran. That is a very short procedure. The

anaesthetic is over at 10:06. Who do you think did

that?

A. Mr. Paran.

Q. Then the next procedure listed is the procedure on147

Mr. Conroy. It is at the very start of the list, where

you are listed as surgeon in charge and operating

surgeon. Why do you think you are listed as surgeon in

charge and operating surgeon?

A. Because when this procedure went wrong I immediately

scrubbed in to try and salvage the case. So the

nursing staff entering the data on the computer screen

would have acknowledged me as the senior person there

doing the operating. I think that is reflected in the

operating notes as well.

Q. Nurse Delaney's evidence, that you of course heard, was148

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that she was in the theatre with you and that you, at

the end of your procedure, asked for the next patient

to be brought down, which was Mr. Conroy, sorry,

Master Conroy. She rang the ward and asked that he be

brought down. He had not had his premedical, and we

know that that was given at 10:30. She says that you

had told her at that stage, which was therefore some

time before 10:30, that Mr. Paran was doing this

surgery. Do you think her version is correct? When do

you believe you had the conversation with Mr. Paran?

A. I had a conversation with Mr. Paran shortly after the

hypospadias case would have finished, or the surgical

part would have finished, and I asked him if he would

like to do the case. I requested whether he would be

happy do to, and he said he would. I was delighted

that he was going to do it.

Q. When you had the conversation with Nurse Delaney, she149

couldn't say whether you had already spoken to

Mr. Paran, because he wasn't there, but she said it

would be unusual for you to ask, to tell her that

Mr. Paran was doing the surgery if you hadn't had the

conversation with Mr. Paran. Do you agree with that?

Do you think by the time you spoke to Nurse Delaney you

had already spoken to Mr. Paran?

A. I cannot be sure of the precise time. I know that I

spoke to Mr. Paran before the patient in question

arrived in theatre, at the theatre reception area even.

That was after the hypospadias repair had been done.

So it was some time between 10:30 and 11:00 o'clock.

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I cannot tell you whether or not I had spoken to Olive

Delaney in advance of that or not. I cannot recall

that.

Q. What did you say to Mr. Paran in relation to the150

performance of the nephrectomy?

A. I asked Mr. Paran if he would like to do the

nephrectomy.

Q. What was his response?151

A. He seemed please and he said, yes, he was more than

happy to do the procedure.

Q. Why did you ask him to do it?152

A. Well Mr. Paran was at that point where he was

transiting from his Senior Registrar training into

consultant status, and I felt that this procedure was

well within his capability to do it, and as an

accomplished trainee I had every confidence in him. I

think it was a measure of the confidence in him and the

trust that we had that he would be given this procedure

or asked to do this procedure.

Q. Mr. Paran, in his observations, says that he had no153

concern about his ability to perform the operation.

Was that the impression you had?

A. Yes. That would be not only my impression but also

Dr. Mannion, the anaesthetist's impression. Very often

anaesthesia are the people who tell you that a trainee,

that they are not happy with a certain trainee doing

the procedure, and they will intervene in that

decision. Dr. Mannion was completely happy with

Mr. Paran doing the procedure.

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Q. Mr. Paran says that you didn't ask would he like to154

perform the nephrectomy until some time after the

patient was anaesthetised, is that correct?

A. Is it correct that Mr. Paran states that or?

Q. I am sorry. Do you believe that his version, as he has155

stated, is correct?

A. No, I do not. I came back into the theatre and the

patient was now asleep on the table, and I asked him

again if he was okay to proceed.

Q. So are you saying you had two conversations with156

Mr. Paran?

A. I had two conversations.

Q. Yes. In the first conversation you asked him if he157

would like to conduct the nephrectomy and he indicated

that he was happy to do so. Is that correct?

A. That's correct.

Q. Yes. Then you subsequently had a conversation when at158

that stage the anaesthesia had been induced?

A. That's correct.

Q. Thank you. We know Professor the external review timed159

the commencement of the operation, by which I mean the

knife to skin, as I think the surgeons call it,

commencement of the operation at 11:40.

Mr. Mannion, the anaesthetist says, while he did not

record it in his anaesthetic note he thinks it was

around 11:40. Mr. Paran said I think for the first

time yesterday that the conversation he had with you

was five minutes before the operation started. Now it

is not clear whether he means five minutes before the

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knife to skin or 5 minutes before the anaesthesia was

induced. That remains to be clarified, but if he is

saying that he was asked five minutes before, and I am

sorry to put it crudely, but to distinguish the time

frame before knife to skin, then he is saying that he

was...(INTERJECTION)

MR. MEENAN: Could I just possibly --

MS. BARRINGTON: Yes.

MR. MEENAN: Intervene here, because I

think when I put the matter

to Mr. Wheeler yesterday, I put it to him very

specifically that this conversation took place after

anaesthesia had been introduced, because I put to

Mr. Wheeler the sequence of events which was namely

that Mr. Paran went back to 5, the patient was being

induced. The anaesthetist asked Mr. Paran to

catheterise the patient, which he did, and he was then

turning to leave. So there is absolutely no dispute

about what I put, which was to the effect that the

conversation I say took place took place after

anaesthesia had been induced.

MR. LEONARD: That is also my memory of

that.

MR. MEENAN: That is entirely clear from

the questioning, and I

think my friend is incorrect to say that there is a

dispute there.

MS. BARRINGTON: Yes.

MR. CROSS: It is a dispute between the

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2 witnesses.

MR. MEENAN: No, no I think Mr. Cross

what had been put to the

witness was it was not clear--

MR. CROSS: That's right.

MR. MEENAN: Whether the conversation

took place either before

anaesthesia or after anaesthesia, and I put very

specifically it took place after anaesthesia.

Q. MS. BARRINGTON: I am grateful to Mr. Meenan160

for that clarification.

One of the questions, and perhaps there are other

questions that make it clearer that I did not

appreciate. He said to Mr. Wheeler the evidence from

Mr. Paran in this case is that he was told he was going

to be doing this elective nephrectomy on the child less

than five minutes before the operation. That is at

page 103, question 250, but it seems, and I am grateful

for the clarification, that what is being said by

Mr. Paran is that he was asked by you to perform this

nephrectomy five minutes before the knife to skin,

which is about 11:35. What do you say about that?

A. I would have to dispute that. That is not my

recollection of events at all.

Q. What did you, when you asked Mr. Paran to perform the161

nephrectomy, what did you expect Mr. Paran to do?

A. I expected to see Mr. Paran after the case was

finished. I expected that Mr. Paran would take over

all aspects of management of the case, as he had done

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many times before. I expected that there would be no

difficulty whatsoever with him doing the case or the

procedural aspects of the case. I had every

expectation that everything would be done properly.

Q. When you say "everything would be done properly", can I162

ask you to be a little bit more specific. What

documentation would you have expected Mr. Paran to have

had regard to?

A. The consent, patient identity and the imaging.

Q. And what would you have expected him to have done with163

the imaging?

A. I would have expected him to confirm that the correct

side was the left side.

Q. And how would he have gone about doing that? Should he164

have, for example, in your view placed the images on

the, is it the image box or the x-ray box?

A. The x-ray screen.

Q. The x-ray screen?165

A. Yes, he could have done that or he could have taken the

images out of the packet and looked at them against the

light.

Q. Mr. Wheeler has expressed the view that it did not166

really matter whether he put it on the box or not, and

that different practitioners have different ways of

doing it, is that your view?

A. That is correct, but normally the x-rays are left on

the box during surgery.

Q. Can you describe this box for us?167

A. It is just an...(INTERJECTION).

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Q. In particular in theatre 5?168

A. It is an illuminated surface, back light, shining

through the surface which highlights the x-ray picture.

Q. What is your practice in relation to imaging when169

performing a nephrectomy?

A. I would like to have the images there all the time.

Q. Do I take it from that, that you mean on the box?170

A. On the box.

Q. Do you believe that Mr. Paran knew that for this type171

of surgery it was necessary to have regard to the

imaging?

A. I would be very surprised if Mr. Paran did not know

that given his level of experience and training and his

track record to that date. I believe that Mr. Paran

would have known the importance and value of looking at

the at x-rays, and also in the context of parental

concern, reviewing the x-rays at that point also.

Q. Do you consider that as Mr. Paran wanted the x-rays172

when he did the ward round in the morning, he was

conscious of the need for the x-rays for surgery?

A. I believe so. I think he was acting properly and with

best practice in mind at that time.

Q. In terms of timing of the commencement of knife to173

skin, who dictates the starting time?

A. The surgeon dictates the start time. There is never in

elective situations, whilst there may be pressure to

get through the list, the surgeon has to be sure that

he is operating on the right side and in the right

context. So the surgeon decides when the list starts

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or the case starts. Knife to skin is the surgeon's

responsibility.

Q. Yes, and we have heard -- the Committee has heard from174

Nurse Delaney and Mr. Mortell and Nurse Davey, that

they all went to look for the images when the patient

was brought to the reception. Why do you believe that

they all went to look for the images?

A. I think they were all being helpful, but they also had

an instinctive belief that the images were important as

part of the procedure. I think in Mr. Mortell's case

that is actually a surgical belief.

Q. And Nurse Delaney says the images were placed on the175

trolley while the parents were still conversing with

Mr. Paran, and that she caught Mr. Paran's eye and

said, "you have everything now Sri" I think she said.

So there seems to be no doubt but that the images were

on the trolley before the patient was brought into

theatre, is that not correct?

A. I think that is correct.

Q. If Mr. Paran had believed that he required more time to176

prepare before commencing the knife to skin part of the

operation, what should he have done?

A. I think with his level of experience and training,

Mr. Paran had every opportunity to say, hold on, let us

pause for a minute, let us review the x-rays first.

Q. In terms of familiarising himself, as you have said he177

should have done, once he was asked to perform the

surgery with the documentation, including the imaging.

How much time does that take?

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A. Well, ideally one should have longer than a few

minutes, but it does essentially take one or 2 minutes

to actually look up an x-ray.

Q. How much time do you believe at a minimum that178

Mr. Paran in fact had between the time when you asked

him to perform the nephrectomy, and the knife to skin

time?

A. I think he had at least 30 minutes, considering that

the procedure started at 11:40. That is knife to skin.

By time line estimate and Dr. Mannion's estimate, the

patient arriving in theatre at around 11:05 perhaps. I

know that somewhere between the end of the hypospadias

case and 11:00 o'clock, I would have asked Mr. Paran if

he wished to do the procedure. So there is at least 30

minutes in that window to look at imaging and discuss

procedure.

Q. How do you think you relate to junior staff?179

MR. MEENAN: Could I just possibly

intervene at this stage,

and there may well be a difficulty here insofar as

virtually none of this was put to the expert by my

friend to Mr. Wheeler, most critically the suggestion

that Mr. Paran had at least 30 minutes to prepare for

this operation.

MR. CROSS: But is that something that

should have been put to the

expert, because it is a matter of fact for the

Committee to decide how long that is the case.

MR. MEENAN: I appreciate that, but what

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appears to be happening now

is that Prof. Corbally is now effectively being used as

an expert witness in allegations of professional

misconduct against Mr. Paran, and I say that is

fundamentally wrong. That should have been put

to...(INTERJECTION)

MR. CROSS: I mean I think the

Professor is being used as

a witness and he is giving opinions certainly in his

own defence.

MR. MEENAN: On the basis that attack is

the best form of defence.

MR. CROSS: No, no, Mr. Meenan. I

think that, yes, certainly

and it was flagged yesterday that there was a

difference between the likely evidence as to the time

that your client was told to do the operation, or asked

could he do the operation and that may have

implications in relation to your --

MR. MEENAN: Yes.

MR. CROSS: But I think the other

matter is matters of his

defence, I think.

MR. MEENAN: We will just see how

matters develop.

MR. CROSS: We will see how matters

develop.

Q. MS. BARRINGTON: Very good. I am sorry I am180

just trying to recall the

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question I was going to ask you, Professor. Yes, I

asked you how do you think you relate to junior staff

or staff more junior to you?

A. Well, I hope that I relate well to junior staff. I

think that I am level headed and balanced, and I think

that it is not that long ago really that I was a junior

doctor myself, and I always think that it is important

that you put yourself in their shoes when you are

dealing with the difficulties they have to deal with on

a regular basis. So I think I am approachable. I

think that I have standards, and those standards should

be met, but standards can be met in an approachable

rather than a dictatorial way, and that is the way I

would like to think my practice runs. I am not in the

least bit dictatorial or aggressive or authoritarian, I

believe, personally.

Q. If Mr. Paran was in any way uncomfortable in relation181

to performing the nephrectomy, whether for timing

reasons or otherwise, what do you think he should have

done?

A. I think Mr. Paran should have spoken to me. Our

relationship was many faceted actually because I would

have regarded Mr. Paran as a friend, not only as a

colleague. So I think that it was always possible to

say I have a problem or I am concerned, and to sit down

together and review that problem. That is always an

option and it is an option with anyone in my practice

to do that. In fact our trainees are encouraged to

actually say, look, we have a problem, to bring it, to

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highlight the issue. There is no criticism whatsoever

if a trainee does that at any level.

Q. Mr. Meenan emphasised two matters yesterday in his182

cross-examination of Mr. Wheeler, which he seemed to

have been suggesting illustrated the fact that

Mr. Paran was not being allowed sufficient time, or

that this delegation should not have happened when it

did happen. The first of those is that he said that it

was for Mr. Paran to do what I think it is referred to

as "the group and hold" in relation to bloods. What is

the normal procedure in relation to performing group

and hold for blood?

A. It is standard operational policy that when a patient

is admitted for a procedure of this type, that blood

will be sent the day before to the lab for a group and

hold. That means that the patient's blood group is

identified, and serum is preserved, the sample is

preserved for subsequent cross-matching against a unit

of blood, should the need arise to transfuse a patient.

We do not routinely group and cross-match, ie., pick a

designated unit of blood for that patient for

nephrectomies because blood less is typically quite low

in nephrectomies.

Q. What is the normal blood loss for a nephrectomy?183

A. For a straightforward nephrectomy I would say about

25/35 mls. I would cross-match blood for a Wilms'

Tumour, only if that tumour was extending into the

inferior vena cava or if there were significantly

pre-operative invasion of the liver, for example, then

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I would definitely need blood in that situation, but

otherwise if you cross-match blood and you don't use

it, the blood has to be thrown out. It is a waste of a

very very valuable resource.

Q. In this case I think the chart shows that one of the184

pre-operative tasks in the nursing care was to perform

a G & H, that is group and hold, is it?

A. Yes, group and hold, yes.

Q. That is at page 50 of the chart. You might please look185

at that Prof. Corbally?

A. Yes.

Q. And then the nurses record at page 52 that on the 21st186

the care was as per plan. If you turn over to page 53,

the second entry there for 20th March, 22 hours, shows

that the group and hold was done?

A. That's correct.

Q. What do you think happened in this case in relation to187

the group and hold?

A. Occasionally the blood bank will run into problems with

the group and hold. I am not quite sure what technical

problems they have. I am not an expert on blood

cross-matching, but very often they will ask for a

second sample to be sent down and that second sample

then would be used to group and hold the patient or

cross-match if necessary.

Q. Who takes the sample?188

A. We have a phlebotomy service in Crumlin. So if it was

during regular working hours, they would take the

sample, but if that problem was highlighted

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intra-operatively, then the anaesthetist generally

would take the sample.

Q. Yes. So is a request for a second group and hold189

something that is directed to the anaesthetist?

A. Well, it may be or it may be directed to the surgeon.

Q. But would it be fair to say that in circumstances where190

the group and hold was done on the 20th, a request for

a second group and hold is not in any way indicative of

a lack of preparation of the list?

A. Not at all, no.

Q. What is the position in relation to the provision of191

assistance? We have heard from Dr. Mohamed that he was

asked outside the theatre by Mr. Paran to make himself

available to assist Mr. Paran in the surgery that he

was to perform. Again, Mr. Meenan seemed to suggest

that it was, perhaps I am overstating it, but somehow

irregular for Mr. Paran to have been asked to perform

the nephrectomy in circumstances where an SHO had not

been formally assigned to him. How does it work? How

does a registrar get his assistant?

A. Well, the surgeon, the operating surgeon recognises the

need for an assistant and then either will directly

contact an SHO or a fellow registrar to come to theatre

and assist, or he may also ask the senior nurse or one

of the circulating nurses to call for an assistant to

come to theatre, and Mr. Paran would recognise that as

best practice and indeed did that.

Q. Is it, therefore, a part of your function to organise192

the SHO for the registrar?

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A. No, it is the operating surgeon's responsibility to a)

recognise the need for an assistant and b) to secure

one.

Q. Dr. Mohamed told us that he came and assisted in the193

surgery which had at that stage commenced, in that the

incision had been made, and that during the course of

the surgery Mr. Paran appreciated that the kidney

looked normal. We have heard from Mr. Meenan's

cross-examination that Mr. Paran had been having a

difficulty, in that the incision he said was too small.

Were you made aware of any of these difficulties?

A. No.

Q. Where were you while the surgery was ongoing?194

A. Initially I went to see a patient in intensive care.

Then I had some calls to make in relation to queries

from patients, and then I was doing some chart work in

the surgical dictation room which is just outside

theatre 5, about 15 feet away.

Q. If Mr. Paran had encountered any particular problems in195

the performance of the nephrectomy, what would you have

expected him to do?

A. Well, colleagues are what they are, they are

colleagues. They are meant to be called in the event

of any difficulty or trouble, and I would have expected

Mr. Paran to call me if there was any difficulty

whatsoever.

Q. I am skipping back a little in time, Professor, and I196

am sorry, there is something I should have addressed.

You said you had 2 conversations with Mr. Paran. The

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first you asked Mr. Paran was he happy to conduct the

surgery, and you understood that he was and he says in

his observations, he had no concerns. Subsequently you

had you said a second conversation with him, can you

outline for the Committee what was that second

conversation?

A. The second conversation occurred when the patient was

asleep on the table, anaesthetised, and I think

Mr. Paran had just finished catheterising the patient.

We were positioning the patient for surgery, I think he

had put a roll under the patient's side to elevate the

left side. I think he indicated that he was going to

do it through a lower incision, which I thought would

be difficult to do the case through the incision, not

impossible, but difficult, and I suggested that he make

a left upper quadrant transverse incision which would

gain access to the left kidney.

Q. Can you recall the basis upon which he indicated to you197

that he was proposing using the old scar?

A. Well, I think as surgeons we are always conscious of

the effect of scars on appearance, and I think

Mr. Paran was thinking of trying to make it as

cosmetically attractive as possible.

Q. And you then said to -- I am sorry I did not quite198

catch the description you gave of the incision?

A. Yes, an incision that goes parallel to the body line.

Q. Yes.199

A. In the left upper quadrant, under the left rib cage.

Q. Yes. So were you saying to him he could not use the200

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old scar?

A. I was saying that I thought he should not use the old

scar. I thought it would be better if he used the

other scar. You could use the lower scar and extend it

but you would have to extend it significantly to access

--

Q. I think you said "the other scar", do you mean to201

create a new scar?

A. No, the patient had a left lower quadrant scar from his

previous colostomy. He had a colostomy at the time he

had his repair of the congenital anorectal problem, and

that colostomy was subsequently closed. So there was a

scar there just below the umbilicus. So I thought that

that incision would be too low to gain access to the

kidney.

Q. It may be suggested by Mr. Paran that because you had202

this conversation, he did not understand that there had

been a full delegation of the surgery to him. Can I

ask you to comment on that?

A. Well, I think it is implicit in asking a colleague of

seniority like Mr. Paran, that if you agree to do the

procedure that is you are accepting delegation of the

procedure. That is what I understood by the

discussion, that he was very happy to do the procedure

and delegation was an efficient process.

Q. Do you think the conversation you had in relation to203

the scar changed that dynamic in any respect?

A. It might have changed the dynamic if I was going to be

physically involved in the procedure, but there was no

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intention or suggestion that I would be. It was still

with Mr. Paran to do the operation.

Q. Can I ask you to look at Mr. Paran's operation note?204

That is at page 70 of the booklet?

A. Yes.

Q. Mr. Paran states at the start of the operation note,205

the third line down, that "consent and chart notes

checked for side". Does that indicate a consciousness

on his part at the commencement of the surgery that he

should verify the laterality?

A. These notes were written after the event.

Q. Yes.206

A. So it may reflect that process was highlighted in his

mind.

Q. But what he checked and what he records that he checked207

at the outset is the consent and the chart notes?

A. That's correct.

Q. That does, does it not, demonstrate a consciousness208

that...(INTERJECTION)

MR. LEONARD: I think the witness has

given his

answer...(INTERJECTION)

MS. BARRINGTON: No, I accept that. I

accept that.

MR. MEENAN: I think there has to be a

limit to the leading

questions, and we have reached it.

Q. MS. BARRINGTON: No, very good. I accept209

that. What do you think

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Mr. Paran should have done when he considered that the

kidney was normal?

A. He should have paused. He should have taken stock of

the situation. He should have asked for the x-rays to

be put on the screen if he was not willing to unscrub

and handle the x-rays himself, and he should have asked

for me to be brought to the theatre immediately.

Q. Mr. Meenan says Mr. Paran did pause, and he did ask I210

think Dr. Mohamed to look at the consent form and the

chart. Do you have any criticism of that?

A. Well, I think Mr. Paran had already looked at the chart

at theatre reception. So there was no point in going

back to check the chart again. At that time you have

to refer -- at that point it is not too late to refer

to the core reference, which are the images and the

images would have clarified the situation.

Q. The images?211

A. The x-ray images.

Q. I am sorry?212

A. Would have clarified.

Q. Would have clarified?213

A. The situation.

Q. When were you called in?214

A. Dr. Mannion called me in in fact. He asked me to go

into theatre 5 and discreetly check the procedure,

because there was some more bleeding than normal and

that would have been maybe 45 minutes later, about 45 I

would say after the procedure had started.

Q. Can you indicate to the Committee what happened when215

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you came in to theatre 5?

A. I went through the anaesthetic room, which is

anaesthetic room 5, which is beside theatre 5's door.

I stood at the door and asked -- I had noted that in

the suction bottle there was more blood than I would

have normally expected in a routine nephrectomy, and I

asked Mr. Paran was he okay and he said he was. He had

some bleeding but it was under control. At that point

the kidney was delivered to the surface of the

abdominal wall, and to me standing at the door it

looked as if it was a normal kidney, and I said such to

Mr. Paran that I thought the kidney looked normal, have

you checked the x-rays? He replied that he had not.

Q. There was a suggestion made through Mr. Meenan216

yesterday that maybe Mr. Paran may have thought,

although it is not articulated in his observations,

that this was a baggy kidney. What should he have done

if he had a concern that this was a baggy kidney?

A. Well, he should have consulted the x-rays and he should

have called me.

Q. What did you do then when Mr. Paran said he had not217

looked at the images?

A. I was initially shocked by this and shocked by the

concept that this was a normal kidney, but I

immediately pulled the x-rays from the packet and put

them on the screening box and asked someone to review

the report. I think Dr. Mannion said the report was

not in the chart, and I believe he was the one who went

to x-ray, to produce an official report, whilst I was

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looking at the imaging. Looking at the imaging it was

immediately apparent that the left kidney was in fact

the kidney contributing 91% of function on the DMSA

scan, and in fact that the wrong kidney had been

devascularised. So I immediately scrubbed in.

Mr. Paran tied off the ureter at this point and removed

the kidney.

MR. LEONARD: Sorry, I did not catch, Mr.

Paran --?

A. Mr. Paran tied off the ureter and removed the kidney.

Q. MS. BARRINGTON: At what stage did he remove218

the kidney?

A. The blood supply to the kidney had already been

divided. So the kidney was devascularised at this

point.

Q. It may be helpful for the Committee if we were to hand219

in an image of the kidney to fully appreciate at what

stage the surgery was at when Prof. Corbally entered

the room. That is exhibit?

CHAIRMAN: 17.

Q. MS. BARRINGTON: 17.220

A. So the diagram shows that there is a renal artery and a

renal vein, which are marked, and the ureter which is

also marked. These are the 3 important components of

the kidney in terms of nephrectomy. They are the three

structures that have to be divided and tied to remove

the kidney. The renal vein lies in front of the renal

artery, and to remove the kidney one has to tie off the

renal vein and the renal artery and then tie off the

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ureter and divide the ureter.

When I entered the theatre, the renal artery and the

renal vein had been already tied off and divided, and

the kidney was now lying on the surface of the abdomen

attached only by the ureter, and the ureter was then --

when I was looking at the imaging Mr. Paran tied off

the ureter.

Q. And did the tying off of the ureter impact on the221

viability of the kidney?

A. I don't think it would have interfered or influenced

the viability at that stage.

Q. And that is because the blood supply through the artery222

and vein had been gone for some time, is that correct?

A. I believe so.

Q. Mr. Mannion has taken us through what happened then and223

the attempts to re-implant the kidney and the

involvement of the Beaumont team. Can I ask you to

move on to your conversation with the parents after,

which I think was at about 3:30 or 4:00 o'clock, is

that correct?

A. It would have been around that time, yes.

Q. The nursing notes at page 56 record a request timed at224

3:30 or rather a call at 3:30 from you requesting to

meet with Master Conroy's parents on the ward. Can you

just briefly outline to the Committee what you said to

the parents?

A. I had attempted to re-vascularise the kidney and had

achieved a very good arterial anastomosis, with free

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blood running through the kidney, but unfortunately

there was some coagulation within the kidney beyond the

arterial anastomosis, which was confirmed...(inaudible

due to coughing) while the anastomosis was intact,

unfortunately the kidney itself was not viable. So at

that point we had Ms. Dilly Little, who is a renal

transplant surgeon in Beaumont in attendance, and she

advised that we should not leave this kidney in place,

that it should be removed because of potential for

complications with this kidney. So I had a very sad

and difficult task to tell both of the parents and

explain, as best I could, that an error had occurred

and that the wrong kidney in fact had been removed and

that I had attempted to revascularise the kidney, but

that our attempts had been unsuccessful. I apologised

profoundly and profusely to the parents, and the memory

of that conversation will live with me for a long time.

They were absolutely devastated and distraught by this

news.

I advise that on further consultation, not only from

the transplant team, but from my colleagues within the

hospital, that the kidney as it now was was not

functioning and was not likely to function, and could

be a source of problems to the child in the next few

days, and that the advice was that the kidney should be

removed.

Q. And the parents say that they did not appreciate during225

the course of that conversation that you did not

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perform the surgery. You apologised to them. Can you

explain to the Committee why you apologised and why you

did not elaborate on your role in relation to the

surgery?

A. I felt that the right thing to do was to apologise to

the parents and explain that an error had occurred, and

not at that point to make the situation worse by trying

to blame somebody else for the procedure. I knew that

the details would emerge in due course, and that that

would be the right time to have -- that the right

information would be available at that time, but I felt

that ethically I had a responsibility to accept

responsibility for this procedure and for the mishap

that occurred. I did not want to put the parents under

any further pressure at that time by adding someone

else into the equation and blaming somebody else for

this procedure.

Q. The independent review, Professor, has identified a226

number of contributory factors in relation to what

occurred here. Can I ask you to look very briefly at

that report, Professor? I am sorry, you do not have

it. It is in the core booklet and I think it is behind

tab 6. I am looking, Professor, at page 4 of the

report and the heading "contributory factors". Do you

agree with the thrust of this report?

A. Absolutely, yes.

Q. Is there any personal criticism of you in this report?227

A. Not that I am aware of.

Q. The contributory factors are identified at page 4 under228

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the heading "contributory factors". Ten of them are

listed. At one, an incorrect imaging report from 6

years earlier had not been identified and corrected.

That is the report of 8th February 2002, is that right?

A. That's correct.

Q. Is it your view that that incorrect background might229

have contributed to your human error?

A. It is possible that it may have.

Q. The second contributory factor is the delay in filing230

hard copy x-ray reports in the medical records, and

lack of reference to an electronic copy. Is that an

issue that continues to be a problem in the hospital?

A. This is a very significant issue for the hospital to

deal with. Whilst the Hospital Board have accepted and

agreed to implement all of the findings and

recommendations of this independent report,

nevertheless as of February of this year there are

18,000 unfiled reports and letters in the hospital

system. I have been trying very hard to encourage the

hospital to appoint a filing clerk purely to actually

file these appropriately, but they have only recently

started to try and cope with a significant backlog of

reports and letters. There have been secretarial

issues and my secretary was not allowed, well, not

given the actual proper system to file and that

resulted in industrial action last year, which happily

is solved at this point.

Q. The third contributory factor is identified as the fact231

that there was no failsafe system to ensure that a

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patient undergoing removal of a major organ was

discussed in a multi-disciplinary setting, as the

consultant had intended. I have not actually asked you

about that, Professor. It does not form part of the

allegations as they now stand. Did you intend at any

stage to have a multi-disciplinary discussion in

relation to the necessity to perform a nephrectomy?

A. Not in so much as the necessity to perform a

nephrectomy. We had a situation of severe recurrent

urinary tract infections. A child on prophylactic

antibiotics, being extremely sick with these infections

and having demonstrated a function of less than 10% in

a scarred kidney. By any, any standard that means the

kidney should be removed.

I wrote to a radiology colleague asking that the images

be reviewed in relation to bladder function, because I

felt the bladder function may have contributed to this

problem, although he had very insignificant bladder

symptomatology and on the ultrasound also said the

bladder was normal. Normally when one writes to a

radiology colleague, it does result in a discussion of

the imaging or the case and that discussion usually

takes place in either the radiologist's office, or the

radiologist brings that to our Wednesday morning

multi-disciplinary meeting, which is attended by x-ray

staff and the surgical teams. So it would have been my

intention, by alerting radiology, that there was a need

for discussion of this patient of the images and

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results of this patient.

Q. But that discussion, if I have understood you232

correctly, was you envisaged a possible discussion in

relation to bladder functioning?

A. Yes, as a discrete problem, yes.

Q. Yes, and why did that discussion not occur?233

A. I cannot answer that. The radiologist question did not

receive -- states he did not receive the letters.

Q. The fourth contributory factor is that patients are234

admitted outside normal working hours. The fifth that

radiology is not normally sent to the ward or the

theatre, and I think that is the policy you indicated

that the hospital had introduced, that the x-rays do

not go with the patient through the patient's journey,

is that right?

A. That's correct. We have had several meetings with

radiology subsequent to this, and radiology will still

not release x-rays to the ward. They are waiting for

the PACS system, but x-rays, all x-rays, no matter

whether they were done 6 months before or 2 years

before on a patient, if the patient is having surgery

all x-rays are brought to the theatre on the day of

surgery.

Q. The sixth contributory factor was that consent is235

generally taken by surgeons not competent to perform

the procedure, and I think that is the taking of

consent by an SHO. Do the SHO's continue to consent

patients in Crumlin?

A. Yes, but in this case the SHO who took consent was

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actually quite competent to take consent, and I have

issue with the statement as written here. Dr. Ghallab,

who took consent, had over 7 years of experience in

paediatric surgery. At least one of those was at a

registrar level in Saudi Arabia, and the content of his

consent, the description of potential complications was

quite reasonable for an SHO. The only issue I would

have is that Dr. Ghallab did not inform of any concerns

nor did he take the opportunity to look at the computer

on the ward to review the radiology report. At this

time if a patient is admitted out-of-hours, the SHO,

who may not be a surgical SHO on the general surgical

team, will take consent for admission, but the

following morning consent will be either by myself or

the SPR.

Q. Or the SPR?236

A. Yes. Sorry, that is for major cases. It is not for

day cases. Generally speaking day cases are, yes, the

consent is taken by the SHO.

Q. The next contributory factor identified is that the237

person taking consent for a procedure will not normally

review imaging. 8, SPR hours and workload and lack of

planning for cross-cover is identified as a factor, and

I think that relates to the fact that Mr. Paran was

only made available to you on the morning of this day,

is that correct?

A. That's correct, because the list goes into theatre the

day before surgery and I would generally look at that

list and review the list with an SHO or my own

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Registrar, but on the day in question of course

Mr. Farhan Tareen was away and Mr. Paran would not have

been with me on the day before surgery. So there was

no opportunity to review the list with the registrar

who was actually helping on the day.

Q. The next factor is that the hospital had no site238

marking policy or common practice, can you just briefly

say what that relates to?

A. Well, that is correct. We advocated sight marking but

it was not always enforced or it was difficult to

enforce, but it is now strictly enforced that no

patient will come to theatre without the proper siting

marking.

Q. Ten, the operation and planning of a parallel theatre239

list. I think you alluded to this earlier on, that the

external review was critical, to some degree, of the

operation of parallel lists but do they continue to

some extent to be a fact of life in Crumlin?

A. No, the second list is no longer available. All the

general surgeons have given up their second lists and

we have one theatre only per list. So Mr. Quinn and I

would have all day theatre lists. I am there on

Monday, Wednesday and Friday. The other part-time

consultants or half time consultants, they work in

Temple Street and/or Tallaght. They would have one

list allocated to them.

Q. I am sorry...(INTERJECTION)240

A. One theatre.

Q. I was not clear about that, and is that as a result of241

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the appointment of new staff?

A. Well, it is to facilitate the appointment of new staff,

but it is also in recognition of the problems that

simultaneous theatre sessions have.

Q. I think the view was expressed to the external review,242

it is at page 11 of the report by the head of

department and that is Prof. Puri, is it?

A. At that time Prof. Puri, yes.

Q. Prof. Puri it is referred to. The last paragraph at243

page 11 that:

"The head of department felt at thetime that without parallel lists thedepartment would not be able to keeppace with its service commitments?"

A. That's correct. As a result -- well, he have increased

our complement by one part-time surgeon and we are

hoping that Mr. Paran will start soon. So we will have

a total of 5 surgeons in Crumlin, 2 full-time, 3

part-time and that may well take some of the pressure

off our list, but we have tried to reduced our service

commitment. Unfortunately, that means extending

waiting lists but that is unavoidable.

Q. The external review made a number of recommendations,244

and I don't propose going through them, Professor, but

have you personally taken steps to seek, insofar as you

can, to implement the recommendations?

A. I am 100% compliant with the concept of time out

surgical pause, which means that before the procedure,

the surgical procedure begins, the patient is

identified, any problems with the patient are

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75

identified. If there is outstanding x-rays, the x-rays

are there. The x-rays have to be reviewed. We cannot

as yet sort out pre-admission clinics. There is a

staff costs implication. We have addressed it with

hospital administration. They are not able to oblige,

to sort that one out just yet. Radiology is sent to

theatre, not to the ward. We have not been able to get

radiology sent to the ward, but we are assured that we

will have a PACS system next year. The consent issue,

as I have addressed already, is not taken by anyone not

competent to take consent.

There is another issue too in that Mr. Quinn and I met

with senior management months before this incident and

advise that there was a serious problem in the medical

records department, and that there was a significant

and unacceptable delay in filing reports. We did

advice that a crisis was waiting to happen, and that we

were assured that the issue would be addressed, but

unfortunately it took several months for that to be

addressed.

Q. How did you feel after this?245

A. Personally devastated by this, by the entire event. I

must say that I felt that I had let this child down. I

felt the surgical team had let this child down, and I

felt that in addition, and significantly, the hospital

had let this child down and again I apologise to the

parents for the trauma caused to them and to their

child. As a paediatric surgery, it is not what we are

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76

there to do. We are there to help children and their

families and improve their quality of life, and this

clearly was not the case and the situation but, yes,

absolutely devastated and shocked, horrified by the

entire procedure, and if that is how I feel like it is

only a small part of how the parents must feel in the

situation, especially when they made so many requests

to be heard and their requests were not listened to.

Q. This tragic and devastating event has prompted your246

desire I think to study risk management, is that right?

A. That's correct.

Q. And that is why you have signed up for the diploma, I247

think the Committee saw referred to in your CV?

A. That's correct.

Q. Lastly, Professor, I wanted to ask you about the 360248

degree review that was conducted in relation to you.

CHAIRMAN: We will call this exhibit

number 18. Sorry for

interrupting.

Q. MS. BARRINGTON: Can you explain to the249

Committee what this is?

A. I think that a variety of medical practitioners were

canvassed by the Medical Council some time ago as to

whether or not they would participate in a trial or a

pilot study called a 360 degree clinical assessment,

which I think was meant by the Medical Council to help

them establish ongoing training accreditation of

practitioners in Ireland. I felt this would be a good

thing to do.

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Q. When were you asked to participate in this?250

A. I cannot remember precisely the date, but I believe it

was before this was sent to the Medical Council

initially, but it was actually only conducted in the

last 6 months I believe. Essentially a 360 clinical is

where all people who you encounter in your daily

practice, so patients, students, junior staff, nurses,

porters, secretaries. So everyone around you in a 360

radius would be asked to score your performance and

your behaviour, etc.

Q. Can I ask you, Professor, to look at page 6. I am251

looking at 3rd August 2010, is that the --?

A. Yes.

Q. And the colleague assessment is set out there, and the252

colleagues then are everybody you work with, is that

right?

A. It would be --

Q. Well, samples I should say?253

A. A sample of everybody, yes.

Q. Of everybody you work with?254

A. Yes.

Q. And they have graded you under various headings, and255

just to go through them very quickly. In relation to

diagnostic skill, 4 of the 12 gave you a good and 8

outstanding. Performance of practical, technical

procedures. 2 good, 9 outstanding. Management of

complex clinical problems, 2 good, ten outstanding.

Appropriate use of resources, 3 good, 9 outstanding.

Conscientious and reliable, they are all agreed that

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78

you are outstanding. Availability for advice and help

when needed. Everybody consulted was agreed that you

were outstanding. Time management, they are most

critical of you on time management. You got 4 good and

only 6 outstanding. Commitment to improving quality of

service, 2 good, 10 outstanding. Keeps up-to-date with

knowledge and skills 1 good, 9 out standing and

contribution to education and supervision of students

and junior colleagues, 4 good and 7 outstanding.

I am going to ask you to turn then to page 10, which

continues the colleague assessment. Question 11, your

spoken English, got one good and 11 outstanding.

Communication with colleagues, 11 outstanding.

Communication with patients, families and carers, 2

good 10, ten outstanding. Are you polite, considerate

and respectful to patients. Everybody is outstanding.

Polite and considerate and respectful to colleagues, 2

good, ten outstanding. Compassion and empathy towards

patients and their relatives. Everybody -- 12

outstanding. Values, the skills and contributions of

multi-disciplinary team members. 2 good, 9

outstanding. Takes the leadership role when

circumstances arise. All those who could comment say

outstanding. Delegates appropriately, 5 good, 7

outstanding.

Then your patients I think were also consulted, and the

scores your patients gave you are reflected at page 16.

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I think 22 patients were consulted. Was the doctor

polite and considerate? All say, yes, definitely. Did

the doctor listen to what you had to say? All say,

yes, definitely. Did the doctor give you an

opportunity to ask questions? 21 of 22 say definitely.

Did the doctor answer all your questions? All say,

yes, definitely. Did the doctor explain things in a

way you could understand? All say, yes, definitely.

Are you involved as much as you want to be in the

decisions about your care and treatment? 20 said, yes,

definitely and one, yes, to some extent. Do you have

confidence in the doctor? 21 say, yes, definitely and

one, yes, to some extent.

Did the doctor respect your views? All those in a

position to answer say, yes, definitely. Did the

doctor ask your permission to examine? Yes,

definitely. If the doctor examined you, did he respect

your privacy and dignity? Yes, definitely. By the end

of the consultation did you feel better able to

understand and manage your condition and care? Yes,

definitely. I take it you are happy, Professor, with

the outcome of that review?

A. Yes.

MS. BARRINGTON: Thanks, Professor, I don't

have any further questions

but Mr. Leonard will do.

A. Thank you.

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END OF DIRECT-EXAMINATION

MR. LEONARD: If I could just have five

minutes, I think I should

be able to complete cross-examination by lunchtime.

CHAIRMAN: Yes, that is fine. We

might take a little break

at the end of that then. Sorry, are you suggesting we

take the break now?

MR. LEONARD: Yes, if I could just have

five minutes, a short break

and then I will finish by lunchtime.

CHAIRMAN: Okay, so will take a short

break then.

SHORT ADJOURNMENT

THE HEARING RESUMED, AS FOLLOWS, AFTER THE SHORT

ADJOURNMENT

CHAIRMAN: We will resume,

Mr. Leonard.

PROF. CORBALLY WAS CROSS-EXAMINED, AS FOLLOWS, BY

MR. LEONARD

Q. MR. LEONARD: Professor, do you have a256

copy of the Notice of

Inquiry?

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A. Is it in the core booklet?

Q. I think it is probably the first tab of the core257

booklet?

A. Yes, I have it here.

Q. There is only a number of allegations remaining against258

you, the first of those is allegations two. I just

want to establish with you where you agree with the

case made by the Chief Executive Officer and where you

disagree with that case. You appreciate that with each

of the remaining allegations the Committee will have

to, first of all, establish whether as a matter of fact

they are true and, secondly, they will have to come to

the view as to whether any proven factual allegations

are also professional misconduct so that you understand

the purpose of the question I am asking you.

I think you agree as a matter of fact with allegation

two that you made a handwritten note Master Conroy's

medical records, erroneously recording a small left

kidney, 9% function of the left side. I think that is

factually true, isn't that right?

A. I am looking at the wrong thing.

Q. I will let you take some time to get that.259

A. I am looking at the Notice of Inquiry for Mr. Paran.

Q. I have your copy, sorry about that, (Handed). On the260

second page is allegation two, you might look at that?

A. Yes.

Q. Just take your time to read that.261

A. Yes.

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Q. I think you would agree that that is factually true?262

A. That is factually correct.

Q. The next one is allegation ten, leaving aside now263

issues of blame or responsibility I think as a matter

of fact you didn't review the medical records, et

cetera, before the operation on 21st March?

A. I reviewed the medical records in theatre when the

patient was anaesthetised, I would have checked the

consent at that time and the patient ID.

Q. If you like deleting the words "medical records" the264

balance of the allegation is factually true, that you

didn't review the radiological imaging or the

radiological reports, isn't that right?

A. That is correct.

Q. Then the next allegation, you say that you delegated265

the performance of the nephrectomy, but I think you say

that he did have adequate time to prepare for it, isn't

that right?

A. My belief is that Mr. Paran had adequate time to

prepare for this, yes.

Q. In allegation 12 I think you agree that you indicated266

that the nephrectomy ought to have been made on the

left upper quadrant transverse. What do you say about

the allegation that you knew or ought to have known

that it ought to have been performed on the right side?

A. I think this is dependent on the planned site of

surgery and since it was a planned left nephrectomy to

operate on the left side through a left upper quadrant

incision was completely correct.

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Q. The same deals with allegation 13 as well, isn't that267

right, the CEO make the same point about allegation 13?

A. I think that is fundamentally the same allegation.

Q. What do you say about the allegation that you failed to268

apply the appropriate standards of clinical judgment

that can be expected of a surgeon with your experience

and expertise?

A. I feel personally that I made a human error in booking

the patient for the wrong side surgery. I feel that

the progression beyond that was limited by the Hospital

systems and the pressures that the surgical teams were

and are under in Crumlin to deliver a service. I do

not feel that I fell below clinical judgment standards

as would be expected from a surgeon of my experience

and expertise.

Q. Just so the Committee understand what you say, you say269

that you made a human error in January 2008 --

A. That is correct.

Q. -- and that beyond that responsibility for this is with270

hospital systems or standards or other people?

A. I believe that part of the allegation really centres or

a significant part of the allegation centres on the

issue of delegation. I feel that it was quite

appropriate to delegate a procedure of this type to

Mr. Paran who was and is an experienced paediatric

surgeon.

Q. May I remind you that on the day in question that you271

apologised to the parents. I will just ask you to look

at the transcript of the first day, I will remind you

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84

of what Ms. Stewart said. You should have it there

somewhere on the desk. It is Day 1, page 65. I will

read to you what Ms. Stewart said, I ask the question:

"Q. Did Prof. Corbally apologise."

CHAIRMAN: What page are we on,

Mr. Leonard?

Q. MR. LEONARD: Page 65. She said:272

"He apologised and said he is takingresponsibility for it."

Can I also remind you of your observations and comments

to the Medical Council, which are at Tab 2 the core

booklet, in which you said on 30th September of last

year:

"I accept that I am ultimatelyresponsible for a patient's safety astheir treating consultant."

A. That is correct.

Q. Ms. Barrington when she was asking you about your273

discussion with the parents and why you didn't tell

them that Mr. Paran had carried out the operation you

said that you felt, I think you used the word

"ethically" you were responsible and that it wasn't the

time to blame someone else?

A. That is correct.

Q. You are now here in this formal forum and you are now274

trying to blame other people for what has happened, you

are trying blame to Mr. Paran, you are trying to blame

the mistake in radiology which took place in February

2002. You have said that Dr. Ghallab ought to have

told and you have just some moments ago blamed hospital

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85

systems. Can I ask you to this Committee to accept

that you personally are professionally responsible for

what happened to Master Conroy?

A. I think you raise a very complicated issue in terms of

who has overall responsibility for a patient in

hospital. I have to be as the admitting consultant

responsible for what happens to a patient but I cannot

be responsible for individual actions that I have no

control over in that environment. I would distinguish

between the two in fact, I think there is an issue of

ultimate responsibility and actual discrete

responsibility. I am not trying to blame anyone in

particular in my explanation of the events, I am merely

trying to detail those events. I think in relation to

accepting responsibility I think that is well within

the Medical Council's Code of Practice that one should

except responsibility and it is the probably better at

a later stage to go over more detailed information

rather than try and apportion blame to everyone, which

seems to me as if one is trying to get out from a

difficult situation. That is not my practice. I do

accept responsibility as the admitting consultant but I

do feel that individuals who work with you or who work

in the Hospital system have to bear responsibility for

their own actions. With respect I would differentiate

between the two.

Q. If you are accepting responsibility I am asking you to275

accept that having regard to everything that went on

here that you fell seriously short of the standards

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86

that would be expected of a surgeon in your position?

A. I believe that I failed this family as a surgeon, yes,

and I believe that the surgical team failed this

patient and his family, as I have said. I also believe

that the Hospital have failed this family. However, I

as the admitting consultant would have to accept

responsibility at all times for what happens patients

under my care, and that is what I do. However, as I

said, I cannot accept responsibility for systems

failures, systems failures that we had highlighted time

and time again to the hospital or failure to file

appropriately within a reasonable time frame. As I

said there are 18,000 un-filed reports and letters in

the Hospital system as of last February. I cannot

accept responsibility for a senior colleague of

Mr. Paran's experience and training for a mistake that

is essentially of his doing at that time. I am not

trying to blame Mr. Paran, these are merely the facts

as they occurred.

Q. You will not accept that you seriously fell short of276

the standards to be expected of a surgeon?

A. Sorry, I didn't quite hear that.

Q. I take it what you are saying to the Committee is you277

do not accept that you fell seriously short of the

standards to be expected by a surgeon, is that correct?

A. That is correct.

Q. Look at the first allegation against you, allegation278

number two, you made what you describe as a human

error, that is the human error by writing down "left"

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as opposed to "right", isn't that right?

A. That is correct.

Q. You have accepted in direct examination that you think279

it is likely that you had an unofficial report which

correctly identified that it would be a right problem

and you accept what the parents say, that you told them

that it was going to be right but that for whatever

reason you wrote down left?

A. I absolutely completely accept what the parents said as

being true.

Q. You went to great lengths in your direct evidence to280

identify a mistake in a radiological report from 2002,

which is at page five of the booklet of medical

records, you went at great length...(INTERJECTION)

A. Sorry, I haven't got that.

Q. If you just get that please, Professor. (Handed)281

A. Thank you.

Q. You emphasise to the Committee the large number of282

times you say that this error was replicated in the

notes. Of course over the page at page 6 was a renal

ultrasound correctly identifying the right kidney as

being a problem, isn't that right?

A. Yes, that is correct.

Q. Several pages forward at page nine is again a detailed283

report of a renal ultrasound identifying problems with

the right kidney?

A. That is correct.

Q. Indeed you must have known about this in October 2007284

when one looks at your own letter on page 22. I will

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read to you what you said in the last paragraph, you

said: "His last ultrasound in 2005 showed a scarred

right kidney.

A. That is correct.

Q. At the time of the DMSA scan you weren't under any285

misapprehension about this being a left kidney problem,

were you?

A. At the time the scan was performed or at the time I

reviewed him in out-patients?

Q. When you wrote this letter?286

A. This letter was written before the DMSA scan.

Q. In October 2007 you were under no misapprehension?287

A. No, I was not.

Q. It is not really fair for you to blame an incorrect288

report in '02 for the mistake which you made in January

'08, is it?

A. I think in the context of looking at a chart and the

reports one doesn't always look at all of the reports

because there would be quite a few reports in the chart

and in the constraints of a busy clinic it is not

possible to go through every report. Whilst at that

time I was aware that the scarring was in the right

kidney and the right kidney was abnormal, subsequently

it was a crucial time in January when I got the

unofficial report of the DMSA scan and I erred at that

time and assigned the wrong side. I think the point

has been made, could the incorrect entries on 11

specific discrete occasions have influenced that? And

I replied: Yes, it could have.

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So it is possible that I could have looked at the chart

and seen left-sided reflux and then confused the side

on that basis. But I think the more likely explanation

is that I was distracted between talking about a

right-sided problem and writing it down as a left-sided

problem in that time frame.

Q. You have told the Committee that you had an intention289

to review the films at a later date?

A. That is correct.

Q. When exactly did you intend to review them?290

A. Well normally if I was booking a patient for a

procedure like this and the images would not be

available, which happens sometimes, I would review the

X-rays in the hospital on the day of surgery. If I had

intended, as I had, to do this procedure myself then I

would have looked at the imaging myself at that time.

My intention was to review the imaging when they became

available in theatre or on admission at that time.

Q. There is no absolute guarantee that you would have been291

the person who was going to do this surgery, is there?

A. I would disagree with that because, as I have stated,

of the four surgical registrars in the hospital at that

time Mr. Paran was the only one who I would consider

suitably trained and experienced to do an nephrectomy

unsupervised. The other three registrars were not at a

sufficient level of experience or training to actually

delegate a procedure like that to. Mr. Tareen, who was

my registrar at the time I booked the procedure, would

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be expected to have been with me on the date. The date

was initially booked some time in July and it came back

to March, I cannot explain how that happened but I

suspect there was a discussion as to who should be put

into the list or perhaps the parents asked for it to be

done early, I am not entirely sure.

At any rate the patient appeared on the list as a left

nephrectomy at a time when Mr. Farhan Tareen was

absent. I would have no knowledge of when Mr. Farhan

Tareen would be taking his annual leave at the time I

booked the patient for the procedure. It would be my

expectation that Mr. Farhan Tareen would be my

registrar at that time and as such I could not possibly

delegate this procedure to anybody else, I could not

delegate it to Mr. Farhan Tareen, it would have to be,

it would just have to simply be me who did the

procedure.

Q. Professor, with respect, that is not the case. Were292

these six month rotations?

A. Six months, yes, or sometimes they extended beyond a

little, six months, yes.

Q. You see in January you wouldn't have known who your293

registrar was going to be in July?

A. That is quite true but it would still have been a

junior registrar, it could not have about Mr. Paran

because Mr. Paran had just finished six months with me,

which finished at the end of December. So even if it

wasn't Mr. Farhan Tareen in July it would have been one

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of the other two registrars who were of an experienced

level the same as Mr. Farhan Tareen and could equally

not do this procedure.

Q. Prof. Corbally isn't the fact that Mr. Paran ended up294

doing the operation proof positive that you couldn't

been sure that you were going to do the operation? You

didn't know which registrar was to be assigned to you

on that day?

A. I had no expectation, my regular registrar would be

away, that Mr. Paran would be the registrar who would

help me with my list on that day.

Q. Professor, you told the Committee in direct evidence295

that it was relatively common not to know which

registrar was assisting you on the morning?

A. Only when my own registrar would be away, but not in

any other circumstance.

Q. You can't know when your registrar is going to be away?296

A. No, registrars take holidays like everybody else.

Q. They could be sick?297

A. Yes, I agree, but that is an unlikely thing.

Q. You couldn't know for certain you would do the298

operation?

A. In the context of having three relatively inexperienced

registrars and Mr. Paran having worked with me for six

months I would suggest that that in fact would be the

case, the likelihood is that it would be me and one of

the other three inexperienced registrars and not

Mr. Paran and therefore not possible to delegate to any

of the other three registrars.

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Q. Isn't that the very reason why you ought to have299

written down in the note in January: I have not seen

the films or the report, this needs to be double

checked prior to the surgery going ahead?

A. I would accept that, I think that is a reasonable

criticism.

Q. If one looks at the Independent Review in the core300

booklet, page 8 of that review, at the bottom of the

page there is a sub-heading saying:

"The person taking consent for aprocedure will not normally reviewimaging."

Do you see that, page 8 of the internal pagination,

page 8 on the bottom right-hand corner. Do you have

that, Professor?

A. Is that the GOS Report?

Q. It is the Great Ormond Street Report?301

A. At the very last paragraph.

Q. The bottom right-hand corner is page number 8 and the302

paragraph heading is numbered 7, do you see that?

A. Yes.

Q. It says:303

"In patient XY's case the imaging wasnot reviewed at any stage:

In clinic at the point of listing forsurgery; at the point of clerking ortaking consent;

On the pre-operative morning wardround;

In response to the parents' query aboutthe operation side.

In addition it was not reviewed intheatre prior to positioning XY for theprocedure or making the incision."

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You were involved at all points up to then, isn't that

right?

A. Well I wasn't involved on the taking clerking and

taking consent, nor was I involved on the preoperative

morning ward round. I was involved at the listing of

surgery, and I have not denied that, and I was not

involved in any aspect of parents' queries about the

operation site.

Q. If I put it differently, the delegation which you say304

took place to Mr. Paran took place at the very end of

that list, isn't that right?

A. You mean in terms of the sequence of the chronology of

events?

Q. Yes?305

A. That is correct.

Q. You were the responsibile person right up until the306

delegation, is that not right?

A. Yes, I would think that is reasonable, yes.

Q. I suggest to you that it was inherently dangerous for307

the imaging not to have been reviewed throughout all

that period?

A. I think the course of a patient through a hospital and

surgery can be a very complicated one but can be at the

same time looked at quite briefly and simplistically in

that at any point along this patient's course through

hospital there were ample opportunities for the imaging

to be reviewed and/or a report to be found, and that is

not something that I am able to do at every point of

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94

patient contact in the hospital. There were I think at

least five medical personnel involved at contact points

with the patient and his family. There were also five

nursing points of contact between the patient and his

family. Concerns were raised at many of these junctures

and if I had been informed about those then yes of

course the imaging would have been reviewed and it

would have been resolved. I would have an expectation

that people involved at those junctures would also

undertake to review the imaging if there is a concern

about laterality.

Q. I want to move on to another comment in this Great308

Ormond Street Report, page 10 at the bottom, I am going

to read to you what it says:

"Patient XY was on a 'parallel' morninglist, running simultaneously in Theatre5 and Theatre 7. The SpR was working inTheatre 7 and the consultant in Theatre5. After the first few patients therewas a pause in between patients comingto Theatre 7 and the SpR went toTheatre 5 to see how he could assist.He helped to prepare and positionPatient XY, now anaesthetised for theoperation. The consultant asked him ifhe would like to do the case. Anephrectomy was within the competenceof the SpR, although he had neverperformed one completely unsupervisedand was handed the case at shortnotice."

Do you see that?

A. Yes.

Q. Did you have an input into the preparation of this309

report?

A. I was certainly interviewed on two occasions by the GOS

team, yes.

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95

Q. Is it true that Mr. Paran had never performed an310

nephrectomy completely unsupervised?

A. That is not true.

Q. That is not true. Do you think you told the team from311

Great Ormond Street that it wasn't true?

A. I cannot comment on that question, there could have

been all sorts of reasons for it. That may be, for

example, quite simply an error in communication. I

would not suggest that or concur with that.

Q. Do you agree that Mr. Paran was handed the case at312

short notice?

A. No, I think Mr. Paran had adequate time to prepare for

the case.

Q. They got that wrong as well?313

A. I think as the surgeon delegated with the procedure it

is that surgeon's responsibility to set the pace and

review the imaging, I think he had time to do that, I

don't think it was short notice. Could I also say that

the way the list ran in Crumlin at that time is that

situations like this arose quite often in that it is a

very busy list, there is a very significant service

commitment and it does happen from time to time that

you are asked to do something or one is asked to do

something at quite short notice. The surgeon who is

the delegee, if you like, always has the option to say:

I will start the operation when I have reviewed the

imaging. So it is not an auto-start, it is up to the

surgeon in question leading the operation, doing the

operation to say 'I am happy that I have checked

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96

everything myself'.

Q. Did you tell the Independent Review Team that you had314

asked Mr. Paran to do this operation between 10.45 and

11 am?

A. I cannot recall if I was asked that.

Q. They don't seem to record that, do they?315

A. I don't think so.

Q. In fact they recount in their report the version of316

events given by Mr. Paran, don't they?

A. I think it is a composite report from a variety of

inputs, including anaesthesia, myself, Mr. Paran and

other surgical members and nursing members of the

theatre.

Q. Would you not agree that it is an important issue as to317

whether you gave 40 minutes, 50 minutes' notice to

Mr. Paran or five minutes' notice?

A. I think it certainly has become an important issue. I

think also the GOS team might consider that perhaps a

longer period might be better, and I agree, in an ideal

world the longer you have to contemplate a case the

better. However, it is possible to take on the role of

operating surgeon with quite short notice, and that is

not uncommon practice either in Crumlin or in any other

hospital in the country.

Q. You heard Mr. Wheeler's evidence about notice and he318

was very unhappy, to put it mildly, with the five

minute notice period?

A. Five minutes I would also be somewhat unhappy about. I

have to suggest to you that it is not unusual in the

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97

situation of a busy service to be requested to do a

procedure at short notice. Short notice can be

anything from 10, 15, 20, 30 minutes. Certainly even

five minutes is adequate time for somebody of

Mr. Paran's training to review the X-rays, because all

one has to do is take the image out of the folder and

look at it, it takes a minute.

Q. Sorry, are you backtracking from the evidence you gave319

earlier or are you simply talking in hypothetical

terms?

A. In what sense do you mean?

Q. If the five minutes' notice wasn't given why are you320

telling the Committee about it?

A. Because you brought it up, you asked me about five

minutes.

Q. I am asking why you didn't mention the longer period to321

Ormond Street Hospital?

A. They never asked me about timing, I believe, at that

time and I think they would probably have asked

Mr. Paran about time. I am not sure in fact.

Q. It is not mentioned...(INTERJECTION)322

A. In the time line it is there. I think the GOS people,

actually the team looked at the time line in detail and

they are aware of the time the patient arrived in the

theatre and the time that the procedure began. If I

recall the GOS team were more anxious to know how my

list ran and whether or not it is normal practice to

delegate procedures to senior registrars or SpRs.

Q. The second thing they say, just down the page, is:323

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"This means that the surgeons may haveno advance knowledge of which patientsthey will be personally operating on.There is no formal briefing at theoutset of the list (or the day before,as has been the practice with oneconsultant..."

Do you see that?

A. Yes.

Q. That is not desirable, is it?324

A. In fact when the list is presented to me for submission

to the theatre on the day before an operating list I

generally to this with the junior team but and we will

not formally assign a patient to any one surgeon

because it is not possible in logistical terms to do

that in the order of the list. It was not possible to

discuss this with Mr. Paran because I was not aware

that Mr. Paran would be assigned to me the next day?

Q. I am not sure what exhibit number this is, this is an325

exhibit that you handed in of the operating list,

Exhibit 16, you might just have that. (Handed)

Presumably as a doctor one can grade these procedures

in terms of seriousness and difficulty?

A. Yes.

Q. Presumably the hernia repairs, the Hickman Broviac326

removals, the fistula repairs, circumcisions they are

all relatively straightforward operations?

A. Yes.

Q. Nephrectomy is not a straightforward operation I think,327

is that right?

A. I regard nephrectomy as a straightforward operation.

Q. Can I use perhaps different wording, it is more328

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99

difficult than the other operations we just talked

about, it is more difficult than a hernia repair?

A. Yes, it would be more difficult than a hernia repair.

Q. And a more serious operation. Are there any other329

serious operations on that list?

A. There was a patient, it doesn't seem to be on this

list, for the resection of a recurrent Wilms' tumour.

Q. Sorry, I didn't catch that, a resection of a?330

A. A recurrent renal tumour. I don't know where that

patient is. I think that might have appeared on

Mr. Quinn's list because Mr. Quinn took over along with

Mr. Gillick and did most of the other cases after this

event.

Q. I see. Of all of the operations on this list the331

nephrectomy is up at the upper end in terms of

seriousness or difficulty?

A. In comparison with the other patients on this list,

yes.

Q. Surely, Prof. Corbally, that means that you are the332

person who should be doing that operation rather than

your specialist registrar?

A. Well, as I have stated already, if Mr. Paran had not

been on the list that day I would certainly have done

the nephrectomy. Mr. Paran was close to leaving the

role of senior registrar to that of consultant and had,

I believe, adequate training to an nephrectomy. I

don't think Mr. Paran himself has denied he was

adequately trained to do an nephrectomy. He had

significant experience in the six months prior to this

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100

period when he came back from Sloan-Kettering and he

had also worked for one year in Sloan-Kettering as a

fellow on paediatric oncology service, where he would

have been exposed to a significant number of more

difficult nephrectomies. I think within the context of

nephrectomy one has to look at simple nephrectomies, as

we anticipated this to be, and a nephrectomy for a

renal tumour, which is a significantly more different

and much more complex procedure. This was a simple

nephrectomy and would not be considered that difficult.

Q. I am asking you to accept that when the parents of a333

sick child go into hospital and there is a series of

operations and procedures being carried out, many of

which are simple, straightforward and short and one of

which is more difficult, more serious, more life

threatening that the parents have the right and the

expectation that the senior man will do that operation?

A. Well I hear what you are saying but I have to disagree

with you in the context, this was a simple nephrectomy

and would not be regarded as being technically

difficult or challenging. It is not always possible

for the senior surgeon to do an operation and in

addition we have an obligations to allow our trainee

surgeons to do procedures. At that level Mr. Paran was

very well qualified do an nephrectomy, a simple

nephrectomy. Indeed, I have to say, qualified and had

done a more difficult nephrectomy.

Q. There is a serious factual dispute between yourself and334

Mr Paran, isn't that right?

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101

A. I accept that.

Q. The Committee are ultimately going to have to make a335

decision as to fact on that. I think you agree with

the evidence of Mr. Wheeler insofar as if this were a

five minute hand over you would agree that that

wouldn't have been proper delegation, isn't that right?

A. There has to be a caveat in that assertion because the

surgeon doing the operation has the authority and the

right as to when he or she starts the operation, and

that necessarily involves crossing the Ts and doting Is

and making sure everything is in place. Mr. Paran had

the opportunity not to proceed, if you say five

minutes, and I am talking if that was the case,

Mr. Paran had the opportunity to stop the procedure

starting and say 'I need to review the imaging first.'

Five minutes I think becomes somewhat academic in that

context when the surgeon has the right, the authority

and indeed the expectation to confirm the imaging is

correct.

Q. In your own observations and comments you described the336

type of list system you worked under and you described

the specialist registrar working

"under my supervision"

are the words you used, you are not trying to pull back

from that?

A. Not at all.

Q. Olive Delaney described that she considered that both337

theatres were under your supervision and Emma Cooney

described how it is the consultant who is responsibile

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102

ultimately, isn't that right?

A. I agree.

Q. Can I ask you to look at the transcript of yesterday,338

it should have a "2" on the front of it?

A. Yes.

Q. Can I ask you to look first of all to page 103, Mr.339

Meenan asked Mr. Wheeler a question at question 250

suggesting that you gave Mr. Paran less than five

minutes and Mr. Wheeler said:

"If that were the case I would say thatthat was an exceedingly short time,very little time for him to come toterms with what he had to do, and Iwould have thought that that wasundesirable."

Further down the page at answer 252 he says:

"I do not think that in five minutesone can necessarily hand over all ofthe appropriate pieces of informationto the delegate, I don't think theynecessary have time to absorb it..."

Do you agree with what Mr. Wheeler says?

A. To some degree. I think in an ideal world five minutes

would not be sufficient, but I have dispute with the

five minute issue, it was not five minutes. In an

ideal world, yes, you need more time to assimilate,

but in reality looking at the X-rays takes a minute and

it is very clear from looking at the X-ray images which

kidney was involved. That is all that it would have

taken, one or two minutes, and then highlighting or

flagging that problem and then the issue would never

have proceeded.

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103

Q. At page 112 I would ask you to look at question 291,340

Mr. Meenan says:

"Implicit in delegation is sufficienttime for the trainee in this case toacquaint himself or herself with thepatient and the records, and so on..."

Do you agree with what Mr. Wheeler says?

A. I think one has to look at delegation to certain levels

of trainees, Mr. Paran was a senior surgical trainee

about to leave the ranks of the SpR and enter

consultant posts. He is perhaps one of the best

trained trainees to come through Crumlin in some time.

So there is a little difference between handing over a

procedure at what you call short notice to a trainee

who is perhaps three or four years as an SpR to someone

of Mr. Paran's experience, I think it is completely

different. I would suggest that in the event of being

handed a procedure which is relatively straightforward

that even five minutes, if that was the case, which it

was not, could have been sufficient to say: Well, yes,

that is the diseased side or hold on, there is a

problem, the side that is marked is not the correct

side and this needs to be reviewed, and to bring it to

my attention.

Q. Prof. Corbally Mr. Paran will clearly say that he was341

your junior, which he was, you were in charge, which

you were, and that you gave him five minutes notice to

do the operation and then directed him as to where he

was to put the incision. If the Committee accepts that

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evidence would you not accept that you had the

responsibility to ensure that the films were checked?

A. I think in a holistic sense the surgeon doing the

procedure has responsibility to ensure that he is doing

the right procedure. There was coercion or force, as

someone suggested yesterday, in the request to do this

procedure or no direction on my part to Mr. Paran to do

this procedure. Mr. Paran would have had ample time

and opportunity to actually review the imaging himself

and to say this was the right thing to do. I think

Mr. Paran's experience level should have satisfied him

that he should be aware of what the imaging said at

that point in the procedure. The incision I think

merely a technical one between two colleagues, I was

not directing him in any sense in an absolute sense.

My recommendation was that the incision from the

previous colostomy enclosure was lower than one would

expect to do a nephrectomy through and that it would be

better to go through the left upper quadrant in the

transverse way and because I expected this to be small

shrunken kidney I asked him to make it cosmetic, that

is all. Apart from that the rest of the procedure was

in Mr. Paran's hands.

Q. If it would only take two minutes to check the X-rays342

why didn't you check them?

A. I really wish I had checked the X-rays. I was

convinced that Mr. Paran would do this and do this

well. From my seven or eight years of experience of

work with Mr. Paran I had no reason to expect anything

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different.

Q. Did you know on the morning of the operation that you343

hadn't seen the films in January of that year?

A. No, I did not.

Q. You didn't remember?344

A. No, I did not remember. The patient was listed for a

left nephrectomy and it appeared as such and when I

checked the consent and the ID they both matched and

they said left nephrectomy.

Q. Why didn't you check the films when you were checking345

the consent?

A. Because I asked Mr. Paran to do the procedure and that

is part, in a holistic sense, the operating surgeon's

expectation to do that.

Q. What were you doing during the procedure?346

A. I went to the surgical dictation room, which is close

beside the actual theatre, and dictated on some charts,

doing some chart work.

Q. On the other operation?347

A. No, on existing patients and out-patients.

Q. During one of the most serious operations on this list348

you were dictating charts on other operations?

A. Well unfortunately there is no provided time for

consultant surgeons in Crumlin, no protected time to do

administrative work, so one has to find time where one

finds it. If I had confidence in Mr. Paran, as I had,

that he would do the procedure properly and completely

then I felt relaxed in the knowledge that I could catch

up with my chart work. I often have to do chart work

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between cases and we have to find time wherever we find

it to do that, there is no protected time to do this.

It is a very busy demanding service.

Q. Are there any protocols as to delegation between349

surgeons and specialist registrars in this situation?

A. There are no written protocols for delegation but there

is an expectation that the consultant will delegate to

trainees only when the consultant is happy that the

trainee has reached a certain level of experience and

competency. I don't know if that is written anywhere

in any protocol in Ireland, that is a matter of

on-going surgical training and education.

Q. Do you not agree, Prof, that when one takes into350

account your initial human error, your failure to

record the necessity to look at the films and the fact

that it was only on the morning of the operation, on

your own evidence, that you handed the matter over to

Mr. Paran that you seriously failed the parents and

Master Conroy himself by never looking at the films?

A. I have already stated that I failed the parents, as did

the team and the hospital. It seems to have been a

constellation of bizarre events that culminated in this

tragic outcome, I don't think anyone could have

predicted this. It seemed that the system could not

apply the brakes appropriately at any point along this

patient's progress through hospital.

MR. LEONARD: Thank you, Professor, those

are the only questions I

have.

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END OF CROSS-EXAMINATION OF PROF. CORBALLY BY

MR. LEONARD

CHAIRMAN: Thank you, Mr. Leonard.

It is now 1 o'clock, I

wonder would Mr. Meenan be agreeable to having a break?

MR. MEENAN: I think so, and I think the

witness is probably

entitled to a break at this stage.

CHAIRMAN: At quarter to two we will

resume. Thank you.

LUNCHEON ADJOURNMENT

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THE HEARING RESUMED, AS FOLLOWS, AFTER THE LUNCHEON

ADJOURNMENT

CHAIRMAN: Okay. If everybody is

present maybe we will

resume. I think maybe Mr. Meenan would like to

cross-examine.

MR. MEENAN: Yes, thank you indeed,

Chairman.

PROF. MARTIN CORBALLY WAS THEN CROSS-EXAMINED, AS

FOLLOWS, BY MR. MEENAN

Q. MR. MEENAN: Prof. Corbally, as you know351

I appear on behalf of

Dr. Sri. You were present towards the end of the

operation, isn't that right?

A. Well, I was present when the kidney had been

revascularised.

Q. Yes. Yes.352

A. That would not be the end of the operation.

Q. All right. You, I think, knew immediately that there353

was a problem, isn't that right?

A. I recognised that the kidney appeared normal when I

entered the theatre itself, at which time I asked

Mr. Paran if everything was okay.

Q. Yes.354

A. In terms of blood loss, and also if he had consulted

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109

the images at that time?

Q. Yes. That is absolutely correct. And Mr. Paran told355

you he hadn't?

A. Mr. Paran said he had not. Correct.

Q. Yes. I guess you then consulted the images, is that356

correct?

A. I retrieved the images from the packet in theatre and

put the images on the screen.

Q. You saw immediately, having consulted the images, that357

a serious error had occurred, isn't that right?

A. That's correct.

Q. This was before the operation had even ended?358

A. This was at a somewhat, proven to be an irreversible

part of the operation.

Q. Yes.359

A. I mean the operation extended from, if you want to call

it the nephrectomy, through to the attempt to

revascularise the kidney, through to another

nephrectomy, if you like.

Q. Yes. But you knew, before even the anaesthetic had360

warn off, two things: 1. That the wrong kidney had

been removed. 2. If the radiography had been checked

it wouldn't have happened, isn't that right?

A. That's correct.

Q. So where we can discuss matter like systems failures,361

the failure of a doctor or a surgeon to read the

radiography before the operation isn't a system

failure, isn't that correct? Or is it?

A. I am not so sure I agree with you, with respect,

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110

Mr. Meenan.

Q. Oh?362

A. Because I think that a systems failure also constitutes

the systems in place to provide the doctor, surgeon, or

otherwise, with the information that is relevant to

making such a decision.

Q. Yes.363

A. I would argue with you, with respect, that such

information was not available, perhaps most likely

because of systems failure within the Hospital, and a

failure to recognise and priorities filing, which we

had addressed with hospital management, which was never

acted upon until well into this, well and truly after

this event.

Q. Yes.364

A. So I would actually have to say that systems are a part

of this problem.

Q. I see. All right. There has been a considerable365

amount of discussion concerning the concerns that were

raised by the parents, isn't that right?

A. I think that is true, yes.

Q. Yes. I would have to suggest to you that if one looks366

at this objectively, in a sense the concerns that were

raised by the parents aren't really relevant insofar as

the reading of the radiography before an operation is

something that should have been done irrespective of

what the parents said?

A. Yes, but I would not wish to undermine or devalue the

concerns of the parents because I think that is crucial

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111

to this situation. Nor would I wish to undermine or

devalue the significance of looking or not looking at

the imaging.

Q. No. I understand that. I am not undermining it or367

devaluing it in any way, but what I am just suggesting

to you is that irrespective of whether the parents had

raised the concerns, the radiography should have been

looked at prior to the commencement of the operation.

Do you agree with that?


Q. Okay. I suppose it also follows from that that whether368

or not radiography is read before the commencement of

the operation, does not depend upon parents raising

concerns, isn't that right?

A. That's correct.

Q. Yes. So obviously you would have known from the word369

go that really one of the core mistakes in this whole

matter was the fact that nobody read the radiography

before the operation commenced, isn't that correct?

A. Can you define what you mean by the word "go"? Is that

that at Out-Patients? I have freely admitted that. Is

that at the hospital admission? I have suggested that

the SHO should have actually looked at the report.

Q. I see.370

A. When the parents raised concerns the following morning,

it is clear that one of the nursing staff did not pass

that concern on at that stage, and at subsequent points

of contact between nursing staff and medical staff,

that concern was not passed on either.

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Q. I see. What I am suggesting to you is this; that371

before the operation had ended, before the patient had

come around after the anaesthetic, you knew that one of

the central defects in this matter was that the

radiography had not been looked at prior to the

commencement of the operation, is that correct?

A. I think that is correct, yes.

Q. Yes. Okay. What you are saying is, what you are372

telling us here this morning, as I understand it, is

that as you had delegated the operation to Mr. Sri

Paran, it was his duty to read the radiography before

the operation, is that right?

A. That would be a standard expectation for someone

removing a kidney.

Q. I understand that it was your evidence this morning373

that Dr. Sri had some thirty minutes prior to the

commencement of the operation to read the radiography,

is that correct?

A. I think that is an approximation, but at least thirty

minutes.

Q. At least thirty minutes. Okay. So so far as you are374

concerned, this operation had been delegated to Mr. Sri

Paran some thirty minutes before the operation had been

commenced, is that correct?

A. Well at least thirty minutes.

Q. At least thirty minutes. Okay?375

A. Yes.

Q. Would you agree with me therefore, it has to follow,376

that that thirty minutes is an absolutely crucial piece

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113

of evidence as to who is responsible for either reading

or not reading the radiography.

A. I am not so sure that time is a crucial element. I

think it is an absolute require of the surgeon doing

the operation. That is the crucial element, not the

time.

Q. Well you know well that Mr. Sri is saying that he had377

less than five minutes before the commencement of the

operation. You are telling this Tribunal, this

Committee, that in fact he had at least thirty minutes,

isn't that right?

A. Well, I was made aware yesterday that Mr. Paran was

saying five minutes. In fact, yes, he had at least

thirty minutes.

Q. At least thirty minutes.378

A. Yes.

Q. Right. In a sense the fact that he had at least thirty379

minutes, and as you say not less than five minutes,

that must mean that so far as you are concerned you do

not have any responsibility for not reading the

radiography before the operation, is that right?

A. Well, in terms of delegating a procedure like this, I

think it is standard practice that the person who

wields the knife, as Mr. Wheeler put it yesterday, that

the person who wields the knife has control over when

the operation starts, and also has responsibility, and

I would regard that responsibility as including

reviewing the x-rays.

Q. Yes, and you said that that, as I understand your380

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114

evidence now is that that responsibility was passed

over by this conversation which you say took place at

least thirty minutes before the commencement of the

operation, isn't that right?

A. That would be my understanding.

Q. How do you mean your understanding? I thought you said381

that is what happened?

A. That is what I understand happened, yes.

Q. Well, no, do you understand happening...(INTERJECTION)?382

A. Sorry.

Q. Sorry, bear with me. Do you say you understand that383

happened or that it did happen?

A. It did happen.

Q. It did happen. Okay. Very good. That thirty minutes,384

I would suggest to you, is absolutely crucial, isn't

it?

A. Well, the thirty minutes is the start time, if you

like.

Q. Yes.385

A. But in fact the surgeon who wields the knife, if I put

it like that, has the opportunity to extend that time

beyond thirty minutes if he so wishes. That is, that

is just a standard securing surgical practice. The

surgeon determines when he starts the operation. So

that thirty minutes could have been forty five minutes,

if Mr. Paran had wished it so, or indeed longer, or you

know, as long as it took to actually establish the

facts.

Q. Sorry, I am a little lost. How could Mr. Paran have386

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115

wanted it to be forty five minutes?

A. I think if there was a concern at any level, that

Mr. Paran could have had the opportunity, and did have

the opportunity to address the imaging.

Q. I see. Yes. So Prof. Corbally, you were then in the387

position on the day of the operation knowing, firstly

that the failure to read the radiography was a crucial

defect in the whole way in which the operation was

done. That is the first thing you know. The second

thing you also knew on the day was that I had given

Mr. Sri Paran some thirty minutes before the operation

to actually read the radiography, isn't that right?

A. That is correct. But I think -- well I will hold my

piece for a second. I think that thirty minutes is a

very adequate time to read an image. It takes one

minute to read an image.

Q. Yes, yes. But he had thirty minutes to do it, isn't388

that right?

A. At least thirty minutes.

Q. At least thirty minutes. So that presumably then,389

Prof. Corbally, if anybody was to criticise you for not

reading the radiography, your immediate answer would be

"well (1) I delegated the operation to Mr. Paran, and

(2) he had at least thirty minutes to read the

radiographs before the operation." Is that correct?

A. I think the most crucial part of that is that I

delegated to Mr. Paran, with the expectation that

Mr. Paran would read the imaging.

Q. Yes.390

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116

A. That's correct.

Q. You had at least thirty minutes for that. So if391

anybody was going to criticise a failure to read the

radiographs, your response was "the doctor or the

surgeon who did the operation had at least thirty

minutes to read the radiographs." Is that right?

A. Could you just repeat that again for me, please?

Q. Yes, of course. So if anybody was going to criticise392

you, Professor, for a failure to read the radiograph or

the radiographs, your answer would be "well, Mr. Paran,

who I delegated to do the operation, had at least

thirty minutes to read those radiographs." Is that

correct?


Q. Yes. So we now know, of course, that this matter was393

investigated, isn't that correct?

A. That's correct.

Q. It was investigated firstly by a team from Ormond394

Street, is that right?

A. Well there was an internal review prior to the Great

Ormond Street Report.

Q. Okay. Let's just look at the Great Ormond Street395

Report. I know Mr. Leonard, on behalf of the CEO, has

discussed this with you, so I won't spend very much

time with it. Internal page 10 of that report.

A. I am sorry, could you bear with me for one second.

Q. Yes, of course.396

A. Page 10.

Q. Yes, the bottom of page 10?397

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A. Yes.

Q.398

"Patient XY was on a "parallel" morninglist, running simultaneously in Theatre5 and Theatre 7. The SPR was workingin Theatre 7 and the consultant inTheatre 5. After the first fewpatients there was a pause in betweenpatients coming to Theatre 7, and theSPR went to Theatre 5 to see how hecould assist. He helped to prepare andposition Patient XY, now anaesthetised,for the operation. The consultantasked him if he would like to do thecase. A nephrectomy was within thecompetence of the SPR, although he hadnever performed one completelyunsupervised, and was handed the case ashort notice."

Now presumably you made a statement, did you, to the

Ormond Street Inquiry?

A. The basis of the Great Ormond Street Inquiry was that

they took statements from all personnel involved.

Q. Yes.399

A. This report was then prepared independently.

Q. Yes.400

A. Both Mr. Paran and myself, and I think all people who

had significant roles in this event, were invited down

to the CEO's office and told that this report could not

be taken from that office and that we could, both

myself and Mr. Paran individually, had several minutes

to review, to actually read this report. I would think

that, and I have always thought that given several

minutes to read a report like this, without any actual

potential to change it, or alter it, or edit it in any

way was not an appropriate way to deal with the report.

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Q. Yes.401

A. So, yes, that is how the report was actually

constructed.

Q. Yes. All right. So you are saying the report is wrong402

there?

A. No, I am not, Sir. I am actually saying that the

report, that the way in which the report was

constructed did not give any potential to those

involved to express their own individual opinions.

Q. Were you asked to make a statement to403

the...(INTERJECTION)?

A. I was asked, I was verbally interviewed, and that was

all, on two occasions.

Q. In the course of that verbal interview, which I am sure404

you recall, did you say anything about you having

delegated the operation to Mr. Paran some at least

thirty minutes before the operation?

A. The time factor was never considered that important in

the interview they had with me.

Q. Oh?405

A. I do not recall them asking me a specific time. All

that I recall in that conversation, on two occasions,

was that I delegated and that I felt that Mr. Paran was

of appropriate training and experience to actually do

the procedure.

Q. I see.406

A. That is all. There was no question, that I can recall,

in relation to how long Mr. Paran had to make up before

doing the case.

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Q. Yes. Would you not have thought that information to407

the effect that you had delegated the operation to your

junior some, at least thirty minutes beforehand, is an

important piece of information which should be

conveyed?

A. I think at this point it is an important piece of

information, but it did not appear important in the

questioning that was directed to me by the Great Ormond

Street Inquiry Team.

Q. Why do you think at this point it is an important piece408

of information?

A. Well, it is clear that the issue is now one of

delegation, and how appropriate delegation was, and

whether or not there was adequate time to prepare the

case.

Q. Yes.409

A. I understand that is the reason why it has become

important.

Q. Yes. It certainly became important when the Medical410

Council got involved, didn't it?

A. Yes, of course it is important.

Q. Yes. I think when the Medical Council got involved,411

you sent them a letter, isn't that right?

A. Yes.

Q. Let's have a look at that letter now. I don't know412

where it is in your pagination.

MR. CROSS: Tab 2.

Q. MR. MEENAN: Sorry Tab 2 of the Core413

Booklet. I just have it,

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unfortunately I have got it loose.

A. 30th September?

Q. Yes, that's right?414

A. Yes.

Q. Well no, sorry, 10th February is the letter that I am415

looking at. I am looking at a letter of -- sorry, I

was looking at a letter dated 10th February 2010?

MR. CROSS: I don't see that,

Mr. Meenan

MR. MEENAN: That is what was furnished

to me.

MR. LEONARD: That hasn't been handed

into the Committee by the

CEO. I am not sure I have a copy of it either.

MR. MEENAN: Okay. Very well.

CHAIRMAN: There is a letter of 30th

September we have, a long

letter.

MR. LEONARD: I will just see if we have

a copy of it.

Q. MR. MEENAN: Yes I think in fact, the416

portion in fact is exactly

the same. So if you just ignore, I just want to go

with that letter which is dated 30th September 2009.

Could I just ask you to look at that letter. You just

might indicate to me in that letter where it says that

you gave the junior doctor, Mr. Paran, some at least

thirty minutes before the operation to, as it were,

acquaint himself with the radiography and so on?

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121

A. I don't believe it says that in that letter.

Q. Why would that crucial bit of information not be in417

that letter?

A. I am not sure why that crucial information would be

left out at that stage? It is -- I am not so sure it

was -- in the context of what I was trying to explain

was that delegation had occurred and that Mr. Paran was

happy to do the procedure.

Q. Yes.418

A. But the issue of time had not entered

into...(INTERJECTION).

Q. Well, I think at this stage now the Medical Council is419

involved, and you know that delegation is a crucial

issue, isn't that right?

A. Delegation is a very important issue, yes.

Q. It is a crucial issue, I would suggest, and you agreed420

with that this morning. Surely your evidence to the

effect that Mr. Sri Paran was given at least thirty

minutes before the operation should have been put into

that letter, is that right?

A. I was merely trying to express the fact that delegation

had occurred.

Q. Yes.421

A. That I think that delegation had been an appropriate

thing to do with Mr. Paran. I had not considered a

time issue at that time.

Q. I just want to suggest to you that you knew delegation422

was crucial. You must have known, couldn't possibly

not know I would suggest, that delegating the operation

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to Mr. Paran at least thirty minutes before the off was

absolutely crucial. It is not, it is not there at all,

is it?

A. Well, could I say that I think, you know, thirty

minutes, or fifteen minutes, or forty five minutes, or

thirty five minutes, all of those are time constraints

in a procedure.

Q. Yes.423

A. But the reality is that the operating surgeon has the

time at his hands, no matter whether it is ten minutes,

or fifteen minutes, or twenty minutes to decide to

stop, to pause, to review the imaging. That is the

reality of any case that is delegated to any doctor. I

don't think, and I think in writing this letter that

probably was my attitude, that Mr. Paran had plenty of

time to review the imaging.

Q. Well did -- sorry, I interrupted you.424

A. Sorry, I beg your pardon. No, but I felt that

Mr. Paran had the ability and knowledge to actually

proceed to examine the imaging.

Q. Yes.425

A. That the timing -- procedures do not start on sort of

auto start, they start when the surgeon is ready. So

the time issue, be it five minutes, ten minutes, twenty

minutes, half an hour, one hour, the time issue is set

by the surgeon in charge. That is what that letter

reflects, not the issue of thirty minutes.

Q. Yes. Did you write that letter yourself?426

A. I wrote that letter myself, yes, with some input from

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my legal team.

Q. Of course, yes. I guess you must have told your legal427

team about the thirty minutes, did you?

A. I did at some point, yes. Well not necessarily thirty

minutes, but that there was a second conversation and

that there was adequate time, I believe, to discuss and

review the imaging.

Q. When did you first tell your legal team that Mr. Sri428

Paran had at least thirty minutes to prepare for the

operation?

A. I am not sure. Several months ago, I believe.

Q. Several months ago?429

A. I believe so, yes.

Q. It is not in that letter at all, no?430

A. Well as I said, the issue of time, really it is an

issue of delegation of appropriate responsibility. The

surgeon has the opportunity to slow the procedure down.

The start of the procedure is at his behest. He can

decide when he starts the operation, and after he has

reviewed the imaging.

Q. Well I suppose when you got the report from431

Mr. Wheeler, upon which the case against you was

brought by the CEO, you will see that it is full of

references to delegation and non-delegation, and proper

delegation and adequate delegation, isn't that right?

A. Delegation is a very important part, as we have agreed.

Q. Yes. That report is full of it, isn't that right?432

A. It is.

Q. Yes. You will have seen then the conclusions of the433

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report involving your good self, Professor, page 9 of

the report.

"In this case, Prof. Corbally delegatedthe operation to Mr. Paran. TheTribunal may find that delegation ofoperative surgery is a part of theaccepted custom."

Then so on.

"Furthermore, the Tribunal may findthat as part of the process ofdelegation, the delegate accepts theresponsibility.

If these two facts are found,Prof. Corbally's failure to review thenotes and imaging and reports beforethe nephrectomy was due to delegationof these tasks, and would not amount toa serious falling short by omission orcommission of the standards expectedamongst doctors."

Mr. Wheeler goes on:

"However, if the Tribunal finds in thealternative, that there is no acceptedpractice of delegation and furthermore,no accepted understanding that with theoperation also goes the responsibilityto review the images, thenProf. Corbally's failure to make thisreview would amount to a seriousfalling short...."

And so on. So you knew when you got that report, which

is dated February, which I think is only just shortly

after the letter, that delegation was absolutely

crucial?

A. Yes, delegation is a crucial part of this. Yes.

Q. Yes. As far as Mr. Wheeler was concerned, your434

evidence to the effect that Mr. Sri Paran was given at

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least thirty minutes before the operation would also be

very important, isn't that right?

A. Well can I just say that, you know, delegation happens

on a very fluid basis in pressured service practices.

I still maintain that Mr. Paran, whether it was half an

hour, or two hours, or what, that Mr. Paran had time to

actually review the imaging.

Q. Yes.435

A. That it is his prerogative as delegated surgeon to

review the imaging.

Q. Yes.436

A. And the start time of the procedure is not dependent on

any auto start button, it is dependent on the surgeon

deciding that he is comfortable with proceeding with

what he has been asked or requested to do.

Q. You were in here yesterday listening to Mr. Wheeler437

talking about various times concerning delegation,

isn't that right?

A. That's correct.

Q. He was talking of times of an hour, an hour and a half,438

maybe as short as fifteen minutes, isn't that right?

A. That's correct.

Q. You have a very experienced and competent solicitor,439

and an extremely experienced and competent barrister.

Did you not suggest to them that maybe they ask

Dr. Wheeler "well, in my case I actually gave Mr. Paran

thirty minutes."?

A. I do not, I did not suggest that to my legal team, no.

Q. Did you even tell them about it?440

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A. They were already aware of that before yesterday.

Q. Okay. Now I want to now -- you say there were two441

conversations before the operation was transferred,

isn't that right?

A. That's correct.

Q. One you say at least thirty minutes, and the second one442

less than five minutes, is that right? Mr. Paran says

less than five minutes. You don't seem to be

disagreeing with that?

A. I am not -- I cannot be firm about the actual time of

the first conversation. I know it was before 11:00

o'clock. The second conversation would have happened

after Mr. Paran had catheterised the patient. That may

have been half past eleven, or it may have been twenty

five past eleven, it may have been twenty five to

twelve, but the patient was now asleep in the operating

theatre at the time, at the time of the second

conversation.

Q. Yes. It was post anaesthesia. Are you disagreeing, I443

mean we will cut to the chase, are you disagreeing with

Mr. Paran when he says it was less than five minutes

before the start?

A. I am not disagreeing with that aspect of it, no.

Q. Okay. Thank you. So then we have got two times. We444

have got one time of more than thirty minutes and a

second time of less than five minutes. That is what

you are saying?

A. No, I am not saying that at all.

Q. Oh?445

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A. I am saying a total time, and I think it should be

viewed as a total time rather than as two separate

times.

Q. Oh, I see. I thought you told me it was more like446

thirty minutes, but in fact it is more twenty five

minutes now you are talking about?

A. No. What I have said is that, and what is evident, is

that the start time of the operation was 11:40 or

thereabouts.

Q. This is the nephrectomy?447

A. The nephrectomy. Correct.

Q. It wasn't, it was 11:09?448

A. That is not correct. The patient arrived in the

theatre reception at 11:05 or 11:09.

Q. I see.449

A. And it would have taken...(INTERJECTION).

Q. Just so we are not at cross purposes on this. The450

sheet you produced this morning says "Start

Anaesthetic: 11:09."

A. Well, my understanding was the patient arrived at the

reception area shortly after 11:00.

Q. Oh, I see. So this appears to be at variance then with451

your recollection, is that right?

A. Well that is not my recollection, that is what is

written on that, on that sheet.

Q. I see. Very well. So this may be wrong then, is that452

right?

A. Well, I cannot comment on that.

Q. Well anyway you produced it. You tell me.453

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A. No, I am sorry, I did not produce that. That is a

hospital document. That is an official record from the

hospital of when the patient actually went into theatre

and had the anaesthetic.

Q. Sorry, Professor, this was a document put into evidence454

on your behalf. Now if you are telling me that you are

querying the accuracy of this document, that is fine.

It is not my document?

A. No, I am sorry, I thought when you said "produced it" I

thought you meant I actually produced it myself.

Q. No, of course not. No.455

A. No, okay. The patient came to theatre around 11:00

o'clock and was brought into the theatre suite and

anaesthetised. That would have been after 11:00

o'clock.

Q. All right. It is 11:09?456

A. Sorry, 11:09. After 11:00.

Q. All right.457

A. I wouldn't be aware precisely, from my own

recollection, of what time the patient came into

theatre, nor would I be aware of what time precisely

the anaesthetic began, but I do know from Dr. Mannion's

testimony, he is the Consultant Anaesthetist, he said

that the surgical time was around 11:40. So between

the patient arriving in theatre to the theatre

reception area and then going to sleep, there is about

thirty minutes or so. So I think, I would respectfully

suggest that it is very difficult to be precise about

that time.

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Q. Yes. Well you were precise by at least, when you were458

referring to at least thirty minutes, isn't that right?

A. Well with respect, I don't think at least is quite

precise. I think that is an approximation. It could

be thirty five minutes or more.

Q. All right. You say that conversation took place some459

time between 10:30 and 11:00, is that right?

A. That's correct.

Q. That is the first conversation. During the course of460

that conversation you said to Mr. Paran, you asked him

would he like to do the nephrectomy, is that correct?

A. I asked him would he like to do the nephrectomy, yes.

Q. Yes, okay. Then the second conversation, which you461

accept occurred less than five minutes before the

operation, was to the effect; " would you like to

proceed with the nephrectomy?", isn't that right?

A. I said are you okay to proceed with the nephrectomy.

Q. All right.462

A. That may have been five minutes before the actual start

time or it may have been ten minutes. I cannot be sure

about that.

Q. No, I thought we had agreed less than five minutes,463

but. Why was it necessary to have that second

conversation with him if, in your view, he was already

delegated to do the operation?

A. Well it wasn't necessary to have that conversation, but

I was there in theatre and it was just something to

discuss with him. That is all. It wasn't actually a

query of his ability or anything.

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Q. No, no, no.464

A. Or his reluctance to do it or not.

Q. I have never suggested there was a query of ability or465

anything like that, but I am just wondering, if you are

firm in your own mind that some thirty minutes before

the operation you had delegated to him, why did you

consider it necessary for him to say some five and a

half, less than five minutes before the operation; "are

you ready to proceed?"?

A. I didn't say "are you ready to proceed?", I asked him

was he okay with proceeding. There was nothing

intended in that comment.

Q. Nothing intended. Okay. Now, I just want to go back466

now to Mr. Paran's movement on that morning.

Mr. Paran, as you know, was operating in No. 7, isn't

that right?

A. That's correct.

Q. And you were in No. 5?467

A. Well we were in and out. He was in and out to Theatre

5 as well. He wasn't solely in Theatre 7.

Q. Yes. Well that is exactly now what I want to deal468

with, because I think your evidence this morning was,

and correct me if I am wrong at this stage, that this

conversation, this is some thirty minutes before the

nephrectomy, you say that conversation with Mr. Paran

occurred at the end of the hypospadias fistula repair,

is that right?


Q. You are saying it occurred at the end of that469

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operation?

A. Towards the end of that operation, yes.

Q. Are you saying that Mr. Paran was present at the470

beginning, the middle and the end of that operation, or

what are you saying?

A. Well what happens, there is a tremendous fluidity

between surgeons moving around between the two

theatres. So it is quite possible that Mr. Paran was

in and out of theatre during that. He did assist me

with the fistula repair, as I understand it. I did ask

him after that, or during that time, in that timeframe

between 10:30 and 11:00 o'clock, was he happy, would he

like to do this procedure?

Q. Yes. Could I possibly ask you that question again,471

Prof. Corbally, maybe you misunderstood it?

A. Sorry.

Q. Is it your evidence to the Committee that it was at the472

conclusion of that fistula operation that you asked

Mr. Paran to do the nephrectomy?

A. I believe it was after the procedure had

finished...(INTERJECTION).

Q. After the procedure is finished.473

A. The hypospadias repair fistula, yes.

Q. How did Mr. Paran, in your recollection, come to be474

present in the fistula operation at all?

A. I think he was free from his Theatre 7 commitment.

Q. You think he was free. So he had nothing to do in475

Theatre 7?

A. Well I know very busy otherwise but, yes, he had

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nothing else to do on that list.

Q. Did you call him?476

A. I cannot recall if I called him or not.

Q. Do you think he wasn't, as it were, do you think he was477

free?

A. Well Mr. Paran is very helpful in a list, and a very

flexible. He will always want to be present.

Q. Indeed. Yes, you are absolutely right. You cannot478

remember whether you called him or he simply wandered

in, is that right?

A. It is more likely that Mr. Paran just came into

theatre.

Q. You think it is more likely he wandered in?479

A. More likely, yes.

Q. All right. Mr. Paran has a very specific recollection,480

Professor, of those events. Can I just put them to you

now? At that stage, when you were doing this, I am

going to call it the fistula operation. Okay?

A. Yes.

Q. He, at the time, was involved in the operation of a481

Hickman/Broviac removal. In fact it is the operation

just before the fistula on this document here. Okay.

When he was completing that he got a call to say -- it

is operation number 515562.

CHAIRMAN: Sorry to interrupt you,

Mr. Meenan. Would it be

possible that the Committee might get a brief

explanation as to what that Hickman/Broviac is? Just a

brief description of what sort of an operation it is.

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MR. MEENAN: Yes, I think I know what it

is. Removal of a central

line, which I understand is not a massive procedure.

CHAIRMAN: Central veinous line say in

the neck where you would

just take it out. So it is a simple operation.

MR. MEENAN: I wonder, maybe Mr. Paran

could probably answer that.

MR. PARAN: This is left in for months

for chemotherapy and it has

a cuff which gets anchored. So again it is not just

simple pull, you have to release the cuff and pull,

more or less about five minutes as opposed

to...(INTERJECTION)

CHAIRMAN: I think that is, that will

be fine. Yes, thank you.

Q. MR. MEENAN: Thank you. In any event,482

Mr. Paran was completing

that when he got a call to say the Professor wanted to

see him, and he went over to 5, and in 5 you were

involved in this hypospadias fistula -- sorry.

A. Hypospadias fistula.

Q. Yes. Sorry, I am sorry, one small detail. After the483

call that the Professor wanted to see him, a nurse came

in to bring him, to summons him over to Theatre 5. So

he went over to Theatre 5, and as I say you were

involved in this hypospadias fistula repair. Mr. Paran

has a very good recollection of what happened. So

firstly, contrary to your recollection, Mr. Paran did

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not wander in. He was actually summoned by yourself.

Now, in the light of that, do you wish

to...(INTERJECTION)?

A. No I cannot comment on that, because there is such an

amount of fluidity in movement between theatres that it

would be impossible to recollect that with accuracy.

Q. You, Professor, wanted to seek Mr. Paran's advice on a484

recurrent fistula and asked Mr. Paran to, as it were,

scrub in, which I understand in layman's terms means

gets involved in the operation?

A. That's correct.

Q. Do you remember that, do you?485

A. I know that Mr. Paran helped me with that procedure.

Q. Yes. Okay. I think you explained to him that the486

patient, this particular patient, in this particular

case the patient's father was a doctor, or you said

words to that effect. Is that right? Can you recall

that?

A. I cannot recall that.

Q. So in any event, Mr. Paran assisted in the operation487

but then left, and left before the end of the

operation. So, do you recall that?

A. I cannot recall Mr. Paran leaving the case, or if I

closed that particular case myself, but I do remember

talking to Mr. Paran after the case had finished in

Theatre 5, when there was no patient there, before

11:00 o'clock, to discuss the delegation to the

nephrectomy patient.

Q. Yes. So if, as I understood your evidence to be, you488

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had this, as it were, what I will call the thirty

minute conversation at the conclusion of the fistula

repair, I am suggesting to you that on Mr. Paran's

account you couldn't have, because in fact he wasn't

there at the end of the operation?

A. With respect, I cannot accept that. I would point out

to you that movements are very fluid between theatres

and surgeons involved in the one list trying to get

through the patient commitment. It is quite common for

surgeons to move in and out of theatre during the

course of a procedure, and the theatres in fact in

question, Theatre 7 and Theatre 5, are quite close.

Q. Yes, indeed.489

A. So movement across the two theatre areas would be quite

common and quite frequent.

Q. Yes. Sorry, I had understood you to say that490

Mr. Paran, at the conclusion of the operation, had in

some sense come back to No. 5, is that right?

A. That's correct. That is my recollection.

Q. I see. Okay. So he left No. 5 during the operation491

and then came back to No. 5, is that right?

A. Well that is, because I, my recollection is that we had

a conversation there was no patient in the theatre at

the end of that procedure.

Q. I see. So presumably he would have come back to No. 5492

because he had nothing else to do anywhere else, is

that right?

A. Well, no. Mr. Paran was busy on the day, and he had

other commitments for his own consultant, Prof. Puri.

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So, I would never imagine that Mr. Paran would be was

wasting time. I think he was doing something else of

clinical importance.

Q. Well, Mr. Paran's evidence in this will be that, yes,493

he did of course assist you in the operation, left

before the end of the operation, went back to Theatre 7

and asked Michelle Cullinane, I think that name is

correct, to send for the next patient for the operation

in No. 7.

A. I believe there was a delay with that patient and

Mr. Paran came back to Theatre 5 with that information,

which was on the basis of that that I realised that he

will be free, and therefore I asked him to do the

nephrectomy.

Q. Ah, well you see isn't this one of the problems,494

because what Mr. Paran will say, and I think you are

probably agreeing, if he had been told, at least thirty

minutes before the nephrectomy, that he would be doing

a nephrectomy, he would have never sent for another

patient to be dealt with in Theatre 7?

A. Well, I can see the logic of that.

Q. Yes.495

A. Of your case there, but in fact there are other people

to do procedures too on the list. So it wouldn't

necessarily be mutually exclusive. In addition, if the

patient had been sent for for a nephrectomy, we would

anticipate at least half an hour for the patient to be

prepared.

Q. Yes.496

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A. And that half an hour would allow another patient with

a minor problem to be dealt with. So it is not

mutually exclusive.

Q. Well I thought you told me a moment ago that you497

thought it might be?

A. I don't recall me saying it might be exclusive.

Q. Well what I am suggesting to you is this, and I thought498

you were agreeing, but maybe you are not, that if

Mr. Paran had been told, as you said he was told some

thirty minutes before the nephrectomy that he was going

to be doing this nephrectomy, he would never have gone

back to 7 and sent for the next patient?

A. Well, Mr. Paran was requested to do the procedure, and

I think it is quite likely within his ambition to get a

list finished that he might do that. I couldn't see

that as being necessarily impossible.

Q. Well it may not be necessarily impossible, but I am499

telling you, I want to suggest to you that for a junior

doctor it is highly implausible that when he is asked

to do an operation like a nephrectomy, which Mr. Paran

will say for him was a serious operation, that his

reaction to that would be to go back to the other

theatre and ask for another patient to be sent down?

A. Well, my recollection is that Mr. Paran came and said

there was a significant delay with getting the patient

into No. 7.

Q. Yes, there was.500

A. And therefore he was available.

Q. Yes, but that was clearly well after thirty minutes.501

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Wasn't it?

A. I cannot actually put the timeframe into that, sorry.

Q. So, Mr. Paran then went back to 7, and as I say he502

asked for the next patient, which as you know we say he

would never have done if he was going to be doing a

nephrectomy. He then was called to go out to speak to

the parents, and that conversation took place. He then

came back and went back to 7 and saw that his patient

was still not there, and he went off to see four

patients in the intensive care unit. Now, I want to

you suggest to you, yet again, if calling for another

patient is inconsistent with being told you are doing a

nephrectomy in thirty minutes, going off to the

intensive care unit to see four more patients is even

more inconsistent. Would you agree with that?

A. Well I would agree with that, but I know that Mr. Paran

is anxious to get through significant workloads.

Q. Yes.503

A. I would, that is part of Mr. Paran's personality,

surgical personality, to try and be as helpful as

possible.

Q. Yes, yes.504

A. Since the patient for nephrectomy was not actually in

theatre at that time, it is quite reasonable to assume

that one could do one more case in Theatre 7 before the

nephrectomy actually arrived in theatre and was

anaesthetised and prepped and everything else. So

there is a...(INTERJECTION).

Q. Sorry, sorry.505

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A. Sorry.

Q. Sorry, I didn't mean to interrupt you, Professor.506

Sorry.

A. There is a potential to actually deal with another

patient before the nephrectomy is ready to start.

Q. Yes. Well presumably the reason you say you told507

Mr. Paran that he would be doing a nephrectomy in at

least thirty minutes was so that he could prepare for

it, isn't that right?

A. No, I anticipated the preparation would be done when

Mr. Paran was ready to do it. I did not consider the

timeframe of thirty minutes or more in that context.

Q. Yes, and calling for another patient and going off to508

the ICU to see four more patients, it doesn't really

fit in with that, does it?

A. That is just efficient use of time.

Q. I see. All right. So he went to the intensive care509

unit, saw the patients there, spent some time there,

and went become to Theatre 7 to see had the patient

arrived, and the patient hadn't arrived because the

patient had to get a premed which somewhat delayed that

operation. So, that really sort of adds to the

inconsistency then, doesn't it? Because what he has

done is, Mr. Paran has sent for the next patient, not

there. He has gone off to the intensive care unit to

see four more patients. Not gone back to do the

nephrectomy, but gone back to 7 to try and do the

patient which he had sent for. It is all very odd,

isn't it?

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A. No, I think it is within keeping of an efficient

surgeon trying to get through a list. I don't regard

it as odd at all. Every surgeon in Crumlin is aware of

the pressures that we are under, and we have to try

and, you know, we are under pressure to deal with

numbers, and we are trying our best to get through a

list.

Q. Well of course...(INTERJECTION)?510

A. Mr. Paran -- sorry, Mr. Paran has been exemplary in his

ability to try and do that.

Q. Yes.511

A. I would think that sending for an additional patient

would be Mr. Paran's, I would absolutely agree that

that would be part of the way he would work.

Q. Yes. He doesn't turn down work, is that what you are512

saying?

A. No, Mr. Paran is an extremely generous person with his

time.

Q. Yes. Yes, you are right. So you don't think then it513

was out of order in Crumlin Hospital at the time, in

the space of some twenty five minutes, because we know

he was there some five minutes before the operation,

maybe even a little bit before that, because we know he

had to catheterise the patient and position the

patient, which all takes a little bit of time, isn't

that right?

A. That does take time, yes.

Q. So he would certainly have been there, although he says514

he was only told about the operation less than five

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minutes beforehand, he would certainly have been

present in the theatre probably about ten minutes.

Would that be right? Would that be right?

A. I cannot comment on when he entered the

theatre...(INTERJECTION).

Q. Yes, but presumably it takes a bit of time to position515

a patient and to catheterise the patient. So I am

suggesting to you about ten minutes?

A. I cannot comment if he was there fifteen minutes, or

ten minutes, or five minutes. I don't know when he

arrived in Theatre 5.

Q. Yes, I know you don't know when he arrived. I am just516

looking at what he did when he arrived, to try and fix

a time for it?

A. Well it would take two or three minutes to catheterise

the patient.

Q. Yes.517

A. It would take a minute or two to position the patient.

Q. Okay. So we will say in around ten minutes. So that518

would probably leave him twenty minutes then after

being told that he was doing a nephrectomy, isn't that

right?

A. Twenty minutes before he was -- I don't understand the

question.

Q. All right. Okay. Well let's just work it forward.519

You say he had at least thirty minutes, you have told

him at least thirty minutes before the operation that

he was going to be doing a nephrectomy. That is what

you are saying?

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A. Well, I have a problem with your choice of words. I do

apologise for that. I asked him to do the operation.

I did not tell him to do the operation.

Q. All right. All right. Okay. Yes, and you say he520

agreed to do it?

A. He absolutely agreed to do it. He was very willing.

Q. So that is, we will say, thirty minutes before the521

operation, is that right?

A. Well, it was about before 11:00 o'clock, and the

operation started at 11:40. So that would be, it is

forty minutes.

Q. Oh, it is 40 minutes. So the thirty minutes is now522

becoming 40 minutes?

A. I am sorry, I don't mean to be disrespectful.

Q. All right.523

A. You said at least thirty minutes...(INTERJECTION).

Q. Well no, I am sorry...(INTERJECTION)?524

A. And I have said that it was before 11:00 o'clock and

that the patient went, the surgical time was actually

11:40.

Q. Look Professor, I won't beat about the bush with you.525

What I am putting to you is simply this; that on your

evidence he had at least thirty minutes before the

operation, more thirty minutes. He was in the

operating theatre ten minutes before the operation,

which left him twenty minutes, and I want to know is it

your evidence to this Council that in the space of

twenty minutes in Crumlin Hospital you would carry out

an operation, go to the ICU and see four patients?

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143

A. What I am suggesting is that Mr. Paran will use the

time very efficiently, and if there is a hiatus in

time, Mr. Paran will actually try and see patients and

fill in that time appropriately. Now whether or not he

is able to see all four patients, or even do a minor

procedure in that case, is something

different...(INTERJECTION).

Q. Well I can tell you what the -- sorry.526

A. Sorry, but the patient, if the patient was asleep in

Theatre 5 and waiting for Mr. Paran to start, Mr. Paran

could be a few minutes late coming to theatre. It is

possible to actually at least have the ambition to do

that, and I think also the potential to do that in that

timeframe.

Q. I am suggesting to you, and the patient who was being527

waited upon in Theatre 7 was a circumcision operation

which took, "started anaesthesia 11:55. Finished

12:24". So that is not a huge operation, but clearly a

lengthy enough operation?

A. Well the start and finish times reflect, they are a

combination of both anaesthetic and surgical times, and

also -- which patient is that? Sorry.

Q. Yes, I can tell you that. If you go to the first page528

of this document you produced, you introduced I suppose

I should in fairness say, it is the fourth one down;

535570?

A. Yes, yes. That was done by Badrul Yeap, who is quite

an accomplished surgeon in his own right, but in a

general sense a circumcision surgically takes eight to

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ten minutes to perform. There is an anaesthetic time

pre and post surgical time interwoven in that.

Q. All right. Okay.529

A. I have no doubt Mr. Paran could have done a

circumcision in eight minutes, or ten minutes.

Q. Yes, and also seen the four patients in the intensive530

care unit, and gone to the intensive care unit, seen

his four patient, and come back from the intensive care

unit?

A. I think, with respect, when Mr. Paran went to the

intensive care unit he could have seen one patient. It

may have been his ambition to see four patients, but if

he hadn't been able to see his four patients, he would

have seen what he would have been able to see and come

back to theatre to complete the nephrectomy.

Q. Also I think at the time Mr. Paran was taking a hand531

over of patients from Mr. Mortell. Are you aware of

that?

A. No, I wasn't aware of that.

Q. That was all going on in this thirty minutes where you532

say he should have been preparing for this operation?

A. Well, I don't wish to detract from that. Mr. Paran is,

as I have said, very accommodating of his time, but he

is also extremely conscientious.

Q. Yes.533

A. He would taken, if that was the case, Mr. Mortell would

have passed on the hand over. But in fact, I have no

information about Mr. Mortell's hand over involvement

with Mr. Paran at that time.

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Q. Can I go back to the narrative anyway. You are right,534

after the intensive care unit, Mr. Paran went back to 7

to see that his patient hadn't arrived, and he had some

ten minutes to spare. He then called over to Theatre

5, where you were, or sorry, where the anaesthetist

was, and the patient was on the table being

anaesthetised. He had some ten minutes to spare. The

anaesthetist asked, as you know, Mr. Paran, would he

catheterise the patient, and Mr. Paran did that, and

also then positioned the patient. You were present, in

Mr. Paran's recollection, looking at the notes. Is

that right?

A. That's correct.

Q. The notes, of course what you were looking at would be535

your own notes?

A. I looked at the consent and I looked at the patient ID.

Q. Yes. Okay. I think you said to him; "left side Sri"536

and he answered "yes", is that right?

A. That's correct.

Q. Mr. Paran says that as he was leaving you said to him;537

"are you happy to go ahead?", and you said it to him

not once but twice, because I think Mr. Paran was quite

surprised to hear you saying that to him at all?

A. I cannot recall saying; "are you okay to go ahead,

Sri?", twice. But in asking him "left side", I was

actually Mr. Paran was he happy with the selection of

the site, and Mr. Paran said yes.

Q. Well his evidence will be just you said; "left side,538

Sri", and his answer was yes, and you were looking at

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146

the notes?

A. That was a question, and Mr. Paran answered yes. I

then asked him was he okay to go ahead. I have no

reason to ask a surgeon of Mr. Paran's experience

twice, in any way question his ability, or put him

under pressure to do that, and I would not, I don't

recall asking him twice.

Q. Well Mr. Paran, who has a very, very clear recollection539

of this, as you might well understand, says it was said

to him twice, because Mr. Paran really probably

couldn't believe what he was hearing when you said it

to him the first time?

A. Well, I don't think I was actually intending to put

Mr. Paran under pressure by asking him. I was merely

just confirming that he was happy in his own mind to

proceed.

Q. We are agreed I think anyway that that event took place540

less than five minutes before the operation began. You

have indicated to the Tribunal, or the Council, that

"well, if Mr. Paran was unhappy to proceed with the

operation he should have said no, I need more time, or

words to that effect", is that right?

A. If Mr. Paran had been unhappy to proceed he had the

option to say he was unhappy to proceed. But also he

had the option and time available to look at the

imaging at that time, which he did not.

Q. Yes. You didn't either?541

A. That's correct, I did not. I assumed that Mr. Paran

would.

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Q. You assumed that.542

A. I gather -- I mean my impression of delegation at that

level to someone of Mr. Paran's experience is that

Mr. Paran would have looked at the imaging.

Q. I presume you are talking about the thirty minutes now?543

A. Within the timeframe of being asked to do the procedure

and starting the procedure.

Q. Yes.544

A. Yes.

Q. Yes. Mr. Paran's evidence will be that you pointed out545

to him where the incision was to be made?

A. I asked Mr. Paran what incision he was going to use,

and he suggested that he should use the previous site

of colostomy closure, which was just below the

umbilicus, perhaps a little bit lower than that, but

around that area. I suggested to him that that was not

going to be an easy operation to do through that

incision and that perhaps he would considered, and I

suggested, that the left upper quadrant transverse

incision was more appropriate to easily access the

kidney, and he agreed with that.

Q. Yes. You were pointing out the left hand side, isn't546

that right?

A. That's correct.

Q. So therefore, I am suggesting to you, that you were547

saying the incision should be made on the left hand

side, is that not right?

A. I was -- it was a left hand sided incision whether you

used the colostomy incision or whether you used the

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148

incision that I pointed out to Mr. Paran.

Q. There was absolutely no doubt then, as far as Mr. Paran548

was concerned was, that this operation was to be

carried out on the left hand side, isn't that right?

A. That's correct.

Q. You were pointing out the left hand side too, weren't549

you?

A. The patient was listed for a left nephrectomy and it

wouldn't make any sense to approach the operative site

through the right hand side. So the intention was to

go through the left hand side. That was an appropriate

decision, based on a left nephrectomy.

Q. Yes, but you were pointing the left hand side?550

A. That's correct.

Q. Your counsel told us yesterday that it was your551

invariable practice to check radiographs before

commencing operations, isn't that right?

A. If I was doing the procedure, yes.

Q. Yes. Well I want to suggest to you that it would be552

entirely reasonable for Mr. Paran to believe that you

had looked at the radiography and you were satisfied

that it was a left hand side, otherwise you would not

have pointed out the left hand side?

A. I pointed out the left hand side on the basis of the

listed procedure, which was a left nephrectomy. I

asked Mr. Paran at the outset a question, was it the

left side, left side, and Mr. Paran said yes. I

believe Mr. Paran was taking that information from the

consent, like I did subsequently, but I was not aware

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that Mr. Paran had not looked at the imaging. I was

not aware that he had no intention of looking -- did

not look at the imaging until after I had gone into

theatre...(INTERJECTION).

Q. Sorry, I just want to stop you there. What do you mean553

by "I was not aware that he had no intention of looking

at the imaging"? What do you mean by that?

A. Well he had not looked at the imaging.

Q. No. Well you said he had no intention. Could you just554

explain that for a minute?

A. Yes. I had no awareness that Mr. Paran had not looked

at the imaging at the outset.

Q. Yes.555

A. And that Mr. Paran did not look at the imaging prior to

making the incision.

Q. No, no, you told us a moment ago that he had no556

intention of looking at it. Can you just explain that?

A. I take that word back. That is not an acceptable term.

Q. Yes. All right. Very good. Yes, you are absolutely557

right, it is not. I want to put to you, Professor,

that in fact you were the one who directed where the

incision was to be made, and so therefore you were the

one who has to take responsibility for operating on the

left hand side?

A. I think Mr. Paran, as an experienced surgeon, and one

to whom many of my colleagues would delegate similar

procedures, would be expected to detail the imaging

prior to surgery, and also during surgery if an event

occurred, would be expected to review the imaging.

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That reflects his experience and his training to date.

So I would expect that Mr. Paran actually should have

looked at the imaging, and the whole situation would

have been avoided.

Q. I want to say to you, Prof. Corbally, that that558

conversation, some thirty minutes or so before the

operation, did not take place, and that you are

incorrect in your recollection of it taking place?

A. I would have to disagree with that.

Q. I also want to say to you again, that the occurrence of559

that conversation is entirely inconsistent with the

movements of Mr. Paran after, when you say that

conversation took place?

A. I would have to disagree with that too.

Q. All right. There was no assistant at the beginning of560

the operation, isn't that right?

A. That's correct.

Q. So Mr. Paran had to go and get an assistant?561

A. Well, that is normal practice for a surgeon. The

surgeon is aware that an assistant is required. So

either he asks an SHO to come to theatre or he asks one

of the nurses to ask an SHO to come to theatre, but it

is a standard practice that the operating surgeon has

the responsibility to ensure he has an assistant.

Q. Yes.562

A. There is nothing unusual in that situation.

Q. Okay. But if Mr. Paran is correct in his recollection563

of events, that he had less than five minutes, he had

less than five minutes to get an assistant, isn't that

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151

right?

A. That depends on whether or not it was actually five

minutes, but in fact it was more than thirty. So

Mr. Paran had an opportunity to get an assistant.

Q. So really in that thirty minutes, not only should he564

have been looking at the radiographs, he also should

have been trying to find an assistant, is that right?

A. It wouldn't necessarily be asked of Mr. Paran to get

the assistant. He merely has to ask the nurse in the

theatre to call for an assistant.

Q. He also said that there was no cross-matching or group565

and hold?

A. I believe that to be incorrect. The nursing records

clearly state that when the patient arrived in hospital

the day before, that a request was made for a group and

hold. I believe Dr. Mannion's statement also reflects

that blood was group and held, but that he was made

aware by Nurse Beata Suska, an anaesthetic nurse,

whilst the patient was in Theatre 5, that there was a

problem with the blood bank and that they were

requesting an additional sample, which Dr. Mannion sent

down to the blood bank. It would not be normal

practice to group and cross-match a patient, which

would be wasteful of blood resources, but it would be

normal practice, and is standard operational policy and

protocol to have a group and hold done when the patient

arrives in the hospital. However...(INTERJECTION)

Q. Well -- yes, sorry, go on.566

A. Sorry. Sometimes there will be a problem with the

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152

blood sample and the blood sample will have -- a repeat

blood sample will have to be sent down. That is not

unusual. It is normal practice. It is part of the

course of the evolution of the list.

Q. But also I think it is something that has to be567

attended to, isn't that right, the availability of

cross-matched blood?

A. Sorry, we don't routinely cross-match nephrectomies.

Q. Yes.568

A. Because we expect blood loss to be minimal in

nephrectomies. In simple nephrectomies blood loss is

minimal. So Mr. Paran did not have to attend to the

issue of blood group, and safe, or if that was his

intention to cross-match, that either all he has to do

is, in a normal situation, is to ask the anaesthetist

to take a blood sample.

Q. I think at the same time another matter which Mr. Paran569

had to attend to was to determine the urgency of a call

which he had received from the A&E, because as you know

he was on-call at the time?

A. I wasn't aware that he had a call to deal with in A&E,

but, and I don't not wish to undermine Mr. Paran's role

in this, Mr. Paran is very adept at being efficient and

dealing with many things at the one time.

Q. Yes.570

A. That is standard practice amongst doctors in Crumlin.

It is a very busy place, and people have adapted to

being, not quite in two places at one time, but also to

deal with many things at the one time.

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153

Q. Yes.571

A. So he would have, he would have wanted to go to A&E to

deal with that patient, but he may have delegated that

to somebody else if he was busy.

Q. Yes. We will just break for the Stenographers.572

CHAIRMAN: Okay, we can resume.

Q. MR. MEENAN: Yes, thank you. Yes, I573

think you are absolutely

correct when you describe Mr. Paran as being more than

willing to take on patients, and I want to suggest to

you that in fact Mr. Paran would never have been in

theatre 5 attending the patient, the subject of this

inquiry, if in fact the patient which he had sent for

number 7 had actually not required a pre-med and

arrived on time?

A. I think that Mr. Paran would probably have finished the

circumcision very quickly, and been in theatre 5, but

can I also say that if he was doing the case that the

patient could wait a few minutes more in theatre 5,

anaesthetised, waiting for Mr. Paran to come to

theatre. So again the start time is dependent on the

surgeon, and he sets the pace.

Q. Yes, and what were you doing while all this was going574

on?

A. I actually had quite a large number of charts to sort

out.

Q. Charts to sort out, yes.575

A. I was sitting in the dictation room.

Q. Yes, you were doing a bit of paperwork?576

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A. Well, a lot of paperwork.

Q. A lot of paperwork, yes. So while Mr. Paran was577

sending for another patient in theatre 7 and going off

to the ICU to see 4 more patients, and going back to

theatre 7 to see if a patient arrived and making sure

that everything was all right in the A&E, you were

there doing your paperwork, is that right?

A. Well, can I just say that, as I have said this morning,

there is no allocated time for consultants to do

paperwork.

Q. Yes.578

A. We contribute 75; 72, 75, 80 hours a week of normal

working hours. In addition, I am on-call ten nights a

month, ten to 12 nights a month on-call every month, in

addition to having an oncology commitment of 24/7 since

2005. I don't have the time to -- I have to find time

between cases to do essential paperwork.

Q. Right.579

A. To answer patients' queries. To call patients with

whatever concerns they have if I can, and occasionally

then to run in and out between cases and see the

patients in ICU or whatever. So I think that paperwork

in a hospital setting is equally as

important...(INTERJECTION).

Q. Yes.580

A. As seeing patients in out-patients or in fact

operating.

Q. Of course I do not want to take from that. Yes, of581

course it is important, yes. Mr. Paran his evidence

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will be first of all he is hearing for the first time

today after all these terrible events have been going

on now for in excess of 2 years; hearing for the first

time today that he was allegedly told he had some 30

minutes to prepare for this operation?

A. Well, the timing never became a crucial issue in my

report, as I have said. I was more concerned about the

delegation and the process of delegation.

Q. Yes, and Mr. Paran will say that if he had been given582

30 minutes he would have dealt with matters entirely

differently. He would have had an opportunity to

review the radiographs and the records?

MS. BARRINGTON: I am terribly sorry to

interrupt Mr. Meenan, but I

think in fairness to the witness he did not say that he

told Mr. Paran he had 30 minutes, but he said that he

asked Mr. Paran would he like to do the surgery at

least 30 minutes in advance.

MR. MEENAN: Yes, that is the same

thing. Well, if it is not,

it is not. I mean I am prepared to go with that, yes.

MS. BARRINGTON: I just wanted it clarified.

Q. MR. MEENAN: But if Mr. Paran had been583

asked to do the surgery

some 30 minutes beforehand and had said, yes, I will,

he would have dealt with matters entirely differently.

Firstly, he would never have gone back to theatre 7 to

get another patient. He would never have gone to the

intensive care unit. He would have reviewed all the

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documentation, including the radiography?

A. I cannot comment on Mr. Paran's thought processes at

that time, but I do know from my extensive dealings and

experience of Mr. Paran that he will try to help the

list along as quickly as possible.

Q. Yes.584

A. He will try to be efficient. He will try to use his

time efficiently and, where possible, he will be as

helpful as possible.

Q. Yes.585

A. And I think that in this context his ambition was to

try and do another case before the actual nephrectomy

started.

Q. I see.586

A. And he has always been regarded as extremely helpful in

that regard.

Q. Yes. I think you heard the report, Mr. Wheeler was587

giving evidence yesterday, and I just want to ask you

to comment on something which Mr. Wheeler said, both in

direct-evidence and indeed on further examination not

by either side here, but by I think it was Mr. O'Neill

on the Committee, and it is on the first page of the

report dealing with Mr. Paran?

A. Sorry, could you tell me what page that is?

Q. Yes, of course, it is page 4 of Mr. Wheeler's report?588

MR. CROSS: It is on the report,

Professor, not of the

transcript yesterday, Mr. Meenan is referring to.

A. Sorry, I do not know where that is.

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Q. MR. MEENAN: I am sure your solicitor589

will give it to you. "In

the circumstances of elective surgery", sorry, are you

with me?

A. Yes, page 4.

Q. Page 4:590

"In the circumstances of electivesurgery, a surgeon would be expected toreview the patient and discuss theforthcoming surgery with the parentsbefore commencing surgery".

Now I am not going to deal with that, and then it goes

on:

"However, it must be acknowledged thattrainees are constrained by thehospital system in which they work. Ifa trainee works within a system wherebyoperations are allocated to traineesonly very shortly before the operationcommences, it would be unreasonable toexpect the trainee to insist that theoperation was delayed until the normalprocess of clinical review andconsultation was completed. To insiston such delay would put a trainee atodd with his seniors and would make hisposition within a surgical departmentexceedingly difficult".

Do you agree with that?

A. No, I do not agree with that.

Q. You do not agree with that?591

A. Well, there are aspects I don't agree with.

Q. You might just tell me the aspects -- well, could you592

first of all tell me the aspects you do agree with?

A. I think if trainees felt under pressure and that there

might be a repercussion for delaying or disagreeing,

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yes, that would be true, but that is not the case on

the situation that applies in Crumlin. I would have

regarded myself as Mr. Paran's friend, his mentor and

his colleague, and I know that I would never in any way

censure or criticise a trainee for telling me that

there was a problem with a patient. I would in fact

welcome that because that would prevent any adverse

outcome to the patient.

Q. Yes.593

A. So Mr. Paran would know that raising a flag to dispute

laterality would only, in my mind, be welcome.

Q. I have to say, Professor, I do not know what you are594

talking about in respect of raising flags in

laterality, but we are actually dealing with a very

specific point here, which is that:

"To insist on any delay would put atrainee at odds with his seniors andwould make his position within asurgical department exceedinglydifficult?"

A. I could not agree with that, I am sorry.

Q. Could not or would not?595

A. Neither, I cannot agree with that.

Q. Well, I mean Mr. Paran will say that in the hierarchal596

system of the medical profession, of course you would

be well familiar with, there was no earthly way, that a

registrar of Mr. Paran's status and experience, could

possibly say to a senior like yourself, no, I can't do

this operation or I won't do this operation?

A. I find that difficult to understand and believe.

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Mr. Paran, apart from what I have already mentioned

about our relationship over many years, Mr. Paran had

been admitted to the specialist register in the Medical

Council of Ireland. Had returned from a very distinct,

hard working fellowship in Sloan-Kettering in New York

City. Had worked for at least 8 years in the practice

of paediatric surgery, at least one, if not one and a

half years was in pure paediatric urology. Had passed

his European State Board exams in paediatric surgery.

Had the support and respect of all his colleagues and

still has in Crumlin for his technical ability, and his

conscientiousness. I would never have expected or

anticipated that Mr. Paran would feel in any way under

threat or pressure or in any way uncomfortable with

saying that he himself was uncomfortable with dealing

with an operation like this. It would never be my

expectation that that would be what Mr. Paran would

think or feel.

Q. I am sure Mr. Paran is very encouraged to hear all this597

praise being heaped on him, but what he will say is

this: That he was asked to do this operation less than

5 minutes beforehand and he simply was not in a

position to say, no, and would you agree with me that

not reading -- you have in the few moments, spent the

last few moments praising Mr. Paran to the heights.

Would you agree with me that not looking at

radiological slides before an operation would be

totally out of keeping with the Mr. Paran you know and

have praised so highly?

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A. I would, I would agree with that, yes, and I think this

is a very unusual situation.

Q. Yes, particularly as you say that he would have had598

some 30 minutes to do so before the operation?

A. Irrespective of the time, it takes a minute to review

an x-ray, and Mr. Paran I know would have normally done

that and that was my competent expectation.

Q. And I take it it is your -- I take it, I am sure599

Ms. Barrington was entirely correct when it was put to

Mr. Wheeler yesterday, that it is your invariable

practice to review radiographs before operations, is

that right?

A. In situations where an organ is to be removed, yes.

Q. Yes, okay, and that is something which the junior600

doctors who work under you would know, that is your

invariable practice?

A. That is the practice, that is standard recommendations

in surgery.

Q. Yes. To return to the issue of the conversations, as601

you know which took place with the parents of the child

involved, you have heard the evidence on that, is that

right?

A. I have.

Q. And I take it you heard the evidence from Nurse Anna602

Davey yesterday, is that right?

A. Yes, I did.

Q. And you heard that she recorded at the time that the603

parents in her, I suppose virtually contemporaneous

note says, "seemed satisfied after speaking with

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161

Dr. Sri Paran". You heard that?

A. I did.

Q. And you have no reason to believe that that is anything604

other than accurate do you?

A. I have no reason to doubt that.

Q. So I suggest to you on the basis of that note,605

Mr. Paran was entirely satisfied, well, was satisfied

that he had put to rest the concerns of the parents?

A. That was Mr. Paran's -- that is his perception, yes.

Q. Okay, and if that was his perception, which it was,606

would you not agree then it would follow that there was

not a duty on him to inform you of what had taken

place?

A. That is very difficult to answer Mr. Meenan. I think

that in the normal context if parents raise a concern,

that one has to be sensitised to that and one has to

act upon that.

Q. Yes?607

A. And in any situation of surgery, especially when an

organ has to be removed, one has to revert back to the

core reference point, which is the imaging. I think it

would have been appropriate to review the imaging at

that point or to, if he had reviewed the imaging and he

was happy with that, then that was fine.

Q. Yes?608

A. But to tell me it was an easy thing to do, I would

regard myself as approachable.

Q. Yes.609

A. And at that point the imaging would have been

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162

thoroughly reviewed.

Q. Of course the imaging was not present when the child610

was taken to the operating theatre, is that not

correct, it only arrived later?

A. I think when Nurse Anna Davey was there the x-rays were

actually there on the trolley. It was Mr. Mortell I

understand brought the imaging from the x-ray

department, and Mr. Paran was still there with the

parents when the x-rays were on the trolley.

Q. I think there may be a dispute in connection with that,611

but certainly from Mr. Paran's point of view he was

looking at the records and when he was doing that, the

imaging or the radiography was not present?

A. That is not my understanding of -- sorry.

Q. But in any event I mean to come back to the question,612

would you agree that Mr. Paran was satisfied, as he

said he was, that the concerns of the parents had been

addressed and obviously Mr. Paran would be fully aware

of the sensitivities involved concerning parents in

this very difficult time, wouldn't he be?

A. I think Mr. Paran would be very very aware of parents'

sensitivities, yes.

Q. And with the sensitivity that you accept that he had,613

and what was noted by the nurse at the time, that the

parents seemed satisfied, that therefore I would

suggest to you that there was not a duty upon Mr. Paran

to inform you of what he had discussed with the

parents?

A. If Mr. Paran was completely happy in himself that the

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163

parents' anxiety had been allayed, I would agree with

that, yes.

Q. Okay. I want to move on to the point at which the614

kidney was removed?

A. Yes.

Q. I think you were present towards the end of that, is615

that not correct?

A. I was present when the kidney had been removed.

Q. Yes, and it is correct that Mr. Paran did not look at616

the radiography at that time?

A. That's correct.

Q. But he will say every over factor there was pointing617

towards it being the correct operating site, the

left-hand side?

A. I think the consent was, the note that I had

erroneously dictated to the GP was, and also my

discussion with him over the left side, yes, all

pointed to the left side.

Q. Yes, and also conversations which he had with an618

anaesthetic registrar also, and also his recollection

of what the mother had said to him about left-hand

side?

A. I believe that the patient's mother had actually

queried the right side and the patient's father was

convinced it was the left side.

Q. Yes?619

A. And I believe that when Mr. Paran consulted with the

anaesthetic registrar, it was on the basis of his

perception that the kidney looked more normal than it

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164

should for 9% function and he asked for the consent to

be shown to him again. I gather that he had looked at

the consent at the theatre reception when the parents

were checking in with this patient.

Q. And in addition to that also, what Mr. Paran thought he620

was dealing with what is referred to as being a baggy

kidney?

A. Yes, in occasions of significant vesicoureteral reflux,

you can have hydronephrosis, where the ureter and the

pelvis of the kidney are dilated and floppy. However,

when you palpate the kidney, if it was a

hydronephrotic, a reflux of hydronephrosis with a

poorly functioning kidney, one would expect the kidney

substance, the meat, if I might call it that, or the

parenchyma of the kidney, would be very thin. You have

to palpate the kidney when you take it, when you

attempt to tie off the vessels. So I think by visual

inspection it might be possible to look at the kidney

and say, this looked hydronephrotic and that would fit

with the planned procedure.

Q. Yes?621

A. But when one palpates the kidney I think that the

discrepancy should become obvious or will be obvious,

because the kidney would actually feel like a normal

kidney.

Q. Are we agreed then anyway that a baggy kidney is not622

inconsistent with a kidney which is caused by the

condition which the patient had in this case?

A. I think in some situations by inspection, yes, but not

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165

by palpation.

Q. I think you told us that you attended a lecture this623

year or maybe it was last year by Prof. Youngson, is

that right?

A. That's correct.

Q. And in the course of that lecture did he deal with what624

is called or what he will describe as "plan

continuation error"?

A. Yes.

Q. And so you know what it is?625

A. Well, it was a workshop which was most enjoyable and

very informative.

Q. Yes?626

A. My understanding of plan continuation error is the

analogy taken from the aviation industry, where in

terms of airline, aircraft crashes or airline

incidents, that the majority of these are actually due

to human error.

Q. Yes?627

A. And that maybe 20% or 20% to 30%, Prof. Youngson can

correct me, is due to technical errors in the aircraft,

and that plan continuation error means that the pilot

in situations of human error has a plan in mind, and

despite obvious signs to the contrary, fails to deviate

from that plan, even though it ultimately results in a

fatal outcome as an error.

Q. Yes?628

A. I think Prof. Youngson had a very good example of a

South American plane approaching La Guardia some time

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ago, which ultimately crashed, and the pilot informed

the air traffic controller that he was out of fuel or

low in fuel, but ultimately said out of fuel. The air

traffic controller informed him that he should circle,

which he did, and ultimately crashed?

Q. That lecture obviously made a big impression on you,629

Professor, did it not?

A. It was a very worthwhile workshop, yes.

Q. Yes, and I do not know if you wish to comment on this,630

but what Prof. Youngson's evidence to this Council will

be, that the removal of the kidney when it was done,

and in the circumstances in which it was done, fitted

into this concept of a plan continuation error?

A. I don't think I can comment in detail on that,

Mr. Meenan, but I would agree that that is a likely

explanation because this has to be regarded as an

aberrant unusual behaviour by Mr. Paran. It was a very

unusual set of circumstances, and not one that in any

way in Mr. Paran's training before this, was there any

concern whatsoever about his surgical performance.

Q. Would you agree with Mr. Wheeler's evidence to the631

effect that if this Council does find that Mr. Paran

only had less than 5 minutes before this operation,

that he did not have sufficient time to do the matters

which you said he should have done?

A. I don't agree that that five minutes is actually the

time, Mr. Meenan, but 5 minutes is a short time, if

that were the case, but again it takes one or 2 minutes

to actually look at a radiograph.

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Q. Would you ever delegate an operation such as a632

nephrectomy less than 5 minutes before it starts?

A. If I had to rush away to do something. If I was called

to the A&E department for a child in a trauma and the

delegee was of sufficient competence to do the

operation, yes.

Q. You were not rushing anywhere here?633

A. No, but you asked would I ever, and would I ever -- the

answer to that is, yes, in that context.

Q. Well, unfortunately, I have to suggest to you that634

although you were not under pressure at the time, that

is unfortunately exactly what you did?

A. Well, I don't accept that it was 5 minutes, it was

longer than that.

Q. As you know, Mr. Paran is absolutely adamant in his own635

evidence and clear, that he was never told 30 minutes

or more than 30 minutes, or even ten minutes before

this operation that he would be doing it. Can I just

turn to the conversation which you had with the

patient's parents after the event. Why didn't you ask

Mr. Paran to speak to the parents?

A. I felt that Mr. Paran was very upset at this event and

I felt that at that point he needed not to talk to the

parents, just until things settled down certainly in

his own mind.

Q. And in fact I think he was -- yes, I think Mr. Paran636

was told that it was -- and he was the surgeon who you

say to whom you say you had delegated the operation.

He says, Mr. Paran will say that he was advised by the

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168

hospital not to speak to the parents. Did that advice

come from you?

A. I would have felt that that would be a reasonable

position at that time, but the advice it may have come

from the hospital, I do not know.

Q. In fact Mr. Paran actually did speak to the parents on637

the Sunday, which I think was Easter Sunday in fact?

A. That's correct.

Q. And he did that of his on volition, are you aware of638

that?

A. Yes, I am.

Q. That he felt he had to speak to the parents?639

A. Yes.

Q. I suppose you think that was an entirely appropriate640

thing to do, wouldn't it?

A. I think at that time the actual horror of the situation

had probably passed somewhat, and one was able to take

a breath I think and discuss this in more logical

terms.

Q. The horror of what had passed?641

A. 48 hours later, of having taken out a normal kidney?

Q. Yes. You see what I do not understand is that, you642

know, if you are correct in your evidence, and you are

undoubtedly correct in your evidence in praising

Mr. Paran to the rafters, and your evidence that this

operation was passed over well in time; why you did not

send Mr. Paran directly to the parents to explain what

had happened. I mean you say he is of seniority. He

was of experience, he had just about everything?

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A. I think that I wished to protect Mr. Paran at that

point, and I did not wish Mr. Paran to be certainly

talking to very anguished and grieving parents at that

time, up set parents, and I felt that it was my

responsibility as the admitting consultant to deal with

that personally myself. I knew that the facts would

come out in due course, and that it would be clear what

had happened, but I felt that I had a responsibility to

the parents to accept responsibility for this. To

explain what had happened in sufficient detail for them

to deal with it at that time and then to develop

further detail as time passed.

Q. Whatever you said to the parents, you are certainly not643

accepting responsibility today, is that not right?

A. No, I am accepting responsibility, as I have done

before, for overall -- as the consultant in overall

charge of the patient.

Q. And if Mr. Paran had not of his own volition gone to644

speak to the parents on Easter Sunday, they would not

have known that it was Mr. Paran who did the operation

rather than yourself, Professor, is that right?

A. I think they would have known sooner or later, yes.

Q. What was it going to be, was it going to be sooner or645

was it going to be later?

A. It was not a matter of trying to hide the facts from

the parents.

Q. When had you planned to tell the parents, Professor?646

A. I had no plan in mind in fact of when to tell the

parents.

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Q. You had no plan at all?647

A. No, no I had no plan in mind at that time but

ultimately this would have happened.

Q. I don't quite follow that. Well, certainly it answers648

the question sooner or later, we now know it is later

but when would you have planned?

A. There would have been an anticipated inquiry in the

hospital, and this would have become clear at that

time.

Q. All right. So the parents would wait for the inquiry.649

I think I am complete in that. Thank you very much

Professor.

A. Thank you Mr. Meenan.

MR. MEENAN: I am nearly sure I am, yes.

END OF CROSS-EXAMINATION

CHAIRMAN: Thank you. Thank you

Prof. Corbally. I would

propose maybe that we might take a short break just to

allow concentration to be restored. There may be some

questions from the Committee and Mr. Leonard may wish

to speak again. Did you want to say something

Ms. Barrington?

MS. BARRINGTON: I will have a few very

brief questions.

CHAIRMAN: Okay. So I think we will

take about 5 minutes just

to let the brain rest. Thank you.

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MS. BARRINGTON: Thank you Chairman.

SHORT ADJOURNMENT

THE HEARING RESUMED AFTER THE SHORT ADJOURNMENT AS

FOLLOWS:

CHAIRMAN: Okay. Perhaps we will

resume. First I would ask

member of the Committee have any questions.

PROF. M. CORBALLY WAS THEN QUESTIONED BY THE COMMITTEE

AS FOLLOWS:

CHAIRMAN: Okay, perhaps we will

resume. Maybe first I

would ask if the members of the Committee have any

questions?

Q. MR. O'NEILL: Just one thing as a lay650

representative, Professor,

that strikes me is, we have heard a lot about

delegation. We have heard a lot about responsibility,

the hospital standards, systems and so on. You are a

senior surgeon. You also have, apart from your medical

roles, you have an administrative role in all of this.

To what extent do you have responsibility for devising

procedures for things like, which we have heard a lot

about, delegation, or for let us say acquiring an

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172

assistant when a surgeon is required. It seems as if

from the way it is described that it is very much on

the hoof, so to speak. Do you as a senior surgeon have

direct responsibility in that area?

A. I do, and so do all of my surgical colleagues.

Q. In your own area?651

A. In my own area, yes, and that delegation arises from a

long and protracted, extended period of knowledge and

acquaintance and experience with the delegees, and with

Mr. Paran that was over 8 years, and we have never had

any issue whatsoever with his management. In fact so

much so that the collective surgical body wrote to the

Medical Council and recommended his admission to the

medical specialist register. Unanimously, there was no

dissension, it was total agreement. So in terms of

protocols there are no written protocols, but the

experience that one gains from interacting with junior

doctors and consultant hospital doctors is such that it

is accumulative, and that you form your opinion as to

what they can do, but you also take them through

procedures. So if, for example, a first year SHO or a

second year SHO in paediatric surgery was doing an

umbilical hernia, well, you might have to show them how

to do an umbilical hernia a few times, and that you

would assist them doing it when they are doing it the

first few times themselves.

We have a training commitment for basic surgical

trainees in the Royal College of Surgeons, that they

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get a certain number of procedures to do. So that

would be 6 hernias, for example, 6 circumcisions and so

forth, and that is the only structured protocol of what

we have. Now more recently the Specialist Advisory

Committee in paediatric surgery in the UK, of which we

are a part, actually has specific guidelines as to what

procedures an SPR or a senior registrar should do at

certain levels, as they progress along the 6 years of

training but that is a fairly recent addition.

Q. There are no protocols specifically in relation to at652

what point or how a delegation is made?

A. No, one takes judgment and experience from your

interaction with the trainee.

Q. Yes, apropos, just you mentioned that your role as an653

associate Professor in the Royal College of Surgeons.

You seem to have an extraordinary long working week, 80

hours, plus ten to 12 nights on-call, 24/7 oncology

commitments and so on. How great is your commitment to

actually teaching in the College of Surgeons?

A. I am responsible for undergraduate surgical teaching

and paediatric surgery, and as such it is a series of

didactic lectures and tutorial based format in the

out-patients and/or the wards, and then setting the

surgical questions on the final medicine paper and

examining on the final medicine papers as well. I also

examine in the diploma for child health in UCD and the

Royal College of Surgeons, and in the membership, what

used to be the fellowship exams, both the first part

and the second part of the membership exams for the

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College of Surgeons.

MR. O'NEILL: Thank you, doctor.

Q. CHAIRMAN: I just have a couple of654

questions for you myself

Prof. Corbally. It came up a little bit yesterday in

the discussion with the expert witness, that fateful

page on the notes in the hospital notes where you made

a decision about the nephrectomy?

A. Yes.

Q. And your notes they say, small left kidney and DMSA 9%655

left kidney. I raised a question about the way it was

written, and it is small "l" with a circle around it

"kidney". Now the expert yesterday said, which would

always be my own practice, that you should write the

word "left" or "right". In fact, I contacted a

colleague of mine last night and asked him what was his

practice just as a check to see was it -- he said what

I do myself is that you always write down the word and

that you teach others to do the same thing, to the

extent that if a junior doctor was writing up an

operation procedure and wrote "l" circle around it, you

would correct them. You would say that is not the way

we do these things here, and to the best of my

knowledge I think it has been taught by say medical

insurance cover that that practice is likely to relate

to errors. It is a very simple -- something in our

brain makes us unthinkingly write down the wrong

letter, and I have seen this in my own clinical

experience.

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So there were many attempts to explain why you wrote

this down in regard to x-rays reports and so on, but

would you accept that the error may be a simple error

of scripting, and that that error may have led to a

sequence of events which we have been discussing over

the last few days?

A. I think that is the root cause of the whole process,

yes. I can accept that "left" as written, the word is

better than left as "l" in the circle, yes.

Q. And as a teacher of medical students, would you not656

have been aware of that?

A. That has come into -- we certainly have adopted that in

our clinical risk management policy in the hospital

now, that we would try to write down words rather than

symbols, and I would accept that too.

Q. Okay. Just the second question then was since this657

incident has occurred I suppose the Medical Council has

a responsibility towards the general public. I was

wondering if you could give us an outline of in what

way maybe your procedures have changed since this

incident? The Medical Council itself endorsed a

time-out procedure for all surgical units, which we

would use, I would use in my hospital. Perhaps if you

could describe maybe what you did, and do you think

that this time-out procedure would have prevented this

incident?

A. The time-out procedure is part of the WHO

recommendations, which I think were recommended in

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2007/2008, had not gained universal acceptance in

surgical units globally. The recognising that of 234

million surgical procedures per year performed

globally, with a complication rate of 5% to 15% and

approximately 45% of those being due to human error or

technical surgical error, then the application of the

time-out process where patients sign in, there is a

time-out before surgery and they sign out, is a very

appropriate response to minimise the actual risk of

human error in theatre. The time-out process is

important in that it ensures that everyone in the

theatre knows the procedure that is to be done and

everything in theatre, or anybody in theatre is

empowered to raise their hand and say, I am sorry, we

have not reviewed the x-rays, or I am sorry we have not

got the cross-match, because we are anticipating blood

loss in this hepatectomy, for example, and we need

blood in theatre. So absolutely time out is a very

important aspect of safety in the theatre. It was not,

however, universally practised certainly in this

country in 2008, and I think it is now almost certainly

universally practised; universally practised throughout

the country. I am 100% compliant with time-out policy

for my patients in Crumlin.

Q. Okay. Yes, I mean are there any other measures that658

you could offer some re-assurance that it would not

happen again?

A. Well, I think that the issue of viewing the imaging is

crucially important, and I don't think that one should

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book a patient for a procedure until the images are

reviewed. So I think in the situation of the options

that were presented by Mr. Wheeler, the option of

sending the patients back if the imaging is not

available, that is an option I would use in the future.

CHAIRMAN: Okay. That is all I have

to say. Maybe one of you

would wish to proceed.

END OF QUESTIONING BY THE COMMITTEE

PROF. M. CORBALLY WAS THEN FURTHER CROSS-EXAMINED BY

MR. LEONARD AS FOLLOWS:

Q. MR. LEONARD: Just very briefly arising659

out of something Mr. Meenan

raised with you Professor. Professor, Mr. Meenan was

asking you why you did not tell the parents that

Mr. Paran had done the operation, and this afternoon

you seemed to say it was to protect or to help

Mr. Paran in some way. Whereas this morning in

response I think to Ms. Barrington, you had I

understood or perhaps it was on questioning from me,

you had said that you did not want to overload the

parents with information.

A. Yes.

Q. And I am just trying to understand what exactly was660

your motivation in keeping that or hiding that from the

parents?

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A. I was not hiding it from the parents. There was a lot

of motivational issues in fact at the time. It was a

very distraught situation, and very disturbing for

everybody involved. I felt that Mr. Paran's

involvement at that time was not necessary in terms of

defining what had happened, apologising to the parents

for what had happened and the measures we had taken to

try and resolve that. So I really felt that it was

better to have that kind of discussion at a later date

when the facts would duly come out in the case.

Q. Can I suggest to you that the better thing and what you661

should have done was be completely upfront and tell

them fully about Mr. Paran's involvement from the

beginning?

A. That may have been a better option to use at the time.

I think that it is important that we do not blame our

colleagues, junior or senior, and I would have perhaps

seen that as an element of blame if I had said that

Mr. Paran had done the nephrectomy, and I did not

really want to apportion blame to Mr. Paran at that

time.

Q. Of course you are doing it now aren't you?662

A. Well, I am merely describing the facts now.

MR. LEONARD: Thank you Professor.

END OF FURTHER CROSS-EXAMINATION

CHAIRMAN: Ms. Barrington, yes.

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PROF. M. CORBALLY WAS THEN RE-EXAMINED BY

MS. BARRINGTON AS FOLLOWS:

Q. MS. BARRINGTON: Thank you Chairman. One or663

2 matters, timing and

relating to timing, Professor. In relation to the

initial scheduling of the surgery on Master Conroy, you

indicated that it might perhaps have been in July. I

think Ms. Stewart said in her evidence that the surgery

was initially scheduled for June?

A. That is possible, yes, yes.

Q. Mr. Meenan has suggested to you that your letter of664

observations to the Medical Council should have

included reference to the fact that Mr. Paran had been

asked to conduct the nephrectomy at least 30 minutes

before he chose to start it. He suggested to you that

there was some deficiency in your letter, insofar as

you did not address the question of timing. I want to

remind you of the chronology of events, Professor. The

letter of complaint in this case from the Chief

Executive of Crumlin hospital to the Medical Council

was in May 2009, is that right?


Q. I think that letter is behind tab 6 of the core book.665

The complaint consisted of forwarding to the Medical

Council the internal review report, and the Great

Ormond Street hospital or external report, is that

right?

A. That's correct.

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Q. Is there any indication in the external report that666

Mr. Paran was going to say that he did not have enough

time to prepare for this surgery, or that had he had

more time he would have looked at the imaging, that you

are aware of?

A. Not that I am aware of.

Q. The Great Ormond Street report deals with specialist667

hours, workload and planning for cross-over. That is,

if the Committee is looking for it, at page 9 of the

Great Ormond Street report, the external report?

MR. CROSS: I don't think the Committee

has the letter of

complaint, but whether it is relevant or not.

MR. LEONARD: Exhibit 3.

MR. CROSS: Exhibit 3.

MS. BARRINGTON: Thank you.

MR. CROSS: Thank you.

Q. MS. BARRINGTON: The external report deals668

at page 9, behind tab 6,

with specialist registrars, and I think I am correct,

Prof. Corbally, am I not, in saying that there is

nothing in that portion of the report or indeed

elsewhere, that says that the delegation in this case

was inappropriate because insufficient time was allowed

to Mr. Paran?

A. I believe that is correct too, yes.

Q. And therefore when you wrote your letter of669

observations in response to the CEO's complaint, you

were responding to the report in general I think in

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September...(INTERJECTION)

MR. MEENAN: This leading really.

MS. BARRINGTON: As a matter of fact you

were responding to the

CEO's complaint, is that not correct?

MR. CROSS: I think it is leading Ms.

Barrington, but --

MR. MEENAN: I really do not want to be

obstructing, but I think it

is obviously an important point, and it is a problem

that could be corrected very straight forwardly.

MR. CROSS: Ms. Barrington has made the

point.

Q. MS. BARRINGTON: Yes, the Notice of Inquiry670

you received in this case,

Prof. Corbally, is dated 1st March 2010?

A. Yes.

Q. So I am correct, am I not, in thinking that the671

observations that you submitted, which are dated

September 2009, were submitted before the Notice of

Inquiry was formulated?

A. I think that would be correct.

Q. And the Notice of Inquiry at allegation 11 raises the672

issue of inadequacy of timing in respect of the

delegation?

A. That's correct.

Q. And Mr. Wheeler in his report...(INTERJECTION)?673

MR. LEONARD: I am just wondering if that

is more for submission?

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MR. MEENAN: I think so at this stage.

MS. BARRINGTON: I am sorry, Mr. Meenan has

criticised Mr. Corbally.

MR. MEENAN: I have.

MS. BARRINGTON: On the basis that his

letter of September 2009

did not...(INTERJECTION)

MR. CROSS: He has, Ms. Barrington, but

-- and you make the point

that the letter that he criticised should be take in

its context in time. That is essentially a matter of

submission.

MS. BARRINGTON: Very good, very good. I

think it is nonetheless

fair -- well, no, I will address this issue then by

way of submission.

MR. CROSS: Thank you.

Q. MS. BARRINGTON: The external report, Prof.674

Corbally, came with a

detailed time line prepared by the authors of the

report, is that correct?

A. That's correct.

Q. And that report puts a time on the conversation between675

yourself and Mr. Paran, does it not?

A. I would have to look at that to be sure.

MR. MEENAN: If my friend could identify

the page, it would be a

great help.

Q. MS. BARRINGTON: Yes, it is behind tab 6 of676

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183

the core book and it is a 3

page document which is the time line prepared by the

external reviewers. Have you got that Professor?

A. I have.

Q. I do not know if the Committee has that. It is perhaps677

a little difficult to manage because it is split up,

but there is an entry for 21st March at 11:00 a.m. I

think that is on probably the fifth page in the

version, the way the Committee and yourself have it

Prof. Corbally. Have you identified that?

A. At page 19, 21st March 10:55, following the last column

is it?

Q. I made the error of stapling this together, so it is678

not in the format that you have it. There is boxes,

the first row of boxes along the top of the page you

should have the date of 21st March, and the second

column is headed 21st March, 11:00 a.m. Does the

Committee have that?

CHAIRMAN: I think our columns may be

a little bit different. I

think it might be the last column, but some of the

writing is missing because of a photocopying problem.

MR. MEENAN: Does it begin

"anaesthetised by

anaesthetic"...(INTERJECTION)

CHAIRMAN: Does it say, "arrival in

theatre".

MS. BARRINGTON: It says "anaesthetised by

anaesthetic SPR", and under

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184

that, about ten lines down:

"The consultant surgeon enters thetheatre and checks the note andverbally confirms that it is a leftsided procedure, and asks the SPR if heis happy to do the procedure and heagrees".

And the Great Ormond Street...(INTERJECTION)

MR. MEENAN: I wonder could my friend

possibly read the first

part of that because I think it is important.

MR. CROSS: Just a second now.

CHAIRMAN: I don't think the Committee

have this at all.

MS. DURKAN: We cannot find it.

MR. CROSS: We cannot find it at least.

It may be that the top of

the page has been cut off.

MS. BARRINGTON: I see. Well, it is

something that perhaps I

can leave over and deal with with Mr. Paran and we can

ensure that the Committee has proper copies for the

morning. I apologise for the confusion. I was not

aware that there was something missing.

MR. LEONARD: I have got a clean copy of

that.

MS. BARRINGTON: We will prepare a full copy

for the Committee for the

morning. I have no further questions, Professor, thank

you.

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END OF RE-EXAMINATION

CHAIRMAN: Thank you. I just raise 2

things. There was

discussion about dates for a future inquiry, and I just

thought I would give it out to the legal people for

their consideration. Dates that the Committee are

suggesting would be the 15th and 16th of December.

Principally one of the expert witnesses is not

available until very late in the time. Anyway, I

suppose that can be decided on maybe at the end of

today's proceedings or tomorrow.

MR. CROSS: Or tomorrow.

CHAIRMAN: I wonder, Ms. Barrington,

if you could give us an

outline as to how you propose to go on now. It is 4:00

o'clock, and how many witnesses you have and so on.

MS. BARRINGTON: Yes, Chairman. I have one

expert witness, Mr. Murphy,

who will be very brief.

CHAIRMAN: Maybe I think Prof.

Corbally could be excused.

A. Thank you very much.

CHAIRMAN: Yes, thank you very much.

THE WITNESS THEN WITHDREW

MS. BARRINGTON: Mr. Murphy...(INTERJECTION)

CHAIRMAN: Sorry, just one witness.

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MS. BARRINGTON: Will be very brief and then

there are two very short

character witnesses, who will not take longer than 5

minute each. I would be anxious to have them dealt

with because they have been here for the day. I think

Mr. Murphy's evidence, certainly insofar as his

direct-evidence is concerned, will not take very long

at all.

CHAIRMAN: Okay. Well, would you

prefer that your 2 people

who have been waiting all day to be dealt with first or

Mr. Murphy first, whatever you wish?

MS. BARRINGTON: I am happy to do it that

way. I am sure they would

be happy also, if Mr. Meenan has no objection?

MR. MEENAN: Absolutely, I mean I would

be very anxious to keep an

eye on tomorrow as to the conclusion. I think as much

as can be done today I think would be desirable.

CHAIRMAN: Okay, whatever way you wish

to do it then

Ms. Barrington.

MS. BARRINGTON: Yes, in that case I will

take your suggestion,

Chairman, and I will ask the 2 short witnesses to give

evidence first. A booklet of testimonials has been

prepared, which we will hand into the Committee.

CHAIRMAN: I think we will call this

number 19, exhibit number

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19.

MS. BARRINGTON: Thank you Chairman. Those

testimonials are something

that I will address by way of submissions, but added to

it has been a testimonial prepared by Mr. Oslizlok, and

I propose calling him now. Mr. Oslizlok please.

MR. P. OSLIZLOK, HAVING BEEN SWORN, WAS THEN

DIRECTLY-EXAMINED BY MS. BARRINGTON, AS FOLLOWS:

Q. MS. BARRINGTON: Thank you Mr. Oslizlok. I679

know you have prepared a

testimonial which has been handed in to the Committee,

and they may like to take a minute to read through

that.

CHAIRMAN: Okay, we have read it.

Thank you.

Q. MS. BARRINGTON: Mr. Oslizlok, you are a680

consultant paediatric

cardiologist?

A. Yes, yes.

Q. And you worked since 1992 in Crumlin hospital, is that681

right?

A. Yes. I have been a consultant paediatric cardiologist

there, yes.

Q. And you have prepared a detailed testimonial on behalf682

of Prof. Corbally saying things that he could not say

for himself. Could I ask, you have indicated amongst

the various qualities that you have noted, that

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Prof. Corbally is generous with his time, not just to

his patients but also to his fellow colleagues. Could

I ask you to elaborate on your testimonial for the

Committee, with emphasis on Prof. Corbally's

interaction with his colleagues, and in particular

perhaps his more junior colleagues?

A. Yes, well, thank you for the opportunity of addressing

the Committee. It has been a pleasure to work with

Prof. Corbally. I think it is important to state at

the outset that Crumlin is an extremely busy hospital,

probably I think generally recognised as being grossly

understaffed from many aspects, and certainly that is

true of paediatric surgery. He is an extremely busy

man. Nevertheless, I think it has been vital to my

work as a cardiologist and indeed as many of the other

disciplines within the hospital, that his opinion has

been available to us at all times by day and by night,

whether he has been on-call or not.

He has been very generous with that. His opinion is

expert. It is much sought after, and that opinion is

available not just to me as a fellow consultant, but

indeed to the junior staff in the hospital, he is

equally available to them, approachable, and I think

that is important to point out because that has not

always been the case amongst my fellow consultants,

particularly where I have worked abroad. Martin is

very approachable and that is a vital part I think of

what makes a hospital work, albeit with the number of

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189

staff, the under staffing that existed there.

Q. Is there anything else you would like to add to the683

testimonial that you have prepared?

A. Well you have read it, and I won't bore you by going

over it. As anyone who works in a hospital will

recognise one of the things that I think is a telling

point is that when you ask yourself: Who would I go to

if my child was ill within the hospital? If you ask

whether it is the consultants, the junior hospital

staff, the nurses, others who work in the hospital who

would they go to for a surgical opinion within Crumlin

if they were concerned about their own child and it is

Prof. Corbally who would be the person, not just

because he is expert at what he does but because he is

approachable and he is there, he does the work. He

works extraordinary hours and I think has been

instrumental in seeing that the many inter-disciplinary

aspect of Our Lady's Hospital have worked.

MS. BARRINGTON: Thank you very much

Mr. Oslizlok. I don't know

if the Committee has any questions for you.

END OF EXAMINATION OF MR. OSLIZLOK BY MS. BARRINGTON

CHAIRMAN: No. Thank you very much.

(The Witness Withdrew)

MS. BARRINGTON: Mr. Finn Breathnach please.

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190

MR. FINN BREATHNACH, HAVING BEEN SWORN, WAS EXAMINED,

AS FOLLOWS BY MS. BARRINGTON

MS. BARRINGTON: Thank you very much,

Mr. Breathnach, you have

also prepared a testimonial on behalf of Prof. Corbally

which the Committee will find at page 8 of the book

that has been provided to the Committee, and they may

like to take one moment, Mr. Breathnach, just to read

through that. (Pause)

CHAIRMAN: We have read that, thank

you.

MS. BARRINGTON: Mr. Breathnach, you were

a Consultant Paediatric

Oncologist in Crumlin from 1981 onwards, is that right?

A. That's right.

Q. You retired a number of years ago?684

A. That's right, in the Summer of 2008.

Q. You therefore worked with Prof. Corbally for a very685

considerable number of years?

A. Yes, I did since 1994 up until 2008, so 14 years.

Q. The reference that you have kindly prepared speaks for686

itself. Could I just ask you in your observation of

Prof. Corbally's work how you perceived he interacted

with his colleagues and in particular with junior

staff?

A. In relation to my involvement in the care of children

with cancer -- and I am very glad to have retired from

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191

the Hospital and no longer responsible for that group

of patients because the task was onerous, to say the

least -- it requires an input from so many different

specialists in so many different areas within the

Hospital in terms of investigating patients, in terms

of determining the exact diagnosis, operative

procedures, radiation, oncology and the administration

of chemotherapy, dealing with parents and dealing with

siblings, etc. My role as a paediatric oncologist was

almost like the conductor of the orchestra and I called

in various elements to manage various problems at

different stages and I set up a multi-disciplinary care

team, a Tumour Board, which met every week to discuss

every single new patient and every aspect. Prof.

Corbally became a part of that in 1994 when he joined

with the surgeon at the time who was involved with

paediatric oncology, Prof. Ray Fitzgerald, and from

that time his role within that Committee from the

surgical perspective continued to grow and grow.

Many a time I have stood with him by the bedside of

sick patients of mine at 3 o'clock in the morning where

he unhesitatingly gave his time, I would pick up the

'phone and call him and he would be there. He is

incredible in the way that he makes himself available,

and has done so probably to his own detriment, to the

detriment of his health and that of his family, but

that is the commitment that he gives and has given over

the years, and I think will continue to give into the

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future.

He has always dealt with me in a very cordial way. He

has dealt with my patients and parents in a very caring

way and given them time, something maybe surgeons

aren't very well known for, but very very caring in his

approach.

I always saw him as being focused on teaching of his

junior staff and I never saw him mistreat any of them,

and if he did so he did so in private, I was certainly

never aware of that, of any mistreatment of any sort,

and I would expect that over the 14 years we worked

together I would have been aware of that from the point

of view of the junior doctors because I was seen as

quite approachable within the Hospital and people would

have come to me with their complaints and problems.

Q. Thank you, Dr. Breathnach, is there anything you wanted687

to add to the testimonial you prepared?

A. Apart from working in the hospital in Crumlin

Prof. Corbally has also worked with me Tanzania and he

had also worked in Vietnam and in Cambodia and given

his time there and his expertise to the children there

in our efforts to try and improve the care for children

with cancer.

MS. BARRINGTON: I don't know if the

Committee may have any

questions for you.

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END OF DIRECT-EXAMINATION OF MR. BREATHNACH BY

MS. BARRINGTON

MR. BREATHNACH WAS CROSS-EXAMINED, AS FOLLOWS, BY

MR. MEENAN

Q. MR. MEENAN: Do you know Mr. Sri Paran?688

A. Yes, I do.

Q. Do you have any views of him?689

A. I certainly have, I think he is a superb doctor, very

very caring. I have always enjoyed working with him.

Mind you my contact with him would not have been any

way near as close a relationship as I have had with

Prof. Corbally.

Q. Of course. I take it you have also always found him to690

be a careful and conscientious surgeon, is that

correct?

A. Absolutely, yes, indeed.

Q. I presume you have also in your experience never found691

him to rush into operations, would that be right?

A. Again in my time with Sri he would have been a junior

colleague, a registrar, I would have known him at a

much earlier stage in his career than now.

MR. MEENAN: Thank you.

END OF CROSS-EXAMINATION OF DR. BREATHNACH BY

MR. MEENAN

CHAIRMAN: Thank you very much

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Dr. Breathnach.


MS. BARRINGTON: Dr. Feilim Murphy please.

MR. LEONARD: Just before the next

witness is called I want to

flag this in advance, I don't recall, perhaps

Ms. Barrington will correct me, Ms. Barrington putting

to Mr. Wheeler any evidence that an expert was going to

give that differed from anything that he said. I am

not sure in circumstances where no differing expert

evidence at all seems to have been put to Mr. Wheeler I

am unclear as to what evidence is going to be given to

this Committee.

MS. BARRINGTON: Yes. Mr. Leonard is

correct that differing

versions were not put to Mr. Wheeler because

Mr. Wheeler expressed the view on a number of occasions

that his views were dependent on practices in Crumlin

Hospital and Mr. Murphy has expertise from his role as

a paediatric urologist having also worked in Crumlin

Hospital. His evidence will be confined to issues

relating to images and the viewing of images and the

practice in relation to the viewing of images and a few

other confined issues.

MR. CROSS: Is he giving factual

evidence as to what happens

in Crumlin or is he giving expert evidence?

MS. BARRINGTON: I think he is giving both,

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195

in relation to his

experience in Crumlin and elsewhere in relation to the

viewing of images. I don't believe that Mr. Murphy

will be giving evidence that differs significantly from

the evidence given by Mr. Wheeler.

MR. LEONARD: I am even more alarmed now.

MS. BARRINGTON: I am entitled to call my

own witness and then

Mr. Leonard can make an objection if he thinks that Mr.

Murphy gives evidence that I should have out to Mr.

Wheeler.

MR. CROSS: That is fair, Mr. Leonard.

MR. LEONARD: Very well.

MR. CROSS: One would be very reluctant

to stop any evidence being

given and if you were in difficulty we will have to

consider recalling your witness but...(INTERJECTION)

MR. LEONARD: Well given that he has

flown back to Southampton I

might have a different application, I might object to

the Committee taking evidence. I don't want to be

difficult either.

MS. BARRINGTON: Mr. Leonard can object as

the questioning progresses

if he thinks there is an issue that I should have

raised with Mr. Wheeler.

MR. CROSS: That is fair enough.

MS. BARRINGTON: Mr. Murphy please.

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MR. MURPHY, HAVING BEEN SWORN, WAS EXAMINED, AS

FOLLOWS, BY MS. BARRINGTON

Q. MS. BARRINGTON: Thank you, Mr. Murphy, we692

are handing in a copy of

your CV to the Committee. (Handed) You are I think a

Consultant Paediatric Surgeon and Urologist, is that

right?

A. Yes, I am a full-time paediatric urologist in

St. George's Hospital in London.

CHAIRMAN: This will be Exhibit 20.

Q. MS. BARRINGTON: Exhibit 20. Your693

qualifications are set out

at page 4 of your CV. I think you qualified in

Ireland, is that right?

A. Yes, I am a graduate of the College of Surgeons in

Ireland. I did some of my basic surgical training

here. I commenced with paediatric surgery in this

country and then went abroad for a number of years. I

then came back to continue my specialist training here

before leaving to finish my final super specialist

training in Great Ormond Street, and I have remained in

the United Kingdom since then.

Q. How many years in total did you spend working in694

Crumlin Hospital?

A. I spent four years in Crumlin Hospital.

Q. Did you work with Prof. Corbally?695

A. I worked with Prof. Corbally.

Q. Did you also work with Mr. Paran?696

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197

A. And Mr. Paran, yes.

Q. How many years did you spend in Great Ormond Street697

Hospital?

A. I spent nearly two years in total in Great Ormond

Street between a role as being a senior registrar and

being a consultant in that position as well.

Q. You are aware, Mr. Murphy, that the allegations are now698

more confined than they were at the outset in relation

to Prof. Corbally, one of the allegations in relation

to Prof. Corbally, allegation number two, is an

allegation in respect of which Mr. Wheeler expressed

the view that Prof. Corbally should not have listed

Master Conroy for surgery unless the images would be

viewed prior to surgery. I want to ask you if you can

say from your time in Crumlin what the practice was for

an operating surgeon in relation to the reviewing of

images prior to surgery?

A. From my time in Crumlin it was normal practice for the

images to be reviewed prior to the commencement of

surgery.

Q. By the operating surgeon?699

A. By the operating surgeon.

Q. In your experience elsewhere is that also the practice?700

A. It is, and a very element of the operating surgeon's

position to ensure that the images are there and that

you actually use them as a guide for the operation

itself.

Q. It has been suggested in the cross-examination of701

Prof. Corbally that Mr. Paran would have reviewed the

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198

images in this case had he had more time, do you have

any observation to make on that?

A. To be honest I am a little confused about this concept

of more time, it gives the implication that there is an

automatic start time for a procedure. One would expect

any operating surgeon to be 100% comfortable when

starting a procedure, and part of that would be

familiarising themselves with the images, looking at

the radiology and looking through the notes. So, yes,

it would be a normal part of practice to look at the

radiology.

MS. BARRINGTON: As you are aware one of the

other principle issues that

Mr. Wheeler was called upon to address was the question

of delegation. The CEO has suggested to

Prof. Corbally...(INTERJECTION)

MR. MEENAN: Does this witness have a

written report or is this

just being done orally?

MS. BARRINGTON: I didn't propose providing

a written report.

MR. CROSS: He doesn't have to have

one.

MR. MEENAN: I appreciate that. Just to

confirm that there isn't a

written report.

MS. BARRINGTON: There isn't a written

report that I propose

providing to the Committee. A number of the

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allegations no longer arise so this witness is dealing

with the only live points that are left.

MR. MEENAN: But there is a report.

Okay. Very

MR. LEONARD: I wonder would the report

with the remaining

allegations be provided?

MR. CROSS: Mr. Leonard that is really

a matter for Ms.

Barrington, she doesn't have to do it, it is usually

done, but if there is a report dealing with matters

that are not now before the Committee it may be

difficult to get a redacted report, or whatever, and it

really is a matter for herself. Obviously it would be

of help to you, presumably, and may be to the Committee

but she doesn't have to do it.

MS. BARRINGTON: Yes. Mr. Murphy is dealing

with a discrete number of

issues, which I think he won't be much longer in

dealing with.

MR. MEENAN: The difficulty about all of

this is what Mr. Murphy is

now being asked to do is to respond to various matters

which were put in cross-examination, and of course that

is entirely appropriate when he is dealing with an

expert report, but what neither Mr. Leonard or myself

have any idea about is what Mr. Murphy's initial views

are and have those views changed on the basis of

cross-examination. It seems to me that is why I would

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200

have thought it is important.

MR. CROSS: You can ask him. I don't

think counsel when

presenting evidence is obliged to produce expert

reports.

MR. MEENAN: That may be but I think at

the same time if there is a

written report which deals with allegations which are

still current it really, I would have thought, should

be produced.

MR. CROSS: It is not a requirement.

MS. BARRINGTON: In relation to the question

of delegation, Mr. Murphy,

it was suggested, and I know you were here earlier on

in the day, by Mr. Leonard that having regard to the

list as it was on the day it was unusual or perhaps

indeed inappropriate for Prof. Corbally to have

delegated the nephrectomy as that was of the operations

appearing on the list that was provided to the

Committee the most complex of the operations. What do

you have to say about the appropriateness of delegating

an nephrectomy in circumstances where the other

procedures listed may be less complicated

MR. LEONARD: Before the witness answers

that question, that is

exactly a point that Mr. Wheeler gave evidence on.

MR. CROSS: Mr. Wheeler said that it

depends on the view the

Committee takes as to the competence

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of...(INTERJECTION)

MR. LEONARD: He also said under no

circumstances would he

delegate that operation and nor would the people that

he worked under. In fact I think this witness works in

one of the hospitals he also worked in. It is exactly

the type of issue, I submit, that this

witness...(INTERJECTION)

MR. CROSS: I don't think, Mr. Leonard,

that you are taken short on

this point. Your expert said inter alia that it

depends on the expertise of the person to whom he has

delegated, I am speaking from memory now. I appreciate

that normally such matters would and should be put to

experts but I don't see how there is a fundamental

unfairness yet. Ms. Barrington has indicated twice

that she will be short and they won't be asking much

more.

MR. LEONARD: I register my objection

MS. BARRINGTON: I note the objection that

is registered by

Mr. Leonard but I don't accept it. Mr. Wheeler said as

a matter of fact that he wouldn't delegate a

nephrectomy. What Mr. Leonard asked Mr Prof. Corbally

in cross-examination was whether it was appropriate

having regard to the fact that he perceived the other

procedures on the list to be less complicated to

delegate a nephrectomy. I am asking Mr. Murphy's view

as to whether in the factual circumstances of this case

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202

he considered it appropriate to delegate the

nephrectomy.

A. It is important as a surgeon that you delegate

appropriate operations to the appropriate trainees. It

would be inappropriate to delegate a significant

operation -- but I would take argument that there is

significant and less significant operations --

operations that require more expertise to a junior

trainee, but it is very appropriate that senior

trainees get more appropriate operations for them to

operate on otherwise we would produce a generation of

surgeons that were only able to do minor operations.

It is normal practice that we would delegate the most

appropriate operation to an appropriate trainee.

Q. Mr. Murphy, if the delegate considers he has702

insufficient time to prepare himself what do you

believe that delegate should do?

A. If the operation surgeon, which I presume one means by

the delegating surgeon, the surgeon taking control of

the case, they have control of the case and therefore

they have to be 100% happy before they would commence

the case. It would be the equivalent, as we have

discussed the airline industry, of a captain on the

airplane handing over controls to the first mate, the

first mate still has to have an understanding of what

is going to happen and go through all of the necessary

checks. It as simple as that really.

Q. One of the issues that Mr. Leonard has also raised is703

the question of the responsibility of a consultant.

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203

Prof. Corbally has accepted that he is responsible for

the patients on his list. It was suggested by the CEO

that as he was responsibile for the patients on his

list he should also take responsibility in terms of

accepting guilt for professional misconduct for

mistakes on the part of his team. What do you have to

say about that? Can you assist the Committee in this

question of responsibility of the consultant?

A. The consultant is ultimately responsible, but that term

is very loosely applied. I would use once again an

analogy about a ship's captain, a ship's captain is

ultimately responsible for the ship but if there is a

fundamental problem within the ship itself they cannot

take the blame because there was a problem with the

building or the construction of the systems that were

put in place. So even though the consultant has

responsibility for each step along the way there are

other people who share that responsibility with that

individual and to produce a safe environment for a

child, or anybody having an operation, it is not just

the consultant's responsibility but it is every single

person's responsibility in that room. The WHO

guidelines and the WHO time-out procedures that we have

now, and we had had for a number of years in the united

Kingdom, are very clear that every single person in

that room is responsible to ensure that that child is

having a safe procedure. So everybody is responsible,

it is not just one person with all of the

responsibility or one person with all of the blame.

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Q. Is there a valid distinction to be drawn between704

responsibility for a patient on the list and liability

for professional misconduct in your view?

A. You can do the very best you can and you can have an

error occur under your watch by your actions or by the

actions of your team but that does not make you a bad

doctor, that does not make you professionally

incompetent or of poor practice that could be

negligence or bad luck but it is a different issue from

professional competence.

Q. Mr. Leonard and to some extent Mr. Meenan have705

criticised the conversation Prof. Corbally had with the

parents after the operation insofar as Prof. Corbally

didn't address Mr. Paran's role in the surgery, do you

have a view as to the appropriate of the conversation?

A. It was very appropriate that Prof. Corbally went to the

parents, he is the consultant in charge and it was his

job, his duty to go to those parents and explain that

something catastrophic had occurred, a truly terrible

thing had occurred. I understand that he decided to

take responsibility at that stage, and that is

perfectly reasonable, I know Prof. Corbally personally

and I know that is the kind of thing he would do, take

personal responsibility. It would seem very very harsh

as a consultant surgeon fro me to go and tell a family

that such a disastrous thing has occurred and then, by

the way it wasn't me that did it. I think that would be

immensely difficult for the family to deal with at that

time. He was right to go, he was right to take

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205

responsibility and at the right time the hospital and

the family would have go through all of the issues, at

and appropriate time go through all of the issues and

explain exactly what is going on.

MS. BARRINGTON: Thank you very much,

Mr. Murphy I don't have any

further questions.

END OF DIRECT EXAMINATION OF MR. MURPHY BY

MS. BARRINGTON

MR. MURPHY WAS CROSS-EXAMINED, AS FOLLOWS, BY

MR. LEONARD

Q. MR. LEONARD: Mr. Murphy, you prepared a706

written report in this

case, is that right?

A. Yes.

Q. Do you have that report with you?707

A. Not all of it.

Q. I am sorry?708

A. Not on my person right now.

Q. What date did you prepare that?709

A. I prepared that written report in July of this year, it

was finalised, the last version was in July this year.

Q. That is to say after the first day's evidence?710

A. The report was mostly completed before that but there

was a number of other issues that were added to it

after that.

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Q. When were you instructed to do it?711

A. When was I initially instructed to do the report?

Q. Yes.712

A. In February/March this year.

Q. Did you see the Notice of Inquiry prior to preparing713

your report?

A. The original Notice of Inquiry?

Q. Yes.714

A. Yes.

Q. Did you receive instructions as to what Prof. Corbally715

would say at the Inquiry?

A. No.

Q. No instructions at all?716

A. I wasn't instructed as to what Prof. Corbally's

statements were going to be prior to writing my report.

I wrote my report based on the evidence that was

available to me, which was the case reports, the

detailed report from the Hospital, the external report,

the internal review, Rob Wheeler's opinion. I based my

report on the evidence I was given, I wasn't aware of

exactly what Prof. Corbally was going to say.

Q. The evidence that was given today about717

Prof. Corbally giving at least half an hour, perhaps a

little longer to Mr. Paran to do the operation must

have come as a surprise to you this morning?

A. No, in discussions we have had since before my report

was finished that did come up in conversation, yes.

Q. I thought you said you were given no details as to what718

he...(INTERJECTION)

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207

A. I was given no details initially by Prof. Corbally or

by the team about what he was going to say and I wrote

my initial report on what was done. Only in

conversations with the team or Prof. Corbally further

information came through, but that didn't particularly

change my report.

Q. So you initially weren't given any details of that 30719

minute...(INTERJECTION)

A. No, but that is because I wasn't in conversation with

Prof. Corbally directly, I was communicating with his

legal team.

MR. LEONARD: Thank you. That is the

only question.

END OF CROSS-EXAMINATION OF MR. MURPHY BY MR. LEONARD

MR. MURPHY WAS CROSS-EXAMINED, AS FOLLOWS, BY

MR. MEENAN

Q. MR. MEENAN: I am little confused as to720

what you are actually doing

here, you apparently discussed the matter with Prof.

Corbally, is that correct?

A. No, I have discussed the matter with Prof. Corbally.

Q. Have you taken a statement from him?721

A. I have discussed the situation in detail with

Prof. Corbally but not after I initially received the

request from his solicitors to deal with the matter.

Q. Your report deals with the allegations that are made722

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208

against Prof. Corbally but doesn't deal at the time

with anything that Prof. Corbally told you, is that

right?

A. I am not really sure...(INTERJECTION)

Q. For example, on delegation?723

A. On delegation, my report is quite clear on the matter

of delegation.

Q. What does it say?724

A. To summarise, my report on delegation is no matter what

time you delegate an operation to an individual the

operating surgeon then takes control of the operation

so there is no start clock or stop clock, it is a case

of you now need to do an operation and you need to take

control of that situation and be fully aware of what

you need to do. It is not a case of some countdown to

the commencement.

Q. Therefore, I take it, you wouldn't agree with725

Dr. Wheeler's evidence to the effect that delegation of

this particular operation in the circumstances of less

than five minutes was not proper or adequate?

A. No, I agree with where Mr. Wheeler is coming from. In

the NHS and in the United Kingdom system we have a very

structured approach towards cases, we have a much

smaller operating load than exists in Dublin and in the

Republic of Ireland and we have a very different way of

doing things because we have time and structure and

there is an awful lot more systems built in to prevent

things happening. We are able to discuss cases and by

tradition case are discussed days before. So the

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209

concept of delegation and a couple of days delegation

is extremely reasonable, and I understand Mr. Wheeler's

view on that. But at the same time once something has

been delegated to someone or once someone has taken

responsibility to do an operation you need to take full

responsibility for that operation and be 100%

comfortable that you are doing the right operation.

Q. You are not seriously suggesting to this Committee, are726

you, Mr. Murphy, that a delegation time of less than

five minutes was appropriate or adequate in this case?

A. No, I am saying that the use of five minutes or 30

minutes or any kind of minutes is somewhat redundant

because I don't understand the logic behind it, it

doesn't make sense to me in a way for you to say that

it is only a five minute delegation time. You have to

take the amount of time that you need to do an

operation safely and to do an operation safely if you

need spend longer to start the operation you spend

longer to start the operation.

Q. You were probably here for what was being put on behalf727

of Mr. Paran to Mr. Wheeler and indeed to Prof.

Corbally which was to the effect that the first time

Mr. Paran knew he had to do this operation was after

the patient had been anaesthetised and catheterised and

less than five minutes before the incision. Are you

giving expert evidence that that is appropriate?

A. What I am saying to you is that if you are delegated an

operation you need to take the time to make sure you

are doing the operation correctly, there therefore

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12

13

14

15

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16:40

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210

isn't an automatic stop clock from the moment you have

been delegated the operation to say that you have five

minutes to get everything ready to do the operation.

That is my statement, it is as simple as that.

Q. Well I must say I don't find it simple at all. I take728

you are talking about time, and I understand that, and

time means different things to different people, but

even in the circumstance of this case I have to suggest

to you that time of less than five minutes is wholly

inadequate for Mr. Paran to prepare himself properly

for that operation. First of all are you familiar with

the circumstances of how Mr. Paran came to do the

operation?

A. I am familiar with a number of different factual

concepts that have been given about the timeline for

that morning, I have listened today to what has been

going on. I am not disagreeing with you, what I am

saying to you is this concept of five minutes implies

that there is a stop clock and that the operation has

to start in five minutes' time, that would be the

equivalent of me saying to you if you are going to take

a plane off at an airport you have to take off in five

minutes and that therefore you don't do the necessary

checks. That doesn't make any sense to me, I am sure it

doesn't make any sense to other surgeons and probably

doesn't even make sense to Mr. Paran, I can't say that.

It makes no sense to me to say that there is an

automatic timeframe that things have to be done in.

You have to do it right and you have to be safe and you

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7

8

9

10

11

12

13

14

15

16

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16:41

16:41

16:42

16:42

16:42


211

have to take the time to do it. I don't understand the

five minutes.

Q. Mr. Murphy in the course of your practice would you729

delegate a nephrectomy to a junior doctor less than

five minutes before the operation commences?

A. As I said earlier I work in the NHS and we have a very

different situation in the NHS, it doesn't happen. If

I was to delegate an operation to a junior doctor no

matter what the operation was, a nephrectomy, or

anything else, I would still expect him to be fully au

fait and up to speed with that operation before the

operation would commence and I would not accept that

you would not do that, that wouldn't be acceptable to

me at all.

MR. MEENAN: That wouldn't be

acceptable. Thank you

Mr. Murphy.

END OF CROSS-EXAMINATION OF MR. MURPHY BY MR. MEENAN

MS. BARRINGTON: Mr. Murphy the Committee

may have some questions for

you.

MR. MURPHY WAS QUESTIONED, AS FOLLOWS, BY THE COMMITTEE

Q. CHAIRMAN: Maybe one just, personally730

I don't find airport

analogies as a doctor myself very helpful. I think

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16:42

16:42

16:43

16:43

16:43


212

when a plane goes up in the air most of the problems

are over, we are dealing with individual human beings.

The only one that appealed to me was the captain of the

ship and, as it were, the captain should probably go

down with the ship. The only point I wanted to raise

with you, we have had a lot of talk about the

protocols, whether you have a protocol for consent or

for blood, or whatever. There were some protocols in

place in this case, maybe, for example, when they came

to the time when the kidney was exposed the doctor did

go back and check the notes, he sensed that there was

something wrong but whatever protocol was there was not

sufficient to prevent what was happening.

It really was a question of thought, there were two

surgeons involved and neither of them seemed to have

got on to the idea that we better check the X-rays or

the scans, I was just wondering what is your opinion

about this, is this a failure of protocols, a systems

failure or a failure of human judgment. I suppose we

are thinking about the cause and the responsibility of

the people.

A. That is an excellent question. The reality of the

situation is that it is a combination of all of those

things. The initial trigger was the laterality issue

that was documented incorrectly in the notes. Then

there is the subsequent data, that kind of

self-fulfilling prophecy of the letters that merely

reflected that error. I appreciate there was some

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3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

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20

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28

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16:44

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16:44

16:44

16:45


213

radiology errors in the past and there was definitely

evidence on the radiology system and the fact that it

is not there on every step along the child's pathway is

not robust. These were all the system errors that

allowed the child to get basically to the hospital.

Then the night before we have a number of human errors

and system errors for which there is no radiology

available, people aren't looking and thinking about: Is

this the right operation? Am I doing the right thing?

They seem to be automatically doing their little bit

but not thinking: Is something more? Should I really

check further? We have lots of people and lots of

report and expert testimony about people checking and

doing lots of wonderful checking, but all in isolation

and not communicating well enough with each other,

which is system related and people related.

Then the parents repeatedly asking questions, which is

a worry, a real real red flag.

Then you have them getting to theatre, people not

thinking, people making errors, people making mistakes

and getting caught down a particular path. I cannot

explain why what happened on the day happened on the

day at the moment in theatre but it is a definite

combination of the human and the system fatally

combined in the worse type of Swiss cheese analogy that

there is: The patient falling from a safe environment,

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4

5

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8

9

10

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12

13

14

15

16

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20

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23

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26

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16:45

16:45

16:45

16:46

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214

falling through all of the holes which are due to

different people and different events and falling into

this terrible, catastrophic event.

There is a number of people and systems that are

responsible. The only people who are not responsible

are the parents who have had to go through all of this,

and the child.

CHAIRMAN: Thank you very much,

Dr. Murphy for that.

END OF QUESTIONING OF DR. MURPHY BY THE COMMITTEE


CHAIRMAN: Ms. Barrington, is that

the end of your

presentation?

MS. BARRINGTON: That is my evidence.

CHAIRMAN: Mr. Meenan, I don't know

whether you propose to

start or what your proposal is, it may be getting a

little bit late.

MR. MEENAN: If I did start it would be

simply to qualify Mr.

Paran, but I suppose that will be done in a matter of

minutes. The sensible thing to do is to commence in the

morning. I can tell the Committee I have Mr. Paran and

another witness, and that is it.

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5

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12

13

14

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26

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16:46

16:46

16:46

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215

CHAIRMAN: Just two witnesses. We

should be all right for

time tomorrow.

MR. MEENAN: I would think so yes.

CHAIRMAN: Mr. Leonard?

MR. LEONARD: I would have thought so,

yes. In terms of

cross-examination I don't expect I would be any longer

than I was today.

CHAIRMAN: We have the process of

submissions after the end

of the evidence.

MR. LEONARD: Let us get through the

evidence and review where

we are on that.

CHAIRMAN: We should be all right for

time. We will reassemble

at 9.30 tomorrow morning. Thank you all.

THE HEARING WAS THEN ADJOURNED TO FRIDAY 3RD SEPTEMBER

AT 09.30 A.M.

'

'02 [1] - 88:15

'08 [1] - 88:16

'parallel' [1] -

94:15

'phone [1] -

191:24

0

09.30 [1] -

215:21

1

1 [6] - 24:19,

78:7, 84:2, 107:6,

109:21, 115:23

1,200 [1] - 9:3

10 [10] - 41:23,

42:16, 78:6,

78:11, 78:16,

94:13, 97:3,

116:25, 116:28,

116:29

10% [1] - 70:12

10.45 [1] - 96:3

100% [5] - 74:26,

176:23, 198:6,

202:21, 209:6

103 [2] - 49:18,

102:6

107 [1] - 3:7

108 [1] - 3:7

10:00 [1] - 23:26

10:06 [1] - 44:15

10:30 [5] - 45:6,

45:8, 45:29,

129:7, 131:12

10:40/10:45 [1] -

44:6

10:45 [1] - 44:6

10:50 [2] - 43:15,

44:4

10:55 [1] -

183:11

10th [3] - 17:18,

120:5, 120:7

11 [9] - 7:18,

74:6, 74:10,

78:12, 78:13,

78:14, 88:27,

96:4, 181:23

112 [1] - 103:1

11:00 [14] -

45:29, 53:13,

126:11, 127:21,

128:12, 128:14,

128:17, 129:7,

131:12, 134:27,

142:9, 142:18,

183:7, 183:17

11:05 [2] - 53:11,

127:14

11:09 [5] -

127:12, 127:14,

127:19, 128:16,

128:17

11:35 [1] - 49:22

11:40 [7] - 47:23,

47:26, 53:9,

127:8, 128:24,

142:10, 142:20

11:55 [1] -

143:17

12 [6] - 7:21,

77:24, 78:20,

82:21, 154:14,

173:17

12:00 [2] - 23:26,

23:28

12:24" [1] -

143:18

13 [3] - 5:2, 83:1,

83:2

13th [2] - 14:13,

15:4

14 [7] - 11:10,

11:11, 11:15,

12:27, 190:22,

192:12

15 [11] - 11:10,

11:14, 11:15,

14:29, 16:2,

41:23, 41:29,

42:16, 44:8,

59:18, 97:3

15% [1] - 176:4

15th [1] - 185:8

16 [3] - 41:1,

78:29, 98:18

16th [1] - 185:8

17 [2] - 65:20,

65:21

170 [1] - 3:7

171 [1] - 3:8

177 [2] - 3:8, 3:8

178 [1] - 3:8

179 [1] - 3:9

17th [3] - 19:8,

19:15, 24:24

18 [1] - 76:18

18,000 [2] -

69:18, 86:13

185 [1] - 3:9

187 [1] - 3:11

189 [1] - 3:11

19 [3] - 183:11,

186:29, 187:1

190 [1] - 3:14

192 [1] - 3:14

193 [1] - 3:14

196 [1] - 3:17

1978 [1] - 5:21

1981 [1] - 190:16

1984 [1] - 6:3

1992 [1] - 187:22

1993 [1] - 5:11

1993/1994 [1] -

7:1

1994 [5] - 5:11,

9:7, 24:11,

190:22, 191:15

19th [1] - 13:8

1:30/2:00 [1] -

23:21

1st [1] - 181:16

2

2 [30] - 1:18,

11:5, 11:20,

11:21, 14:29,

17:13, 24:19,

49:1, 53:2, 59:29,

71:20, 74:17,

77:26, 77:27,

78:6, 78:15,

78:18, 78:22,

84:11, 102:4,

109:22, 115:24,

119:27, 119:28,

155:3, 166:28,

179:5, 185:3,

186:10, 186:25

20 [6] - 41:23,

41:29, 79:10,

97:3, 196:11,

196:12

20% [2] - 165:20

2002 [8] - 11:23,

12:13, 13:1, 13:5,

14:13, 69:4,

84:28, 87:12

2004 [2] - 13:8,

13:14

2005 [3] - 9:9,

88:2, 154:16

2005/2006 [1] -

9:28

2006 [4] - 14:6,

14:27, 15:4,

15:29

2007 [10] - 1:4,

14:9, 16:5, 17:9,

17:18, 17:20,

17:22, 40:8,

87:28, 88:12

2007/2008 [1] -

176:1

2008 [8] - 8:10,

8:12, 10:4, 19:8,

83:17, 176:21,

190:19, 190:22

2009 [4] -

120:24, 179:22,

181:20, 182:6

2010 [6] - 1:15,

4:2, 8:10, 77:12,

120:7, 181:16

205 [2] - 3:17,

3:17

207 [2] - 3:17,

3:18

20th [4] - 29:29,

30:22, 57:14,

58:7

21 [3] - 17:13,

79:5, 79:12

211 [2] - 3:18,

3:18

214 [1] - 3:18

21st [8] - 30:13,

40:27, 57:12,

82:6, 183:7,

183:11, 183:16,

183:17

22 [5] - 18:3,

57:14, 79:1, 79:5,

87:29

22nd [1] - 18:2

23 [1] - 17:22

234 [1] - 176:2

24/7 [3] - 9:9,

154:15, 173:17

25 [2] - 41:24,

41:29

25/35 [1] - 56:26

250 [2] - 49:18,

102:7

252 [1] - 102:14

28 [2] - 18:25,

19:14

29 [2] - 18:25,

19:14

291 [1] - 103:1

2ND [2] - 1:15,

4:1

3

3 [9] - 1:15,

24:19, 65:24,

74:17, 77:28,

180:14, 180:15,

183:1, 191:22

30 [17] - 8:4,

25:4, 53:8, 53:14,

53:23, 97:3,

155:4, 155:10,

155:16, 155:18,

155:25, 160:4,

167:16, 167:17,

179:15, 207:7,

209:11

30% [1] - 165:20

30th [4] - 84:12,

120:2, 120:16,

120:24

35 [3] - 10:21,

10:28, 23:1

360 [4] - 76:15,

76:25, 77:5, 77:8

3:30 [4] - 23:22,

66:20, 66:24

3RD [1] - 215:20

3rd [1] - 77:12

4

4 [11] - 3:6,

68:23, 68:29,

77:24, 78:4, 78:9,

154:4, 156:25,

157:5, 157:6,

196:14

40 [3] - 96:15,

142:12, 142:13

45 [4] - 10:22,

23:1, 63:27

45% [1] - 176:5

48 [1] - 168:21

481283 [1] - 43:5

483570 [1] -

43:14

4:00 [2] - 66:20,

185:16

5

5 [49] - 5:20,

11:19, 37:26,

43:26, 43:27,

43:28, 44:2, 48:1,

48:15, 51:1,

59:18, 63:25,

64:1, 64:3, 74:17,

78:25, 94:16,

94:17, 94:18,

117:4, 117:5,

117:7, 130:18,

130:20, 133:20,

133:25, 133:26,

134:26, 135:12,


1

135:18, 135:20,

135:21, 135:25,

136:11, 141:11,

143:10, 145:5,

151:19, 153:12,

153:17, 153:19,

159:22, 166:23,

166:27, 167:2,

167:13, 170:28,

186:3

5% [1] - 176:4

5's [1] - 64:3

50 [2] - 57:9,

96:15

515562 [2] -

44:12, 132:24

52 [1] - 57:12

53 [1] - 57:13

535492 [1] -

42:21

535570 [1] -

143:26

542878 [1] - 43:1

56 [1] - 66:23

6

6 [13] - 68:23,

69:2, 71:20, 77:5,

77:11, 78:5,

87:20, 173:2,

173:8, 179:24,

180:19, 182:29

65 [2] - 84:2,

84:7

690 [1] - 16:3

6:30/7:00 [1] -

23:13

7

7 [39] - 2:16,

4:12, 4:14, 37:26,

38:2, 38:6, 38:8,

44:1, 72:3, 78:9,

78:25, 92:19,

94:16, 94:16,

94:18, 117:4,

117:5, 117:6,

130:15, 130:20,

131:26, 131:28,

135:12, 136:6,

136:9, 136:20,

137:12, 137:26,

138:3, 138:8,

138:25, 139:19,

139:27, 143:16,

145:2, 153:14,

154:3, 154:5,

155:27

70 [1] - 62:4

72 [1] - 154:12

75 [2] - 154:12

75/80 [1] - 24:7

8

8 [10] - 1:3,

72:22, 77:24,

92:8, 92:12,

92:13, 92:18,

159:6, 172:10,

190:8

80 [4] - 3:6, 3:7,

154:12, 173:16

8:00 [4] - 23:23,

23:24, 30:7

8:36 [1] - 42:24

8:45 [1] - 42:24

8:54 [1] - 43:4

8th [2] - 11:23,

69:4

9

9 [7] - 77:26,

77:28, 78:7,

78:22, 124:1,

180:9, 180:19

9% [6] - 18:26,

25:8, 25:17,

81:20, 164:1,

174:10

9.30 [1] - 215:18

91% [2] - 25:17,

65:3

9:00 [1] - 23:25

9:07 [1] - 43:7

9:25 [1] - 43:15

9:27 [1] - 43:4

9:30 [1] - 23:15

9:35 [1] - 43:8

9:55 [1] - 44:12

A

A&E [5] -

152:19, 152:21,

153:2, 154:6,

167:4

a...(

INTERJECTION)

[1] - 138:28

a.m [3] - 23:25,

183:7, 183:17

A.M [1] - 215:21

ABBEY [1] -

2:15

abdomen [2] -

42:8, 66:5

abdominal [1] -

64:10

aberrant [1] -

166:17

ability [8] -

39:26, 46:21,

122:19, 129:29,

130:3, 140:10,

146:5, 159:11

able [17] - 7:29,

10:27, 28:27,

29:2, 30:27,

74:12, 75:5, 75:7,

79:20, 80:5,

93:29, 143:5,

144:13, 144:14,

168:17, 202:12,

208:28

abnormal [3] -

18:14, 23:17,

88:23

abnormalities

[1] - 15:19

abnormality [5]

- 15:12, 16:19,

16:29, 18:19,

18:20

above-named

[1] - 1:30

abroad [4] - 6:5,

6:29, 188:27,

196:19

absence [2] -

25:12, 38:16

absent [1] -

90:10

absolute [4] -

33:11, 89:20,

104:15, 113:4

absolutely [23] -

27:4, 38:14,

38:19, 48:18,

67:18, 68:26,

76:4, 87:9, 109:2,

112:29, 114:15,

122:2, 124:25,

132:8, 140:13,

142:6, 148:2,

149:19, 153:8,

167:15, 176:18,

186:16, 193:18

absorb [1] -

102:18

academic [2] -

36:16, 101:16

accept [33] -

34:9, 34:27,

43:17, 62:23,

62:24, 62:28,

68:12, 84:14,

85:1, 85:22,

85:28, 86:6, 86:9,

86:15, 86:20,

86:24, 87:6, 87:9,

92:5, 100:11,

101:1, 104:1,

129:14, 135:6,

162:23, 167:13,

169:9, 175:4,

175:9, 175:16,

201:22, 211:12

acceptable [4] -

37:15, 149:18,

211:13, 211:16

acceptance [1] -

176:1

accepted [7] -

43:20, 69:14,

87:3, 124:5,

124:18, 124:19,

203:1

accepting [6] -

61:22, 85:15,

85:27, 169:14,

169:15, 203:5

accepts [2] -

103:29, 124:9

access [5] -

31:7, 60:17, 61:5,

61:14, 147:20

accommodatin

g [1] - 144:23

accompany [1] -

20:7

accomplished

[3] - 38:26, 46:16,

143:28

account [2] -

106:14, 135:4

accreditation [1]

- 76:27

accumulative

[1] - 172:19

accuracy [2] -

128:7, 134:6

accurate [2] -

1:28, 161:4

achieved [1] -

66:29

achievement [1]

- 16:28

acknowledged

[2] - 44:26, 157:13

acquaint [2] -

103:5, 120:29

acquaintance

[1] - 172:9

acquiring [1] -

171:29

act [2] - 24:12,

161:17

ACT [1] - 1:4

acted [1] -

110:13

acting [1] -

51:21

action [2] - 1:30,

69:26

actions [4] -

85:8, 85:25,

204:5, 204:6

active [1] - 7:13

actual [10] -

20:27, 69:25,

85:11, 105:17,

117:27, 126:10,

129:19, 156:12,

168:16, 176:9

adamant [1] -

167:15

adapted [1] -

152:27

add [3] - 37:19,

189:2, 192:18

added [2] -

187:4, 205:28

adding [1] -

68:15

addition [12] -

7:13, 9:5, 9:10,

9:12, 75:26,

92:28, 100:23,

136:25, 154:13,

154:15, 164:5,

173:9

additional [4] -

9:23, 11:7,

140:12, 151:21

address [7] -

9:27, 115:4,

179:18, 182:15,

187:4, 198:14,

204:14

addressed [7] -

59:28, 75:4,

75:10, 75:19,

75:21, 110:12,

162:18

addressing [1] -

188:7

adds [2] - 24:11,

139:22

adept [1] -

152:23

adequate [11] -

82:17, 82:19,

95:12, 97:4,

99:26, 115:15,

119:14, 123:6,

123:25, 208:20,

209:10

adequately [1] -

99:28

adhered [1] -

29:18

adjoining [1] -

22:22

ADJOURNED

[1] - 215:20

ADJOURNMEN

T [6] - 80:16,

80:19, 107:14,

108:2, 171:3,

171:6

administration

[3] - 25:27, 75:5,

191:7

administrative

[2] - 105:25,

171:26

admission [13] -

17:21, 17:22,

17:25, 30:1, 30:4,

30:5, 31:1, 39:8,

72:13, 75:3,

89:19, 111:22,

172:13

admitted [7] -

29:25, 29:29,

56:14, 71:10,

72:11, 111:21,

159:3

admitting [4] -

85:6, 85:22, 86:6,

169:5

adopted [1] -

175:13

adults [1] - 6:12

advance [5] -

39:1, 46:2, 98:1,

155:18, 194:7

adverse [1] -

158:7

advice [6] -

67:26, 75:18,

78:1, 134:7,

168:1, 168:4

advise [2] -

67:21, 75:15

advised [3] -

32:1, 67:8,

167:29

Advisory [1] -

173:4

advocated [1] -

73:9

Africa [1] - 5:27


2

AFTER [3] -

80:18, 108:1,

171:6

afternoon [2] -

10:16, 177:19

age [3] - 15:11,

15:21, 15:25

aggressive [1] -

55:15

ago [9] - 55:6,

76:23, 84:29,

123:11, 123:12,

137:4, 149:16,

166:1, 190:18

agree [45] - 27:4,

27:7, 28:10, 38:2,

45:22, 61:21,

68:25, 81:7,

81:17, 82:1,

82:21, 91:20,

95:10, 96:14,

96:19, 101:3,

101:5, 102:2,

102:19, 103:7,

106:13, 109:29,

111:9, 112:28,

138:15, 138:16,

140:13, 157:22,

157:23, 157:24,

157:25, 157:27,

158:20, 158:22,

159:23, 159:26,

160:1, 161:11,

162:16, 163:1,

166:15, 166:21,

166:26, 208:17,

208:21

agreeable [1] -

107:7

agreed [11] -

69:15, 77:29,

78:2, 121:16,

123:26, 129:22,

142:5, 142:6,

146:17, 147:21,

164:26

agreeing [2] -

136:17, 137:8

agreement [1] -

172:15

agrees" [1] -

184:5

ahead [4] - 92:4,

145:21, 145:24,

146:3

air [3] - 166:2,

166:3, 212:1

aircraft [2] -

165:16, 165:21

airline [3] -

165:16, 202:23

airplane [1] -

202:24

airport [2] -

210:22, 211:28

airway [1] -

23:19

alarmed [1] -

195:6

albeit [2] - 25:8,

188:29

alerted [2] -

31:2, 31:4

alerting [1] -

70:28

alia [1] - 201:11

alike [1] - 36:28

allayed [6] -

33:14, 34:20,

34:22, 35:2, 35:3,

163:1

allegation [18] -

81:17, 81:26,

82:3, 82:11,

82:15, 82:21,

82:24, 83:1, 83:2,

83:3, 83:4, 83:21,

83:22, 86:27,

181:23, 197:10,

197:11

allegations [12]

- 54:3, 70:5, 81:5,

81:6, 81:10,

81:13, 197:7,

197:9, 199:1,

199:7, 200:8,

207:29

allegedly [1] -

155:4

allocated [4] -

36:29, 73:26,

154:9, 157:15

allow [3] -

100:23, 137:1,

170:21

allowed [6] -

22:6, 25:10, 56:6,

69:24, 180:24,

213:5

alluded [3] -

14:11, 14:12,

73:15

almost [2] -

176:21, 191:10

alter [1] - 117:28

alternative [1] -

124:18

amazed [1] -

34:6

ambition [4] -

137:14, 143:12,

144:12, 156:11

American [1] -

165:29

amount [6] -

7:22, 110:19,

124:13, 124:21,

134:5, 209:16

ample [2] -

93:27, 104:8

an...(

INTERJECTION)

[1] - 50:29

anaesthesia [17]

- 41:24, 42:3,

42:7, 42:12,

42:13, 42:15,

46:25, 47:18,

48:1, 48:13,

48:21, 49:8, 49:9,

96:11, 126:19,

143:17

anaesthetic [29]

- 24:16, 32:18,

41:20, 41:22,

42:4, 42:6, 42:23,

42:24, 43:3, 43:8,

43:15, 44:3,

44:12, 44:15,

47:25, 64:2, 64:3,

109:20, 112:3,

128:4, 128:22,

143:21, 144:1,

151:18, 163:20,

163:28, 183:29

Anaesthetic [1]

- 127:19

anaesthetic"...(

INTERJECTION

[1] - 183:25

anaesthetised

[13] - 41:25, 47:3,

60:8, 82:8, 94:19,

117:8, 128:14,

138:27, 145:7,

153:20, 183:24,

183:28, 209:24

anaesthetist [7]

- 47:24, 48:16,

58:1, 58:4, 145:5,

145:8, 152:15

Anaesthetist [1]

- 128:23

anaesthetist's

[1] - 46:24

analgesia [1] -

41:26

analogies [1] -

211:29

analogy [3] -

165:15, 203:11,

213:28

anastomosis [3]

- 66:29, 67:3,

67:4

anchored [1] -

133:11

anguished [1] -

169:3

Anna [2] -

160:24, 162:5

annual [1] -

90:11

anorectal [5] -

12:10, 15:12,

16:19, 16:29,

61:11

answer [11] -

71:7, 79:6, 79:16,

102:14, 115:22,

116:10, 133:8,

145:29, 154:19,

161:14, 167:9

answer...(

INTERJECTION

[1] - 62:22

answered [3] -

34:29, 145:18,

146:2

answers [3] -

5:16, 170:4,

200:24

antegrade [1] -

12:6

Antibiotic [1] -

18:12

antibiotics [3] -

18:11, 18:29,

70:11

anticipate [1] -

136:27

anticipated [4] -

100:7, 139:10,

159:13, 170:7

anticipating [1]

- 176:16

antiquated [1] -

22:19

anus [3] - 15:13,

15:15, 17:1

anxiety [2] -

34:7, 163:1

anxious [4] -

97:26, 138:17,

186:4, 186:17

anyway [5] -

127:29, 145:1,

146:17, 164:26,

185:10

apart [4] -

104:22, 159:1,

171:25, 192:19

apologise [5] -

68:5, 75:27, 84:4,

142:2, 184:21

apologised [5] -

67:15, 68:1, 68:2,

83:28, 84:8

apologising [1]

- 178:6

apparent [2] -

16:10, 65:2

appealed [1] -

212:3

appear [4] -

14:14, 30:24,

108:16, 119:7

appearance [1] -

60:21

APPEARANCE

S [1] - 2:1

appeared [4] -

90:8, 99:10,

105:7, 108:25

appearing [1] -

200:19

appellant [1] -

2:27

application [2] -

176:6, 195:20

applied [3] - 4:7,

29:15, 203:10

applies [1] -

158:2

apply [5] -

37:27, 40:13,

40:14, 83:5,

106:25

appoint [2] -

37:20, 69:20

appointed [3] -

5:11, 9:29, 37:21

appointment [3]

- 13:28, 74:1,

74:2

apportion [2] -

85:19, 178:20

appreciate [8] -

49:14, 53:29,

65:17, 67:28,

81:9, 198:24,

201:13, 212:29

appreciated [1] -

59:7

approach [3] -

148:9, 192:6,

208:23

approachable

[7] - 55:10, 55:12,

161:27, 188:24,

188:28, 189:15,

192:15

approaching [1]

- 165:29

appropriate [31]

- 16:12, 32:2,

37:13, 77:28,

83:5, 83:24,

102:17, 117:29,

118:24, 119:13,

121:24, 123:16,

147:20, 148:11,

161:22, 168:14,

176:9, 199:25,

201:25, 202:1,

202:4, 202:9,

202:10, 202:14,

204:15, 204:16,

205:3, 209:10,

209:26

appropriately

[7] - 10:25, 33:17,

69:21, 78:25,

86:12, 106:25,

143:4

appropriatenes

s [1] - 200:21

approval [1] -

20:20

approved [1] -

39:8

approximation

[2] - 112:19, 129:4

April [3] - 13:14,

14:27, 15:4

apropos [1] -

173:14

Arabia [1] - 72:5

archaic [1] -

22:19

archive [1] -

20:14

area [7] - 45:27,

127:21, 128:26,

147:16, 172:4,

172:6, 172:7

areas [2] -

135:14, 191:4

argue [1] - 110:8

argument [1] -

202:6

arise [3] - 56:19,

78:24, 199:1

arises [1] -

172:7

arising [1] -

177:15

arose [1] - 95:20

arranged [1] -

17:20


3

arrangement [2]

- 37:15, 39:3

arrival [1] -

183:26

arrive [1] - 28:18

arrived [15] -

45:27, 97:24,

127:13, 127:20,

138:26, 139:20,

141:11, 141:12,

141:13, 145:3,

151:14, 153:15,

154:5, 162:4

arrives [1] -

151:27

arriving [2] -

53:11, 128:25

arterial [2] -

66:29, 67:3

artery [5] -

65:22, 65:28,

65:29, 66:3,

66:13

articles [1] - 8:3

articulated [1] -

64:16

AS [17] - 4:1,

4:25, 80:18,

80:24, 108:1,

108:12, 171:6,

171:14, 177:13,

179:2, 187:9,

190:3, 193:4,

196:1, 205:12,

207:17, 211:25

ascertain [1] -

26:10

aside [1] - 82:3

asleep [4] - 47:8,

60:8, 126:16,

143:9

aspect [6] -

16:18, 93:8,

126:23, 176:19,

189:18, 191:14

aspects [7] -

36:4, 49:29, 50:3,

157:25, 157:26,

157:27, 188:12

assertion [1] -

101:7

assessment [3]

- 76:25, 77:14,

78:12

ASSESSOR [1] -

2:8

assign [1] -

98:11

assigned [10] -

12:24, 32:13,

38:2, 38:4, 38:12,

40:5, 58:19,

88:26, 91:7,

98:15

assignment [1] -

33:4

assimilate [1] -

102:23

assist [10] -

43:28, 44:2,

58:14, 58:24,

94:18, 117:7,

131:9, 136:5,

172:25, 203:7

assistance [1] -

58:12

assistant [14] -

58:20, 58:22,

58:25, 59:2,

150:15, 150:18,

150:20, 150:24,

150:29, 151:4,

151:7, 151:9,

151:10, 172:1

assisted [3] -

43:20, 59:4,

134:20

assisting [2] -

10:26, 91:14

associate [1] -

173:15

Associate [1] -

5:8

associated [1] -

12:11

association [1] -

12:10

assume [1] -

138:24

assumed [2] -

146:28, 147:1

assuming [1] -

30:25

assurance [1] -

176:26

assured [6] -

20:8, 31:25,

31:26, 35:4, 75:8,

75:19

AT [2] - 1:16,

215:21

atresia [1] -

23:16

attached [1] -

66:6

attack [1] -

54:11

attempt [4] -

10:2, 19:2,

109:17, 164:17

attempted [3] -

34:1, 66:28,

67:14

attempts [3] -

66:17, 67:15,

175:2

attend [4] - 8:14,

23:27, 152:12,

152:18

attendance [3] -

16:2, 16:4, 67:7

attended [7] -

8:5, 8:10, 8:12,

24:25, 70:26,

152:6, 165:2

attending [1] -

153:12

attention [1] -

103:24

attitude [1] -

122:15

attractive [1] -

60:23

attributing [1] -

12:1

au [1] - 211:10

audit [1] - 23:24

augment [1] -

40:19

Augmentin [1] -

18:11

August [3] -

16:5, 40:8, 77:12

authored [1] -

8:4

authoritarian [1]

- 55:15

authority [3] -

32:3, 101:8,

101:17

authors [1] -

182:20

auto [3] - 95:27,

122:23, 125:13

auto-start [1] -

95:27

automatic [3] -

198:5, 210:1,

210:28

automatically

[1] - 213:11

availability [3] -

25:26, 78:1,

152:6

available [35] -

19:14, 19:16,

19:17, 20:9,

20:12, 21:22,

21:26, 22:1, 26:8,

32:23, 32:26,

32:28, 33:12,

35:24, 37:2,

37:22, 38:22,

39:4, 58:14,

68:11, 72:25,

73:19, 89:14,

89:19, 110:9,

137:28, 146:25,

177:5, 185:10,

188:17, 188:22,

188:24, 191:25,

206:17, 213:9

average [1] - 9:3

aviation [1] -

165:15

avoided [1] -

150:4

aware [34] -

17:16, 33:25,

59:11, 68:28,

88:22, 97:24,

98:14, 104:12,

113:12, 126:1,

128:19, 128:21,

140:3, 144:17,

144:19, 148:29,

149:2, 149:6,

150:20, 151:18,

152:21, 162:18,

162:21, 168:9,

175:12, 180:5,

180:6, 184:22,

192:11, 192:13,

197:7, 198:12,

206:20, 208:14

awareness [1] -

149:11

awful [1] -

208:27

awoken [1] -

42:7

B

background [1]

- 69:6

backlog [1] -

69:22

backtracking [1]

- 97:8

bacteria [1] -

12:8

bad [2] - 204:6,

204:9

Badrul [1] -

143:27

baggy [4] -

64:17, 64:18,

164:6, 164:26

balance [2] -

24:12, 82:11

balanced [1] -

55:5

bank [3] - 57:19,

151:20, 151:22

barely [1] -

22:20

Barrington [16] -

4:7, 84:17, 160:9,

170:24, 177:22,

178:28, 181:7,

181:12, 182:8,

185:14, 186:22,

194:8, 199:10,

201:16, 214:16

BARRINGTON

[80] - 2:18, 3:6,

3:9, 3:11, 3:14,

3:17, 4:9, 4:16,

4:20, 4:25, 4:27,

11:11, 11:16,

11:21, 34:27,

41:2, 48:8, 48:28,

49:10, 54:28,

62:23, 62:28,

65:11, 65:21,

76:20, 79:25,

155:13, 155:22,

170:25, 171:1,

179:2, 179:4,

180:16, 180:18,

181:3, 181:14,

182:2, 182:5,

182:13, 182:18,

182:29, 183:28,

184:17, 184:25,

185:18, 185:28,

186:1, 186:13,

186:23, 187:2,

187:9, 187:11,

187:18, 189:19,

189:23, 189:29,

190:3, 190:5,

190:14, 192:25,

193:2, 194:4,

194:15, 194:29,

195:7, 195:23,

195:28, 196:2,

196:4, 196:12,

198:12, 198:20,

198:27, 199:17,

200:12, 201:20,

205:5, 205:10,

211:21, 214:19

barrister [1] -

125:24

based [7] - 7:26,

19:12, 31:6,

148:12, 173:22,

206:16, 206:19

basic [2] -

172:28, 196:17

basis [14] - 24:9,

33:21, 54:11,

55:10, 60:18,

89:4, 117:15,

125:4, 136:12,

148:24, 161:6,

163:28, 182:5,

199:28

bear [3] - 85:24,

114:11, 116:26

beat [1] - 142:21

Beata [1] -

151:18

Beaumont [2] -

66:18, 67:7

became [7] -

15:5, 17:6, 17:14,

89:18, 119:19,

155:6, 191:15

become [10] -

13:23, 15:19,

16:26, 16:27,

24:14, 96:17,

119:17, 139:19,

164:23, 170:8

becomes [2] -

37:2, 101:16

becoming [1] -

142:13

bedside [1] -

191:21

BEEN [4] - 4:24,

187:8, 190:2,

196:1

beforehand [4] -

119:3, 141:1,

155:25, 159:22

beg [1] - 122:18

began [3] -

97:25, 128:22,

146:18

begin [1] -

183:23

beginning [3] -

131:4, 150:15,

178:14

begins [1] -

74:28

behalf [6] -

108:16, 116:23,

128:6, 187:26,

190:7, 209:20

behaviour [2] -

77:10, 166:17

behest [1] -

123:18

behind [5] -

68:22, 179:24,


4

180:19, 182:29,

209:13

beings [1] -

212:2

belief [3] - 52:9,

52:11, 82:19

below [4] -

24:19, 61:13,

83:13, 147:14

beside [2] -

64:3, 105:17

best [11] - 25:25,

33:11, 35:2,

51:22, 54:12,

58:27, 67:12,

103:11, 140:6,

174:23, 204:4

better [12] -

34:13, 61:3,

79:20, 85:17,

96:19, 96:21,

104:19, 175:10,

178:9, 178:11,

178:15, 212:17

between [36] -

22:7, 25:15,

25:19, 36:23,

41:6, 41:14,

45:29, 48:29,

53:5, 53:12,

54:16, 85:10,

85:26, 89:5, 94:4,

94:17, 96:3,

100:28, 103:13,

104:14, 106:1,

106:4, 111:28,

117:6, 128:24,

129:7, 131:7,

131:12, 134:5,

135:7, 154:17,

154:21, 182:23,

197:5, 204:1

beyond [5] -

67:2, 83:10,

83:19, 90:21,

114:22

bifida [1] - 10:15

big [1] - 166:6

bigger [1] -

11:18

birth [1] - 41:5

bit [14] - 16:14,

20:3, 50:6, 55:15,

121:2, 140:23,

140:25, 141:6,

147:15, 153:29,

174:5, 183:20,

213:11, 214:23

bizarre [1] -

106:22

BL [3] - 2:11,

2:18, 2:22

bladder [9] -

12:7, 19:3, 19:4,

19:6, 70:17,

70:18, 70:19,

70:21, 71:4

blame [15] -

68:8, 82:4, 84:22,

84:25, 84:26,

85:12, 85:19,

86:18, 88:14,

178:16, 178:18,

178:20, 203:14,

203:29

blamed [1] -

84:29

blaming [1] -

68:16

bleeding [2] -

63:26, 64:8

blood [33] -

56:12, 56:14,

56:16, 56:19,

56:21, 56:22,

56:24, 56:26,

57:1, 57:2, 57:3,

57:19, 57:21,

64:5, 65:13,

66:13, 67:1,

108:29, 151:17,

151:20, 151:22,

151:24, 152:1,

152:2, 152:7,

152:10, 152:11,

152:13, 152:16,

176:16, 176:18,

212:8

bloods [1] -

56:10

board [1] - 23:27

Board [5] -

23:27, 39:20,

69:14, 159:9,

191:13

body [3] - 13:10,

60:26, 172:12

book [6] - 17:23,

18:3, 177:1,

179:24, 183:1,

190:8

Book [1] - 11:4

booked [6] -

10:21, 29:4,

30:18, 89:29,

90:2, 90:12

booking [3] -

33:3, 83:8, 89:12

Booklet [1] -

119:29

booklet [12] -

11:14, 14:28,

17:13, 25:4, 62:4,

68:22, 81:1, 81:3,

84:12, 87:13,

92:8, 186:26

booklets [5] -

11:7, 11:18,

11:19, 12:27,

16:1

bore [1] - 189:4

born [1] - 15:12

bottle [1] - 64:5

bottom [6] -

16:4, 92:8, 92:13,

92:18, 94:13,

116:29

bowel [3] -

14:24, 15:10,

16:13

box [8] - 50:16,

50:23, 50:27,

50:28, 51:7, 51:8,

64:26

boxes [2] -

183:14, 183:15

brain [2] -

170:29, 174:27

brakes [3] -

29:14, 106:25

break [8] - 80:7,

80:9, 80:11,

80:14, 107:7,

107:10, 153:5,

170:20

breath [1] -

168:18

Breathnach [6] -

189:29, 190:6,

190:10, 190:14,

192:17, 194:1

BREATHNACH

[5] - 3:13, 190:2,

193:1, 193:4,

193:26

brief [5] -

132:27, 132:29,

170:26, 185:20,

186:1

briefing [1] -

98:2

briefly [6] - 8:18,

66:26, 68:20,

73:7, 93:25,

177:15

bring [3] - 55:29,

103:23, 133:25

bringing [1] -

22:28

brings [1] -

70:25

brought [11] -

29:27, 45:3, 45:5,

52:6, 52:17, 63:7,

71:22, 97:14,

123:23, 128:13,

162:7

Broviac [1] -

98:22

building [1] -

203:15

BUILDING [1] -

2:15

built [1] - 208:27

Burke [1] - 43:19

BURKE [1] -

2:22

bush [1] -

142:21

busy [17] -

22:18, 22:25,

23:1, 23:6, 23:28,

24:13, 24:14,

88:20, 95:21,

97:1, 106:3,

131:29, 135:28,

152:27, 153:4,

188:10, 188:13

but...(

INTERJECTION

[1] - 195:17

button [1] -

125:13

BY [25] - 2:12,

2:19, 2:24, 4:25,

80:24, 107:2,

108:13, 171:13,

177:10, 177:12,

179:1, 187:9,

189:23, 190:3,

193:1, 193:4,

193:26, 196:2,

205:9, 205:12,

207:15, 207:17,

211:19, 211:25,

214:12

C

cage [1] - 60:28

Cambodia [1] -

192:21

Cancer [2] - 6:8,

6:10

cancer [3] -

6:12, 190:29,

192:24

cannot [32] -

43:25, 45:25,

46:1, 46:2, 71:7,

75:2, 77:2, 85:7,

86:9, 86:14, 90:3,

95:6, 96:5,

126:10, 127:28,

129:20, 132:3,

132:8, 134:4,

134:19, 134:23,

135:6, 138:2,

141:4, 141:9,

145:24, 156:2,

158:22, 184:13,

184:14, 203:13,

213:24

canvassed [1] -

76:23

capability [1] -

46:15

CAPEL [1] - 2:15

captain [5] -

202:23, 203:11,

212:3, 212:4

cardiac [1] -

7:29

cardiologist [3]

- 187:20, 187:24,

188:15

Care [1] - 8:9

care [19] - 57:6,

57:13, 59:14,

79:10, 79:21,

86:8, 138:10,

138:14, 139:17,

139:25, 144:7,

144:8, 144:11,

145:2, 155:29,

190:28, 191:12,

192:23

career [2] - 29:2,

193:23

careful [1] -

193:16

carers [1] -

78:15

caring [3] -

192:3, 192:5,

193:11

carried [5] -

18:24, 19:10,

84:19, 100:13,

148:4

carry [1] -

142:28

cascade [1] -

33:25

case [88] - 11:3,

16:18, 17:21,

20:10, 21:15,

23:9, 23:11,

23:12, 23:20,

26:7, 27:9, 30:12,

33:6, 38:8, 43:24,

43:29, 44:24,

45:12, 45:14,

49:15, 49:27,

49:29, 50:2, 50:3,

52:1, 52:10,

53:13, 53:28,

57:5, 57:17,

60:14, 70:23,

71:29, 76:3, 81:8,

81:9, 90:19,

91:26, 92:22,

94:20, 94:22,

95:10, 95:13,

96:20, 101:13,

102:10, 103:4,

103:19, 117:9,

117:11, 118:29,

119:15, 122:13,

123:22, 124:3,

125:26, 134:16,

134:23, 134:24,

134:25, 136:23,

138:25, 143:6,

144:26, 153:18,

156:12, 158:1,

164:28, 166:28,

178:10, 179:20,

180:23, 181:15,

186:23, 188:26,

198:1, 201:29,

202:20, 202:22,

205:17, 206:17,

208:12, 208:15,

208:29, 209:10,

210:8, 212:9

cases [11] -

25:24, 38:7,

72:17, 72:18,

99:12, 106:1,

154:17, 154:21,

208:23, 208:28

catastrophic [2]

- 204:19, 214:3

catch [4] -

60:25, 65:8, 99:8,

105:28

catheter [1] -

41:26

catheterise [5] -

48:17, 140:24,

141:7, 141:15,

145:9

catheterised [2]

- 126:13, 209:24

catheterising [1]

- 60:9

caught [2] -

52:14, 213:24


5

caused [2] -

75:28, 164:27

cava [1] - 56:28

caveat [1] -

101:7

censure [1] -

158:5

central [3] -

112:4, 133:2,

133:4

Centre [2] - 6:8,

6:10

centre [2] - 6:9,

24:16

centres [2] -

83:21, 83:22

CEO [7] - 2:11,

83:2, 116:23,

120:14, 123:23,

198:15, 203:2

CEO's [3] -

117:22, 180:28,

181:5

certain [8] -

27:14, 36:16,

46:26, 91:21,

103:8, 106:9,

173:1, 173:8

certainly [23] -

28:13, 31:9, 54:9,

54:14, 94:28,

96:17, 97:3,

99:23, 119:19,

140:28, 141:1,

162:11, 167:24,

169:2, 169:13,

170:4, 175:13,

176:20, 176:21,

186:6, 188:12,

192:10, 193:10

certify [1] - 1:27

cetera [1] - 82:6

chairman [1] -

34:24

Chairman [8] -

4:9, 4:17, 108:9,

171:1, 179:4,

185:18, 186:25,

187:2

CHAIRMAN [53]

- 2:4, 4:4, 4:10,

4:18, 11:9, 11:15,

11:20, 40:29,

65:20, 76:17,

80:6, 80:13,

80:21, 84:5,

107:5, 107:11,

108:4, 120:16,

132:25, 133:4,

133:15, 153:6,

170:18, 170:27,

171:9, 171:16,

174:3, 177:6,

178:28, 183:19,

183:26, 184:11,

185:3, 185:14,

185:21, 185:24,

185:29, 186:9,

186:20, 186:28,

187:16, 189:25,

190:12, 193:29,

196:11, 211:27,

214:9, 214:16,

214:20, 215:1,

215:5, 215:10,

215:16

challenging [1] -

100:21

chance [2] -

29:7, 29:8

chances [1] -

20:17

change [2] -

117:28, 207:6

changed [5] -

26:4, 61:27,

61:28, 175:21,

199:28

channel [1] -

15:16

character [1] -

186:3

charge [13] -

36:8, 41:8, 41:9,

41:11, 42:23,

43:2, 43:6, 44:20,

44:22, 103:26,

122:26, 169:17,

204:17

charge/

surgeon [2] -

41:5, 41:7

chart [44] - 11:8,

12:16, 12:19,

14:18, 15:28,

19:17, 19:20,

19:21, 19:23,

20:10, 20:12,

20:23, 21:14,

21:19, 21:21,

21:27, 22:1, 25:7,

26:7, 26:9, 26:17,

27:16, 28:8,

30:27, 41:4,

42:21, 43:1, 43:5,

57:5, 57:9, 59:16,

62:7, 62:16,

63:10, 63:11,

63:13, 64:28,

88:17, 88:19,

89:2, 105:18,

105:29

charts [5] -

10:24, 105:17,

105:22, 153:25,

153:27

chase [1] -

126:20

check [10] -

63:13, 63:25,

104:24, 104:25,

105:10, 148:16,

174:17, 212:11,

212:17, 213:13

checked [11] -

62:8, 62:15,

64:13, 82:8, 92:4,

95:29, 104:2,

104:26, 105:8,

109:22

checking [5] -

31:9, 105:10,

164:4, 213:14,

213:15

checks [3] -

184:3, 202:27,

210:24

cheese [1] -

213:28

chemotherapy

[2] - 133:10, 191:8

chest [2] - 23:9

Chief [3] - 39:14,

81:8, 179:20

child [20] -

15:25, 22:21,

49:16, 67:25,

70:10, 75:24,

75:25, 75:27,

75:29, 100:12,

160:20, 162:2,

167:4, 173:26,

189:8, 189:12,

203:20, 203:26,

213:5, 214:8

child's [1] -

213:3

children [5] -

24:19, 76:1,

190:28, 192:22,

192:23

choice [1] -

142:1

chose [1] -

179:16

Christina [1] -

7:25

chronology [2] -

93:13, 179:19

circle [4] -

166:4, 174:12,

174:21, 175:10

circulating [1] -

58:25

circumcision [4]

- 143:16, 143:29,

144:5, 153:17

circumcisions

[2] - 98:23, 173:2

circumstance

[2] - 91:16, 210:8

circumstances

[16] - 29:9, 30:2,

34:22, 58:6,

58:18, 78:24,

157:3, 157:7,

166:12, 166:18,

194:11, 200:22,

201:3, 201:29,

208:19, 210:12

City [1] - 159:6

clarification [2] -

49:11, 49:19

clarified [6] -

25:6, 48:2, 63:16,

63:20, 63:21,

155:22

clean [2] - 18:16,

184:23

clear [17] -

27:26, 27:28,

32:17, 41:15,

47:29, 48:24,

49:4, 73:29,

102:25, 111:26,

119:12, 146:8,

167:16, 169:7,

170:8, 203:25,

208:6

clearer [1] -

49:13

clearly [10] -

12:1, 25:13,

28:24, 28:25,

33:7, 76:3,

103:25, 137:29,

143:18, 151:14

clerk [1] - 69:20

clerking [2] -

92:24, 93:4

client [1] - 54:17

Clinic [2] -

21:16, 22:3

clinic [13] -

10:16, 10:19,

10:20, 10:22,

10:26, 15:22,

21:25, 22:21,

23:8, 23:26,

88:20, 92:23

clinical [11] -

6:14, 7:13, 76:25,

77:5, 77:27, 83:5,

83:13, 136:3,

157:18, 174:28,

175:14

clinics [1] - 75:3

clock [4] -

208:12, 210:1,

210:19

close [4] - 99:24,

105:16, 135:12,

193:13

closed [3] -

42:9, 61:12,

134:24

closely [1] -

39:23

closure [1] -

147:14

coagulation [1]

- 67:2

Code [1] - 85:16

coercion [1] -

104:5

colleague [11] -

15:14, 55:24,

61:20, 70:16,

70:22, 77:14,

78:12, 86:15,

158:4, 174:16,

193:22

colleagues [23] -

7:26, 12:3, 23:13,

24:6, 24:17,

37:28, 40:6,

59:22, 59:23,

67:22, 77:15,

78:9, 78:14,

78:18, 104:14,

149:26, 159:10,

172:5, 178:17,

188:2, 188:5,

188:6, 190:26

collective [1] -

172:12

College [14] -

5:9, 5:13, 5:21,

7:14, 7:24, 8:8,

9:27, 39:29,

172:29, 173:15,

173:19, 173:27,

174:1, 196:16

colon [4] -

16:23, 16:25,

17:5

colostomy [6] -

61:10, 61:12,

104:17, 147:14,

147:29

column [5] -

41:4, 41:15,

183:11, 183:17,

183:21

columns [1] -

183:19

combination [3]

- 143:21, 212:24,

213:27

combined [1] -

213:28

comfortable [3]

- 125:14, 198:6,

209:7

coming [5] -

22:27, 94:17,

117:6, 143:11,

208:21

commence [3] -

202:21, 211:12,

214:27

commenced [4]

- 59:5, 111:19,

112:24, 196:18

commencemen

t [12] - 47:21,

47:23, 51:23,

62:9, 111:8,

111:12, 112:6,

112:17, 113:8,

114:3, 197:19,

208:16

commences [2]

- 157:16, 211:5

commencing [4]

- 11:13, 52:21,

148:17, 157:9

commended [1]

- 6:22

comment [14] -

18:28, 61:19,

78:24, 94:12,

95:6, 127:28,

130:12, 134:4,

141:4, 141:9,

156:2, 156:19,

166:9, 166:14

comments [2] -

84:10, 101:20

commission [1]

- 124:14

commitment

[16] - 7:10, 9:11,

9:20, 10:11,

10:18, 24:4,

35:22, 74:20,

78:5, 95:22,

131:26, 135:9,

154:15, 172:28,

173:18, 191:28


6

commitments

[7] - 9:5, 22:13,

23:7, 36:12,

74:13, 135:29,

173:18

COMMITTEE [8]

- 1:3, 2:4, 3:8,

3:18, 171:13,

177:10, 211:25,

214:12

Committee [82] -

4:11, 4:29, 5:2,

5:5, 5:17, 6:8,

7:7, 8:17, 10:11,

11:3, 11:6, 11:28,

12:28, 14:17,

15:9, 17:10, 18:5,

18:25, 19:13,

22:13, 25:19,

30:1, 33:19,

33:20, 52:3,

53:28, 60:5,

63:29, 65:16,

66:26, 68:2,

76:13, 76:21,

81:10, 83:16,

85:1, 86:23,

87:18, 89:8,

91:12, 97:13,

101:2, 103:29,

113:10, 120:13,

131:17, 132:27,

156:22, 170:22,

171:11, 171:18,

173:5, 180:9,

180:11, 183:5,

183:9, 183:18,

184:11, 184:20,

184:26, 185:7,

186:27, 187:13,

188:4, 188:8,

189:21, 190:8,

190:9, 191:18,

192:26, 194:14,

195:21, 196:6,

198:29, 199:12,

199:15, 200:20,

200:29, 203:7,

209:8, 211:21,

214:28

common [5] -

20:11, 73:7,

91:13, 135:9,

135:15

communicate

[1] - 31:10

communicated

[1] - 34:7

communicatin

g [3] - 31:28,

207:10, 213:16

communicatio

n [3] - 78:14,

78:15, 95:8

comparison [1]

- 99:17

compassion [1]

- 78:19

competence [5]

- 94:21, 117:10,

167:5, 200:29,

204:10

competency [1]

- 106:10

competent [7] -

10:27, 71:25,

72:1, 75:11,

125:23, 125:24,

160:7

complaint [5] -

179:20, 179:25,

180:13, 180:28,

181:5

complaints [1] -

192:16

complement [1]

- 74:15

complementar

y [1] - 39:16

complete [3] -

80:5, 144:15,

170:11

completed [2] -

157:18, 205:27

completely [11] -

31:25, 46:28,

82:29, 87:9,

94:22, 95:2,

103:16, 105:27,

117:10, 162:29,

178:12

completing [2] -

132:23, 133:18

complex [4] -

7:28, 77:27,

100:9, 200:20

complexity [1] -

7:27

compliant [2] -

74:26, 176:23

complicated [4]

- 85:4, 93:24,

200:23, 201:27

complication [1]

- 176:4

complications

[2] - 67:10, 72:6

components [1]

- 65:24

composite [1] -

96:10

computer [9] -

22:6, 22:7, 26:13,

26:14, 26:18,

31:6, 31:8, 44:25,

72:9

computerised

[1] - 20:14

concentration

[1] - 170:21

concept [6] -

64:24, 74:26,

166:13, 198:3,

209:1, 210:18

concepts [1] -

210:15

concern [14] -

30:22, 34:7,

34:16, 34:19,

35:5, 46:21,

51:17, 64:18,

94:10, 111:27,

111:29, 115:2,

161:15, 166:20

concerned [8] -

55:25, 112:22,

113:19, 124:28,

148:3, 155:7,

186:7, 189:12

concerning [3] -

110:19, 125:17,

162:19

concerns [21] -

29:16, 29:17,

31:16, 33:13,

34:5, 34:20,

34:21, 35:1, 35:3,

60:3, 72:8, 94:5,

110:19, 110:23,

110:29, 111:7,

111:14, 111:25,

154:20, 161:8,

162:17

concluded [1] -

44:5

conclusion [4] -

131:18, 135:2,

135:17, 186:18

conclusions [1]

- 123:29

concur [1] - 95:9

condition [3] -

23:20, 79:21,

164:28

conduct [3] -

47:14, 60:1,

179:15

conducted [4] -

32:6, 42:20,

76:16, 77:4

conducting [1] -

33:8

conductor [1] -

191:10

conduit [1] -

15:16

cone [1] - 16:24

conference [4] -

12:23, 14:11,

14:12, 14:13

confidence [4] -

46:16, 46:17,

79:12, 105:26

confined [3] -

194:22, 194:25,

197:8

confirm [8] -

18:21, 33:5,

34:14, 35:10,

50:12, 101:18,

198:25

confirmed [1] -

12:3

confirmed...(

inaudible [1] -

67:3

confirming [1] -

146:15

confirms [1] -

184:3

confused [3] -

89:3, 198:3,

207:20

confusing [1] -

11:17

confusion [1] -

184:21

congenital [4] -

16:18, 18:20,

23:16, 61:11

connection [2] -

23:18, 162:10

conroy [1] - 45:3

Conroy [18] -

11:3, 13:24,

14:23, 14:26,

16:5, 17:14,

17:19, 19:7,

29:25, 29:29,

30:21, 32:19,

44:19, 45:4, 85:3,

106:19, 179:7,

197:13

Conroy's [5] -

22:11, 24:25,

24:27, 66:25,

81:18

conscientious

[4] - 39:25, 77:29,

144:24, 193:16

conscientious

ness [1] - 159:12

conscious [3] -

33:7, 51:20,

60:20

consciousness

[2] - 62:8, 62:18

consent [31] -

30:23, 31:24,

50:9, 62:7, 62:16,

63:9, 71:24,

71:27, 71:29,

72:1, 72:3, 72:6,

72:13, 72:14,

72:19, 72:21,

75:9, 75:11, 82:9,

92:10, 92:24,

93:5, 105:8,

105:11, 145:16,

148:29, 163:15,

164:1, 164:3,

212:7

consenting [1] -

31:15

consider [7] -

18:16, 51:18,

89:24, 96:18,

130:7, 139:11,

195:17

considerable [2]

- 110:18, 190:21

considerably [1]

- 17:7

considerate [3] -

78:16, 78:18,

79:2

consideration

[1] - 185:7

considered [12]

- 4:11, 18:14,

18:18, 28:16,

38:24, 63:1,

100:10, 101:27,

118:18, 121:25,

147:18, 202:1

considering [3]

- 16:29, 29:4,

53:8

considers [1] -

202:15

consisted [1] -

179:25

consistently [1]

- 9:22

constellation [1]

- 106:22

constitutes [1] -

110:3

constrained [1]

- 157:14

constraints [2] -

88:20, 122:6

constructed [2]

- 118:3, 118:8

construction [1]

- 203:15

consult [1] -

21:29

consultant [39] -

35:27, 36:1, 36:2,

36:6, 36:7, 36:22,

40:14, 41:8,

46:14, 70:3,

84:15, 85:6,

85:22, 86:6,

94:16, 94:20,

99:25, 101:29,

103:11, 105:24,

106:7, 106:8,

117:5, 117:8,

135:29, 169:5,

169:16, 172:18,

184:2, 187:19,

187:24, 188:22,

197:6, 202:29,

203:8, 203:9,

203:16, 204:17,

204:25

Consultant [9] -

5:6, 10:4, 13:22,

13:25, 26:1,

32:12, 128:23,

190:15, 196:7

consultant's [1]

- 203:21

consultant.. [1]

- 98:4

consultants [7] -

9:24, 40:13,

73:24, 154:9,

188:26, 189:9

consultation [3]

- 67:21, 79:20,

157:18

consulted [8] -

64:19, 78:2,

78:28, 79:1,

108:29, 109:5,

109:9, 163:27

consulting [1] -

22:8

contact [8] -

8:20, 32:4, 58:23,

94:1, 94:2, 94:4,

111:28, 193:12

contacted [1] -

174:15

contamination

[1] - 18:17

contemplate [1]


7

- 96:20

contemporane

ous [1] - 160:28

content [2] -

25:22, 72:5

contents [1] -

27:8

context [13] -

51:16, 51:29,

88:17, 91:23,

100:5, 100:19,

101:17, 121:6,

139:12, 156:11,

161:15, 167:9,

182:11

continence [3] -

15:19, 15:24,

17:2

continent [5] -

15:21, 16:26,

16:27, 16:28,

17:6

continuation [4]

- 165:8, 165:14,

165:22, 166:13

continue [5] -

18:29, 71:27,

73:17, 191:29,

196:20

continued [1] -

191:19

continues [2] -

69:12, 78:12

contrary [2] -

133:29, 165:24

contribute [1] -

154:12

contributed [2] -

69:7, 70:18

contributing [2]

- 18:17, 65:3

contribution [1]

- 78:8

contributions

[1] - 78:21

contributory [9]

- 68:19, 68:24,

68:29, 69:1, 69:9,

69:28, 71:9,

71:24, 72:20

control [7] -

64:8, 85:9,

113:25, 202:19,

202:20, 208:11,

208:14

controller [2] -

166:2, 166:4

controls [1] -

202:24

conversation

[44] - 45:10,

45:11, 45:17,

45:22, 47:13,

47:17, 47:27,

48:12, 48:20,

49:6, 60:4, 60:6,

60:7, 61:17,

61:26, 66:19,

67:17, 67:29,

114:2, 118:22,

123:5, 126:11,

126:12, 126:18,

129:6, 129:9,

129:10, 129:13,

129:24, 129:26,

130:24, 130:25,

135:2, 135:23,

138:7, 150:6,

150:11, 150:13,

167:19, 182:23,

204:12, 204:15,

206:27, 207:9

conversations

[7] - 47:10, 47:12,

59:29, 126:3,

160:19, 163:19,

207:4

conversing [1] -

52:13

conveyed [1] -

119:5

convinced [2] -

104:27, 163:25

Coombe [2] -

13:26, 13:29

coombe [1] -

13:28

Cooney [3] -

36:13, 37:9,

101:28

cope [1] - 69:22

copies [2] -

20:17, 184:20

copy [13] - 4:29,

5:2, 19:18, 19:19,

69:10, 69:11,

80:28, 81:25,

120:14, 120:20,

184:23, 184:25,

196:5

COPYRIGHT [1]

- 2:25

CORBALLY [10]

- 1:9, 2:18, 3:5,

4:24, 80:24,

107:2, 108:12,

171:13, 177:12,

179:1

Corbally [56] -

4:22, 14:28,

34:29, 54:2,

57:10, 65:18,

84:4, 91:4, 99:19,

103:25, 108:15,

115:5, 115:21,

124:3, 150:5,

170:19, 174:5,

180:21, 181:16,

182:3, 182:19,

183:10, 185:22,

187:27, 188:1,

188:9, 189:13,

190:7, 190:20,

191:15, 192:20,

193:14, 196:27,

196:28, 197:9,

197:12, 197:29,

200:17, 201:24,

203:1, 204:12,

204:13, 204:16,

204:22, 206:10,

206:21, 206:23,

207:1, 207:4,

207:10, 207:23,

207:24, 207:27,

208:1, 208:2,

209:22

corbally [2] -

131:15, 197:10

Corbally's [5] -

124:11, 124:20,

188:4, 190:25,

206:14

Corbally...(

INTERJECTION

[1] - 198:16

cordial [1] -

192:2

Core [1] - 119:28

core [10] - 63:15,

68:22, 81:1, 81:2,

84:11, 92:7,

111:17, 161:21,

179:24, 183:1

Cork [1] - 5:24

corner [2] -

92:13, 92:18

correct [155] -

5:22, 5:25, 5:28,

6:2, 6:4, 6:19,

6:27, 7:2, 7:20,

12:17, 12:18,

13:6, 13:13,

13:20, 14:2, 14:5,

14:15, 14:16,

14:22, 14:25,

15:1, 15:3, 15:8,

17:23, 17:24,

18:27, 18:28,

22:7, 25:5, 26:3,

26:21, 27:6,

30:15, 33:5,

34:15, 35:4, 35:7,

35:13, 35:18,

36:9, 37:12,

37:27, 38:14,

40:6, 40:7, 42:26,

43:12, 43:22,

45:9, 47:3, 47:4,

47:6, 47:15,

47:16, 47:19,

50:12, 50:26,

52:18, 52:19,

57:16, 62:17,

66:14, 66:21,

69:5, 71:16,

72:26, 72:27,

73:9, 74:14,

76:11, 76:14,

82:2, 82:14,

82:29, 83:18,

84:16, 84:23,

86:25, 86:26,

87:2, 87:23,

87:27, 88:4,

89:10, 93:16,

101:19, 103:22,

109:2, 109:4,

109:6, 109:11,

109:24, 109:28,

111:10, 111:15,

111:19, 112:6,

112:7, 112:18,

112:24, 115:13,

115:25, 116:1,

116:13, 116:14,

116:16, 116:17,

125:19, 125:22,

126:5, 127:11,

127:13, 129:8,

129:11, 130:17,

130:23, 130:28,

134:11, 135:19,

136:8, 145:13,

145:19, 146:28,

147:24, 148:5,

148:14, 150:17,

150:27, 153:9,

160:9, 162:4,

163:7, 163:9,

163:11, 163:13,

165:5, 165:21,

168:8, 168:23,

168:24, 174:22,

179:23, 179:29,

180:20, 180:26,

181:5, 181:18,

181:22, 181:26,

182:21, 182:22,

193:17, 194:8,

194:16, 207:23

corrected [2] -

69:3, 181:11

correctly [7] -

21:17, 22:4, 33:7,

71:3, 87:5, 87:21,

209:29

corridor [1] -

22:24

cosmetic [1] -

104:21

cosmetically [1]

- 60:23

costs [1] - 75:4

couch [1] -

22:19

coughing [2] -

15:23, 67:4

COUNCIL [1] -

1:2

Council [19] -

39:8, 76:23,

76:26, 77:3,

84:11, 119:20,

119:22, 121:12,

142:27, 146:19,

159:4, 166:10,

166:22, 172:13,

175:18, 175:22,

179:13, 179:21,

179:26

Council's [1] -

85:16

counsel [2] -

148:15, 200:3

countdown [1] -

208:15

country [6] -

36:11, 37:13,

96:24, 176:21,

176:23, 196:19

couple [2] -

174:3, 209:1

course [39] -

5:5, 5:18, 8:5,

8:8, 21:2, 30:12,

35:11, 44:29,

59:6, 67:29, 68:9,

73:1, 87:20,

93:23, 93:26,

94:7, 116:8,

116:15, 116:27,

118:14, 119:21,

123:2, 128:11,

129:9, 135:11,

136:5, 145:14,

152:4, 154:28,

154:29, 156:25,

158:24, 162:2,

165:6, 169:7,

178:22, 193:15,

199:24, 211:3

Course [1] -

8:14

course...(

INTERJECTION

[1] - 140:8

courses [2] -

8:5, 8:10

cover [4] -

38:16, 38:29,

72:23, 174:25

crashed [2] -

166:1, 166:5

crashes [1] -

165:16

create [2] -

15:15, 61:8

crisis [1] - 75:18

critical [3] -

31:27, 73:16,

78:4

critically [2] -

35:23, 53:22

criticise [4] -

115:21, 116:3,

116:8, 158:5

criticised [3] -

182:3, 182:10,

204:12

criticism [4] -

56:1, 63:10,

68:27, 92:6

CROSS [49] -

2:8, 3:7, 3:7, 3:8,

3:14, 3:17, 3:18,

48:29, 49:5,

53:25, 54:7,

54:13, 54:21,

54:26, 80:24,

107:2, 108:12,

119:27, 120:8,

156:26, 170:16,

177:12, 178:26,

180:11, 180:15,

180:17, 181:6,

181:12, 182:8,

182:17, 184:10,

184:14, 185:13,

193:4, 193:26,

194:26, 195:12,

195:14, 195:27,

198:22, 199:8,

200:2, 200:11,

200:27, 201:9,

205:12, 207:15,

207:17, 211:19

cross [30] - 31:9,

37:1, 38:16,

38:29, 43:19,

49:2, 56:4, 56:18,


8

56:20, 56:26,

57:2, 57:22,

57:25, 59:9,

72:23, 80:5,

108:7, 127:17,

151:11, 151:23,

152:7, 152:8,

152:14, 176:16,

180:8, 197:28,

199:24, 199:29,

201:25, 215:8

cross-

checking [1] -

31:9

cross-cover [1]

- 72:23

CROSS-

EXAMINATION

[6] - 107:2,

170:16, 178:26,

193:26, 207:15,

211:19

cross-

examination [8] -

56:4, 59:9, 80:5,

197:28, 199:24,

199:29, 201:25,

215:8

cross-examine

[1] - 108:7

CROSS-

EXAMINED [6] -

80:24, 108:12,

177:12, 193:4,

205:12, 207:17

cross-

examining [1] -

43:19

cross-match [8]

- 56:20, 56:26,

57:2, 57:25,

151:23, 152:8,

152:14, 176:16

cross-matched

[1] - 152:7

cross-

matching [3] -

56:18, 57:22,

151:11

cross-over [1] -

180:8

crossing [1] -

101:10

crucial [17] -

88:24, 110:29,

112:29, 113:3,

113:5, 114:15,

115:7, 115:26,

121:2, 121:4,

121:13, 121:16,

121:28, 122:2,

124:26, 124:27,

155:6

crucially [1] -

176:29

crudely [1] -

48:4

Crumlin [54] -

5:7, 5:10, 6:3,

7:1, 7:5, 7:8, 7:9,

8:15, 9:15, 13:25,

13:28, 13:29,

22:8, 24:21,

25:27, 30:4, 32:1,

35:26, 36:10,

36:11, 36:24,

36:26, 37:28,

40:17, 57:27,

71:28, 73:18,

74:17, 83:12,

95:19, 96:23,

103:12, 105:24,

140:3, 140:20,

142:28, 152:26,

158:2, 159:11,

176:24, 179:21,

187:22, 188:10,

189:11, 190:16,

192:19, 194:19,

194:21, 194:28,

195:2, 196:25,

196:26, 197:15,

197:18

cuff [2] - 133:11,

133:12

Cullinane [1] -

136:7

culminated [1] -

106:22

current [1] -

200:9

custom [1] -

124:5

cut [2] - 126:20,

184:16

CV [8] - 4:29,

5:3, 5:20, 7:19,

8:4, 76:13, 196:6,

196:14

D

daily [1] - 77:6

damage [2] -

12:9, 18:22

dangerous [1] -

93:20

data [2] - 44:25,

212:27

date [12] - 29:27,

41:5, 51:14, 77:2,

78:6, 89:9, 90:1,

150:1, 178:9,

183:16, 205:23

dated [6] - 15:4,

120:7, 120:24,

124:24, 181:16,

181:19

dates [2] -

185:5, 185:7

Davey [5] -

33:15, 33:16,

52:4, 160:25,

162:5

DAY [1] - 1:15

day's [1] -

205:26

days [12] - 8:23,

8:28, 9:1, 10:8,

17:6, 23:5, 24:2,

24:10, 67:26,

175:7, 208:29,

209:1

deal [22] - 7:18,

10:27, 17:11,

23:15, 24:9, 55:9,

69:14, 117:29,

130:21, 139:4,

140:5, 152:21,

152:29, 153:3,

157:11, 165:6,

169:5, 169:11,

184:19, 204:28,

207:28, 208:1

dealing [17] -

6:11, 22:10,

32:29, 55:9,

152:24, 156:23,

158:14, 159:15,

164:6, 191:8,

199:1, 199:11,

199:17, 199:20,

199:25, 212:2

dealings [1] -

156:3

deals [5] - 83:1,

180:7, 180:18,

200:8, 207:29

dealt [8] -

136:20, 137:2,

155:10, 155:26,

186:4, 186:11,

192:2, 192:3

debate [1] -

37:12

December [2] -

90:28, 185:8

decide [3] -

53:28, 122:11,

123:19

decided [5] -

19:26, 20:5,

20:29, 185:11,

204:20

decides [1] -

51:29

deciding [1] -

125:14

decision [5] -

46:28, 101:3,

110:6, 148:12,

174:8

decisions [1] -

79:10

dedicated [1] -

39:24

defect [1] -

115:8

defects [1] -

112:4

defence [3] -

54:10, 54:12,

54:23

deficiency [1] -

179:17

define [1] -

111:20

defining [1] -

178:6

definite [1] -

213:26

definitely [13] -

57:1, 79:2, 79:4,

79:5, 79:7, 79:8,

79:11, 79:12,

79:16, 79:18,

79:19, 79:22,

213:1

definitions [1] -

36:17

degree [6] -

12:8, 31:8, 73:16,

76:16, 76:25,

102:20

Delaney [12] -

33:20, 33:21,

33:22, 38:2, 43:9,

43:20, 45:17,

45:23, 46:2, 52:4,

52:12, 101:27

Delaney's [1] -

44:29

delay [6] - 69:9,

75:17, 136:10,

137:25, 157:19,

158:16

delayed [2] -

139:21, 157:17

delaying [1] -

157:29

delegate [24] -

10:25, 83:24,

89:28, 90:15,

90:16, 91:28,

97:28, 102:17,

106:7, 124:9,

149:26, 167:1,

201:4, 201:23,

201:28, 202:1,

202:3, 202:5,

202:13, 202:15,

202:17, 208:10,

211:4, 211:8

delegated [24] -

37:15, 41:10,

82:15, 95:15,

112:10, 112:22,

115:23, 115:27,

116:11, 118:16,

118:23, 119:2,

122:13, 124:3,

125:9, 129:25,

130:6, 153:3,

167:28, 200:18,

201:13, 209:4,

209:27, 210:2

delegates [1] -

78:25

delegating [4] -

113:22, 121:29,

200:21, 202:19

delegation [55] -

56:7, 61:18,

61:22, 61:25,

83:23, 93:10,

93:18, 101:6,

103:4, 103:8,

106:4, 106:6,

119:13, 121:7,

121:13, 121:15,

121:21, 121:24,

121:27, 123:16,

123:24, 123:25,

123:26, 124:4,

124:9, 124:12,

124:18, 124:25,

124:27, 125:3,

125:17, 134:27,

147:2, 155:8,

171:23, 171:29,

172:7, 173:11,

180:23, 181:25,

198:15, 200:13,

208:5, 208:6,

208:7, 208:9,

208:18, 209:1,

209:9, 209:15

delegee [2] -

95:25, 167:5

delegees [1] -

172:9

deleting [1] -

82:10

delighted [2] -

38:19, 45:15

deliver [5] -

7:25, 9:16, 9:21,

24:4, 83:12

delivered [3] -

36:2, 36:7, 64:9

demanding [3] -

23:3, 23:28,

106:3

demands [1] -

23:7

demonstrate [1]

- 62:18

demonstrated

[1] - 70:12

denied [2] -

93:7, 99:27

denies [1] -

35:11

Department [14]

- 10:10, 15:2,

15:29, 19:8,

19:18, 19:25,

20:5, 20:25, 21:6,

21:16, 21:19,

21:23, 22:14,

24:26

department [8] -

74:7, 74:11,

74:12, 75:16,

157:20, 158:18,

162:8, 167:4

dependent [5] -

82:26, 125:12,

125:13, 153:21,

194:19

describe [5] -

50:28, 86:28,

153:9, 165:7,

175:25

described [6] -

35:28, 101:20,

101:21, 101:27,

101:29, 172:2

describing [1] -

178:23

description [3] -

60:25, 72:6,

132:29

designated [2] -

36:19, 56:21

desirable [2] -

98:7, 186:19

desire [1] -

76:10

desk [2] - 22:20,


9

84:2

despite [1] -

165:24

detail [13] -

22:10, 22:11,

29:19, 43:17,

43:25, 85:14,

97:23, 133:23,

149:27, 166:14,

169:10, 169:12,

207:26

detailed [5] -

85:18, 87:24,

182:20, 187:26,

206:18

details [6] -

36:16, 43:24,

68:9, 206:28,

207:1, 207:7

determine [1] -

152:18

determines [1] -

114:24

determining [1]

- 191:6

detract [1] -

144:22

detriment [2] -

191:26, 191:27

devalue [2] -

110:28, 111:2

devaluing [1] -

111:5

devascularised

[2] - 65:5, 65:14

devastated [3] -

67:18, 75:23,

76:4

devastating [1] -

76:9

develop [3] -

54:25, 54:27,

169:11

development [1]

- 17:1

deviate [1] -

165:24

devising [1] -

171:27

diagnosis [3] -

14:4, 14:8, 191:6

diagnostic [1] -

77:24

diagram [1] -

65:22

dictated [2] -

105:17, 163:16

dictates [2] -

51:24, 51:25

dictating [1] -

105:22

dictation [3] -

59:17, 105:16,

153:28

dictatorial [2] -

55:13, 55:15

didactic [1] -

173:22

differed [1] -

194:10

difference [4] -

25:19, 41:6,

54:16, 103:13

different [21] -

13:15, 38:21,

50:24, 98:29,

100:8, 103:17,

105:1, 183:20,

191:3, 191:4,

191:12, 195:20,

204:9, 208:25,

210:7, 210:14,

211:7, 214:2

different...(

INTERJECTION)

[1] - 143:7

differential [1] -

25:14

differentiate [1]

- 85:25

differently [3] -

93:10, 155:11,

155:26

differing [2] -

194:11, 194:16

differs [1] -

195:4

difficult [25] -

30:8, 31:22,

31:27, 60:14,

60:15, 67:11,

73:10, 85:21,

99:1, 99:2, 99:3,

100:5, 100:10,

100:15, 100:21,

100:27, 128:28,

158:18, 158:29,

161:14, 162:20,

183:6, 195:22,

199:13, 204:28

difficult" [1] -

157:20

difficulties [2] -

55:9, 59:11

difficulty [12] -

5:14, 10:1, 19:24,

50:2, 53:20,

59:10, 59:24,

59:25, 98:20,

99:16, 195:16,

199:21

dignity [1] -

79:19

dilated [1] -

164:10

Dilly [1] - 67:6

diploma [3] -

8:8, 76:12,

173:26

DIRECT [8] -

3:6, 3:9, 3:11,

3:14, 3:17, 80:1,

193:1, 205:9

direct [7] - 5:16,

87:3, 87:11,

91:12, 156:20,

172:4, 186:7

direct-

evidence [2] -

156:20, 186:7

DIRECT-

EXAMINATION

[2] - 80:1, 193:1

directed [5] -

58:4, 58:5,

103:28, 119:8,

149:21

directing [1] -

104:15

direction [3] -

4:7, 12:6, 104:7

directly [3] -

58:22, 168:27,

207:10

DIRECTLY [1] -

187:9

DIRECTLY-

EXAMINED [1] -

187:9

Director [1] -

32:1

disagree [5] -

81:9, 89:22,

100:18, 150:9,

150:14

disagreeing [6] -

126:9, 126:19,

126:20, 126:23,

157:29, 210:17

disastrous [1] -

204:26

disciplinary [7] -

12:23, 70:2, 70:6,

70:26, 78:22,

189:17, 191:12

disciplines [1] -

188:16

discovered [1] -

38:18

discreetly [1] -

63:25

discrepancy [1]

- 164:23

discrete [5] -

17:12, 71:5,

85:11, 88:28,

199:18

discuss [12] -

19:11, 34:16,

53:15, 98:14,

109:25, 123:6,

129:28, 134:27,

157:8, 168:18,

191:13, 208:28

discussed [11] -

14:14, 28:1,

39:13, 70:2,

116:24, 162:27,

202:23, 207:22,

207:24, 207:26,

208:29

discussing [2] -

19:9, 175:6

discussion [15]

- 61:24, 70:6,

70:22, 70:23,

70:29, 71:2, 71:3,

71:6, 84:18, 90:4,

110:19, 163:17,

174:6, 178:9,

185:5

discussions [1]

- 206:26

disease [1] -

33:1

diseased [1] -

103:21

dispute [8] -

48:18, 48:27,

48:29, 49:23,

100:28, 102:21,

158:10, 162:10

disrespectful [1]

- 142:14

dissension [1] -

172:15

distal [2] - 13:3,

23:18

distinct [1] -

159:4

distinction [4] -

41:13, 41:15,

41:17, 204:1

distinguish [2] -

48:4, 85:9

distracted [3] -

28:2, 89:5

distractions [1]

- 22:26

distraught [2] -

67:18, 178:3

disturbing [1] -

178:3

divide [1] - 66:1

divided [3] -

65:14, 65:26,

66:4

division [1] -

42:22

DMSA [7] -

17:26, 18:21,

65:3, 88:5, 88:11,

88:25, 174:10

doctor [26] -

55:7, 79:1, 79:3,

79:4, 79:6, 79:7,

79:12, 79:15,

79:17, 79:18,

98:19, 109:26,

110:4, 116:4,

120:27, 122:13,

134:16, 137:19,

174:2, 174:20,

193:10, 204:7,

211:4, 211:8,

211:29, 212:10

doctors [7] -

7:15, 124:14,

152:26, 160:15,

172:18, 192:14

document [7] -

128:2, 128:5,

128:7, 128:8,

132:22, 143:24,

183:2

documentation

[3] - 50:7, 52:28,

156:1

documented [1]

- 212:26

done [49] - 6:17,

7:22, 30:28, 34:8,

34:11, 34:13,

36:29, 38:13,

45:28, 49:29,

50:4, 50:5, 50:10,

50:19, 52:22,

52:27, 55:20,

57:15, 58:7, 63:1,

64:17, 71:20,

90:6, 99:23,

100:27, 110:26,

115:9, 138:5,

139:10, 139:24,

143:27, 144:4,

151:26, 160:6,

166:11, 166:12,

166:25, 169:15,

176:12, 177:19,

178:12, 178:19,

186:19, 191:26,

198:19, 199:11,

207:3, 210:28,

214:26

door [4] - 22:22,

64:3, 64:4, 64:10

doting [1] -

101:10

double [2] -

19:4, 92:3

doubt [5] -

37:17, 52:16,

144:4, 148:2,

161:5

doubts [1] -

39:25

down [36] -

16:14, 20:3, 27:8,

28:14, 33:16,

43:1, 43:5, 45:3,

45:5, 55:25,

57:23, 62:7,

75:24, 75:25,

75:27, 86:29,

87:8, 89:6, 92:2,

97:29, 102:14,

117:21, 123:17,

137:23, 140:15,

143:25, 151:22,

152:2, 167:24,

174:18, 174:27,

175:3, 175:15,

184:1, 212:5,

213:24

DR [5] - 1:9, 2:4,

2:21, 193:26,

214:12

Dr [48] - 11:12,

11:13, 12:28,

13:22, 13:29,

14:3, 14:7, 14:9,

15:6, 17:11,

17:28, 30:2,

30:23, 30:26,

31:2, 31:15,

31:24, 32:6, 32:7,

32:18, 32:20,

32:21, 38:16,

39:14, 39:15,

46:24, 46:28,

53:10, 58:12,

63:9, 63:24,

64:27, 72:2, 72:8,

84:28, 108:17,

112:16, 125:26,

128:22, 151:16,

151:21, 161:1,

192:17, 194:1,

194:4, 208:18,

214:10


10

dr [1] - 59:4

Dr.White [1] -

13:24

drawn [1] -

204:1

drugs [1] - 42:15

Dublin [2] - 8:8,

208:24

DUBLIN [2] -

1:18, 2:16

due [9] - 15:22,

67:4, 68:9,

124:12, 165:17,

165:21, 169:7,

176:5, 214:1

duly [1] - 178:10

duplicated [1] -

21:11

during [14] -

32:22, 39:17,

50:27, 57:28,

59:6, 67:28,

105:15, 105:21,

129:9, 131:9,

131:11, 135:10,

135:20, 149:28

DURKAN [2] -

2:5, 184:13

duties [4] - 7:7,

7:9, 7:18, 23:3

duty [4] -

112:11, 161:12,

162:26, 204:18

dynamic [4] -

36:26, 37:5,

61:27, 61:28

E

ear [1] - 5:15

early [2] - 14:13,

90:6

earthly [1] -

158:25

ease [1] - 34:12

easily [1] -

147:20

Easter [2] -

168:7, 169:19

easy [2] -

147:17, 161:26

edit [1] - 117:28

education [3] -

5:19, 78:8,

106:12

effect [11] -

48:19, 60:21,

119:2, 121:18,

124:29, 129:15,

134:17, 146:22,

166:22, 208:18,

209:22

effectively [2] -

16:26, 54:2

efficient [5] -

61:25, 139:16,

140:1, 152:23,

156:7

efficiently [2] -

143:2, 156:8

efforts [1] -

192:23

eight [6] - 9:29,

39:21, 104:28,

143:29, 144:5

either [14] -

18:22, 49:7,

58:22, 70:24,

72:14, 96:23,

111:29, 113:1,

120:14, 146:27,

150:21, 152:14,

156:21, 195:22

elaborate [3] -

25:18, 68:3,

188:3

elective [4] -

49:16, 51:26,

157:3, 157:7

electronic [1] -

69:11

element [4] -

113:3, 113:5,

178:18, 197:24

elements [1] -

191:11

elevate [1] -

60:11

eleven [3] -

12:22, 126:14,

126:15

eligible [1] -

40:12

elsewhere [3] -

180:23, 195:2,

197:23

emerge [1] -

68:9

emergency [3] -

9:8, 24:8, 24:13

Emma [3] -

36:13, 37:9,

101:28

empathy [1] -

78:19

emphasis [1] -

188:4

emphasise [1] -

87:18

emphasised [1]

- 56:3

empowered [1] -

176:14

empty [3] -

16:13, 16:25,

19:3

enclosure [1] -

104:17

encounter [1] -

77:6

encountered [1]

- 59:19

encourage [1] -

69:19

encouraged [2]

- 55:28, 159:19

END [13] - 80:1,

107:2, 170:16,

177:10, 178:26,

185:1, 189:23,

193:1, 193:26,

205:9, 207:15,

211:19, 214:12

end [33] - 23:18,

41:20, 41:21,

41:22, 42:2, 42:4,

42:11, 42:24,

43:4, 43:8, 43:15,

44:3, 45:2, 53:12,

79:19, 80:8,

90:28, 93:11,

99:15, 108:17,

108:22, 130:26,

130:29, 131:2,

131:4, 134:21,

135:5, 135:24,

136:6, 163:6,

185:11, 214:17,

215:11

ended [3] - 91:4,

109:12, 112:2

endorsed [1] -

175:22

enema [1] -

16:22

enforce [1] -

73:11

enforced [2] -

73:10, 73:11

English [1] -

78:13

enjoyable [1] -

165:11

enjoyed [1] -

193:11

enrolled [2] -

8:6, 8:7

ensure [11] -

32:25, 33:2, 33:9,

33:12, 69:29,

104:2, 104:4,

150:24, 184:20,

197:25, 203:26

ensured [1] -

32:27

ensures [1] -

176:11

enter [1] -

103:10

entered [5] -

65:18, 66:3,

108:26, 121:10,

141:4

entering [1] -

44:25

enters [1] -

184:2

entire [2] -

75:23, 76:5

entirely [10] -

48:24, 90:6,

148:20, 150:11,

155:10, 155:26,

160:9, 161:7,

168:14, 199:25

entitled [2] -

107:10, 195:7

entity [1] - 36:26

entries [1] -

88:27

entry [2] - 57:14,

183:7

environment [3]

- 85:9, 203:19,

213:29

envisaged [1] -

71:3

epidural [1] -

41:25

equally [4] -

38:7, 91:2,

154:23, 188:24

equation [1] -

68:16

equivalent [2] -

202:22, 210:21

erred [1] - 88:25

erroneous [1] -

12:4

erroneously [5]

- 13:11, 25:2,

27:28, 81:19,

163:16

error [34] -

12:13, 12:16,

13:4, 14:15,

14:20, 27:8, 28:4,

67:12, 68:6, 69:7,

83:8, 83:17,

86:29, 87:19,

95:8, 106:14,

109:10, 165:8,

165:14, 165:18,

165:22, 165:23,

165:26, 166:13,

175:4, 175:5,

176:5, 176:6,

176:10, 183:13,

204:5, 212:29

errors [10] -

26:5, 33:3,

165:21, 174:26,

213:1, 213:4,

213:7, 213:8,

213:23

escalate [1] -

34:19

escalated [1] -

31:11

especially [3] -

15:18, 76:7,

161:19

essential [1] -

154:17

essentially [5] -

16:21, 53:2, 77:5,

86:17, 182:11

establish [6] -

7:29, 17:27,

76:27, 81:7,

81:11, 114:27

estimate [2] -

53:10

et [1] - 82:5

etc [2] - 77:10,

191:9

ethically [2] -

68:12, 84:21

European [2] -

39:20, 159:9

evening [1] -

30:22

event [21] -

19:26, 20:4,

27:15, 33:27,

37:19, 59:23,

62:11, 75:23,

76:9, 99:13,

103:17, 110:14,

117:21, 133:17,

134:20, 146:17,

149:28, 162:15,

167:20, 167:22,

214:3

events [14] -

14:21, 48:14,

49:24, 85:13,

85:14, 93:14,

96:9, 106:22,

132:16, 150:28,

155:2, 175:6,

179:19, 214:2

evidence [66] -

1:29, 26:29,

27:24, 35:28,

44:29, 49:14,

54:16, 87:11,

91:12, 96:25,

97:8, 101:4,

104:1, 106:17,

112:15, 113:1,

114:1, 121:17,

124:29, 128:5,

130:22, 131:17,

134:29, 136:4,

142:23, 142:27,

145:28, 147:10,

154:29, 156:18,

156:20, 160:21,

160:24, 166:10,

166:21, 167:16,

168:23, 168:24,

168:25, 179:9,

186:6, 186:7,

186:26, 194:9,

194:12, 194:13,

194:22, 194:27,

194:28, 195:4,

195:5, 195:10,

195:15, 195:21,

200:4, 200:26,

205:26, 206:16,

206:20, 206:22,

208:18, 209:26,

213:2, 214:19,

215:12, 215:14

evident [1] -

127:7

evolution [1] -

152:4

exact [1] - 191:6

exactly [11] -

9:25, 17:8, 89:11,

120:22, 130:21,

167:12, 177:27,

200:26, 201:6,

205:4, 206:21

examination

[11] - 18:14, 56:4,

59:9, 80:5, 87:3,

156:20, 197:28,

199:24, 199:29,

201:25, 215:8

EXAMINATION

[12] - 3:4, 80:1,

107:2, 170:16,

178:26, 185:1,

189:23, 193:1,

193:26, 205:9,


11

207:15, 211:19

examine [4] -

79:17, 108:7,

122:20, 173:26

EXAMINED [11]

- 4:24, 80:24,

108:12, 177:12,

179:1, 187:9,

190:2, 193:4,

196:1, 205:12,

207:17

examined [1] -

79:18

examining [2] -

43:19, 173:25

example [10] -

23:7, 50:15,

56:29, 95:8,

165:28, 172:21,

173:2, 176:17,

208:5, 212:9

exams [3] -

159:9, 173:28,

173:29

exceedingly [3]

- 102:10, 157:20,

158:18

excellent [1] -

212:23

except [1] -

85:17

exceptional [1] -

24:7

excess [1] -

155:3

exclusive [3] -

136:25, 137:3,

137:6

excused [1] -

185:22

Executive [2] -

81:8, 179:21

exemplary [1] -

140:9

exhibit [10] - 5:1,

11:11, 11:20,

65:19, 76:17,

98:16, 98:17,

180:15, 186:29,

196:12

Exhibit [13] -

5:1, 11:5, 11:11,

11:14, 11:21,

12:27, 14:29,

16:2, 17:13,

40:29, 98:18,

180:14, 196:11

Exhibits [1] -

11:9

existed [2] -

23:19, 189:1

existing [1] -

105:20

exists [1] -

208:24

exit [1] - 39:19

expect [12] -

15:25, 49:26,

104:18, 104:29,

150:2, 152:10,

157:17, 164:13,

192:12, 198:5,

211:10, 215:8

expectation [12]

- 50:4, 90:13,

91:9, 94:8,

100:17, 101:18,

105:14, 106:7,

112:13, 115:27,

159:17, 160:7

expected [21] -

49:27, 49:28,

50:1, 50:7, 50:10,

50:12, 59:21,

59:24, 64:6, 83:6,

83:14, 86:1,

86:21, 86:25,

90:1, 104:20,

124:14, 149:27,

149:29, 157:8,

159:12

experience [29] -

6:15, 7:16, 40:18,

51:13, 52:23,

72:3, 83:6, 83:14,

86:16, 89:27,

99:29, 103:16,

104:11, 104:28,

106:9, 118:24,

146:4, 147:3,

150:1, 156:4,

158:26, 168:29,

172:9, 172:17,

173:12, 174:29,

193:19, 195:2,

197:23

experienced [6]

- 83:25, 89:25,

91:1, 125:23,

125:24, 149:25

expert [18] -

53:21, 53:27,

54:3, 57:21,

174:6, 174:13,

185:9, 185:19,

188:21, 189:14,

194:9, 194:11,

194:28, 199:26,

200:4, 201:11,

209:26, 213:14

expertise [6] -

83:7, 83:15,

192:22, 194:20,

201:12, 202:8

experts [1] -

201:15

explain [18] -

10:11, 11:28,

28:22, 67:12,

68:2, 68:6, 76:20,

79:7, 90:3, 121:6,

149:10, 149:17,

168:27, 169:10,

175:2, 204:18,

205:4, 213:25

explained [1] -

134:14

explanation [4] -

85:13, 89:4,

132:28, 166:16

exposed [3] -

39:12, 100:4,

212:10

express [3] -

29:16, 118:9,

121:21

expressed [4] -

50:22, 74:5,

194:18, 197:11

extend [3] -

61:4, 61:5,

114:21

extended [3] -

90:21, 109:16,

172:8

extending [2] -

56:27, 74:20

extensive [2] -

6:15, 156:3

extent [8] -

35:16, 35:26,

73:18, 79:11,

79:13, 171:27,

174:20, 204:11

external [11] -

47:20, 73:16,

74:5, 74:22,

179:27, 180:1,

180:10, 180:18,

182:18, 183:3,

206:18

Extracts [1] -

11:4

extracts [2] -

11:7, 14:18

extraordinary

[2] - 173:16,

189:16

extremely [11] -

38:9, 38:26,

39:16, 70:11,

125:24, 140:17,

144:24, 156:15,

188:10, 188:13,

209:2

eye [2] - 52:14,

186:18

F

faced [1] - 28:7

faceted [1] -

55:22

facilitate [1] -

74:2

fact [64] - 6:17,

12:4, 12:24, 13:8,

26:8, 27:26,

34:18, 35:12,

41:21, 53:5,

53:27, 55:28,

56:5, 63:24, 65:2,

65:4, 67:13,

69:28, 72:24,

73:18, 81:11,

81:17, 82:5,

85:10, 91:4,

91:25, 96:8,

97:20, 98:8,

101:3, 106:15,

111:18, 113:10,

113:13, 113:17,

114:20, 120:21,

120:22, 121:21,

127:5, 132:21,

135:4, 135:11,

136:23, 144:27,

149:21, 151:3,

153:11, 153:13,

154:26, 158:6,

167:26, 168:6,

168:7, 169:28,

172:11, 174:15,

178:2, 179:14,

181:3, 201:5,

201:23, 201:26,

213:2

factor [9] - 69:9,

69:28, 71:9,

71:24, 72:20,

72:23, 73:6,

118:18, 163:12

factors [2] -

68:19, 68:29

factors" [2] -

68:24, 69:1

facts [7] - 86:18,

114:28, 124:11,

169:6, 169:25,

178:10, 178:23

factual [5] -

81:13, 100:28,

194:26, 201:29,

210:14

factually [4] -

81:21, 82:1, 82:2,

82:11

faecal [1] - 18:17

faeces [4] -

15:21, 16:17,

16:25

failed [6] - 83:4,

86:2, 86:3, 86:5,

106:18, 106:20

fails [1] - 165:24

failsafe [1] -

69:29

failure [15] -

86:11, 106:14,

109:26, 109:28,

110:3, 110:10,

110:11, 115:7,

116:3, 116:9,

124:11, 124:20,

212:19, 212:20

failures [3] -

86:10, 109:25

fair [6] - 16:5,

58:6, 88:14,

182:15, 195:12,

195:27

fairly [1] - 173:9

fairness [3] -

36:5, 143:25,

155:15

fait [1] - 211:11

fallible [1] -

29:12

falling [5] -

124:13, 124:21,

213:29, 214:1,

214:2

familiar [3] -

158:25, 210:11,

210:14

familiarising [2]

- 52:26, 198:8

families [2] -

76:2, 78:15

family [9] - 86:2,

86:4, 86:5, 94:3,

94:5, 191:27,

204:25, 204:28,

205:2

fantastic [1] -

16:28

far [5] - 23:18,

112:21, 113:19,

124:28, 148:2

Farhan [7] -

29:1, 73:2, 90:9,

90:10, 90:16,

90:29, 91:2

farhan [3] -

30:17, 38:11,

90:13

fatal [1] - 165:26

fatally [1] -

213:27

fateful [1] -

174:6

father [2] -

134:16, 163:24

February [13] -

8:13, 11:23,

12:13, 13:5,

14:13, 40:16,

69:4, 69:17,

84:27, 86:14,

120:5, 120:7,

124:24

February/

March [1] - 206:4

feelings [1] -

38:15

feet [1] - 59:18

Feilim [1] -

194:4

fell [4] - 83:13,

85:29, 86:20,

86:24

fellow [5] -

58:23, 100:3,

188:2, 188:22,

188:26

fellowship [7] -

6:14, 6:16, 6:17,

39:11, 39:19,

159:5, 173:28

fellowships [1] -

6:29

felt [24] - 19:1,

40:20, 46:14,

68:5, 68:11,

70:18, 74:11,

75:24, 75:25,

75:26, 76:28,

84:20, 105:28,

118:23, 122:18,

157:28, 167:22,

167:23, 168:3,

168:12, 169:4,

169:8, 178:4,

178:8

fever [1] - 18:13

few [14] - 53:1,

67:25, 88:19,

94:17, 117:5,

143:11, 153:19,

159:24, 159:25,


12

170:25, 172:24,

172:26, 175:7,

194:24

fifteen [4] -

122:5, 122:11,

125:21, 141:9

fifth [2] - 71:10,

183:8

file [3] - 69:21,

69:25, 86:11

filed [1] - 86:13

filing [4] - 69:9,

69:20, 75:17,

110:11

fill [2] - 10:2,

143:4

films [7] - 89:9,

92:3, 104:2,

105:3, 105:10,

106:15, 106:19

final [4] - 41:17,

173:24, 173:25,

196:21

finalised [1] -

205:25

findings [2] -

18:5, 69:15

fine [4] - 80:6,

128:7, 133:16,

161:24

finish [4] -

23:26, 80:12,

143:20, 196:21

finished [15] -

23:13, 23:20,

42:10, 45:12,

45:13, 49:28,

60:9, 90:27,

90:28, 131:22,

134:25, 137:15,

143:17, 153:16,

206:27

finished...(

INTERJECTION)

[1] - 131:21

finishes [2] -

37:3, 42:7

Finn [1] - 189:29

FINN [1] - 190:2

firm [2] - 126:10,

130:5

First [1] - 210:11

first [53] - 8:2,

13:3, 13:16,

14:26, 15:4,

16:12, 17:14,

17:16, 17:28,

22:16, 31:13,

33:27, 42:19,

43:11, 47:13,

47:26, 52:25,

56:8, 60:1, 81:2,

81:6, 81:11,

83:29, 86:27,

94:17, 101:15,

102:6, 115:9,

117:5, 123:8,

126:11, 129:9,

143:23, 146:12,

155:1, 155:3,

156:22, 157:27,

171:10, 171:17,

172:21, 172:26,

173:28, 183:15,

184:8, 186:11,

186:12, 186:26,

202:24, 202:25,

205:26, 209:22

firstly [6] - 8:19,

30:29, 115:6,

116:18, 133:29,

155:27

fistula [16] -

23:16, 44:6, 44:9,

98:23, 130:26,

131:10, 131:18,

131:23, 131:25,

132:18, 132:22,

133:21, 133:22,

133:27, 134:8,

135:2

fit [2] - 139:15,

164:19

FITNESS [1] -

1:3

fitted [1] -

166:12

Fitzgerald [4] -

13:10, 13:15,

15:13, 191:17

five [71] - 22:7,

23:5, 26:18,

47:28, 47:29,

48:3, 49:17,

49:21, 80:3,

80:11, 87:13,

94:2, 94:3, 96:16,

96:26, 97:4,

97:12, 97:14,

101:5, 101:12,

101:16, 102:8,

102:16, 102:20,

102:22, 103:19,

103:27, 113:8,

113:13, 113:18,

114:25, 115:1,

122:5, 122:6,

122:24, 126:7,

126:8, 126:15,

126:21, 126:26,

127:5, 129:5,

129:14, 129:19,

129:22, 130:7,

130:8, 133:13,

140:21, 140:22,

140:29, 141:10,

146:18, 150:28,

150:29, 151:2,

166:26, 208:20,

209:10, 209:11,

209:15, 209:25,

210:2, 210:9,

210:18, 210:20,

210:22, 211:2,

211:5

Five [1] - 96:28

fix [1] - 141:13

flag [5] - 29:15,

158:10, 194:7,

213:20

flagged [1] -

54:15

flagging [1] -

102:28

flags [1] -

158:13

flexible [1] -

132:7

floppy [1] -

164:10

flown [1] -

195:19

fluid [5] - 16:22,

36:26, 37:5,

125:4, 135:7

fluidity [2] -

131:6, 134:5

focus [1] - 36:27

focused [1] -

192:8

folder [5] -

19:19, 20:28,

21:12, 35:9, 97:6

folders [1] - 20:6

follow [4] - 21:1,

112:28, 161:11,

170:4

following [6] -

1:28, 32:6, 42:29,

72:14, 111:25,

183:11

FOLLOWS [17] -

4:1, 4:25, 80:18,

80:24, 108:1,

108:13, 171:7,

171:14, 177:13,

179:2, 187:9,

190:3, 193:4,

196:2, 205:12,

207:17, 211:25

follows [1] -

111:11

FOR [3] - 2:11,

2:18, 2:21

force [1] - 104:5

forget [1] - 33:29

form [7] - 25:16,

27:5, 28:3, 54:12,

63:9, 70:4,

172:19

formal [2] -

84:24, 98:2

formally [2] -

58:19, 98:11

format [2] -

173:22, 183:14

formed [2] -

15:13, 23:17

formulated [1] -

181:21

forth [1] - 173:3

forthcoming [1]

- 157:9

fortunate [2] -

6:13, 38:25

forty [4] -

114:25, 115:1,

122:5, 142:11

forum [2] - 9:28,

84:24

forward [3] -

29:27, 87:24,

141:25

forwarding [1] -

179:25

forwardly [1] -

181:11

Foundation [1] -

7:25

four [17] - 9:25,

15:11, 15:20,

15:25, 89:23,

103:15, 138:9,

138:14, 139:14,

139:26, 142:29,

143:5, 144:6,

144:8, 144:12,

144:13, 196:26

fourth [3] -

33:15, 71:9,

143:25

frame [3] - 48:5,

86:12, 89:7

free [7] - 18:10,

19:1, 66:29,

131:26, 131:27,

132:5, 136:13

freely [1] -

111:21

frequent [1] -

135:15

Friday [5] - 8:26,

8:29, 37:24,

38:18, 73:23

FRIDAY [1] -

215:20

Friend [1] -

34:26

friend [6] -

48:26, 53:22,

55:23, 158:3,

182:26, 184:7

fro [1] - 204:25

front [2] - 65:27,

102:4

fuel [3] - 166:2,

166:3

fulfilling [1] -

212:28

full [12] - 9:14,

9:26, 10:4, 10:6,

30:8, 61:18,

74:17, 123:23,

123:27, 184:25,

196:9, 209:5

full-time [6] -

9:14, 9:26, 10:4,

10:6, 74:17,

196:9

fully [5] - 65:17,

162:18, 178:13,

208:14, 211:10

function [14] -

18:22, 18:27,

25:8, 25:14,

25:17, 58:28,

65:3, 67:24,

70:12, 70:17,

70:18, 81:20,

164:1

functioning [3] -

67:24, 71:4,

164:13

fundamental [2]

- 201:15, 203:13

fundamentally

[2] - 54:5, 83:3

furnished [1] -

120:10

FURTHER [3] -

3:8, 177:12,

178:26

furthermore [2]

- 124:8, 124:18

future [3] -

177:5, 185:5,

192:1

G

gain [3] - 7:16,

60:17, 61:14

gained [2] -

6:14, 176:1

gains [1] -

172:17

Galway [3] -

5:21, 40:1, 40:2

gather [3] -

35:14, 147:2,

164:2

general [7] -

17:11, 18:7,

72:12, 73:20,

143:29, 175:19,

180:29

generality [2] -

7:10, 9:19

generally [9] -

26:12, 30:6, 30:9,

58:1, 71:25,

72:18, 72:28,

98:10, 188:11

generated [1] -

21:10

generation [1] -

202:11

generous [4] -

38:9, 140:17,

188:1, 188:20

George [1] -

8:15

George's [1] -

196:10

Ghallab [9] -

30:2, 30:23,

30:26, 31:2,

31:15, 31:24,

72:2, 72:8, 84:28

Gillick [1] -

99:12

given [32] - 9:4,

41:21, 42:2,

42:11, 42:15,

44:3, 45:6, 46:18,

51:13, 62:21,

69:25, 73:20,

96:9, 97:12,

115:10, 117:26,

121:18, 124:29,

155:9, 191:28,

192:4, 192:21,

194:13, 195:5,

195:16, 195:18,

206:20, 206:22,

206:28, 207:1,

207:7, 210:15


13

glad [1] - 190:29

globally [3] -

6:9, 176:2, 176:4

GOS [5] - 92:15,

94:28, 96:18,

97:22, 97:26

GP [2] - 18:2,

163:16

grade [2] -

13:17, 98:19

Grade [1] -

11:26

graded [1] -

77:22

Graduate [2] -

7:15, 8:7

graduate [1] -

196:16

graduated [1] -

5:20

grateful [2] -

49:10, 49:18

great [8] - 29:16,

37:12, 43:17,

43:25, 87:11,

87:14, 173:18,

182:28

Great [16] - 6:26,

27:11, 92:16,

94:12, 95:5,

116:20, 116:22,

117:15, 119:8,

179:26, 180:7,

180:10, 184:6,

196:22, 197:2,

197:4

grieving [1] -

169:3

grossly [1] -

188:11

group [21] -

56:10, 56:11,

56:15, 56:16,

56:20, 57:7, 57:8,

57:15, 57:18,

57:20, 57:24,

58:3, 58:7, 58:8,

151:11, 151:15,

151:17, 151:23,

151:26, 152:13,

191:1

grow [2] -

191:19

guarantee [1] -

89:20

Guardia [1] -

165:29

guess [2] -

109:5, 123:2

guidance [1] -

35:6

guide [1] -

197:26

guidelines [2] -

173:6, 203:23

guilt [1] - 203:5

H

half [12] - 13:15,

39:21, 73:24,

122:25, 125:5,

125:20, 126:14,

130:8, 136:27,

137:1, 159:8,

206:23

hand [31] - 4:28,

11:6, 16:4, 25:9,

27:2, 30:8, 40:26,

65:16, 92:13,

92:18, 101:5,

102:16, 144:16,

144:27, 144:28,

147:22, 147:26,

147:28, 148:4,

148:6, 148:10,

148:11, 148:13,

148:22, 148:23,

148:24, 149:24,

163:14, 163:21,

176:14, 186:27

handed [9] -

25:17, 94:22,

95:10, 98:17,

103:18, 106:17,

117:11, 120:12,

187:13

HANDED [3] -

5:4, 11:8, 40:28

Handed [3] -

87:16, 98:18,

196:6

Handed) [1] -

81:25

HANDED) [1] -

5:1

handing [3] -

103:13, 196:5,

202:24

handle [1] - 63:6

hands [2] -

104:23, 122:10

handwritten [2]

- 27:20, 81:18

happening...(

INTERJECTION

[1] - 114:9

happily [1] -

69:26

happy [25] -

4:14, 6:20, 39:5,

45:15, 46:10,

46:26, 46:28,

47:15, 60:1,

61:24, 79:22,

95:29, 106:8,

121:8, 131:12,

145:21, 145:26,

146:15, 161:24,

162:29, 184:4,

186:13, 186:15,

202:21

hard [3] - 69:10,

69:19, 159:5

harsh [1] -

204:24

Hart [3] - 31:17,

31:20

has...(

INTERJECTION)

[1] - 42:17

HAVING [4] -

4:24, 187:8,

190:2, 196:1

he...(

INTERJECTION

[1] - 206:29

head [2] - 74:6,

74:11

headache [1] -

18:13

headed [2] -

55:5, 183:17

heading [4] -

68:24, 69:1, 92:9,

92:19

headings [1] -

77:22

Health [1] - 8:9

health [2] -

173:26, 191:27

heaped [1] -

159:20

hear [4] - 86:22,

100:18, 145:23,

159:19

HEARD [1] -

1:14

heard [24] - 5:5,

24:24, 27:24,

30:2, 30:21,

33:19, 33:20,

36:13, 37:9,

44:29, 52:3,

58:12, 59:8, 76:8,

96:25, 156:17,

160:21, 160:24,

160:27, 161:1,

171:22, 171:23,

171:28

hearing [4] -

5:14, 146:11,

155:1, 155:3

HEARING [6] -

1:14, 4:1, 80:18,

108:1, 171:6,

215:20

heart [1] - 8:1

heights [1] -

159:25

held [1] - 151:17

help [8] - 76:1,

76:26, 78:1,

91:11, 156:4,

177:20, 182:28,

199:15

helped [3] -

94:19, 117:7,

134:13

helpful [9] -

26:12, 38:9, 52:8,

65:16, 132:6,

138:20, 156:9,

156:15, 211:29

helping [6] -

30:16, 30:20,

38:20, 38:25,

43:24, 73:5

hepatectomy [1]

- 176:17

hepatobiliary [2]

- 7:12, 9:18

hernia [6] - 43:3,

98:22, 99:2, 99:3,

172:23, 172:24

hernias [1] -

173:2

herself [2] -

103:5, 199:14

hiatus [2] -

41:28, 143:2

Hickman [1] -

98:22

Hickman/

Broviac [2] -

132:21, 132:28

hide [1] - 169:25

hiding [2] -

177:28, 178:1

hierarchal [1] -

158:23

hierarchical [1] -

31:23

high [3] - 15:12,

16:19, 19:27

highlight [1] -

56:1

highlighted [3] -

57:29, 62:13,

86:10

highlighting [1]

- 102:27

highlights [1] -

51:3

highly [4] - 6:22,

32:9, 137:19,

159:29

himself [15] -

14:3, 52:26,

58:13, 63:6,

99:27, 103:5,

104:9, 106:19,

120:29, 159:15,

162:29, 187:28,

191:25, 202:16,

210:10

hold [18] - 52:24,

56:10, 56:12,

56:16, 57:7, 57:8,

57:15, 57:18,

57:20, 57:24,

58:3, 58:7, 58:8,

103:21, 115:13,

151:12, 151:16,

151:26

holes [1] - 214:1

holidays [1] -

91:18

holistic [2] -

104:3, 105:13

home [2] -

23:14, 23:22

honest [1] -

198:3

hoof [1] - 172:3

hope [3] - 11:21,

37:29, 55:4

hopefully [1] -

9:25

hoping [1] -

74:16

horrified [1] -

76:4

horror [2] -

168:16, 168:20

Hospital [33] -

5:7, 5:10, 5:13,

5:24, 5:29, 6:26,

8:8, 13:26, 20:19,

30:4, 35:27,

36:10, 69:14,

83:10, 85:24,

86:5, 86:14,

97:17, 110:10,

140:20, 142:28,

189:18, 191:1,

191:5, 192:15,

194:20, 194:22,

196:10, 196:25,

196:26, 197:3,

206:18

hospital [63] -

7:16, 8:1, 20:1,

20:8, 20:13,

20:14, 21:2, 22:5,

28:14, 29:11,

29:26, 67:23,

69:12, 69:13,

69:18, 69:20,

71:13, 73:6, 75:5,

75:26, 83:20,

84:29, 85:6,

86:11, 89:15,

89:23, 93:23,

93:27, 94:1,

96:24, 100:12,

106:21, 106:26,

110:12, 111:22,

128:2, 128:3,

151:14, 151:27,

154:23, 157:14,

168:1, 168:5,

170:8, 171:24,

172:18, 174:7,

175:14, 175:24,

179:21, 179:27,

187:22, 188:10,

188:16, 188:23,

188:29, 189:5,

189:8, 189:9,

189:10, 192:19,

205:1, 213:5

hospitals [4] -

22:5, 24:17,

36:11, 201:6

hour [13] -

10:29, 22:15,

23:2, 23:9, 24:8,

122:25, 125:6,

125:20, 136:27,

137:1, 206:23

hours [14] -

10:23, 11:1,

57:14, 57:28,

71:10, 72:11,

72:22, 125:6,

154:12, 154:13,

168:21, 173:17,

180:8, 189:16

HOUSE [1] -

1:16

however...(

INTERJECTION

[1] - 151:27

huge [1] -

143:18

human [15] -

28:4, 69:7, 83:8,

83:17, 86:28,


14

86:29, 106:14,

165:18, 165:23,

176:5, 176:10,

212:2, 212:20,

213:7, 213:27

humanitarian

[1] - 7:22

hydronephrosi

s [2] - 164:9,

164:12

hydronephroti

c [2] - 164:12,

164:19

hypospadias

[10] - 43:16, 44:9,

45:12, 45:28,

53:12, 130:26,

131:23, 133:21,

133:22, 133:27

hypothetical [1]

- 97:9

I

ICU [6] - 30:10,

30:11, 139:14,

142:29, 154:4,

154:22

ID [3] - 82:9,

105:8, 145:16

idea [4] - 26:23,

30:18, 199:27,

212:17

ideal [3] - 96:19,

102:20, 102:23

ideally [1] - 53:1

identified [14] -

26:8, 26:16,

36:20, 56:17,

68:18, 68:29,

69:3, 69:28,

72:20, 72:23,

74:29, 75:1, 87:5,

183:10

identify [2] -

87:12, 182:26

identifying [2] -

87:21, 87:25

identity [1] -

50:9

ignore [1] -

120:23

ill [2] - 35:23,

189:8

illuminated [1] -

51:2

illustrated [1] -

56:5

image [6] -

20:27, 50:16,

65:17, 97:6,

115:15, 115:16

images [47] -

12:24, 20:21,

20:22, 20:23,

20:28, 21:4,

21:17, 21:20,

22:6, 25:22, 33:9,

34:22, 50:15,

50:20, 51:6, 52:5,

52:7, 52:9, 52:12,

52:16, 63:15,

63:16, 63:17,

63:18, 64:22,

70:16, 70:29,

89:13, 102:25,

109:1, 109:5,

109:7, 109:8,

109:9, 124:20,

177:1, 194:23,

194:24, 195:3,

197:13, 197:17,

197:19, 197:25,

198:1, 198:8

imagine [1] -

136:1

imaging [70] -

19:11, 19:12,

19:23, 21:11,

28:23, 28:25,

29:7, 29:9, 29:20,

35:10, 50:9,

50:11, 51:4,

51:11, 52:28,

53:15, 65:1, 66:7,

69:2, 70:23,

72:22, 82:12,

89:17, 89:18,

92:11, 92:22,

93:21, 93:27,

94:7, 94:10,

95:17, 95:27,

101:15, 101:18,

104:9, 104:12,

111:3, 115:4,

115:28, 122:12,

122:16, 122:20,

123:7, 123:20,

124:12, 125:7,

125:10, 146:26,

147:4, 149:1,

149:3, 149:7,

149:8, 149:12,

149:14, 149:27,

149:29, 150:3,

161:21, 161:22,

161:23, 161:29,

162:2, 162:7,

162:13, 176:28,

177:4, 180:4

immediate [1] -

115:22

immediately [7]

- 44:23, 63:7,

64:25, 65:2, 65:5,

108:23, 109:9

immensely [1] -

204:28

impact [1] - 66:9

implant [1] -

66:17

implausible [1] -

137:19

implement [2] -

69:15, 74:25

implication [2] -

75:4, 198:4

implications [1]

- 54:19

implicit [1] -

61:20

Implicit [1] -

103:4

implies [1] -

210:18

importance [2] -

51:15, 136:3

important [28] -

33:2, 52:9, 55:7,

65:24, 96:14,

96:17, 118:18,

119:4, 119:6,

119:7, 119:10,

119:18, 119:19,

119:21, 121:15,

123:26, 125:2,

154:29, 176:11,

176:19, 176:29,

178:16, 181:10,

184:9, 188:9,

188:25, 200:1,

202:3

important...(

INTERJECTION)

[1] - 154:24

impossible [4] -

60:15, 134:6,

137:16, 137:17

impression [5] -

46:22, 46:23,

46:24, 147:2,

166:6

improve [4] -

9:21, 28:19, 76:2,

192:23

improved [1] -

17:7

improving [1] -

78:5

inadequacy [1] -

181:24

inadequate [1] -

210:10

inappropriate

[3] - 180:24,

200:17, 202:5

inaudible [1] -

15:22

incident [6] -

8:13, 12:15,

75:14, 175:18,

175:22, 175:27

incidents [1] -

165:17

incision [24] -

59:6, 59:10,

60:13, 60:14,

60:16, 60:25,

60:26, 61:14,

82:29, 92:29,

103:29, 104:13,

104:16, 147:11,

147:12, 147:18,

147:20, 147:26,

147:28, 147:29,

148:1, 149:15,

149:22, 209:25

include [1] -

24:8

included [1] -

179:14

including [6] -

8:5, 23:4, 52:28,

96:11, 113:27,

156:1

incompetent [1]

- 204:8

inconsistency

[1] - 139:23

inconsistent [4]

- 138:12, 138:15,

150:11, 164:27

incontinence [1]

- 16:6

incontinent [1] -

16:16

inconvenience

[1] - 36:28

incorporate [1] -

24:13

incorrect [9] -

12:2, 27:12,

48:26, 69:2, 69:6,

88:14, 88:27,

150:8, 151:13

incorrectly [1] -

212:26

increase [1] -

24:21

increased [2] -

24:22, 74:14

increasingly [1]

- 24:17

incredible [1] -

191:25

indeed [16] -

30:19, 58:27,

87:28, 100:26,

101:18, 108:8,

114:26, 132:8,

135:13, 156:20,

180:22, 188:15,

188:23, 193:18,

200:17, 209:21

Independent [2]

- 92:7, 96:2

independent [2]

- 68:18, 69:16

independently

[1] - 117:18

INDEX [1] - 3:2

indicate [5] -

27:11, 31:18,

62:8, 63:29,

120:26

indicated [14] -

6:28, 26:29,

30:26, 31:18,

38:11, 47:14,

60:12, 60:18,

71:12, 82:21,

146:19, 179:8,

187:28, 201:16

indication [1] -

180:1

indicative [1] -

58:8

individual [5] -

85:8, 118:9,

203:19, 208:10,

212:2

individually [1] -

117:24

individuals [1] -

85:23

induced [4] -

47:18, 48:2,

48:16, 48:21

industrial [1] -

69:26

industry [2] -

165:15, 202:23

inexperienced

[2] - 91:23, 91:27

infection [3] -

18:10, 19:2, 19:5

infections [7] -

17:27, 18:9,

18:18, 28:17,

28:19, 70:10,

70:11

inferior [1] -

56:28

influenced [2] -

66:11, 88:28

inform [4] -

33:28, 72:8,

161:12, 162:27

information [19]

- 25:10, 25:14,

26:10, 68:11,

85:18, 102:17,

110:5, 110:9,

119:1, 119:4,

119:7, 119:11,

121:2, 121:4,

136:11, 144:28,

148:28, 177:25,

207:5

informative [1] -

165:12

informed [5] -

18:6, 34:4, 94:6,

166:1, 166:4

inherently [1] -

93:20

initial [7] - 5:23,

14:23, 106:14,

179:7, 199:27,

207:3, 212:25

input [3] - 94:26,

122:29, 191:3

inputs [1] -

96:11

inquiry [6] - 4:6,

4:12, 153:13,

170:7, 170:10,

185:5

Inquiry [11] -

80:29, 81:24,

117:14, 117:15,

119:9, 181:14,

181:21, 181:23,

206:5, 206:7,

206:11

inserted [1] -

41:26

insignificant [1]

- 70:19

insist [3] -

157:17, 157:18,

158:16

insofar [7] -

53:20, 74:24,

101:4, 110:24,

179:17, 186:6,

204:13

inspection [2] -

164:18, 164:29

instances [1] -


15

13:4

instinctive [1] -

52:9

instituted [1] -

17:4

institution [2] -

6:11, 6:23

institutionally

[1] - 10:1

instructed [3] -

206:1, 206:2,

206:14

INSTRUCTED

[3] - 2:12, 2:19,

2:24

instructions [2]

- 206:10, 206:13

instrumental [1]

- 189:17

insufficient [2] -

180:24, 202:16

insurance [1] -

174:25

intact [1] - 67:4

intend [2] - 70:5,

89:11

intended [8] -

27:28, 27:29,

28:24, 28:25,

70:3, 89:16,

130:12, 130:13

intending [1] -

146:13

intensive [11] -

59:14, 138:10,

138:14, 139:17,

139:25, 144:6,

144:7, 144:8,

144:11, 145:2,

155:29

intention [11] -

29:19, 62:1,

70:28, 89:8,

89:18, 148:10,

149:2, 149:6,

149:9, 149:17,

152:14

inter [2] -

189:17, 201:11

inter-

disciplinary [1] -

189:17

interacted [1] -

190:25

interacting [1] -

172:17

interaction [4] -

22:11, 36:22,

173:13, 188:5

interfered [1] -

66:11

internal [5] -

92:12, 116:20,

116:25, 179:26,

206:19

interrupt [3] -

132:25, 139:2,

155:14

interrupted [1] -

122:17

interrupting [1] -

76:19

intervene [3] -

46:27, 48:9,

53:19

interview [2] -

118:14, 118:19

interviewed [2] -

94:28, 118:12

interwoven [1] -

144:2

into...(

INTERJECTION)

[1] - 121:11

intra [1] - 58:1

intra-

operatively [1] -

58:1

introduce [1] -

16:20

introduced [3] -

48:13, 71:13,

143:24

invariable [3] -

148:16, 160:10,

160:16

invasion [1] -

56:29

investigated [2]

- 116:16, 116:18

investigating [1]

- 191:5

invited [1] -

117:21

involve [1] -

7:23

involved [29] -

13:23, 15:5,

17:14, 23:8,

61:29, 79:9, 93:2,

93:4, 93:5, 93:6,

93:8, 94:2, 94:9,

102:26, 117:16,

118:9, 119:20,

119:22, 121:13,

132:20, 133:21,

133:27, 134:10,

135:8, 160:21,

162:19, 178:4,

191:16, 212:16

involvement [7]

- 11:2, 14:23,

66:18, 144:28,

178:5, 178:13,

190:28

involves [2] -

8:20, 101:10

involving [1] -

124:1

Iraq [1] - 6:5

Ireland [8] -

6:25, 7:24, 76:28,

106:11, 159:4,

196:15, 196:17,

208:25

Irish [1] - 39:8

irregular [1] -

58:17

irrespective [3] -

110:26, 111:6,

160:5

irreversible [1] -

109:13

isolation [1] -

213:15

issue [50] -

15:19, 15:23,

15:24, 17:12,

30:26, 31:1,

31:17, 31:19,

32:4, 33:14,

33:17, 34:9,

34:10, 56:1,

69:12, 69:13,

72:2, 72:7, 75:9,

75:13, 75:19,

83:23, 85:4,

85:10, 96:14,

96:17, 102:22,

102:28, 119:12,

121:10, 121:14,

121:15, 121:16,

121:26, 122:24,

122:25, 122:27,

123:15, 123:16,

152:13, 155:6,

160:19, 172:11,

176:28, 181:24,

182:15, 195:25,

201:7, 204:9,

212:25

issued [1] -

25:24

issues [17] -

14:24, 15:10,

15:18, 15:24,

16:7, 17:15,

69:24, 82:4,

178:2, 194:22,

194:25, 198:13,

199:19, 202:28,

205:2, 205:3,

205:28

it.. [1] - 102:18

itself [6] - 67:5,

108:26, 175:22,

190:24, 197:27,

203:13

IV [1] - 41:26

J

January [10] -

13:8, 19:8, 19:15,

24:24, 83:17,

88:15, 88:24,

90:23, 92:2,

105:3

job [1] - 204:18

joined [1] -

191:15

joint [1] - 13:28

journey [2] -

20:1, 71:14

JP [1] - 2:12

judgment [4] -

83:5, 83:13,

173:12, 212:20

juggling [1] -

24:12

July [7] - 40:8,

90:2, 90:24,

90:29, 179:8,

205:24, 205:25

junctures [2] -

94:5, 94:9

June [5] - 14:6,

14:9, 15:29, 16:3,

179:10

junior [27] -

53:17, 55:2, 55:3,

55:4, 55:6, 77:7,

78:9, 90:26,

98:10, 103:26,

119:3, 120:27,

137:18, 160:14,

172:17, 174:20,

178:17, 188:6,

188:23, 189:9,

190:26, 192:9,

192:14, 193:21,

202:8, 211:4,

211:8

K

keep [4] - 5:16,

19:1, 74:12,

186:17

keeping [3] -

140:1, 159:28,

177:28

keeps [1] - 78:6

Kenny [2] -

17:11, 17:28

kept [3] - 19:19,

19:20, 20:28

Kettering [13] -

6:7, 6:10, 6:18,

6:20, 6:21, 6:24,

39:11, 39:15,

40:7, 100:1,

100:2, 159:5

kidney [78] -

12:9, 18:27,

25:15, 34:1, 34:2,

59:7, 60:17,

61:15, 63:2, 64:9,

64:11, 64:12,

64:17, 64:18,

64:24, 65:2, 65:3,

65:4, 65:7, 65:10,

65:12, 65:13,

65:14, 65:17,

65:25, 65:27,

65:28, 66:5,

66:10, 66:17,

66:28, 67:1, 67:2,

67:5, 67:8, 67:10,

67:13, 67:14,

67:23, 67:26,

70:13, 70:14,

81:20, 87:21,

87:26, 88:3, 88:6,

88:23, 102:26,

104:21, 108:19,

108:25, 109:18,

109:21, 112:14,

147:21, 163:4,

163:8, 163:29,

164:7, 164:10,

164:11, 164:13,

164:15, 164:16,

164:18, 164:22,

164:24, 164:25,

164:26, 164:27,

166:11, 168:21,

174:10, 174:11,

212:10

kidney" [1] -

174:13

kidneys [1] -

18:23

kind [5] - 40:11,

178:9, 204:23,

209:12, 212:27

kindly [1] -

190:23

Kingdom [3] -

196:23, 203:25,

208:22

KINGRAM [2] -

1:16, 1:17

Kings [1] - 5:12

knife [12] -

47:22, 48:1, 48:5,

49:21, 51:23,

52:1, 52:21, 53:6,

53:9, 113:24,

113:25, 114:20

knowing [1] -

115:6

knowledge [9] -

30:16, 33:27,

78:7, 90:10, 98:1,

105:28, 122:19,

172:8, 174:24

known [10] -

51:15, 82:24,

87:28, 90:23,

111:16, 121:28,

169:20, 169:22,

192:5, 193:22

knows [1] -

176:12

L

lab [1] - 56:15

lack [3] - 58:9,

69:11, 72:22

Lady's [1] -

189:18

large [4] - 7:10,

20:28, 87:18,

153:25

largest [1] - 6:11

last [19] - 6:16,

7:6, 22:16, 40:11,

69:26, 74:9, 77:5,

84:12, 86:14,

88:1, 88:2, 92:17,

159:25, 165:3,

174:16, 175:7,

183:11, 183:21,

205:25

lastly [1] - 76:15

late [4] - 63:14,

143:11, 185:10,

214:23

laterality [14] -

26:6, 30:25, 31:5,

31:14, 32:5, 33:1,

33:9, 34:5, 34:9,

62:10, 94:11,

158:11, 158:14,

212:25

laterally [1] -


16

16:13

laxative [1] -

16:23

lay [1] - 171:20

layman's [1] -

134:9

leadership [1] -

78:23

leading [5] -

34:25, 62:26,

95:28, 181:2,

181:6

learned [1] - 8:3

least [51] -

10:21, 16:15,

20:17, 41:29,

53:8, 53:14,

53:23, 55:15,

72:4, 94:2,

112:19, 112:21,

112:25, 112:26,

113:10, 113:13,

113:15, 113:17,

114:3, 115:19,

115:20, 115:24,

116:2, 116:5,

116:11, 118:16,

119:3, 120:27,

121:18, 122:1,

123:9, 125:1,

126:6, 129:1,

129:2, 129:3,

136:17, 136:27,

139:8, 141:26,

141:27, 142:16,

142:23, 143:12,

155:18, 159:6,

159:7, 179:15,

184:14, 191:3,

206:23

leave [8] - 30:17,

30:19, 48:18,

67:8, 90:11,

103:10, 141:20,

184:19

leaving [6] -

12:6, 82:3, 99:24,

134:23, 145:20,

196:21

lecture [3] -

165:2, 165:6,

166:6

lectures [1] -

173:22

led [4] - 35:27,

36:1, 36:6, 175:5

left [81] - 11:26,

12:1, 12:20,

12:25, 13:3,

13:11, 13:18,

14:1, 14:4, 14:8,

14:10, 14:19,

25:2, 25:9, 25:15,

27:29, 33:4, 35:4,

50:13, 50:26,

60:12, 60:16,

60:17, 60:28,

61:9, 65:2, 81:19,

81:20, 82:23,

82:27, 82:28,

86:29, 87:8, 88:6,

89:3, 89:6, 90:8,

104:19, 105:7,

105:9, 121:5,

133:9, 134:21,

135:20, 136:5,

142:26, 145:17,

145:25, 145:28,

147:19, 147:22,

147:26, 147:28,

148:4, 148:6,

148:8, 148:11,

148:12, 148:13,

148:22, 148:23,

148:24, 148:25,

148:27, 149:24,

163:14, 163:17,

163:18, 163:21,

163:25, 174:10,

174:11, 174:15,

175:9, 175:10,

184:3, 199:2

left-hand [2] -

163:14, 163:21

left-sided [6] -

12:1, 14:8, 14:10,

14:19, 89:3, 89:6

LEGAL [1] - 2:8

legal [6] - 123:1,

123:2, 123:8,

125:28, 185:6,

207:11

length...(

INTERJECTION

[1] - 87:14

lengths [1] -

87:11

lengthy [1] -

143:19

LEONARD [36] -

2:11, 3:7, 3:8,

3:17, 48:22,

62:20, 65:8, 80:3,

80:10, 80:25,

80:27, 84:7,

106:27, 107:3,

120:12, 120:19,

177:13, 177:15,

178:24, 180:14,

181:28, 184:23,

194:5, 195:6,

195:13, 195:18,

199:5, 200:24,

201:2, 201:19,

205:13, 205:15,

207:12, 207:15,

215:6, 215:13

Leonard [19] -

79:27, 80:22,

84:6, 107:5,

116:23, 170:22,

194:15, 195:9,

195:12, 195:23,

199:8, 199:26,

200:15, 201:9,

201:22, 201:24,

202:28, 204:11,

215:5

less [30] - 9:4,

49:16, 56:22,

70:12, 102:8,

113:8, 113:18,

126:7, 126:8,

126:21, 126:26,

129:14, 129:22,

130:8, 133:13,

140:29, 146:18,

150:28, 150:29,

159:21, 166:23,

167:2, 200:23,

201:27, 202:7,

208:19, 209:9,

209:25, 210:9,

211:4

lest [1] - 20:23

letter [47] -

11:12, 11:13,

12:28, 13:1, 13:7,

13:8, 13:11,

13:14, 13:21,

14:3, 14:6, 14:8,

17:12, 17:18,

18:2, 87:29,

88:10, 88:11,

119:23, 119:25,

120:5, 120:6,

120:7, 120:16,

120:18, 120:24,

120:25, 120:26,

121:1, 121:3,

121:20, 122:14,

122:26, 122:28,

122:29, 123:14,

124:25, 174:28,

179:12, 179:17,

179:20, 179:24,

180:12, 180:27,

182:6, 182:10

letters [5] -

69:18, 69:23,

71:8, 86:13,

212:28

level [16] - 5:23,

35:6, 35:22,

42:13, 51:13,

52:23, 55:5, 56:2,

72:5, 89:27, 91:2,

100:24, 104:11,

106:9, 115:2,

147:3

levels [2] -

103:8, 173:8

liability [1] -

204:2

lies [1] - 65:27

life [5] - 23:20,

28:19, 73:18,

76:2, 100:15

life-threatening

[1] - 23:20

lift [1] - 33:15

light [5] - 26:4,

37:19, 50:21,

51:2, 134:2

likelihood [1] -

91:26

likely [13] -

18:19, 27:13,

54:16, 67:24,

87:4, 89:4, 110:9,

132:11, 132:13,

132:14, 137:14,

166:15, 174:25

limit [1] - 62:26

limited [1] -

83:10

line [11] - 34:5,

42:29, 53:10,

60:26, 62:7,

97:22, 97:23,

133:3, 133:4,

182:20, 183:2

lines [2] - 41:26,

184:1

list [74] - 8:25,

24:14, 30:16,

35:15, 35:16,

35:20, 35:24,

36:8, 36:13,

36:15, 36:17,

36:18, 36:24,

36:25, 36:26,

38:20, 40:24,

41:9, 41:11,

42:12, 43:18,

44:19, 51:27,

51:29, 58:9,

72:27, 72:29,

73:4, 73:15,

73:19, 73:21,

73:26, 74:19,

90:5, 90:8, 91:11,

93:12, 94:15,

95:19, 95:21,

97:27, 98:3, 98:8,

98:9, 98:13,

98:17, 99:5, 99:7,

99:11, 99:14,

99:17, 99:23,

101:21, 105:21,

117:4, 132:1,

132:6, 135:8,

136:24, 137:15,

140:2, 140:7,

152:4, 156:5,

200:16, 200:19,

201:27, 203:2,

203:4, 204:2

listed [17] - 8:3,

41:18, 42:18,

42:20, 42:22,

43:6, 43:14,

44:13, 44:18,

44:20, 44:21,

69:2, 105:6,

148:8, 148:25,

197:12, 200:23

listen [1] - 79:3

listened [4] -

29:18, 35:7, 76:8,

210:16

listening [1] -

125:16

listing [3] -

40:26, 92:23,

93:6

lists [8] - 36:23,

37:11, 37:13,

73:17, 73:20,

73:22, 74:12,

74:21

lists" [1] - 36:14

live [2] - 67:17,

199:2

liver [2] - 5:12,

56:29

load [1] - 208:24

loaned [1] - 2:26

Locum [1] - 6:1

logic [2] -

136:21, 209:13

logical [1] -

168:18

logistical [1] -

98:12

London [4] -

5:13, 6:26, 8:12,

196:10

longest [1] - 7:3

look [41] - 12:26,

24:21, 34:14,

35:9, 35:12,

41:16, 52:5, 52:7,

53:3, 53:15,

55:29, 57:9, 62:3,

63:9, 68:20, 72:9,

72:28, 77:11,

81:26, 83:28,

86:27, 88:18,

97:7, 100:6,

102:3, 102:6,

103:1, 103:8,

106:15, 116:22,

119:25, 120:25,

142:21, 146:25,

149:3, 149:14,

163:9, 164:18,

166:29, 182:25,

198:10

looked [27] -

4:12, 26:7, 50:20,

59:8, 63:11,

64:11, 64:12,

64:22, 89:2,

89:17, 93:25,

97:23, 111:8,

111:23, 112:5,

145:16, 147:4,

148:21, 149:1,

149:8, 149:11,

150:3, 163:29,

164:2, 164:19,

180:4

looking [35] -

5:19, 9:23, 25:3,

27:27, 51:15,

65:1, 66:7, 68:23,

77:12, 81:22,

81:24, 88:17,

102:24, 102:25,

106:19, 111:2,

120:6, 120:7,

141:13, 145:11,

145:14, 145:29,

149:2, 149:6,

149:17, 151:6,

159:26, 162:12,

180:9, 198:8,

198:9, 213:9

looks [4] -

42:18, 87:29,

92:7, 110:22

loose [1] - 120:1

loosely [1] -

203:10

loss [5] - 56:24,

108:29, 152:10,

152:11, 176:17

lost [3] - 19:28,

20:24, 114:29


17

low [3] - 56:22,

61:14, 166:3

lower [5] -

60:13, 61:4, 61:9,

104:17, 147:15

luck [1] - 204:9

LUNCHEON [2]

- 107:14, 108:1

lunchtime [2] -

80:5, 80:12

lying [1] - 66:5

M

main [2] - 14:28,

17:13

maintain [2] -

7:9, 125:5

major [2] - 70:1,

72:17

majority [1] -

165:17

Malaysian [1] -

32:10

male [1] - 15:25

Malone [3] -

1:27, 2:25, 2:27

man [2] -

100:17, 188:14

manage [3] -

79:21, 183:6,

191:11

Management [1]

- 8:9

management

[14] - 13:24, 16:6,

27:26, 28:15,

28:18, 49:29,

75:14, 76:10,

77:26, 78:3, 78:4,

110:12, 172:11,

175:14

managing [1] -

18:15

manner [1] -

2:26

mannion [1] -

64:27

Mannion [6] -

46:24, 46:28,

47:24, 63:24,

66:16, 151:21

Mannion's [3] -

53:10, 128:22,

151:16

March [10] -

13:1, 40:27,

57:14, 82:6, 90:3,

181:16, 183:7,

183:11, 183:16,

183:17

marked [3] -

65:23, 65:24,

103:22

marking [3] -

73:7, 73:9, 73:13

martin [1] -

188:27

MARTIN [2] -

4:24, 108:12

Mary [1] - 13:22

MARY'S [1] -

2:15

massive [1] -

133:3

Master [21] -

11:3, 13:24,

14:23, 14:26,

16:5, 17:14,

17:19, 19:7,

22:11, 24:24,

24:27, 29:25,

29:29, 32:19,

45:4, 66:25,

81:18, 85:3,

106:19, 179:7,

197:13

match [8] -

56:20, 56:26,

57:2, 57:25,

151:23, 152:8,

152:14, 176:16

matched [2] -

105:8, 152:7

matching [3] -

56:18, 57:22,

151:11

mate [2] -

202:24, 202:25

mATHESON [1]

- 2:19

matter [31] -

4:12, 17:19,

48:10, 50:23,

53:27, 54:22,

71:19, 81:11,

81:17, 82:4,

106:11, 106:17,

109:25, 111:18,

112:4, 116:15,

122:10, 152:17,

169:25, 181:3,

182:11, 199:9,

199:14, 201:23,

207:22, 207:24,

207:28, 208:6,

208:9, 211:9,

214:26

matters [11] -

54:22, 54:25,

54:26, 56:3,

155:10, 155:26,

166:24, 179:5,

199:11, 199:23,

201:14

McDOWELL [2]

- 2:12, 2:14

MCUG [2] - 13:2,

13:17

mean [24] -

27:23, 38:5,

47:21, 51:7, 54:7,

61:7, 93:13,

97:11, 109:16,

111:20, 113:19,

114:6, 126:20,

139:2, 142:14,

147:2, 149:5,

149:7, 155:21,

158:23, 162:15,

168:28, 176:25,

186:16

means [12] -

17:5, 47:29,

56:16, 70:13,

74:20, 74:27,

98:1, 99:19,

134:9, 165:22,

202:18, 210:7

meant [4] - 36:6,

59:23, 76:26,

128:10

measure [3] -

27:25, 27:26,

46:17

measures [3] -

16:11, 176:25,

178:7

meat [1] -

164:14

med [1] - 153:14

Medical [16] -

39:8, 76:23,

76:26, 77:3,

84:11, 85:16,

119:19, 119:22,

121:12, 159:3,

172:13, 175:18,

175:22, 179:13,

179:21, 179:25

MEDICAL [2] -

1:2, 1:4

medical [17] -

11:4, 39:28,

69:10, 75:15,

76:22, 81:19,

82:5, 82:7, 82:10,

87:13, 94:2,

111:28, 158:24,

171:25, 172:14,

174:24, 175:11

medications [1]

- 42:14

medicine [3] -

40:1, 173:24,

173:25

MEENAN [55] -

2:21, 3:7, 3:14,

3:18, 34:24, 48:7,

48:9, 48:24, 49:2,

49:6, 53:18,

53:29, 54:11,

54:20, 54:24,

62:25, 107:8,

108:8, 108:13,

108:15, 119:28,

120:10, 120:15,

120:21, 133:1,

133:7, 133:17,

153:7, 155:19,

155:23, 157:1,

170:14, 181:2,

181:8, 182:1,

182:4, 182:26,

183:23, 184:7,

186:16, 193:5,

193:7, 193:24,

193:27, 198:17,

198:24, 199:3,

199:21, 200:6,

207:18, 207:20,

211:15, 211:19,

214:24, 215:4

meenan [6] -

34:18, 107:7,

108:6, 110:1,

120:9, 132:26

Meenan [21] -

49:10, 54:13,

56:3, 58:15, 63:8,

64:14, 102:7,

103:2, 155:14,

156:28, 161:14,

166:15, 166:27,

170:13, 177:16,

177:17, 179:12,

182:2, 186:15,

204:11, 214:20

Meenan's [1] -

59:8

meet [1] - 66:25

meeting [7] -

12:23, 19:14,

22:12, 23:24,

33:29, 70:26

meetings [1] -

71:16

member [3] -

30:5, 32:4,

171:11

members [4] -

78:22, 96:12,

171:18

membership [2]

- 173:27, 173:29

Memorial [2] -

6:10, 39:11

memory [3] -

48:22, 67:16,

201:13

mention [1] -

97:16

mentioned [2] -

159:1, 173:14

mentioned...(

INTERJECTION

[1] - 97:21

mentor [1] -

158:3

merely [8] -

85:13, 86:18,

104:14, 121:21,

146:14, 151:9,

178:23, 212:28

met [5] - 24:26,

55:12, 75:13,

191:13

Michael [1] -

39:14

Michelle [1] -

136:7

middle [1] -

131:4

might [29] -

5:15, 24:2, 30:3,

37:19, 57:9,

61:28, 69:6, 80:7,

81:26, 96:18,

96:19, 98:18,

99:10, 120:26,

132:27, 137:5,

137:6, 137:15,

146:9, 157:26,

157:29, 164:14,

164:18, 170:20,

172:23, 179:8,

183:21, 195:20

mild [1] - 13:17

mildly [1] -

96:26

million [1] -

176:3

mind [10] -

51:22, 62:14,

130:5, 146:15,

158:11, 165:23,

167:25, 169:28,

170:2, 193:12

mine [2] -

174:16, 191:22

minimal [4] -

11:26, 13:2,

152:10, 152:12

minimise [2] -

36:28, 176:9

minimised [1] -

20:18

minimum [1] -

53:4

minor [3] -

137:2, 143:5,

202:12

minute [14] -

52:25, 96:27,

97:7, 101:5,

102:22, 102:24,

115:16, 135:2,

141:18, 149:10,

160:5, 186:4,

187:14, 209:15

minute...(

INTERJECTION

[1] - 207:8

minutes [183] -

35:8, 41:24,

41:29, 42:16,

44:8, 47:28,

47:29, 48:1, 48:3,

49:17, 49:21,

53:2, 53:8, 53:15,

53:23, 63:27,

80:4, 80:11,

96:15, 96:28,

97:3, 97:4, 97:15,

101:13, 101:16,

102:9, 102:16,

102:20, 102:22,

102:27, 103:19,

103:27, 104:24,

112:16, 112:20,

112:21, 112:23,

112:25, 112:26,

112:29, 113:8,

113:10, 113:13,

113:14, 113:15,

113:18, 114:3,

114:14, 114:17,

114:22, 114:25,

115:1, 115:11,

115:14, 115:17,

115:19, 115:20,

115:24, 116:2,

116:6, 116:12,

117:24, 117:27,

118:17, 119:3,

120:28, 121:19,

122:1, 122:5,

122:6, 122:10,

122:11, 122:24,


18

122:25, 122:27,

123:3, 123:5,

123:9, 125:1,

125:21, 125:27,

126:6, 126:7,

126:8, 126:21,

126:25, 126:26,

127:5, 127:6,

128:27, 129:2,

129:5, 129:14,

129:19, 129:20,

129:22, 130:5,

130:8, 130:24,

133:13, 136:18,

137:10, 137:29,

138:13, 139:8,

139:12, 140:21,

140:22, 141:1,

141:2, 141:8,

141:9, 141:10,

141:15, 141:19,

141:20, 141:23,

141:26, 141:27,

142:7, 142:11,

142:12, 142:13,

142:23, 142:24,

142:25, 142:26,

142:28, 143:11,

144:1, 144:5,

144:20, 145:4,

145:7, 146:18,

147:5, 150:6,

150:28, 150:29,

151:3, 151:5,

153:19, 155:5,

155:10, 155:16,

155:18, 155:25,

159:22, 160:4,

166:23, 166:26,

166:27, 166:28,

167:2, 167:13,

167:16, 167:17,

170:28, 179:15,

208:20, 209:10,

209:11, 209:12,

209:25, 210:3,

210:9, 210:18,

210:23, 211:2,

211:5, 214:27

minutes' [4] -

96:15, 96:16,

97:12, 210:20

minutes...(

INTERJECTION)

[1] - 142:16

misapprehensi

on [2] - 88:6,

88:12

misconduct [4] -

54:4, 81:14,

203:5, 204:3

mishap [1] -

68:13

mislaid [1] -

21:9

mislaying [1] -

20:18

misplaced [1] -

19:28

missing [3] -

20:13, 183:22,

184:22

mistake [4] -

84:27, 86:16,

87:12, 88:15

mistakes [4] -

29:13, 111:17,

203:6, 213:23

mistreat [1] -

192:9

mistreatment

[1] - 192:11

misunderstood

[1] - 131:15

mls [1] - 56:26

Mohamed [3] -

58:12, 59:4, 63:9

moment [5] -

137:4, 149:16,

190:10, 210:1,

213:26

moments [3] -

84:29, 159:24,

159:25

MONAGHAN [1]

- 2:4

Monday [4] -

8:25, 8:29, 37:23,

73:23

month [7] - 9:8,

24:11, 40:9,

90:20, 154:14

months [17] -

6:6, 39:10, 39:24,

40:10, 40:12,

71:20, 75:14,

75:20, 77:5,

90:21, 90:22,

90:27, 91:25,

99:29, 123:11,

123:12, 133:9

morning [48] -

4:4, 4:13, 10:14,

10:15, 10:23,

23:4, 23:21,

23:23, 29:22,

30:6, 30:11,

30:13, 32:6,

32:16, 32:17,

33:8, 35:15,

38:18, 38:22,

38:29, 43:10,

51:19, 70:25,

72:14, 72:25,

91:14, 92:25,

93:6, 94:15,

105:2, 106:16,

111:25, 112:9,

112:15, 117:3,

121:17, 127:18,

130:14, 130:22,

154:8, 177:21,

184:21, 184:27,

191:22, 206:25,

210:16, 214:28,

215:18

Mortell [5] -

15:6, 52:4,

144:17, 144:26,

162:6

mortell's [1] -

144:28

Mortell's [1] -

52:10

most [15] - 7:4,

18:18, 26:12,

32:2, 39:7, 53:22,

78:3, 99:12,

105:21, 110:9,

115:26, 165:11,

200:20, 202:13,

212:1

mostly [2] -

7:27, 205:27

mother [2] -

163:21, 163:23

motivation [1] -

177:28

motivational [1]

- 178:2

move [7] - 11:2,

29:24, 37:4,

66:19, 94:12,

135:10, 163:3

movement [3] -

130:14, 134:5,

135:14

movements [2] -

135:7, 150:12

moving [1] -

131:7

MR [139] - 2:5,

2:8, 2:11, 2:22,

3:7, 3:7, 3:8,

3:10, 3:13, 3:14,

3:16, 3:17, 3:18,

34:24, 48:7, 48:9,

48:22, 48:24,

48:29, 49:2, 49:5,

49:6, 53:18,

53:25, 53:29,

54:7, 54:11,

54:13, 54:20,

54:21, 54:24,

54:26, 62:20,

62:25, 65:8, 80:3,

80:10, 80:25,

80:27, 84:7,

106:27, 107:3,

107:8, 108:8,

108:13, 108:15,

119:27, 119:28,

120:8, 120:10,

120:12, 120:15,

120:19, 120:21,

133:1, 133:7,

133:9, 133:17,

153:7, 155:19,

155:23, 156:26,

157:1, 170:14,

171:20, 174:2,

177:13, 177:15,

178:24, 180:11,

180:14, 180:15,

180:17, 181:2,

181:6, 181:8,

181:12, 181:28,

182:1, 182:8,

182:17, 182:26,

183:23, 184:7,

184:10, 184:14,

184:23, 185:13,

186:16, 189:23,

190:2, 193:1,

193:4, 193:5,

193:7, 193:24,

193:27, 194:5,

194:26, 195:6,

195:12, 195:13,

195:14, 195:18,

195:27, 196:1,

198:17, 198:22,

198:24, 199:3,

199:5, 199:8,

199:21, 200:2,

200:6, 200:11,

200:24, 200:27,

201:2, 201:9,

201:19, 205:9,

205:12, 205:13,

205:15, 207:12,

207:15, 207:17,

207:18, 207:20,

211:15, 211:19,

211:25, 214:24,

215:4, 215:6,

215:13

MS [79] - 2:5,

2:13, 2:18, 3:6,

3:9, 3:11, 3:14,

3:17, 4:9, 4:16,

4:20, 4:25, 4:27,

11:11, 11:16,

11:21, 34:27,

41:2, 48:8, 48:28,

49:10, 54:28,

62:23, 62:28,

65:11, 65:21,

76:20, 79:25,

155:13, 155:22,

170:25, 171:1,

179:2, 179:4,

180:16, 180:18,

181:3, 181:14,

182:2, 182:5,

182:13, 182:29,

183:28, 184:17,

184:25, 185:18,

185:28, 186:1,

186:13, 186:23,

187:2, 187:9,

187:11, 187:18,

189:19, 189:23,

189:29, 190:3,

190:5, 190:14,

192:25, 193:2,

194:4, 194:15,

194:29, 195:7,

195:23, 196:2,

196:12, 198:12,

198:20, 198:27,

199:17, 200:12,

201:20, 205:5,

205:10, 211:21,

214:19

multi [6] - 12:23,

70:2, 70:6, 70:26,

78:22, 191:12

multi-

disciplinary [6] -

12:23, 70:2, 70:6,

70:26, 78:22,

191:12

multiple [1] -

39:12

MURPHY [9] -

3:16, 196:1,

205:9, 205:12,

207:15, 207:17,

211:19, 211:25,

214:12

murphy [1] -

214:10

Murphy [19] -

185:19, 186:12,

194:4, 194:20,

195:3, 195:10,

195:28, 196:4,

197:7, 199:17,

199:22, 200:13,

202:15, 205:6,

205:15, 209:9,

211:3, 211:17,

211:21

Murphy's [3] -

186:6, 199:27,

201:28

Murphy...(

INTERJECTION

[1] - 185:28

muscle [2] -

17:1, 17:2

must [10] - 2:26,

75:24, 76:6,

87:28, 113:19,

121:28, 123:2,

157:13, 206:24,

210:5

mutually [2] -

136:25, 137:3

myself' [1] - 96:1

N

name [2] - 41:3,

136:7

named [1] - 1:30

namely [1] -

48:14

nappies [1] -

16:16

narrative [1] -

145:1

national [2] -

9:16, 24:15

nature [1] - 6:9

near [1] - 193:13

nearly [2] -

170:14, 197:4

necessarily [9] -

36:2, 36:7,

101:10, 102:16,

123:4, 136:25,

137:16, 137:17,

151:8

necessary [10] -

20:25, 51:10,

57:25, 102:18,

129:23, 129:26,

130:7, 178:5,

202:26, 210:23

necessity [3] -

70:7, 70:8,

106:15

neck [1] - 133:5

need [20] -

20:16, 33:7,

34:19, 51:20,

56:19, 57:1,

58:22, 59:2,


19

70:28, 101:15,

102:23, 146:21,

176:17, 208:13,

208:15, 209:5,

209:16, 209:18,

209:28

needed [4] -

9:29, 19:1, 78:2,

167:23

needs [2] - 92:3,

103:23

negligence [1] -

204:9

neonatal [2] -

7:11, 9:17

neonate [1] -

23:15

Neonatologist

[1] - 13:25

nephrectomies

[9] - 40:21, 40:23,

56:22, 56:23,

100:5, 100:6,

152:8, 152:11

nephrectomy

[95] - 24:29, 25:1,

25:2, 27:1, 27:27,

27:29, 28:1, 29:3,

38:13, 46:5, 46:7,

47:2, 47:14,

49:16, 49:21,

49:26, 51:5, 53:6,

55:18, 56:24,

56:25, 58:18,

59:20, 64:6,

65:25, 70:7, 70:9,

82:16, 82:22,

82:27, 89:25,

90:9, 94:21, 95:2,

98:26, 98:28,

99:15, 99:24,

99:26, 99:28,

100:6, 100:7,

100:10, 100:19,

100:25, 100:26,

100:27, 104:18,

105:7, 105:9,

109:17, 109:19,

117:9, 124:12,

127:10, 127:11,

129:11, 129:12,

129:16, 129:17,

130:25, 131:19,

134:28, 136:14,

136:18, 136:19,

136:26, 137:10,

137:11, 137:20,

138:6, 138:13,

138:23, 138:26,

139:5, 139:7,

139:27, 141:21,

141:28, 144:15,

148:8, 148:12,

148:25, 156:12,

167:2, 174:8,

178:19, 179:15,

200:18, 200:22,

201:24, 201:28,

202:2, 211:4,

211:9

nephrectomy"

[1] - 27:22

Nephrologist [1]

- 13:23

nephropathy [1]

- 12:11

neurosurgical

[1] - 10:17

never [27] -

33:29, 51:25,

94:21, 95:1,

97:18, 102:28,

106:19, 110:12,

117:10, 118:18,

130:3, 136:1,

136:19, 137:11,

138:5, 153:11,

155:6, 155:27,

155:28, 158:4,

159:12, 159:16,

167:16, 172:10,

192:9, 192:11,

193:19

nevertheless [2]

- 69:17, 188:14

new [7] - 15:15,

37:20, 37:21,

61:8, 74:1, 74:2,

191:14

New [1] - 159:5

newborn [1] -

23:15

news [1] - 67:19

next [23] - 14:3,

14:8, 14:10,

16:19, 40:9,

42:29, 43:4,

43:13, 44:11,

44:18, 45:2,

67:25, 72:20,

73:6, 75:9, 82:3,

82:15, 98:15,

136:8, 137:12,

138:4, 139:24,

194:5

NHS [3] -

208:22, 211:6,

211:7

night [3] -

174:16, 188:17,

213:7

nights [4] - 9:8,

154:13, 154:14,

173:17

nine [1] - 87:24

NO'S [1] - 3:4

no-one [1] - 34:6

Noble [1] - 7:25

nobody [1] -

111:18

non [1] - 123:24

non-delegation

[1] - 123:24

none [2] - 16:14,

53:21

nonetheless [1]

- 182:14

norm [2] - 24:1,

39:2

normal [29] -

31:23, 38:12,

39:3, 56:11,

56:24, 59:8, 63:2,

63:26, 64:11,

64:12, 64:24,

70:21, 71:10,

97:27, 108:25,

150:19, 151:22,

151:25, 152:3,

152:15, 154:12,

157:17, 161:15,

163:29, 164:24,

168:21, 197:18,

198:10, 202:13

normally [13] -

19:18, 21:18,

21:22, 26:23,

50:26, 64:6,

70:21, 71:11,

72:21, 89:12,

92:10, 160:6,

201:14

not...(

INTERJECTION

[1] - 182:7

note [20] - 11:3,

14:11, 14:29,

25:3, 25:8, 25:11,

27:22, 27:28,

28:24, 41:16,

47:25, 62:3, 62:6,

81:18, 92:2,

160:29, 161:6,

163:15, 184:3,

201:20

noted [8] -

12:19, 12:20,

18:6, 25:7, 25:9,

64:4, 162:24,

187:29

notes [22] - 1:29,

14:18, 14:20,

15:29, 26:23,

44:28, 62:7,

62:11, 62:16,

66:23, 87:20,

124:12, 145:11,

145:14, 145:15,

146:1, 174:7,

174:10, 198:9,

212:11, 212:26

nothing [8] -

18:13, 130:11,

130:13, 131:27,

132:1, 135:26,

150:26, 180:22

Notice [7] -

80:28, 81:24,

181:14, 181:20,

181:23, 206:5,

206:7

notice [15] -

94:23, 95:11,

95:18, 95:24,

96:15, 96:16,

96:22, 96:25,

96:27, 97:2,

97:12, 103:14,

103:27, 117:11

noting [1] - 27:8

November [4] -

17:21, 17:25,

18:1, 18:2

nozzle [1] -

16:24

number [39] -

10:23, 12:16,

14:18, 19:27,

28:9, 36:19,

36:21, 41:4,

42:21, 43:1, 43:5,

68:19, 74:22,

76:18, 81:5,

86:28, 87:18,

92:18, 98:16,

100:4, 132:24,

153:14, 153:25,

173:1, 186:29,

188:29, 190:18,

190:21, 194:18,

196:19, 197:10,

198:29, 199:18,

203:24, 205:28,

210:14, 213:7,

214:5

numbered [1] -

92:19

numbers [3] -

9:21, 10:21,

140:6

Nurse [19] -

31:17, 31:18,

31:20, 33:15,

33:16, 33:18,

33:20, 33:22,

43:9, 43:19,

45:17, 45:23,

52:4, 52:12,

151:18, 160:24,

162:5

nurse [12] -

26:18, 26:25,

31:17, 31:29,

32:3, 33:18,

44:29, 58:24,

133:24, 151:9,

151:18, 162:24

nurses [6] -

22:28, 57:12,

58:25, 77:7,

150:22, 189:10

nurses' [2] -

22:8, 30:7

Nursing [1] -

32:1

nursing [11] -

26:12, 31:22,

31:27, 44:25,

57:6, 66:23, 94:4,

96:12, 111:26,

111:28, 151:13

O

o'clock [18] -

23:14, 23:21,

23:23, 23:24,

30:7, 45:29,

53:13, 66:20,

107:6, 126:12,

128:13, 128:15,

131:12, 134:27,

142:9, 142:18,

185:17, 191:22

O'CONNOR [1] -

2:24

O'Neill [1] -

156:21

O'NEILL [3] -

2:5, 171:20,

174:2

object [2] -

195:20, 195:23

objection [4] -

186:15, 195:9,

201:19, 201:20

objectively [1] -

110:23

obligation [1] -

9:6

obligations [3] -

8:18, 24:3,

100:23

oblige [1] - 75:5

obliged [1] -

200:4

observation [2]

- 190:24, 198:2

observations [9]

- 38:1, 46:20,

60:3, 64:16,

84:10, 101:20,

179:13, 180:28,

181:19

obstructing [1] -

181:9

obtained [1] -

31:24

obtaining [1] -

40:16

obvious [3] -

164:23, 165:24

obviously [5] -

111:16, 162:18,

166:6, 181:10,

199:14

occasion [2] -

31:13, 31:17

occasionally [3]

- 20:13, 57:19,

154:20

occasions [8] -

12:17, 37:6,

88:28, 94:28,

118:13, 118:22,

164:8, 194:18

occur [3] -

30:13, 71:6,

204:5

occurred [18] -

12:5, 60:7, 67:12,

68:6, 68:14,

68:20, 86:19,

109:10, 121:7,

121:22, 129:14,

130:26, 130:29,

149:29, 175:18,

204:19, 204:20,

204:26

occurrence [2] -

20:11, 150:10

October [3] -

17:20, 87:28,

88:12

odd [3] - 139:28,

140:3, 157:19

odds [1] -

158:17

oesophageal [1]

- 23:16


20

oesophagus [2]

- 23:17, 23:19

OF [23] - 1:3,

1:14, 80:1, 107:2,

170:16, 177:10,

178:26, 185:1,

189:23, 193:1,

193:26, 205:9,

207:15, 211:19,

214:12

of...(

INTERJECTION

[1] - 201:1

offer [1] - 176:26

office [3] -

70:24, 117:22,

117:23

Officer [1] - 81:8

official [13] -

19:21, 21:29,

25:12, 25:20,

25:21, 25:29,

26:4, 26:15,

27:14, 27:16,

27:18, 64:29,

128:2

often [7] - 15:17,

25:23, 37:6,

46:24, 57:22,

95:20, 105:29

old [3] - 60:19,

61:1, 61:2

olive [1] - 38:2

Olive [2] - 46:1,

101:27

omission [1] -

124:13

ON [2] - 1:14,

4:1

on-call [14] - 9:6,

9:7, 9:8, 9:11,

9:13, 10:9, 23:5,

23:7, 24:10,

152:20, 154:13,

154:14, 173:17,

188:18

on-going [1] -

106:12

on.. [1] - 103:5

once [5] - 52:27,

145:22, 203:10,

209:3, 209:4

oncological [3] -

7:11, 9:9, 9:18

Oncologist [2] -

5:7, 190:16

oncologist [1] -

191:9

Oncology [2] -

23:27, 39:15

oncology [7] -

6:15, 40:19,

100:3, 154:15,

173:17, 191:7,

191:17

one [134] - 6:11,

6:22, 8:12, 12:22,

12:26, 13:3, 14:3,

15:25, 21:11,

22:7, 22:20,

22:21, 24:11,

26:18, 27:19,

28:9, 28:11,

32:27, 33:1, 34:6,

35:8, 37:23,

37:24, 40:6,

41:15, 42:18,

49:12, 53:1, 53:2,

57:5, 58:24, 59:3,

64:28, 65:28,

69:2, 70:21, 72:4,

73:21, 73:25,

73:28, 74:15,

75:6, 78:13,

79:11, 79:13,

82:3, 85:16,

85:20, 87:29,

88:18, 89:24,

90:29, 91:26,

92:7, 93:24,

94:22, 95:23,

97:6, 98:3, 98:11,

98:19, 100:2,

100:6, 100:14,

102:16, 102:27,

103:8, 103:11,

104:14, 104:17,

105:21, 105:25,

106:13, 110:22,

111:17, 111:26,

112:3, 115:15,

116:26, 117:10,

119:12, 122:25,

126:6, 126:25,

133:23, 135:8,

136:15, 138:25,

143:25, 144:11,

149:21, 149:23,

149:25, 150:21,

152:24, 152:28,

152:29, 159:7,

161:16, 161:20,

164:13, 164:22,

166:18, 166:28,

168:17, 171:20,

172:17, 173:12,

176:29, 177:7,

179:4, 185:9,

185:18, 185:29,

189:6, 190:10,

195:14, 197:9,

198:5, 198:12,

198:23, 201:6,

202:18, 202:28,

203:28, 203:29,

211:27, 212:3

onerous [3] -

9:20, 23:6, 191:2

ones [1] - 4:15

ongoing [5] -

12:10, 24:4,

24:13, 59:13,

76:27

onwards [1] -

190:16

open [1] - 7:29

operate [6] -

8:27, 9:2, 24:19,

35:19, 82:28,

202:11

operated [4] -

34:15, 35:16,

36:20, 36:21

operates [2] -

22:14, 36:13

operating [34] -

8:25, 10:9, 41:12,

43:2, 43:6, 44:13,

44:20, 44:22,

44:27, 44:28,

51:28, 58:21,

59:1, 96:22, 98:2,

98:9, 98:17,

105:13, 122:9,

126:16, 130:15,

142:25, 149:23,

150:23, 154:27,

162:3, 163:13,

197:16, 197:21,

197:22, 197:24,

198:6, 208:11,

208:24

operation [189] -

15:15, 28:26,

37:25, 41:18,

41:19, 41:21,

42:20, 42:21,

44:4, 46:21,

47:21, 47:23,

47:28, 49:17,

52:22, 53:24,

54:17, 54:18,

62:2, 62:3, 62:6,

73:14, 73:17,

82:6, 84:19, 91:5,

91:6, 91:22,

92:27, 93:9,

94:20, 95:26,

95:28, 95:29,

96:3, 98:26,

98:28, 99:4,

99:20, 100:17,

100:22, 101:8,

101:9, 103:28,

105:2, 105:19,

106:16, 108:18,

108:22, 109:12,

109:14, 109:16,

109:27, 110:25,

111:8, 111:13,

111:19, 112:2,

112:6, 112:10,

112:12, 112:17,

112:22, 112:23,

113:5, 113:9,

113:21, 113:26,

114:4, 114:24,

115:6, 115:8,

115:11, 115:23,

115:25, 116:5,

116:11, 117:8,

118:16, 118:17,

119:2, 120:28,

121:19, 121:29,

123:10, 123:19,

124:4, 124:19,

125:1, 126:3,

127:8, 129:15,

129:25, 130:6,

130:8, 131:1,

131:2, 131:4,

131:18, 131:25,

132:18, 132:20,

132:21, 132:24,

132:29, 133:6,

134:10, 134:20,

134:22, 135:5,

135:17, 135:20,

136:5, 136:6,

136:8, 137:20,

137:21, 139:22,

140:22, 140:29,

141:27, 142:2,

142:3, 142:8,

142:10, 142:24,

142:25, 142:29,

143:16, 143:18,

143:19, 144:21,

146:18, 146:21,

147:17, 148:3,

150:7, 150:16,

155:5, 157:16,

157:17, 158:28,

159:16, 159:21,

159:27, 160:4,

166:23, 167:1,

167:6, 167:18,

167:28, 168:26,

169:20, 174:21,

177:19, 197:26,

201:4, 202:6,

202:14, 202:18,

203:20, 204:13,

206:24, 208:10,

208:11, 208:13,

208:19, 209:5,

209:6, 209:7,

209:17, 209:18,

209:19, 209:23,

209:28, 209:29,

210:2, 210:3,

210:11, 210:13,

210:19, 211:5,

211:8, 211:9,

211:11, 211:12,

213:10

operational [3] -

41:16, 56:13,

151:25

operations [18] -

98:24, 99:1, 99:5,

99:14, 100:13,

105:21, 105:22,

148:17, 157:15,

160:11, 193:20,

200:18, 200:20,

202:4, 202:7,

202:8, 202:10,

202:12

operative [6] -

56:29, 57:6,

92:25, 124:5,

148:9, 191:6

Operative [2] -

8:11, 8:14

operatively [1] -

58:1

opinion [7] -

172:19, 188:16,

188:20, 188:21,

189:11, 206:19,

212:18

opinions [3] -

22:27, 54:9,

118:9

opportunities

[1] - 93:27

opportunity [16]

- 29:21, 29:23,

52:24, 72:9, 73:4,

79:5, 101:12,

101:14, 104:9,

114:21, 115:3,

115:4, 123:17,

151:4, 155:11,

188:7

opposed [2] -

87:1, 133:13

option [12] -

28:13, 28:20,

28:21, 55:27,

95:25, 146:24,

146:25, 177:3,

177:5, 178:15

options [3] -

28:9, 28:11,

177:2

or...(

INTERJECTION

[1] - 26:26

orally [1] -

198:19

orchestra [1] -

191:10

order [4] - 26:19,

42:19, 98:13,

140:20

organ [3] - 70:1,

160:13, 161:20

organise [2] -

6:20, 58:28

organised [1] -

18:20

original [3] -

13:17, 29:27,

206:7

Ormond [19] -

6:26, 27:11,

92:16, 94:13,

95:5, 97:17,

116:18, 116:21,

116:22, 117:14,

117:15, 119:8,

179:27, 180:7,

180:10, 184:6,

196:22, 197:2,

197:4

ORMSBY [1] -

2:19

orthopaedic [1]

- 23:12

Oslizlok [4] -

187:5, 187:6,

187:18, 189:20

OSLIZLOK [3] -

3:10, 187:8,

189:23

oslizlok [1] -

187:11

otherwise [6] -

55:19, 57:2,

110:5, 131:29,

148:22, 202:11

ought [5] -

82:22, 82:24,

82:25, 84:28,

92:1

out-of-hours [1]

- 72:11

out-patient [1] -

10:14

out-patients [7]


21

- 8:21, 10:19,

16:8, 88:9,

105:20, 154:26,

173:23

Out-Patients

[14] - 10:10, 15:2,

15:29, 19:7,

19:18, 21:15,

21:18, 21:23,

22:3, 22:14,

22:18, 24:25,

26:13, 111:21

outcome [4] -

79:23, 106:23,

158:8, 165:26

outline [12] -

6:8, 7:7, 8:4,

8:17, 15:9, 18:5,

22:12, 24:26,

60:5, 66:26,

175:20, 185:16

outs [1] - 24:9

outset [7] -

14:24, 62:16,

98:3, 148:26,

149:12, 188:10,

197:8

outside [4] -

31:23, 58:13,

59:17, 71:10

outstanding [19]

- 75:1, 77:25,

77:26, 77:27,

77:28, 78:1, 78:3,

78:5, 78:6, 78:9,

78:13, 78:14,

78:16, 78:17,

78:19, 78:21,

78:23, 78:25,

78:26

overall [4] -

41:8, 85:5,

169:16

overload [1] -

177:24

overseas [1] -

5:26

overstating [1] -

58:16

own [25] - 30:11,

54:10, 72:29,

85:25, 87:29,

91:15, 101:20,

106:17, 118:9,

128:19, 130:5,

135:29, 143:28,

145:15, 146:15,

167:15, 167:25,

169:18, 172:6,

172:7, 174:14,

174:28, 189:12,

191:26, 195:8

P

pace [3] - 74:13,

95:16, 153:22

packet [10] -

20:6, 20:27,

20:29, 21:13,

21:17, 27:17,

27:19, 50:20,

64:25, 109:7

packets [2] -

21:1, 21:4

PACS [7] -

20:15, 20:18,

20:20, 22:5, 22:9,

71:19, 75:9

Paediatric [13] -

5:6, 5:7, 5:8, 7:1,

7:4, 10:5, 13:22,

32:12, 39:9,

39:14, 39:20,

190:15, 196:7

paediatric [34] -

6:12, 6:15, 7:11,

7:12, 7:17, 7:27,

7:28, 9:14, 9:16,

9:19, 9:23, 24:5,

24:15, 24:16,

39:22, 40:18,

72:4, 75:29,

83:25, 100:3,

159:7, 159:8,

159:9, 172:22,

173:5, 173:21,

187:19, 187:24,

188:13, 191:9,

191:17, 194:21,

196:9, 196:18

paediatrician [1]

- 32:10

Paediatrician [2]

- 13:25, 40:17

page [71] - 5:20,

7:18, 7:21, 8:4,

11:19, 13:7,

13:14, 13:21,

14:29, 16:3,

17:13, 17:22,

18:3, 18:25,

19:14, 25:3,

43:14, 49:18,

57:9, 57:12,

57:13, 62:4,

66:23, 68:23,

68:29, 74:6,

74:10, 77:11,

78:11, 78:29,

81:26, 84:2, 84:5,

84:7, 87:13,

87:20, 87:24,

87:29, 92:8, 92:9,

92:12, 92:13,

92:18, 94:13,

97:29, 102:6,

102:14, 103:1,

116:25, 116:28,

116:29, 124:1,

143:23, 156:22,

156:24, 156:25,

157:5, 157:6,

174:7, 180:9,

180:19, 182:27,

183:2, 183:8,

183:11, 183:15,

184:16, 190:8,

196:14

PAGE [1] - 3:4

pages [1] -

87:24

pagination [3] -

16:3, 92:12,

119:26

palpate [2] -

164:11, 164:16

palpates [1] -

164:22

palpation [1] -

165:1

paper [1] -

173:24

papers [1] -

173:25

paperwork [7] -

153:29, 154:1,

154:2, 154:7,

154:10, 154:17,

154:22

paragraph [6] -

13:2, 13:16, 74:9,

88:1, 92:17,

92:19

parallel [11] -

36:14, 36:15,

36:17, 36:18,

37:11, 37:13,

60:26, 73:14,

73:17, 74:12,

117:3

Paran [314] -

6:17, 6:21, 13:9,

30:14, 30:15,

30:20, 32:6,

32:21, 32:27,

33:21, 33:22,

34:8, 35:11,

35:12, 37:18,

38:8, 38:16,

38:19, 38:25,

39:4, 39:6, 39:19,

39:24, 39:29,

43:7, 43:9, 43:13,

43:20, 44:14,

45:8, 45:10,

45:11, 45:19,

45:21, 45:22,

45:24, 45:26,

46:4, 46:6, 46:12,

46:20, 46:29,

47:1, 47:4, 47:11,

47:26, 48:15,

48:16, 49:15,

49:20, 49:25,

49:26, 49:27,

49:28, 50:7, 51:9,

51:12, 51:14,

51:18, 52:14,

52:20, 52:24,

53:5, 53:13,

53:23, 54:4,

55:17, 55:21,

55:23, 56:6, 56:9,

58:13, 58:14,

58:17, 58:26,

59:7, 59:9, 59:19,

59:25, 59:29,

60:1, 60:9, 60:22,

61:16, 61:21,

62:2, 62:6, 63:1,

63:8, 63:11,

64:12, 64:15,

64:21, 65:9, 66:7,

72:24, 73:2,

74:16, 81:24,

82:19, 83:25,

84:19, 84:26,

86:18, 89:24,

90:26, 90:27,

91:4, 91:10,

91:24, 91:28,

93:11, 95:1,

95:10, 95:12,

96:9, 96:11,

96:16, 97:20,

98:14, 98:15,

99:22, 99:24,

99:27, 100:24,

100:29, 101:11,

101:14, 102:8,

103:9, 103:25,

104:7, 104:8,

104:27, 104:29,

105:12, 105:26,

106:18, 108:27,

109:2, 109:4,

112:11, 112:23,

113:12, 114:26,

114:29, 115:3,

115:11, 115:23,

115:27, 115:28,

116:10, 117:20,

117:24, 118:16,

118:23, 118:28,

120:27, 121:7,

121:18, 121:25,

122:1, 122:15,

122:19, 123:9,

124:4, 124:29,

125:5, 125:6,

125:26, 126:7,

126:13, 126:21,

129:10, 130:15,

130:25, 131:3,

131:8, 131:19,

131:24, 132:6,

132:11, 132:15,

133:7, 133:18,

133:27, 133:29,

134:8, 134:13,

134:20, 134:23,

134:25, 135:17,

135:28, 136:1,

136:11, 136:16,

137:9, 137:13,

137:20, 137:24,

138:3, 138:16,

139:7, 139:11,

139:24, 140:9,

140:17, 143:1,

143:3, 143:10,

144:4, 144:10,

144:16, 144:22,

144:29, 145:2,

145:8, 145:9,

145:20, 145:22,

145:26, 145:27,

146:2, 146:8,

146:10, 146:14,

146:20, 146:23,

146:28, 147:4,

147:12, 148:1,

148:20, 148:26,

148:27, 148:28,

149:1, 149:11,

149:14, 149:25,

150:2, 150:12,

150:18, 150:27,

151:4, 151:8,

152:12, 152:17,

152:23, 153:11,

153:16, 154:2,

154:29, 155:9,

155:16, 155:17,

155:23, 156:4,

156:23, 158:23,

159:1, 159:2,

159:13, 159:19,

159:28, 160:6,

161:7, 162:8,

162:16, 162:18,

162:21, 162:26,

162:29, 163:9,

163:27, 164:5,

166:17, 166:22,

167:15, 167:21,

167:22, 167:26,

168:6, 168:25,

168:27, 169:1,

169:2, 169:18,

169:20, 172:10,

177:19, 177:21,

178:19, 178:20,

179:14, 180:2,

180:25, 182:24,

193:7, 196:29,

197:1, 197:29,

206:24, 209:21,

209:23, 210:10,

210:12, 210:26,

214:26, 214:28

PARAN [3] - 1:9,

2:21, 133:9

paran [13] -

44:17, 64:7, 65:6,

65:10, 96:3,

148:2, 153:9,

153:20, 158:10,

159:17, 159:25,

167:29, 184:19

Paran" [1] -

161:1

paran's [1] -

62:3

Paran's [28] -

38:1, 38:3, 52:14,

86:16, 97:5,

103:16, 104:11,

104:23, 130:14,

134:7, 135:3,

136:4, 138:19,

140:13, 145:11,

146:4, 147:3,

147:10, 152:22,

156:2, 158:3,

158:26, 161:9,

162:11, 166:19,

178:4, 178:13,

204:14

paranoid [1] -

33:2

pardon [1] -

122:18

parenchyma [1]

- 164:15

parent [2] -

22:21, 34:3

parent's [4] -

29:17, 34:20,

34:21, 35:1

parental [1] -


22

51:16

parents [93] -

19:2, 22:11,

23:22, 24:25,

26:17, 26:22,

26:24, 26:28,

28:1, 28:10,

28:14, 29:16,

30:25, 31:1,

31:13, 31:25,

32:15, 32:21,

33:13, 33:26,

33:28, 33:29,

35:5, 35:6, 35:11,

36:28, 52:13,

66:19, 66:25,

66:27, 67:11,

67:16, 67:28,

68:6, 68:14,

75:28, 76:6,

83:28, 84:18,

87:6, 87:9, 90:5,

100:11, 100:16,

106:18, 106:20,

110:20, 110:24,

110:27, 110:29,

111:6, 111:13,

111:25, 138:7,

157:9, 160:20,

160:28, 161:8,

161:15, 162:9,

162:17, 162:19,

162:25, 162:28,

164:3, 167:20,

167:21, 167:24,

168:1, 168:6,

168:12, 168:27,

169:3, 169:4,

169:9, 169:13,

169:19, 169:26,

169:27, 169:29,

170:10, 177:18,

177:25, 177:29,

178:1, 178:6,

191:8, 192:3,

204:13, 204:17,

204:18, 213:19,

214:7

parents' [4] -

92:27, 93:8,

162:21, 163:1

part [40] - 9:16,

9:26, 10:7, 22:16,

28:4, 37:21,

45:13, 52:10,

52:21, 58:28,

62:9, 70:4, 73:23,

74:15, 74:18,

76:6, 83:21,

83:22, 104:7,

105:13, 109:14,

110:16, 115:26,

123:26, 124:5,

124:9, 124:27,

138:19, 140:14,

152:3, 173:6,

173:28, 173:29,

175:28, 184:9,

188:28, 191:15,

198:7, 198:10,

203:6

PART [1] - 1:3

part-time [7] -

9:16, 9:26, 10:7,

37:21, 73:23,

74:15, 74:18

participate [2] -

76:24, 77:1

particular [12] -

23:29, 38:4, 51:1,

59:19, 85:13,

134:15, 134:24,

188:5, 190:26,

208:19, 213:24

particularly [8] -

16:17, 22:18,

22:25, 22:29,

23:6, 160:3,

188:27, 207:5

party [1] - 2:27

pass [2] - 31:18,

111:26

passed [13] -

16:23, 33:17,

33:19, 33:21,

39:19, 111:29,

114:1, 144:27,

159:8, 168:17,

168:20, 168:26,

169:12

passes [1] - 12:7

past [3] -

126:14, 126:15,

213:1

path [1] - 213:24

pathway [1] -

213:3

pathways [1] -

20:21

patient [151] -

8:20, 10:14, 12:2,

15:6, 15:11,

15:20, 15:27,

20:7, 21:1, 28:16,

28:21, 29:20,

30:18, 32:5,

35:24, 36:27,

37:2, 37:4, 41:3,

41:12, 41:25,

42:6, 43:18, 45:2,

45:26, 47:3, 47:8,

48:15, 48:17,

50:9, 52:5, 52:17,

53:11, 56:13,

56:19, 56:21,

57:24, 59:14,

60:7, 60:9, 60:10,

61:9, 70:1, 70:29,

71:1, 71:14,

71:21, 72:11,

73:12, 74:28,

74:29, 82:8, 82:9,

83:9, 85:5, 85:7,

86:4, 89:12, 90:8,

90:12, 92:22,

93:23, 94:1, 94:3,

94:4, 94:15,

97:24, 98:11,

99:6, 99:10,

103:5, 105:6,

112:2, 117:3,

126:13, 126:16,

127:13, 127:20,

128:3, 128:12,

128:20, 128:25,

134:15, 134:26,

134:28, 135:9,

135:23, 136:8,

136:10, 136:20,

136:26, 136:27,

137:1, 137:12,

137:23, 137:25,

138:4, 138:8,

138:12, 138:23,

139:5, 139:13,

139:19, 139:20,

139:21, 139:24,

139:28, 140:12,

140:24, 140:25,

141:7, 141:16,

141:18, 142:19,

143:9, 143:15,

143:22, 144:8,

144:11, 145:3,

145:6, 145:9,

145:10, 145:16,

148:8, 151:14,

151:19, 151:23,

151:26, 153:3,

153:12, 153:13,

153:19, 154:3,

154:5, 155:28,

157:8, 158:6,

158:8, 164:4,

164:28, 169:17,

177:1, 191:14,

204:2, 209:24,

213:29

Patient [2] -

94:19, 117:8

patient's [18] -

12:10, 19:17,

19:19, 19:20,

19:29, 20:7,

21:14, 41:5,

56:16, 60:11,

71:14, 84:14,

93:26, 106:26,

134:16, 163:23,

163:24, 167:20

Patients [14] -

10:10, 15:2,

15:29, 19:7,

19:18, 21:15,

21:18, 21:23,

22:3, 22:14,

22:18, 24:25,

26:13, 111:21

patients [77] -

6:13, 8:21, 9:2,

10:19, 10:20,

10:21, 10:22,

10:24, 10:26,

16:8, 23:2, 24:13,

24:15, 24:21,

30:3, 30:5, 30:10,

35:15, 35:19,

35:23, 36:18,

36:20, 36:21,

36:28, 37:1,

40:23, 40:24,

41:9, 59:16, 71:9,

71:28, 77:7,

78:15, 78:17,

78:20, 78:28,

78:29, 79:1, 86:7,

88:9, 94:17,

94:17, 98:1,

99:17, 105:20,

117:6, 117:6,

138:10, 138:14,

139:14, 139:18,

139:26, 142:29,

143:3, 143:5,

144:6, 144:12,

144:13, 144:17,

153:10, 154:4,

154:19, 154:22,

154:26, 173:23,

176:7, 176:24,

177:4, 188:2,

191:2, 191:5,

191:22, 192:3,

203:2, 203:3

patients' [1] -

154:19

pattern [1] -

24:20

pause [7] -

52:25, 63:8,

74:27, 94:17,

117:6, 122:12,

190:11

paused [1] -

63:3

pelvis [1] -

164:10

people [29] -

22:27, 34:5, 37:9,

46:25, 77:6,

83:20, 84:25,

94:9, 97:22,

117:20, 136:23,

152:27, 185:6,

186:10, 192:15,

201:4, 203:18,

210:7, 212:22,

213:9, 213:13,

213:14, 213:17,

213:22, 213:23,

214:2, 214:5,

214:6

per [5] - 10:20,

16:16, 57:13,

73:21, 176:3

perceived [2] -

190:25, 201:26

perception [3] -

161:9, 161:10,

163:29

perfectly [1] -

204:22

perform [17] -

8:23, 17:26,

39:26, 46:21,

47:2, 49:20,

49:25, 52:27,

53:6, 57:6, 58:15,

58:17, 68:1, 70:7,

70:8, 71:25,

144:1

performance [7]

- 39:16, 46:5,

59:20, 77:9,

77:25, 82:16,

166:20

performed [11] -

15:15, 18:1,

40:21, 40:23,

43:9, 82:25, 88:8,

94:22, 95:1,

117:10, 176:3

performing [4] -

30:23, 51:5,

55:18, 56:11

perhaps [27] -

4:10, 24:18,

34:28, 35:3,

49:12, 53:11,

58:16, 90:5,

96:18, 98:29,

103:11, 103:15,

110:9, 147:15,

147:18, 171:9,

171:16, 175:24,

177:23, 178:17,

179:8, 183:5,

184:18, 188:6,

194:7, 200:16,

206:23

period [11] -

10:29, 22:15,

23:2, 23:4, 40:9,

93:22, 96:19,

96:27, 97:16,

100:1, 172:8

peripheral [1] -

24:17

permission [2] -

2:27, 79:17

persists [1] -

25:25

person [16] -

41:11, 44:26,

72:21, 89:21,

92:10, 93:17,

99:20, 113:23,

113:25, 140:17,

189:13, 201:12,

203:25, 203:28,

203:29, 205:22

person's [1] -

203:22

personal [2] -

68:27, 204:24

personality [2] -

138:19, 138:20

personally [9] -

55:16, 74:24,

75:23, 83:8, 85:2,

98:2, 169:6,

204:22, 211:27

personnel [2] -

94:2, 117:16

perspective [2] -

44:5, 191:19

phenomenon

[1] - 19:22

phlebotomy [1]

- 57:27

phone [1] -

22:29

photocopied [1]

- 2:26

photocopying

[1] - 183:22

physically [2] -

35:21, 61:29

pick [2] - 56:20,

191:23

picked [3] -

12:13, 14:15,


23

14:21

picture [1] - 51:3

piece [5] -

112:29, 115:14,

119:4, 119:6,

119:10

pieces [1] -

102:17

pilot [3] - 76:25,

165:22, 166:1

pity [1] - 29:16

place [32] -

17:29, 21:9,

22:18, 22:26,

23:1, 23:3, 28:15,

29:11, 48:12,

48:20, 49:7, 49:9,

67:8, 70:24,

84:27, 93:11,

101:11, 110:4,

114:2, 129:6,

138:7, 146:17,

150:7, 150:8,

150:13, 152:27,

160:20, 161:13,

203:16, 212:9

PLACE [1] - 1:17

placed [2] -

50:15, 52:12

places [1] -

152:28

plan [14] - 19:12,

27:27, 28:15,

28:18, 57:13,

165:7, 165:14,

165:22, 165:23,

165:25, 166:13,

169:28, 170:1,

170:2

plane [3] -

165:29, 210:22,

212:1

planned [5] -

82:26, 82:27,

164:20, 169:27,

170:6

planning [3] -

72:23, 73:14,

180:8

platform [1] -

7:26

pleasure [1] -

188:8

plenty [1] -

122:15

plus [1] - 173:17

point [48] - 4:7,

8:2, 31:2, 31:5,

31:11, 39:22,

40:12, 40:13,

46:12, 51:17,

63:12, 63:14,

64:8, 65:6, 65:15,

67:6, 68:7, 69:27,

83:2, 88:26,

92:23, 92:24,

93:26, 93:29,

104:13, 106:25,

119:6, 119:10,

123:4, 135:6,

158:15, 161:21,

161:23, 161:29,

162:11, 163:3,

167:23, 169:2,

173:11, 181:10,

181:13, 182:9,

188:25, 189:7,

192:13, 200:26,

201:11, 212:5

pointed [6] -

9:28, 147:10,

148:1, 148:23,

148:24, 163:18

pointing [4] -

147:22, 148:6,

148:13, 163:12

points [8] - 8:20,

19:29, 20:7, 93:2,

94:2, 94:4,

111:27, 199:2

policy [6] -

56:13, 71:12,

73:7, 151:25,

175:14, 176:23

polite [3] -

78:16, 78:18,

79:2

politically [1] -

10:1

poor [2] - 17:1,

204:8

poorly [1] -

164:13

porters [1] -

77:8

portion [2] -

120:22, 180:22

position [18] -

6:29, 32:11,

40:17, 58:11,

79:16, 86:1,

94:19, 115:6,

117:8, 140:24,

141:6, 141:18,

157:20, 158:17,

159:23, 168:4,

197:6, 197:25

positioned [1] -

145:10

positioning [2] -

60:10, 92:29

positions [1] -

10:2

positive [1] -

91:5

possibility [1] -

19:5

possible [26] -

19:3, 30:6, 31:9,

31:10, 35:21,

35:25, 55:24,

60:23, 69:8, 71:3,

88:21, 89:2,

91:28, 96:21,

98:12, 98:13,

100:21, 131:8,

132:27, 138:21,

143:12, 156:5,

156:8, 156:9,

164:18, 179:11

possibly [9] -

10:28, 29:4, 48:7,

53:18, 90:14,

121:28, 131:14,

158:27, 184:8

post [5] - 40:13,

40:14, 40:16,

126:19, 144:2

Post [1] - 7:15

posts [1] -

103:11

potential [6] -

67:9, 72:6,

117:28, 118:8,

139:4, 143:13

practical [1] -

77:25

practice [42] -

10:24, 25:25,

32:23, 32:25,

38:6, 40:19, 51:4,

51:22, 55:14,

55:27, 58:27,

73:7, 77:7, 85:21,

96:23, 97:27,

98:3, 113:23,

114:23, 124:18,

148:16, 150:19,

150:23, 151:23,

151:25, 152:3,

152:26, 159:6,

160:11, 160:16,

160:17, 174:14,

174:17, 174:25,

194:24, 197:15,

197:18, 197:23,

198:10, 202:13,

204:8, 211:3

Practice [1] -

85:16

practices [2] -

125:4, 194:19

PRACTISE [1] -

1:3

practised [3] -

176:20, 176:22

practitioner [2] -

17:11, 18:7

practitioners [3]

- 50:24, 76:22,

76:28

PRACTITIONE

RS [1] - 1:4

praise [1] -

159:20

praised [1] -

159:29

praising [2] -

159:25, 168:24

pre [6] - 56:29,

57:6, 75:3, 92:25,

144:2, 153:14

pre-admission

[1] - 75:3

pre-med [1] -

153:14

pre-operative

[3] - 56:29, 57:6,

92:25

precise [4] -

45:25, 128:28,

129:1, 129:4

precisely [3] -

77:2, 128:19,

128:21

predecessor [1]

- 15:14

predicted [1] -

106:24

prefer [1] -

186:10

premed [1] -

139:21

premedical [1] -

45:5

PRENTICE [1] -

2:19

preoperative [1]

- 93:5

preparation [3] -

58:9, 94:26,

139:10

prepare [16] -

52:21, 53:23,

82:17, 82:20,

94:19, 95:12,

117:7, 119:14,

123:9, 139:8,

155:5, 180:3,

184:25, 202:16,

205:23, 210:10

prepared [16] -

24:18, 117:18,

136:28, 155:21,

182:20, 183:2,

186:27, 187:5,

187:12, 187:26,

189:3, 190:7,

190:23, 192:18,

205:15, 205:24

preparing [2] -

144:21, 206:5

prepped [1] -

138:27

prerogative [1] -

125:9

present [12] -

108:5, 108:17,

108:19, 131:3,

131:25, 132:7,

141:2, 145:10,

162:2, 162:13,

163:6, 163:8

presentation [1]

- 214:18

presented [2] -

98:8, 177:3

presenting [1] -

200:4

preserved [2] -

56:17, 56:18

pressure [10] -

40:20, 51:26,

68:15, 74:18,

140:5, 146:6,

146:14, 157:28,

159:14, 167:11

pressured [1] -

125:4

pressures [2] -

83:11, 140:4

presumably [9] -

26:7, 42:10,

98:22, 115:20,

117:13, 135:25,

139:6, 141:6,

199:15

Presumably [1]

- 98:19

presume [4] -

28:2, 147:5,

193:19, 202:18

prevent [3] -

158:7, 208:27,

212:13

prevented [1] -

175:26

previous [5] -

18:19, 39:23,

61:10, 104:17,

147:13

previously [3] -

40:3, 40:21,

40:23

primarily [5] -

6:12, 15:22,

15:24, 19:11,

33:4

principally [1] -

185:9

principle [1] -

198:13

print [1] - 26:19

printed [2] -

26:27, 26:28

priorities [1] -

110:11

privacy [1] -

79:19

private [1] -

192:10

problem [34] -

9:13, 15:9, 15:20,

16:18, 17:17,

19:25, 31:10,

55:25, 55:26,

55:29, 57:29,

61:11, 69:12,

70:19, 71:5,

75:15, 87:5,

87:22, 88:6, 89:6,

89:7, 102:28,

103:22, 108:24,

110:17, 137:2,

142:1, 151:20,

151:29, 158:6,

181:10, 183:22,

203:13, 203:14

problems [14] -

9:9, 12:11, 57:19,

57:21, 59:19,

67:25, 74:3,

74:29, 77:27,

87:25, 136:15,

191:11, 192:16,

212:1

procedural [1] -

50:3

procedure [107]

- 28:28, 29:4,

29:5, 39:27,

41:28, 42:1,

42:18, 42:25,

42:27, 42:28,

42:29, 43:4,

43:11, 43:13,

43:16, 43:21,

44:11, 44:14,

44:18, 44:23,

45:2, 46:10,


24

46:14, 46:18,

46:19, 46:27,

46:29, 52:10,

53:9, 53:14,

53:16, 56:11,

56:14, 61:22,

61:23, 61:24,

61:29, 63:25,

63:28, 68:8,

68:13, 68:17,

71:26, 72:21,

74:27, 74:28,

76:5, 83:24,

89:13, 89:16,

89:28, 89:29,

90:12, 90:15,

90:18, 91:3,

92:10, 92:29,

95:15, 97:2,

97:25, 100:9,

101:14, 103:14,

103:18, 104:4,

104:5, 104:7,

104:8, 104:13,

104:22, 105:12,

105:15, 105:27,

113:22, 118:25,

121:8, 122:7,

123:17, 123:18,

125:12, 131:13,

131:20, 131:22,

133:3, 134:13,

135:11, 135:24,

137:13, 143:6,

147:6, 147:7,

148:18, 148:25,

164:20, 174:21,

175:23, 175:26,

175:28, 176:12,

177:1, 184:4,

184:4, 198:5,

198:7, 203:27

procedures [23]

- 7:28, 36:29,

40:27, 41:27,

43:10, 77:26,

97:28, 98:19,

100:13, 100:24,

122:22, 136:24,

149:27, 171:28,

172:21, 173:1,

173:7, 175:21,

176:3, 191:7,

200:23, 201:27,

203:23

proceed [12] -

47:9, 101:12,

122:20, 129:16,

129:17, 130:9,

130:10, 146:16,

146:20, 146:23,

146:24, 177:8

proceeded [1] -

102:29

proceeding [3] -

4:21, 125:14,

130:11

proceedings [1]

- 185:12

process [12] -

31:15, 33:3, 37:5,

61:25, 62:13,

124:9, 155:8,

157:18, 175:8,

176:7, 176:10,

215:10

processes [1] -

156:2

produce [6] -

26:14, 64:29,

128:1, 200:4,

202:11, 203:19

produced [6] -

127:18, 127:29,

128:9, 128:10,

143:24, 200:10

producing [1] -

15:16

Prof [77] - 4:22,

13:10, 13:15,

14:28, 15:13,

34:29, 40:10,

54:2, 57:10,

65:18, 74:7, 74:8,

74:9, 84:4, 91:4,

99:19, 103:25,

106:13, 108:15,

115:5, 115:21,

124:3, 124:11,

124:20, 131:15,

135:29, 150:5,

165:3, 165:20,

165:28, 166:10,

170:19, 174:5,

180:21, 181:16,

182:18, 183:10,

185:21, 187:27,

188:1, 188:4,

188:9, 189:13,

190:7, 190:20,

190:25, 191:14,

191:17, 192:20,

193:14, 196:27,

196:28, 197:9,

197:10, 197:12,

197:29, 198:16,

200:17, 201:24,

203:1, 204:12,

204:13, 204:16,

204:22, 206:10,

206:14, 206:21,

206:23, 207:1,

207:4, 207:10,

207:22, 207:24,

207:27, 208:1,

208:2, 209:21

pROF [2] - 1:9,

3:5

PROF [8] - 2:18,

4:24, 80:24,

107:2, 108:12,

171:13, 177:12,

179:1

profession [1] -

158:24

professional [5]

- 54:3, 81:14,

203:5, 204:3,

204:10

professionally

[2] - 85:2, 204:7

professor [1] -

80:27

Professor [60] -

4:27, 5:2, 5:6,

5:8, 5:15, 5:20,

8:14, 8:16, 11:2,

11:5, 11:16, 20:2,

29:24, 38:27,

40:26, 42:3,

47:20, 54:8, 55:1,

59:27, 68:18,

68:21, 68:23,

70:4, 74:23,

76:15, 77:11,

79:22, 79:25,

87:16, 90:19,

91:12, 92:14,

106:27, 116:9,

124:1, 128:5,

132:16, 133:19,

133:24, 134:7,

139:2, 142:21,

149:20, 156:27,

158:12, 166:7,

169:21, 169:27,

170:12, 171:21,

173:15, 177:17,

178:24, 179:6,

179:19, 183:3,

184:27

Professor's [1] -

4:29

profoundly [1] -

67:16

profusely [1] -

67:16

Programme [4] -

16:21, 17:4,

18:16

progress [3] -

20:8, 106:26,

173:8

progresses [1] -

195:24

progression [1]

- 83:10

proleptic [1] -

5:12

prompted [1] -

76:9

proof [1] - 91:5

proper [6] -

69:25, 73:12,

101:6, 123:24,

184:20, 208:20

properly [6] -

34:21, 50:4, 50:5,

51:21, 105:27,

210:10

prophecy [1] -

212:28

prophylactic [2]

- 18:29, 70:10

Prophylaxis [1]

- 18:12

proposal [1] -

214:22

propose [8] -

4:20, 74:23,

170:20, 185:16,

187:6, 198:20,

198:28, 214:21

proposing [1] -

60:19

protect [2] -

169:1, 177:20

protected [2] -

105:24, 106:2

protocol [5] -

106:11, 151:26,

173:3, 212:7,

212:12

protocols [8] -

106:4, 106:6,

172:16, 173:10,

212:7, 212:8,

212:19

protracted [1] -

172:8

proven [2] -

81:13, 109:13

provide [1] -

110:4

provided [5] -

35:26, 105:23,

190:9, 199:7,

200:19

providing [4] -

38:16, 38:28,

198:20, 198:29

provision [1] -

58:11

public [1] -

175:19

pull [4] - 35:9,

101:24, 133:12

pulled [1] -

64:25

Punang [1] -

32:12

PURCELL [1] -

2:14

pure [1] - 159:8

purely [1] -

69:20

Puri [5] - 40:10,

74:7, 74:8, 74:9,

135:29

purpose [2] -

32:28, 81:15

purposes [1] -

127:17

put [45] - 7:4,

20:20, 34:18,

41:25, 43:9, 48:4,

48:10, 48:11,

48:13, 48:19,

49:3, 49:8, 50:23,

53:21, 53:26,

54:5, 55:8, 60:11,

63:5, 64:25,

68:14, 90:4,

93:10, 96:26,

103:29, 109:8,

113:24, 114:20,

121:19, 128:5,

132:16, 138:2,

146:5, 146:13,

149:20, 157:19,

158:16, 160:9,

161:8, 194:12,

194:17, 199:24,

201:14, 203:16,

209:20

puts [1] - 182:23

putting [2] -

142:22, 194:8

Q

quadrant [7] -

60:16, 60:28,

61:9, 82:23,

82:28, 104:19,

147:19

Quaglia [2] -

39:14, 39:15

qualifications

[1] - 196:13

qualified [3] -

100:25, 100:26,

196:14

qualify [1] -

214:25

qualities [1] -

187:29

Quality [1] - 8:9

quality [5] -

28:19, 37:17,

37:18, 76:2, 78:5

quarter [1] -

107:11

queried [1] -

163:24

queries [4] -

33:25, 59:15,

93:8, 154:19

query [6] -

31:14, 32:15,

32:16, 92:27,

129:29, 130:3

querying [1] -

128:7

QUESTIONED

[3] - 3:8, 171:13,

211:25

qUESTIONED

[1] - 3:18

QUESTIONING

[2] - 177:10,

214:12

questioning [4]

- 48:25, 119:8,

177:23, 195:24

questions [19] -

49:12, 49:13,

62:27, 79:5, 79:6,

79:26, 106:28,

170:22, 170:26,

171:11, 171:19,

173:24, 174:4,

184:27, 189:21,

192:27, 205:7,

211:22, 213:19

quickly [3] -

77:23, 153:17,

156:5

quinn [3] -

73:21, 75:13,

99:11

Quinn [2] - 10:6,

31:18

Quinn's [1] -

99:11

quite [37] - 9:20,

18:8, 18:12,

20:11, 23:2,

23:28, 38:10,

44:7, 56:22,


25

57:20, 60:24,

72:1, 72:7, 83:23,

86:22, 88:19,

90:25, 93:25,

95:8, 95:20,

95:24, 96:22,

129:3, 131:8,

135:9, 135:12,

135:14, 135:15,

137:14, 138:24,

143:27, 145:22,

152:28, 153:25,

170:4, 192:15,

208:6

R

radiation [1] -

191:7

radiograph [2] -

116:9, 166:29

radiographs [9]

- 115:25, 116:4,

116:6, 116:10,

116:12, 148:16,

151:6, 155:12,

160:11

Radiography [1]

- 20:24

radiography [19]

- 109:22, 109:27,

110:25, 111:7,

111:12, 111:18,

112:5, 112:11,

112:17, 113:2,

113:21, 115:7,

115:12, 115:22,

120:29, 148:21,

156:1, 162:13,

163:10

radiological [4]

- 82:12, 82:13,

87:12, 159:27

radiologist [4] -

21:10, 25:21,

70:25, 71:7

Radiologist [1] -

26:2

radiologist's [1]

- 70:24

radiology [18] -

12:3, 20:29,

25:13, 70:16,

70:22, 70:28,

71:11, 71:17,

72:10, 75:6, 75:8,

84:27, 198:9,

198:11, 213:1,

213:2, 213:8

radius [1] - 77:9

rafters [1] -

168:25

raise [6] - 30:26,

85:4, 161:15,

176:14, 185:3,

212:5

raised [20] -

30:22, 30:25,

31:1, 31:5, 31:14,

31:16, 32:15,

33:14, 34:10,

35:5, 94:5,

110:20, 110:24,

111:7, 111:25,

174:11, 177:17,

195:26, 202:28

raises [1] -

181:23

raising [3] -

111:13, 158:10,

158:13

ran [2] - 95:19,

97:27

rang [1] - 45:4

ranks [1] -

103:10

rate [2] - 90:8,

176:4

rather [8] - 12:6,

55:13, 66:24,

85:19, 99:20,

127:2, 169:21,

175:15

Ray [1] - 191:17

ray [34] - 12:23,

14:10, 14:11,

14:13, 19:19,

19:25, 20:5, 20:6,

20:9, 20:12,

20:16, 20:27,

20:29, 21:6, 21:9,

21:12, 27:17,

27:18, 27:19,

35:9, 50:16,

50:17, 50:18,

51:3, 53:3, 63:18,

64:29, 69:10,

70:26, 102:25,

160:6, 162:7

rays [53] - 19:17,

19:27, 19:28,

20:11, 20:13,

20:15, 20:18,

20:22, 20:27,

21:8, 21:13,

21:22, 21:24,

22:2, 25:13,

27:17, 32:22,

32:25, 32:28,

33:12, 34:14,

35:13, 50:26,

51:16, 51:17,

51:18, 51:20,

52:25, 63:4, 63:6,

64:13, 64:19,

64:25, 71:13,

71:18, 71:19,

71:22, 75:1, 75:2,

89:15, 97:5,

102:24, 104:24,

104:26, 113:28,

162:5, 162:9,

175:3, 176:15,

212:17

re [4] - 34:5,

66:17, 66:28,

176:26

RE [3] - 3:9,

179:1, 185:1

re-assurance [1]

- 176:26

RE-DIRECT [1] -

3:9

RE-

EXAMINATION

[1] - 185:1

RE-EXAMINED

[1] - 179:1

re-implant [1] -

66:17

re-vascularise

[1] - 66:28

reached [2] -

62:27, 106:9

reaction [1] -

137:22

read [27] - 81:28,

84:3, 88:1, 94:14,

109:26, 111:12,

111:18, 112:11,

112:17, 115:7,

115:12, 115:15,

115:16, 115:24,

115:28, 116:3,

116:6, 116:9,

116:12, 117:25,

117:27, 184:8,

187:14, 187:16,

189:4, 190:10,

190:12

reading [6] -

110:25, 113:1,

113:2, 113:20,

115:22, 159:24

ready [6] -

122:23, 130:9,

130:10, 139:5,

139:11, 210:3

real [2] - 213:20

realised [3] -

29:6, 38:15,

136:12

reality [4] -

102:24, 122:9,

122:13, 212:23

really [25] -

25:28, 28:15,

50:23, 55:6,

83:21, 88:14,

104:26, 110:24,

111:17, 123:15,

139:14, 139:22,

146:10, 151:5,

178:8, 178:20,

181:2, 181:8,

199:8, 199:14,

200:9, 202:27,

208:4, 212:15,

213:12

reason [9] -

33:5, 87:8, 92:1,

104:29, 119:17,

139:6, 146:4,

161:3, 161:5

reasonable [9] -

72:7, 86:12, 92:5,

93:19, 138:24,

148:20, 168:3,

204:22, 209:2

reasons [2] -

55:19, 95:7

reassemble [1] -

215:17

recalling [1] -

195:17

receive [3] -

71:8, 206:10

received [3] -

152:19, 181:15,

207:27

recent [1] -

173:9

recently [6] -

7:29, 9:15, 18:9,

39:7, 69:21,

173:4

reception [7] -

45:27, 52:6,

63:12, 127:14,

127:21, 128:26,

164:3

recognise [5] -

29:12, 58:26,

59:2, 110:11,

189:6

recognised [2] -

108:25, 188:11

recognises [1] -

58:21

recognising [1]

- 176:2

recognition [1] -

74:3

recollect [1] -

134:6

recollection [17]

- 27:1, 49:24,

127:23, 127:24,

128:20, 131:24,

132:15, 133:28,

133:29, 135:19,

135:22, 137:24,

145:11, 146:8,

150:8, 150:27,

163:20

recommendati

on [1] - 104:16

recommendati

ons [6] - 24:27,

69:16, 74:22,

74:25, 160:17,

175:29

recommended

[4] - 24:29, 25:1,

172:13, 175:29

reconstruction

[1] - 23:10

record [10] -

14:10, 16:2,

17:22, 47:25,

51:14, 57:12,

66:23, 96:6,

106:15, 128:2

recorded [4] -

11:25, 18:26,

25:2, 160:27

recording [2] -

14:9, 81:19

records [14] -

11:4, 13:1, 62:15,

69:10, 75:16,

81:19, 82:5, 82:7,

82:10, 87:14,

103:5, 151:13,

155:12, 162:12

recount [1] -

96:8

rectum [2] -

15:13, 15:15

recurrent [5] -

18:8, 70:9, 99:7,

99:9, 134:8

red [3] - 29:15,

213:20

redacted [2] -

41:2, 199:13

reduced [1] -

74:19

redundant [1] -

209:12

refer [3] - 24:15,

63:14

reference [6] -

36:14, 63:15,

69:11, 161:21,

179:14, 190:23

references [1] -

123:24

referral [2] -

17:12, 24:20

referred [8] -

14:26, 15:22,

17:10, 37:10,

56:9, 74:9, 76:13,

164:6

referring [4] -

14:7, 14:19,

129:2, 156:28

refers [3] -

13:11, 13:29,

14:4

reflect [2] -

62:13, 143:20

reflected [3] -

44:27, 78:29,

212:29

reflects [3] -

122:27, 150:1,

151:16

reflux [16] -

11:26, 12:2, 12:4,

12:5, 12:9, 12:11,

12:12, 12:20,

13:2, 13:11,

13:18, 14:1, 89:3,

164:8, 164:12

regard [12] -

24:2, 50:8, 51:10,

85:28, 98:28,

113:27, 140:2,

156:16, 161:27,

175:3, 200:15,

201:26

regarded [6] -

39:26, 55:23,

100:20, 156:15,

158:3, 166:16

register [3] -

159:3, 172:14,

201:19

registered [1] -

201:21

Registrar [20] -

6:1, 6:3, 13:9,

13:15, 15:6,

22:23, 22:25,

28:27, 28:29,

30:9, 31:3, 36:21,

37:16, 38:21,

38:28, 39:1, 39:9,


26

40:5, 46:13, 73:1

registrar [24] -

58:20, 58:23,

58:29, 72:5, 73:4,

89:29, 90:14,

90:24, 90:26,

91:7, 91:9, 91:10,

91:14, 91:15,

91:17, 99:21,

99:25, 101:22,

158:26, 163:20,

163:28, 173:7,

193:22, 197:5

registrars [10] -

89:23, 89:26,

91:1, 91:18,

91:24, 91:27,

91:29, 97:28,

106:5, 180:20

Registrars [5] -

10:25, 16:10,

22:28, 38:24,

39:7

regrettably [2] -

20:10, 27:10

regular [4] -

24:9, 55:10,

57:28, 91:9

relate [4] -

53:17, 55:2, 55:4,

174:25

related [4] -

14:24, 16:1,

213:17

relates [2] -

72:24, 73:8

relating [2] -

179:6, 194:23

relation [35] -

15:10, 16:6,

17:15, 26:10,

31:14, 38:3, 46:4,

51:4, 54:19,

55:17, 56:10,

56:11, 57:17,

58:11, 59:15,

61:26, 68:3,

68:19, 70:7,

70:17, 71:4,

76:16, 77:23,

85:14, 118:28,

173:10, 179:6,

190:28, 194:24,

195:1, 195:2,

197:8, 197:9,

197:16, 200:12

relations [1] -

6:19

relationship [3]

- 55:22, 159:2,

193:13

relatively [5] -

18:10, 91:13,

91:23, 98:24,

103:18

relatives [1] -

78:20

relaxed [1] -

105:28

release [3] -

20:6, 71:18,

133:12

released [1] -

19:29

relevant [3] -

110:5, 110:24,

180:13

reliable [1] -

77:29

reluctance [1] -

130:2

reluctant [1] -

195:14

remained [3] -

24:23, 34:16,

196:22

remaining [3] -

81:5, 81:10,

199:6

remains [1] -

48:2

remember [7] -

43:25, 77:2,

105:5, 105:6,

132:9, 134:12,

134:24

remind [4] -

83:27, 83:29,

84:10, 179:19

removal [4] -

70:1, 132:21,

133:2, 166:11

removals [1] -

98:23

remove [4] -

41:3, 65:11,

65:26, 65:28

removed [12] -

34:1, 65:6, 65:10,

67:9, 67:13,

67:27, 70:14,

109:22, 160:13,

161:20, 163:4,

163:8

removing [1] -

112:14

renal [16] -

15:23, 17:26,

18:19, 65:22,

65:23, 65:27,

65:29, 66:3, 66:4,

67:6, 87:20,

87:25, 99:9,

100:8

repair [13] -

43:3, 44:6, 44:7,

44:9, 45:28,

61:11, 99:2, 99:3,

130:26, 131:10,

131:23, 133:27,

135:3

repairs [2] -

98:22, 98:23

repeat [2] -

116:7, 152:1

repeatedly [1] -

213:19

repercussion

[1] - 157:29

rephrase [1] -

34:26

replicated [2] -

12:16, 87:19

replication [1] -

13:4

replied [2] -

64:13, 88:29

report [131] -

11:22, 11:25,

11:29, 12:4,

12:13, 13:5,

14:14, 19:18,

19:20, 19:21,

21:10, 21:11,

21:13, 21:19,

21:26, 21:29,

25:6, 25:12,

25:16, 25:18,

25:20, 25:21,

25:23, 25:29,

26:5, 26:14,

26:15, 26:16,

26:20, 26:21,

26:27, 26:28,

27:5, 27:6, 27:9,

27:12, 27:14,

27:16, 27:18,

27:20, 28:8,

30:27, 64:27,

64:29, 68:21,

68:24, 68:25,

68:27, 69:2, 69:4,

69:16, 72:10,

74:6, 87:4, 87:12,

87:25, 88:15,

88:21, 88:25,

92:3, 93:28,

94:27, 96:8,

96:10, 111:23,

116:25, 117:18,

117:22, 117:25,

117:27, 117:29,

118:2, 118:4,

118:7, 123:21,

123:27, 124:1,

124:2, 124:23,

155:7, 156:17,

156:23, 156:25,

156:26, 179:26,

179:27, 180:1,

180:7, 180:10,

180:18, 180:22,

180:29, 182:18,

182:21, 182:23,

198:18, 198:21,

198:26, 198:28,

199:3, 199:5,

199:11, 199:13,

199:26, 200:8,

205:16, 205:19,

205:24, 205:27,

206:2, 206:6,

206:15, 206:16,

206:18, 206:20,

206:26, 207:3,

207:6, 207:29,

208:6, 208:9,

213:14

Report [5] -

92:15, 92:16,

94:13, 116:21,

116:23

report...(

INTERJECTION

[1] - 181:27

reports [28] -

19:13, 19:16,

19:21, 19:23,

20:9, 20:12,

21:12, 25:6,

25:26, 25:28,

26:4, 26:6, 26:8,

31:7, 31:8, 69:10,

69:18, 69:23,

75:17, 82:13,

86:13, 88:18,

88:19, 124:12,

175:3, 200:5,

206:17

reports...(

INTERJECTION)

[1] - 21:3

representative

[1] - 171:21

reproduced [1] -

2:26

Republic [1] -

208:25

reputation [1] -

6:9

request [6] -

58:3, 58:7, 66:23,

104:6, 151:15,

207:28

requested [4] -

45:14, 97:1,

125:15, 137:13

requesting [2] -

66:24, 151:21

requests [2] -

76:7, 76:8

require [2] -

113:4, 202:8

required [5] -

27:27, 52:20,

150:20, 153:14,

172:1

requirement [1]

- 200:11

requires [1] -

191:3

requiring [1] -

18:11

research [1] -

6:14

resection [2] -

99:7, 99:8

resolve [1] -

178:8

resolved [1] -

94:8

resource [1] -

57:4

resources [2] -

77:28, 151:24

respect [14] -

61:27, 79:15,

79:18, 85:25,

90:19, 109:29,

110:8, 129:3,

135:6, 144:10,

158:13, 159:10,

181:24, 197:11

respectful [2] -

78:17, 78:18

respectfully [1] -

128:27

respond [1] -

199:23

respondent [1] -

2:27

responding [2] -

180:29, 181:4

response [6] -

46:8, 92:27,

116:4, 176:9,

177:22, 180:28

responsibile [3]

- 93:17, 101:29,

203:3

responsibility

[54] - 52:2, 59:1,

68:12, 68:13,

82:4, 83:19, 84:8,

85:5, 85:11,

85:12, 85:15,

85:17, 85:22,

85:24, 85:27,

86:7, 86:9, 86:15,

95:16, 104:2,

104:4, 113:20,

113:26, 113:27,

114:1, 123:16,

124:10, 124:19,

149:23, 150:24,

169:5, 169:8,

169:9, 169:14,

169:15, 171:23,

171:27, 172:4,

175:19, 202:29,

203:4, 203:8,

203:17, 203:18,

203:21, 203:22,

203:29, 204:2,

204:21, 204:24,

205:1, 209:5,

209:6, 212:21

responsible [16]

- 7:13, 84:14,

84:21, 85:2, 85:7,

85:8, 113:1,

173:20, 191:1,

203:1, 203:9,

203:12, 203:26,

203:27, 214:6

rest [3] - 104:22,

161:8, 170:29

restored [1] -

170:21

result [4] -

25:23, 70:22,

73:29, 74:14

resulted [2] -

24:20, 69:26

results [8] -

16:29, 18:24,

19:12, 20:21,

22:28, 26:10,

71:1, 165:25

resume [7] - 4:8,

80:21, 107:12,

108:6, 153:6,

171:10, 171:17

RESUMED [4] -

4:1, 80:18, 108:1,

171:6

retain [1] - 42:15

retained [2] -

16:24, 21:4

retired [2] -


27

190:18, 190:29

retrieval [1] -

20:15

retrieved [2] -

20:25, 109:7

retrograde [1] -

16:22

retrogradely [1]

- 12:7

retrospect [2] -

12:1, 34:12

return [3] - 6:24,

23:23, 160:19

returned [3] -

39:10, 40:7,

159:4

revascularise

[3] - 34:2, 67:14,

109:18

revascularised

[1] - 108:20

revert [1] -

161:20

review [55] -

10:24, 12:3,

19:11, 22:2,

28:25, 29:7, 29:8,

29:19, 47:20,

52:25, 55:26,

64:26, 68:18,

72:10, 72:22,

72:29, 73:4,

73:16, 74:5,

74:22, 76:16,

79:23, 82:5,

82:12, 89:9,

89:11, 89:14,

89:18, 92:8,

92:10, 94:10,

95:17, 97:5,

101:15, 104:9,

116:20, 117:25,

122:12, 122:16,

123:7, 124:11,

124:20, 124:21,

125:7, 125:10,

149:29, 155:12,

157:8, 157:18,

160:5, 160:11,

161:22, 179:26,

206:19, 215:14

Review [3] -

27:12, 92:7, 96:2

reviewed [24] -

12:24, 21:10,

22:6, 25:21,

29:10, 70:17,

75:2, 82:7, 88:9,

92:22, 92:28,

93:21, 93:28,

94:7, 95:26,

103:23, 123:20,

155:29, 161:23,

162:1, 176:15,

177:2, 197:19,

197:29

reviewers [1] -

183:3

reviewing [3] -

51:17, 113:28,

197:16

rib [1] - 60:28

right" [1] -

174:15

right-hand [3] -

16:4, 92:13,

92:18

right-sided [1] -

89:6

risk [4] - 26:6,

76:10, 175:14,

176:9

Risk [1] - 8:9

Rob [1] - 206:19

robust [1] -

213:4

role [14] - 7:13,

38:4, 68:3, 78:23,

96:21, 99:25,

152:22, 171:26,

173:14, 191:9,

191:18, 194:20,

197:5, 204:14

roles [2] -

117:21, 171:26

roll [1] - 60:11

room [13] -

22:19, 22:20,

22:22, 22:24,

26:22, 59:17,

64:2, 64:3, 65:19,

105:16, 153:28,

203:22, 203:26

rooms [2] - 22:8,

26:18

root [1] - 175:8

rota [2] - 9:13,

10:10

rotate [1] - 7:16

rotating [1] -

40:10

rotation [1] -

6:21

rotations [1] -

90:20

roughly [1] -

17:5

round [13] -

29:22, 30:10,

30:11, 30:12,

30:14, 32:7,

32:22, 32:24,

33:8, 51:19,

92:26, 93:6

rounds [5] -

8:22, 23:14,

23:25, 30:7, 30:9

routine [1] - 64:6

routinely [2] -

56:20, 152:8

row [1] - 183:15

Royal [4] - 5:9,

172:29, 173:15,

173:27

run [4] - 8:14,

37:11, 57:19,

154:21

running [3] -

67:1, 94:15,

117:4

runs [1] - 55:14

rush [2] - 167:3,

193:20

rushing [1] -

167:7

RYAN [1] - 2:13

S

sacral [1] -

15:18

sad [1] - 67:10

sadness [1] -

29:17

safe [5] - 152:13,

203:19, 203:27,

210:29, 213:29

safely [2] -

209:17

Safer [2] - 8:10,

8:14

safety [2] -

84:14, 176:19

saline [1] - 16:22

salvage [1] -

44:24

SAME [4] - 5:1,

5:4, 11:8, 40:27

sample [12] -

56:17, 57:23,

57:26, 57:29,

58:2, 77:19,

151:21, 152:1,

152:2, 152:16

samples [1] -

77:18

sat [1] - 39:19

satisfied [7] -

104:11, 148:21,

160:29, 161:7,

162:16, 162:25

Saudi [1] - 72:5

saw [10] - 15:6,

16:10, 19:7,

26:25, 76:13,

109:9, 138:8,

139:18, 192:8,

192:9

SC [2] - 2:8, 2:21

scan [11] -

17:26, 18:21,

18:24, 18:25,

18:26, 19:9, 65:4,

88:5, 88:8, 88:11,

88:25

scanned [1] -

19:13

scans [4] - 18:1,

25:7, 26:11,

212:18

scar [10] - 60:19,

61:1, 61:3, 61:4,

61:7, 61:8, 61:9,

61:13, 61:27

scarred [2] -

70:13, 88:2

scarring [1] -

88:22

scars [1] - 60:21

scenario [2] -

27:13, 37:10

schedule [1] -

23:28

scheduled [1] -

179:10

scheduling [1] -

179:7

school [1] - 40:2

score [1] - 77:9

scores [1] -

78:29

screen [9] -

20:16, 25:26,

26:26, 27:21,

44:25, 50:17,

50:18, 63:5,

109:8

screening [1] -

64:26

scripting [1] -

175:5

scrub [1] - 134:9

scrubbed [2] -

44:24, 65:5

second [31] -

31:17, 37:22,

42:20, 57:14,

57:23, 58:3, 58:8,

60:4, 60:5, 60:7,

69:9, 73:19,

73:20, 81:26,

97:29, 115:9,

115:14, 116:26,

123:5, 126:6,

126:12, 126:17,

126:26, 129:13,

129:23, 172:22,

173:29, 175:17,

183:16, 184:10

secondary [1] -

40:2

secondly [1] -

81:12

secretarial [1] -

69:23

secretaries [1] -

77:8

secretary [1] -

69:24

secure [1] - 59:2

securing [1] -

114:23

see [66] - 10:20,

10:23, 10:28,

13:29, 14:17,

17:19, 23:1, 24:5,

26:28, 28:21,

29:21, 30:3,

33:28, 49:27,

54:24, 54:26,

59:14, 90:23,

92:12, 92:19,

94:18, 94:24,

98:5, 99:14,

110:18, 111:24,

112:1, 115:5,

117:7, 118:26,

120:8, 120:19,

123:23, 127:4,

127:15, 127:22,

127:26, 133:20,

133:24, 135:20,

135:25, 136:15,

136:21, 137:15,

138:9, 138:14,

139:14, 139:17,

139:19, 139:26,

142:29, 143:3,

143:5, 144:12,

144:13, 144:14,

145:3, 154:4,

154:5, 154:21,

156:14, 168:22,

174:17, 184:17,

201:15, 206:5

seeing [2] -

154:26, 189:17

seek [2] - 74:24,

134:7

seem [10] -

14:20, 31:19,

32:20, 42:19,

96:6, 99:6, 126:8,

173:16, 204:24,

213:11

sees [1] - 30:5

selection [1] -

145:26

self [2] - 124:1,

212:28

self-fulfilling [1]

- 212:28

send [2] - 136:8,

168:27

sending [3] -

140:12, 154:3,

177:4

senior [22] - 7:4,

15:14, 31:28,

32:4, 39:6, 39:7,

44:26, 58:24,

75:14, 86:15,

97:28, 99:25,

100:17, 100:22,

103:9, 158:27,

171:25, 172:3,

173:7, 178:17,

197:5, 202:9

Senior [7] -

28:26, 28:29,

31:3, 36:20,

37:16, 39:6,

46:13

seniority [2] -

61:21, 168:28

seniors [2] -

157:19, 158:17

sense [16] -

16:27, 97:11,

104:3, 104:15,

105:13, 110:23,

113:17, 135:18,

143:29, 148:9,

209:14, 210:24,

210:25, 210:26,

210:27

sensed [1] -

212:11

sensible [1] -

214:27

sensitised [1] -

161:16

sensitivities [2]

- 162:19, 162:22

sensitivity [1] -

162:23

sent [17] - 17:28,

56:15, 57:23,

71:11, 75:6, 75:8,


28

77:3, 119:23,

136:19, 136:26,

137:12, 137:23,

139:24, 139:28,

151:21, 152:2,

153:13

separate [2] -

20:28, 127:2

SEPTEMBER [3]

- 1:15, 4:2,

215:20

September [9] -

8:6, 17:9, 17:18,

84:12, 120:2,

120:17, 120:24,

181:20, 182:6

September...(

INTERJECTION

[1] - 181:1

sequence [3] -

48:14, 93:13,

175:6

series [3] -

29:14, 100:12,

173:21

serious [11] -

15:20, 75:15,

99:4, 99:5,

100:15, 100:28,

105:21, 109:10,

124:13, 124:21,

137:21

seriously [6] -

25:28, 85:29,

86:20, 86:24,

106:18, 209:8

seriousness [2]

- 98:20, 99:16

serum [1] -

56:17

service [21] -

7:10, 9:17, 10:17,

23:7, 24:4, 28:27,

35:22, 35:26,

35:27, 36:6,

36:12, 57:27,

74:13, 74:19,

78:6, 83:12,

95:21, 97:1,

100:3, 106:3,

125:4

Services [3] -

1:27, 2:26, 2:27

services [1] -

24:5

serving [1] - 7:3

sessions [2] -

10:14, 74:4

set [8] - 7:21,

77:14, 95:16,

122:25, 166:18,

169:4, 191:12,

196:13

sets [1] - 153:22

setting [3] -

70:2, 154:23,

173:23

settled [1] -

167:24

seven [3] - 23:4,

23:5, 104:28

several [8] - 7:9,

71:16, 75:20,

87:24, 117:24,

117:26, 123:11,

123:12

severe [3] -

18:8, 28:17, 70:9

shaped [1] -

16:24

share [2] -

26:19, 203:18

sheet [2] -

127:18, 127:25

Sheridan [3] -

11:13, 12:28

shining [1] -

51:2

ship [4] -

203:12, 203:13,

212:4, 212:5

ship's [2] -

203:11

SHO [22] - 5:23,

22:23, 22:24,

32:7, 32:9, 41:10,

58:18, 58:23,

58:29, 71:27,

71:29, 72:7,

72:11, 72:12,

72:19, 72:29,

111:23, 150:21,

150:22, 172:21,

172:22

SHO's [1] -

71:27

shocked [3] -

64:23, 76:4

shoes [1] - 55:8

SHORT [4] -

80:16, 80:18,

171:3, 171:6

short [27] -

42:25, 43:10,

44:14, 80:11,

80:13, 85:29,

86:20, 86:24,

94:22, 95:11,

95:18, 95:24,

96:22, 97:2,

100:14, 102:10,

103:14, 117:11,

124:13, 125:21,

166:27, 170:20,

186:2, 186:25,

201:10, 201:17

short... [1] -

124:21

shorthand [1] -

1:29

shortly [5] -

8:12, 45:11,

124:24, 127:21,

157:16

SHOs [2] -

10:25, 22:27

show [1] -

172:23

showed [2] -

13:17, 88:2

showing [1] -

13:2

shown [1] -

164:2

shows [4] -

15:28, 57:5,

57:14, 65:22

shrunken [1] -

104:21

siblings [1] -

191:9

sick [5] - 35:22,

70:11, 91:19,

100:12, 191:22

side [53] - 12:5,

12:9, 12:12,

12:25, 13:18,

16:4, 25:9, 27:2,

28:3, 33:1, 34:14,

34:15, 35:4, 35:5,

35:10, 50:13,

51:28, 60:11,

60:12, 81:20,

82:25, 82:28,

83:9, 88:26, 89:3,

92:27, 103:21,

103:22, 103:23,

145:17, 145:25,

145:28, 147:22,

147:27, 148:4,

148:6, 148:10,

148:11, 148:13,

148:22, 148:23,

148:24, 148:27,

149:24, 156:21,

163:14, 163:17,

163:18, 163:22,

163:24, 163:25

side" [1] - 62:8

sided [14] -

11:26, 12:1,

12:20, 13:11,

14:1, 14:4, 14:8,

14:10, 14:19,

89:3, 89:6,

147:28, 184:4

sight [1] - 73:9

sign [2] - 176:7,

176:8

signed [4] -

25:12, 25:22,

26:1, 76:12

significance [2]

- 11:28, 111:2

significant [25] -

7:22, 9:11, 9:13,

10:9, 12:8, 18:8,

24:20, 28:17,

29:18, 36:12,

42:11, 69:13,

69:22, 75:16,

83:22, 95:21,

99:29, 100:4,

117:21, 137:25,

138:17, 164:8,

202:5, 202:7

significantly [7]

- 24:22, 24:23,

56:28, 61:5,

75:26, 100:8,

195:4

signs [1] -

165:24

similar [2] -

22:22, 149:26

simple [13] -

100:6, 100:9,

100:14, 100:19,

100:25, 133:6,

133:12, 152:11,

174:26, 175:4,

202:27, 210:4,

210:5

simplistically

[1] - 93:25

simply [8] -

26:25, 90:17,

95:8, 97:9, 132:9,

142:22, 159:22,

214:25

simultaneous

[1] - 74:4

simultaneously

[3] - 37:8, 94:15,

117:4

single [4] -

35:24, 191:14,

203:21, 203:25

sink [1] - 22:20

sit [4] - 22:21,

22:23, 22:25,

55:25

site [7] - 73:6,

82:26, 93:9,

145:27, 147:13,

148:9, 163:13

siting [1] - 73:12

sitting [1] -

153:28

situation [33] -

16:17, 17:7, 28:8,

29:6, 32:2, 32:29,

35:8, 37:10, 57:1,

63:4, 63:16,

63:22, 68:7, 70:9,

76:3, 76:7, 85:21,

97:1, 106:5,

111:1, 150:3,

150:26, 152:15,

158:2, 160:2,

161:19, 168:16,

177:2, 178:3,

207:26, 208:14,

211:7, 212:24

situations [5] -

51:26, 95:20,

160:13, 164:29,

165:23

six [12] - 6:6,

39:10, 39:23,

40:8, 40:9, 40:12,

90:20, 90:21,

90:22, 90:27,

91:24, 99:29

sixth [1] - 71:24

size [1] - 22:22

skill [1] - 77:24

skills [3] - 7:25,

78:7, 78:21

skin [9] - 47:22,

48:1, 48:5, 49:21,

51:24, 52:1,

52:21, 53:6, 53:9

skipping [1] -

59:27

sleep [1] -

128:26

slides [1] -

159:27

slight [1] - 5:14

slightly [1] -

41:24

Sloan [13] - 6:7,

6:10, 6:18, 6:20,

6:21, 6:24, 39:11,

39:15, 40:7,

100:1, 100:2,

159:5

Sloan-

Kettering [13] -

6:7, 6:10, 6:18,

6:20, 6:21, 6:24,

39:11, 39:15,

40:7, 100:1,

100:2, 159:5

slot [1] - 37:3

slow [3] - 16:14,

20:2, 123:17

small [11] - 11:7,

16:1, 16:23,

22:19, 59:10,

76:6, 81:19,

104:20, 133:23,

174:10, 174:12

smaller [3] -

11:14, 12:27,

208:24

socially [3] -

16:26, 16:28,

17:6

soiling [1] - 16:7

solely [1] -

130:20

solicitor [2] -

125:23, 157:1

solicitors [1] -

207:28

SOLICITORS [3]

- 2:14, 2:20, 2:24

solid [1] - 39:12

solved [1] -

69:27

someone [9] -

64:26, 68:15,

84:22, 103:15,

104:6, 112:13,

147:3, 209:4

sometimes [5] -

10:22, 41:23,

89:14, 90:21,

151:29

somewhat [6] -

96:28, 101:16,

109:13, 139:21,

168:17, 209:12

somewhere [2] -

53:12, 84:2

soon [2] - 9:26,

74:16

sooner [3] -

169:22, 169:23,

170:5

Sorry [4] -

87:15, 97:8, 99:8,

185:29

sorry [63] - 20:4,

38:27, 39:2, 42:6,

45:3, 47:5, 48:4,

54:28, 59:28,

60:24, 63:19,


29

65:8, 68:21,

72:17, 76:18,

80:8, 81:25,

86:22, 114:10,

114:11, 114:29,

116:26, 119:28,

120:5, 120:6,

122:17, 122:18,

128:1, 128:5,

128:9, 128:17,

131:16, 132:25,

133:21, 133:23,

135:16, 138:2,

138:29, 139:1,

139:2, 139:3,

140:9, 142:14,

143:8, 143:9,

143:22, 145:5,

149:5, 151:28,

151:29, 152:8,

155:13, 156:24,

156:29, 157:3,

158:20, 162:14,

176:14, 176:15,

182:2, 205:21

sorry...(

INTERJECTION

[2] - 73:27, 142:17

sort [10] - 15:24,

28:18, 75:3, 75:6,

122:22, 132:29,

139:22, 153:25,

153:27, 192:11

sorts [1] - 95:7

sought [1] -

188:21

sound [1] -

34:24

source [2] -

19:5, 67:25

South [1] -

165:29

Southampton

[1] - 195:19

space [2] -

140:21, 142:27

spare [2] -

145:4, 145:7

speaking [4] -

17:5, 72:18,

160:29, 201:13

speaks [1] -

190:23

Specialist [2] -

39:9, 173:4

specialist [9] -

99:21, 101:22,

106:5, 159:3,

172:14, 180:7,

180:20, 196:20,

196:21

specialists [1] -

191:4

specific [7] -

25:14, 50:6,

88:28, 118:21,

132:15, 158:15,

173:6

specifically [3] -

48:12, 49:9,

173:10

speed [1] -

211:11

spend [5] -

116:24, 196:24,

197:2, 209:18

spent [6] - 6:22,

40:8, 139:18,

159:24, 196:26,

197:4

spina [1] - 10:15

split [2] - 25:17,

183:6

spoken [6] -

23:22, 45:18,

45:24, 46:1,

55:21, 78:13

SPR [16] - 22:23,

30:20, 38:6,

38:12, 39:23,

40:9, 41:10,

72:15, 72:16,

72:22, 117:4,

117:7, 117:10,

173:7, 183:29,

184:4

SpR [5] - 94:16,

94:18, 94:21,

103:10, 103:15

SpRs [3] - 16:9,

38:24, 97:28

SRI [2] - 1:9,

2:21

Sri [16] - 52:15,

108:17, 112:10,

112:16, 112:22,

113:7, 115:11,

121:18, 123:8,

124:29, 145:17,

145:25, 145:29,

161:1, 193:7,

193:21

ST [1] - 2:15

St [1] - 196:10

staff [24] - 6:20,

9:21, 26:12,

31:22, 31:27,

32:4, 44:25,

53:17, 55:2, 55:3,

55:4, 70:27, 74:1,

74:2, 75:4, 77:7,

111:26, 111:28,

188:23, 189:1,

189:10, 190:27,

192:9

staffing [1] -

189:1

stage [26] -

14:21, 15:7,

21:21, 26:19,

29:2, 31:11,

33:24, 45:7,

47:18, 53:19,

59:5, 65:11,

65:18, 66:12,

70:6, 85:18,

92:22, 107:10,

111:27, 121:5,

121:12, 130:23,

132:17, 182:1,

193:23, 204:21

stages [2] -

14:19, 191:12

stand [1] - 70:5

standard [13] -

32:23, 35:6,

37:17, 37:18,

56:13, 70:13,

112:13, 113:23,

114:23, 150:23,

151:25, 152:26,

160:17

standards [11] -

55:11, 55:12,

83:5, 83:13,

83:20, 85:29,

86:21, 86:25,

124:14, 171:24

standing [2] -

64:10, 78:7

stapling [1] -

183:13

start [38] - 23:25,

41:19, 41:28,

42:1, 42:23, 43:3,

43:7, 43:14,

44:12, 44:19,

51:25, 62:6,

74:16, 95:26,

95:27, 114:17,

122:22, 122:23,

123:18, 125:12,

125:13, 126:22,

127:8, 129:19,

139:5, 143:10,

143:20, 153:21,

179:16, 198:5,

208:12, 209:18,

209:19, 210:20,

214:22, 214:24

Start [1] - 127:18

started [8] - 6:3,

47:28, 53:9,

63:28, 69:22,

142:10, 143:17,

156:13

starting [5] -

12:28, 51:24,

101:15, 147:7,

198:7

starts [7] -

51:29, 52:1,

101:9, 113:26,

114:24, 123:19,

167:2

stasis [1] - 19:6

state [4] - 25:28,

30:29, 151:14,

188:9

State [1] - 159:9

statement [6] -

72:2, 117:13,

118:10, 151:16,

207:25, 210:4

statements [2] -

117:16, 206:15

states [3] - 47:4,

62:6, 71:8

station [1] - 22:9

status [2] -

46:14, 158:26

Stenographer

[1] - 20:3

Stenographers

[1] - 153:5

Stenography [3]

- 1:27, 2:26, 2:27

step [3] - 16:19,

203:17, 213:3

steps [2] -

31:21, 74:24

stewart [1] -

179:9

Stewart [4] -

29:26, 30:21,

84:1, 84:3

still [16] - 10:13,

16:15, 16:16,

21:8, 31:16,

52:13, 62:1,

71:17, 90:25,

125:5, 138:9,

159:11, 162:8,

200:9, 202:25,

211:10

stimulant [1] -

16:22

stimulate [1] -

16:13

stock [1] - 63:3

stood [2] - 64:4,

191:21

stop [8] - 25:26,

101:14, 122:12,

149:5, 195:15,

208:12, 210:1,

210:19

stopped [2] -

4:6, 42:4

straight [1] -

181:11

straightforwar

d [8] - 39:27, 44:7,

56:25, 98:24,

98:26, 98:28,

100:14, 103:18

Street [22] -

5:29, 6:26, 10:18,

27:11, 40:14,

73:25, 92:16,

94:13, 95:5,

97:17, 116:19,

116:21, 116:22,

117:14, 117:15,

119:9, 179:27,

180:7, 180:10,

196:22, 197:2,

197:5

Street...(

INTERJECTION

[1] - 184:6

strictly [1] -

73:11

strikes [1] -

171:22

structure [1] -

208:26

structured [2] -

173:3, 208:23

structures [1] -

65:26

Student [1] - 8:7

students [3] -

77:7, 78:8,

175:11

study [2] -

76:10, 76:25

sub [1] - 92:9

sub-heading [1]

- 92:9

subject [1] -

153:12

submission [4] -

98:8, 181:29,

182:12, 182:16

submissions [2]

- 187:4, 215:11

submit [1] -

201:7

submitted [2] -

181:19, 181:20

subsequent [7] -

19:9, 30:1, 31:15,

56:18, 71:17,

111:27, 212:27

subsequently

[6] - 32:11, 47:17,

60:3, 61:12,

88:23, 148:29

substance [1] -

164:14

successful [2] -

15:17, 40:15

suction [1] -

64:5

sufficient [10] -

37:17, 56:6,

89:27, 102:21,

103:4, 103:20,

166:24, 167:5,

169:10, 212:13

suggest [24] -

27:5, 58:15,

91:25, 93:20,

95:9, 96:29,

103:17, 110:22,

114:15, 121:16,

121:27, 121:29,

125:25, 125:28,

128:28, 137:18,

138:11, 148:19,

153:10, 161:6,

162:26, 167:10,

178:11, 210:8

suggested [14] -

60:15, 61:16,

104:6, 111:22,

130:3, 147:13,

147:16, 147:19,

179:12, 179:16,

197:28, 198:15,

200:14, 203:2

suggesting [13]

- 56:5, 80:8,

102:8, 111:5,

112:1, 135:3,

137:7, 141:8,

143:1, 143:15,

147:25, 185:8,

209:8

suggestion [5] -

38:1, 53:22, 62:1,

64:14, 186:24

suitably [1] -

89:25

suite [1] -

128:13

summarise [1] -

208:9

summary [2] -


30

14:4, 14:7

Summer [1] -

190:19

summoned [1] -

134:1

summons [1] -

133:25

Sunday [3] -

168:7, 169:19

super [1] -

196:21

superb [1] -

193:10

superior [1] -

33:19

supervision [3] -

78:8, 101:23,

101:28

supplied [1] -

2:26

supply [2] -

65:13, 66:13

support [1] -

159:10

suppose [9] -

111:11, 123:21,

143:24, 160:28,

168:14, 175:18,

185:11, 212:20,

214:26

sure...(

INTERJECTION

[1] - 208:4

surely [2] -

99:19, 121:17

surface [4] -

51:2, 51:3, 64:9,

66:5

surgeon [87] -

8:18, 32:10,

38:26, 39:25,

41:5, 41:6, 41:8,

41:9, 41:11,

41:12, 41:13,

41:27, 41:29,

42:22, 42:23,

43:2, 43:3, 43:6,

43:7, 44:13,

44:20, 44:21,

44:22, 51:25,

51:27, 51:29,

58:5, 58:21, 67:7,

74:15, 83:6,

83:14, 83:26,

86:1, 86:2, 86:21,

86:25, 95:15,

95:24, 95:28,

96:22, 98:11,

100:22, 101:8,

101:17, 104:3,

109:26, 110:4,

113:4, 114:20,

114:24, 116:5,

122:9, 122:23,

122:26, 123:17,

125:9, 125:13,

140:2, 140:3,

143:28, 146:4,

149:25, 150:19,

150:20, 150:23,

153:22, 157:8,

167:27, 171:25,

172:1, 172:3,

184:2, 191:16,

193:16, 197:16,

197:21, 197:22,

198:6, 202:3,

202:18, 202:19,

204:25, 208:11

Surgeon [6] -

5:6, 7:1, 7:4,

32:12, 40:17,

196:7

surgeon's [5] -

52:1, 59:1, 95:16,

105:13, 197:24

Surgeons [11] -

5:9, 7:15, 7:24,

9:27, 10:5,

172:29, 173:15,

173:19, 173:27,

174:1, 196:16

surgeons [26] -

9:15, 9:16, 9:26,

9:29, 10:6, 10:7,

37:20, 37:21,

44:13, 47:22,

60:20, 71:25,

73:20, 74:17,

98:1, 100:24,

105:24, 106:5,

131:7, 135:8,

135:10, 192:4,

202:12, 210:25,

212:16

surgeries [1] -

39:13

surgery [85] -

7:11, 7:12, 7:17,

7:27, 8:1, 8:20,

8:23, 9:17, 9:18,

9:19, 23:11,

23:12, 29:26,

30:6, 30:11,

30:18, 33:23,

33:24, 36:7,

36:19, 39:22,

40:19, 42:4,

42:10, 45:9,

45:21, 50:27,

51:10, 51:20,

52:28, 58:14,

59:5, 59:7, 59:13,

60:2, 60:10,

61:18, 62:9,

65:18, 68:1, 68:4,

71:21, 71:23,

72:4, 72:28, 73:3,

75:29, 82:27,

83:9, 89:15,

89:21, 92:4,

92:24, 93:7,

93:24, 124:5,

149:28, 155:17,

155:24, 157:3,

157:8, 157:9,

159:7, 159:9,

160:18, 161:19,

172:22, 173:5,

173:21, 176:8,

179:7, 179:9,

180:3, 188:13,

196:18, 197:13,

197:14, 197:17,

197:20, 204:14

Surgery [4] -

5:9, 8:11, 39:9,

39:20

surgery" [1] -

157:9

Surgical [4] -

5:7, 13:9, 16:9,

39:15

surgical [50] -

6:15, 7:28, 9:5,

9:9, 9:17, 9:28,

23:24, 24:5,

24:16, 37:28,

42:7, 42:16, 44:5,

45:12, 52:11,

59:17, 70:27,

72:12, 74:27,

74:28, 75:25,

83:11, 86:3,

89:23, 96:12,

103:9, 105:16,

106:12, 114:23,

128:24, 138:20,

142:19, 143:21,

144:2, 157:20,

158:18, 166:20,

172:5, 172:12,

172:28, 173:20,

173:24, 175:23,

176:2, 176:3,

176:6, 189:11,

191:19, 196:17

surgically [1] -

143:29

surmise [1] -

25:16

surprise [1] -

206:25

surprised [2] -

51:12, 145:23

Suska [2] -

33:18, 151:18

suspect [1] -

90:4

Swiss [1] -

213:28

SWORN [4] -

4:24, 187:8,

190:2, 196:1

symbols [1] -

175:16

symptomatic [1]

- 18:12

symptomatolo

gy [1] - 70:20

system [28] -

20:13, 20:15,

20:19, 20:20,

21:9, 22:5, 22:9,

31:23, 69:19,

69:25, 69:29,

71:19, 75:9,

85:24, 86:14,

101:21, 106:24,

109:27, 157:14,

157:15, 158:24,

208:22, 213:2,

213:4, 213:8,

213:17, 213:27

systems [16] -

29:11, 83:11,

83:20, 85:1, 86:9,

86:10, 109:25,

110:3, 110:4,

110:10, 110:16,

171:24, 203:15,

208:27, 212:19,

214:5

T

tab [6] - 68:23,

81:2, 119:27,

179:24, 180:19,

182:29

Tab [2] - 84:11,

119:28

table [3] - 47:8,

60:8, 145:6

taken...(

INTERJECTION)

[1] - 127:16

talented [1] -

38:26

Tallaght [1] -

73:25

Tanzania [1] -

192:20

Tareen [12] -

29:1, 30:17,

38:11, 38:17,

73:2, 89:28, 90:9,

90:11, 90:13,

90:16, 90:29,

91:2

tareen [1] -

30:19

task [2] - 67:11,

191:2

tasks [2] - 57:6,

124:13

taught [1] -

174:24

teach [1] -

174:19

teacher [1] -

175:11

teaching [5] -

7:14, 7:18,

173:19, 173:20,

192:8

team [32] - 9:2,

14:27, 15:5,

28:29, 30:5, 32:8,

32:13, 32:18,

66:18, 67:22,

72:13, 75:25,

78:22, 86:3,

94:29, 95:4,

96:18, 97:23,

97:26, 98:10,

106:21, 116:18,

123:1, 123:3,

123:8, 125:28,

191:13, 203:6,

204:6, 207:2,

207:4, 207:11

Team [2] - 96:2,

119:9

teams [2] -

70:27, 83:11

technical [6] -

57:20, 77:25,

104:14, 159:11,

165:21, 176:6

technically [1] -

100:20

technique [1] -

16:20

Temple [4] -

5:29, 10:18,

40:14, 73:25

temporising [2]

- 27:25, 27:26

ten [27] - 9:7,

16:15, 23:9,

24:10, 69:1,

73:14, 77:27,

78:16, 78:19,

82:3, 122:10,

122:24, 129:20,

141:2, 141:8,

141:10, 141:19,

142:25, 144:1,

144:5, 145:4,

145:7, 154:13,

154:14, 167:17,

173:17, 184:1

tend [1] - 38:6

tendency [1] -

24:15

term [3] - 36:14,

149:18, 203:9

terms [23] - 9:17,

15:16, 51:23,

52:26, 65:25,

85:4, 93:13,

97:10, 98:12,

98:20, 99:15,

102:11, 108:29,

113:22, 134:9,

165:16, 168:19,

172:15, 178:5,

191:5, 203:4,

215:7

terrible [3] -

155:2, 204:19,

214:3

terribly [1] -

155:13

testimonial [7] -

187:5, 187:13,

187:26, 188:3,

189:3, 190:7,

192:18

testimonials [2]

- 186:26, 187:3

testimony [2] -

128:23, 213:14

THAMBIPILLAI

[1] - 1:9

that...(

INTERJECTION

[1] - 62:19

THE [19] - 1:2,

1:3, 2:11, 2:15,

3:8, 3:18, 4:1,

80:18, 108:1,

171:6, 171:13,

177:10, 185:26,

211:25, 214:12,

215:20

the...(

INTERJECTION


31

[1] - 118:11

theaters [1] -

37:25

theatre [95] -

8:21, 27:16,

29:20, 33:16,

33:18, 36:27,

37:1, 37:3, 37:4,

37:5, 37:16,

37:22, 37:23,

37:24, 38:4,

40:27, 45:1,

45:27, 47:7, 51:1,

52:18, 53:11,

58:13, 58:23,

58:26, 59:18,

63:7, 63:12,

63:25, 64:1, 64:3,

66:3, 71:12,

71:22, 72:27,

73:12, 73:14,

73:21, 73:22,

73:28, 74:4, 75:7,

82:7, 89:19,

92:29, 96:13,

97:25, 98:9,

105:17, 108:26,

109:7, 126:17,

127:14, 128:3,

128:12, 128:13,

128:21, 128:25,

129:27, 131:9,

132:12, 135:10,

135:14, 135:23,

137:23, 138:24,

138:26, 141:2,

142:25, 143:11,

144:15, 150:21,

150:22, 151:10,

153:12, 153:17,

153:19, 153:21,

154:3, 154:5,

155:27, 162:3,

164:3, 176:10,

176:12, 176:13,

176:18, 176:19,

184:3, 213:22,

213:26

Theatre [41] -

37:26, 38:2, 38:6,

38:7, 43:26,

43:27, 43:28,

44:1, 44:2, 94:15,

94:16, 94:16,

94:18, 94:18,

117:4, 117:4,

117:5, 117:5,

117:6, 117:7,

130:19, 130:20,

131:26, 131:28,

133:25, 133:26,

134:26, 135:12,

136:6, 136:11,

136:20, 138:25,

139:19, 141:11,

143:10, 143:16,

145:4, 151:19

theatre" [1] -

183:27

theatre...(

INTERJECTION)

[2] - 141:5, 149:4

theatres [6] -

37:6, 101:28,

131:8, 134:5,

135:7, 135:11

themselves [6] -

20:23, 21:4,

21:24, 25:13,

172:26, 198:8

THEN [7] -

108:12, 171:13,

177:12, 179:1,

185:26, 187:8,

215:20

theoretically [1]

- 20:17

theory [1] -

21:20

thereabouts [1]

- 127:9

thereafter [2] -

5:23, 14:17

therefore [15] -

45:7, 58:28,

91:28, 112:28,

136:13, 137:28,

147:25, 149:22,

162:25, 180:27,

190:20, 202:20,

208:17, 209:29,

210:23

thin [1] - 164:15

thinking [6] -

60:22, 181:18,

212:21, 213:9,

213:12, 213:23

thinks [3] -

47:25, 195:9,

195:25

third [6] - 4:6,

13:1, 16:1, 32:16,

62:7, 69:28

thirty [65] -

112:16, 112:19,

112:21, 112:23,

112:25, 112:26,

112:29, 113:10,

113:14, 113:15,

113:17, 114:3,

114:14, 114:17,

114:22, 114:25,

115:11, 115:14,

115:17, 115:19,

115:20, 115:24,

116:2, 116:5,

116:12, 118:17,

119:3, 120:28,

121:18, 122:1,

122:4, 122:6,

122:27, 123:3,

123:4, 123:9,

125:1, 125:27,

126:6, 126:25,

127:5, 128:27,

129:2, 129:5,

130:5, 130:24,

135:1, 136:17,

137:10, 137:29,

138:13, 139:8,

139:12, 141:26,

141:27, 142:7,

142:12, 142:16,

142:23, 142:24,

144:20, 147:5,

150:6, 151:3,

151:5

thoroughly [1] -

162:1

threat [1] -

159:14

threatening [2] -

23:20, 100:16

three [16] - 8:28,

9:1, 10:8, 11:18,

19:25, 20:4,

38:23, 43:1,

65:25, 89:26,

91:23, 91:27,

91:29, 103:15,

141:15

throughout [3] -

21:1, 93:21,

176:22

thrown [1] - 57:3

thrust [1] - 68:25

Thursday [4] -

10:14, 10:22,

23:4, 23:5

THURSDAY [2] -

1:15, 4:1

tie [4] - 42:22,

65:28, 65:29,

164:17

tied [5] - 65:6,

65:10, 65:26,

66:4, 66:7

time-out [8] -

175:23, 175:26,

175:28, 176:7,

176:8, 176:10,

176:23, 203:23

timed [2] -

47:20, 66:23

timeframe [6] -

131:11, 138:2,

139:12, 143:14,

147:6, 210:28

timeline [1] -

210:15

timing [12] -

41:18, 41:19,

42:2, 51:23,

55:18, 97:18,

122:22, 155:6,

179:5, 179:6,

179:18, 181:24

TO [3] - 1:3, 5:4,

215:20

to...(

INTERJECTION

[3] - 54:6, 133:14,

134:3

today [7] -

155:2, 155:4,

169:14, 186:19,

206:22, 210:16,

215:9

today's [1] -

185:12

together [3] -

55:26, 183:13,

192:13

toilet [1] - 15:26

tomorrow [5] -

185:12, 185:13,

186:18, 215:3,

215:18

tongue [1] -

42:22

took [25] - 5:11,

5:26, 6:29, 27:17,

48:12, 48:20,

49:7, 49:9, 71:29,

72:3, 75:20,

84:27, 93:11,

99:11, 114:2,

114:27, 117:16,

129:6, 138:7,

143:17, 146:17,

150:13, 160:20

top [3] - 25:29,

183:15, 184:15

total [8] - 9:29,

12:22, 74:17,

127:1, 127:2,

172:15, 196:24,

197:4

totally [3] -

30:29, 31:27,

159:28

towards [7] -

78:19, 108:17,

131:2, 163:6,

163:13, 175:19,

208:23

track [1] - 51:14

tract [4] - 17:27,

18:9, 18:18,

70:10

tradition [1] -

208:29

traditional [1] -

38:5

traffic [2] -

166:2, 166:4

tragic [2] - 76:9,

106:23

train [1] - 7:26

trained [5] -

15:26, 32:9,

89:25, 99:28,

103:12

trainee [17] -

46:16, 46:25,

46:26, 56:2,

100:23, 103:4,

103:9, 103:14,

106:9, 157:15,

157:17, 157:19,

158:5, 158:17,

173:13, 202:9,

202:14

trainees [10] -

55:28, 103:9,

103:12, 106:8,

157:14, 157:15,

157:28, 172:29,

202:4, 202:10

training [25] -

5:12, 5:23, 6:7,

7:14, 7:15, 39:13,

39:28, 40:11,

46:13, 51:13,

52:23, 76:27,

86:16, 89:27,

97:5, 99:26,

106:12, 118:24,

150:1, 166:19,

172:28, 173:9,

196:17, 196:20,

196:22

transcribed [1] -

26:25

TRANSCRIPT

[1] - 1:14

transcript [5] -

1:28, 4:13, 83:29,

102:3, 156:28

Transcripts [1] -

2:25

transferred [2] -

10:17, 126:3

transfuse [1] -

56:19

transit [1] -

19:29

transiting [1] -

46:13

transplant [2] -

67:7, 67:22

transplantation

[1] - 5:12

transverse [4] -

60:16, 82:23,

104:20, 147:19

trauma [3] -

9:18, 75:28,

167:4

treat [1] - 35:23

treating [1] -

84:15

treatment [5] -

16:11, 19:9,

19:12, 24:28,

79:10

tree [1] - 6:13

tremendous [1]

- 131:6

trial [1] - 76:24

Tribunal [5] -

113:9, 124:4,

124:8, 124:17,

146:19

tried [3] - 16:11,

25:25, 74:19

trigger [1] -

212:25

trolley [4] -

52:13, 52:17,

162:6, 162:9

trouble [1] -

59:24

true [16] - 1:28,

16:27, 35:14,

81:12, 81:21,

82:1, 82:11,

87:10, 90:25,

95:1, 95:3, 95:4,

95:5, 110:21,

158:1, 188:13

truly [2] -

110:13, 204:19

trust [1] - 46:18

try [22] - 5:15,

10:2, 16:12,

16:14, 24:12,

26:9, 44:24,

69:22, 85:19,

138:20, 139:27,

140:4, 140:10,


32

141:13, 143:3,

156:4, 156:7,

156:12, 175:15,

178:8, 192:23

trying [24] -

9:21, 20:19, 23:1,

37:20, 54:29,

60:22, 68:7,

69:19, 84:25,

84:26, 85:12,

85:14, 85:20,

86:18, 101:24,

121:6, 121:21,

135:8, 140:2,

140:6, 151:7,

169:25, 177:27

Ts [1] - 101:10

Tuesday [2] -

10:14, 10:16

Tumour [3] -

23:27, 56:27,

191:13

tumour [7] -

23:9, 23:27,

39:12, 56:27,

99:7, 99:9, 100:8

turn [8] - 13:7,

14:27, 21:20,

33:18, 57:13,

78:11, 140:15,

167:19

turning [2] -

13:21, 48:18

tutorial [1] -

173:22

twelve [3] - 9:7,

24:10, 126:16

twenty [10] -

122:11, 122:24,

126:14, 126:15,

127:5, 140:21,

141:20, 141:23,

142:26, 142:28

twice [7] - 10:19,

145:22, 145:25,

146:5, 146:7,

146:10, 201:16

two [60] - 9:14,

9:15, 9:26, 10:4,

10:6, 10:13,

10:23, 10:29,

11:1, 11:6, 12:27,

17:6, 19:25, 20:4,

20:21, 22:15,

23:2, 35:8, 36:23,

37:6, 37:21,

37:25, 41:14,

43:5, 43:10,

47:10, 47:12,

56:3, 81:6, 81:18,

81:26, 85:10,

85:26, 86:28,

91:1, 94:28,

102:27, 104:14,

104:24, 107:11,

109:21, 118:13,

118:22, 124:11,

125:6, 126:2,

126:24, 127:2,

131:7, 135:14,

141:15, 141:18,

152:28, 186:2,

197:4, 197:10,

212:15, 215:1

tying [1] - 66:9

type [8] - 24:1,

41:18, 51:9,

56:14, 83:24,

101:21, 201:7,

213:28

typically [2] -

24:7, 56:22

typographical

[1] - 26:5

U

UCD [1] - 173:26

UK [2] - 37:14,

173:5

ultimate [1] -

85:11

ultimately [14] -

6:28, 16:10, 17:9,

29:29, 84:14,

101:2, 102:1,

165:25, 166:1,

166:3, 166:5,

170:3, 203:9,

203:12

ultrasound [7] -

17:26, 18:6,

18:21, 70:20,

87:21, 87:25,

88:2

umbilical [2] -

172:23, 172:24

umbilicus [2] -

61:13, 147:15

un-filed [1] -

86:13

unacceptable

[1] - 75:17

unaided [1] -

29:3

unanimously [1]

- 172:14

unavoidable [1]

- 74:21

unclear [1] -

194:13

uncomfortable

[3] - 55:17,

159:14, 159:15

uncommon [1] -

96:23

UNDER [1] - 1:3

under [28] -

14:7, 16:5, 60:11,

60:28, 64:8,

68:14, 68:29,

77:22, 83:12,

86:8, 88:5, 88:12,

101:21, 101:23,

101:28, 140:4,

140:5, 146:6,

146:14, 157:28,

159:13, 160:15,

167:11, 183:29,

189:1, 201:2,

201:5, 204:5

undergoing [1] -

70:1

Undergraduate

[2] - 5:19, 7:14

undergraduate

[1] - 173:20

undermine [3] -

110:28, 111:1,

152:22

undermining [1]

- 111:4

understaffed [1]

- 188:12

understating [1]

- 37:29

understood [9] -

21:16, 22:4,

33:22, 60:2,

61:23, 71:2,

134:29, 135:16,

177:23

undertake [1] -

94:10

undesirable [1] -

102:12

undoubtedly [1]

- 168:24

unfairness [1] -

201:16

unfiled [1] -

69:18

unfortunately

[13] - 14:20,

25:24, 29:22,

33:13, 34:2, 67:1,

67:5, 74:20,

75:20, 105:23,

120:1, 167:10,

167:12

unhappy [5] -

96:26, 96:28,

146:20, 146:23,

146:24

unhesitatingly

[1] - 191:23

unilaterally [1] -

19:26

unit [12] - 56:18,

56:21, 138:10,

138:14, 139:18,

139:25, 144:7,

144:9, 144:11,

145:2, 155:29

United [2] -

196:23, 208:22

united [1] -

203:24

units [2] -

175:23, 176:2

universal [1] -

176:1

universally [3] -

176:20, 176:22

University [3] -

5:21, 8:8, 39:29

unless [1] -

197:13

unlikely [1] -

91:20

unofficial [14] -

25:16, 25:18,

25:20, 25:23,

25:26, 25:28,

26:3, 26:6, 26:15,

26:20, 27:20,

31:7, 87:4, 88:25

unreasonable

[1] - 157:16

unsatisfactory

[1] - 31:4

unscrub [1] -

63:5

unsuccessful

[3] - 34:3, 40:15,

67:15

unsupervised

[4] - 89:26, 94:22,

95:2, 117:11

unthinkingly [1]

- 174:27

unusual [11] -

19:22, 38:21,

38:27, 45:20,

96:29, 150:26,

152:3, 160:2,

166:17, 166:18,

200:16

up [32] - 5:16,

6:29, 9:15, 12:14,

14:15, 14:21,

21:20, 28:14,

29:15, 32:11,

53:3, 73:20,

76:12, 78:6, 91:4,

93:2, 93:17,

95:27, 97:14,

99:15, 105:29,

118:28, 169:4,

174:5, 174:20,

183:6, 190:22,

191:12, 191:23,

206:27, 211:11,

212:1

up-to-date [1] -

78:6

upfront [1] -

178:12

upper [7] -

60:16, 60:28,

82:23, 82:28,

99:15, 104:19,

147:19

upset [1] -

167:22

ureter [12] -

12:7, 13:3, 65:6,

65:10, 65:23,

66:1, 66:6, 66:8,

66:9, 164:9

urgency [2] -

17:19, 152:18

urinary [6] -

17:15, 17:16,

17:27, 18:9,

18:18, 70:10

urine [3] - 12:5,

12:8, 19:1

urological [1] -

15:23

urologist [2] -

194:21, 196:9

Urologist [1] -

196:7

urology [1] -

159:8

V

valid [1] - 204:1

valuable [1] -

57:4

value [1] - 51:15

values [1] -

78:21

variance [1] -

127:22

variety [3] -

16:11, 76:22,

96:10

various [8] - 8:3,

14:19, 77:22,

125:17, 187:29,

191:11, 199:23

vascularise [1] -

66:28

vein [5] - 65:23,

65:27, 65:29,

66:4, 66:14

veinous [1] -

133:4

vena [1] - 56:28

verbal [1] -

118:14

verbally [2] -

118:12, 184:3

verified [1] -

33:10

verify [1] - 62:10

version [5] -

45:9, 47:5, 96:8,

183:9, 205:25

versions [1] -

194:17

vesicoureteral

[1] - 164:8

vessels [1] -

164:17

viability [2] -

66:10, 66:12

viable [1] - 67:5

Vietnam [2] -

7:27, 192:21

view [21] - 19:8,

30:28, 34:8,

34:21, 38:3,

50:15, 50:22,

50:25, 69:6, 74:5,

81:13, 129:24,

162:11, 192:14,

194:18, 197:12,

200:28, 201:28,

204:3, 204:15,

209:3

viewed [4] -

20:16, 34:23,

127:2, 197:14

viewing [4] -

176:28, 194:23,

194:24, 195:3

views [5] -

79:15, 193:9,

194:19, 199:27,

199:28

virtually [2] -

53:21, 160:28

visiting [1] -

6:29


33

visual [1] -

164:17

vital [2] - 188:14,

188:28

voice [1] - 5:16

voiding [1] -

19:4

volition [2] -

168:9, 169:18

vomiting [1] -

18:13

VUR [2] - 14:4,

14:10

VUR" [2] - 14:8,

14:19

W

wait [2] - 153:19,

170:10

waited [1] -

143:16

waiting [6] -

71:18, 74:21,

75:18, 143:10,

153:20, 186:11

Waldron [2] -

13:22, 13:29

wall [3] - 23:9,

64:10

wander [1] -

134:1

wandered [2] -

132:9, 132:13

ward [23] - 8:22,

29:21, 30:8, 30:9,

30:11, 30:12,

30:14, 31:6, 32:7,

32:22, 32:24,

33:8, 45:4, 51:19,

66:25, 71:11,

71:18, 72:10,

75:7, 75:8, 92:25,

93:6

wards [1] -

173:23

warn [1] -

109:21

WAS [14] - 4:24,

80:24, 108:12,

171:13, 177:12,

179:1, 187:8,

190:2, 193:4,

196:1, 205:12,

207:17, 211:25,

215:20

was...(

INTERJECTION

[1] - 48:6

washes [1] -

16:24

washing [1] -

17:5

Washout [4] -

16:20, 16:21,

17:4, 18:15

waste [1] - 57:3

wasteful [1] -

151:24

wasting [1] -

136:2

watch [1] - 204:5

ways [1] - 50:24

Wednesday [5] -

8:25, 8:29, 37:24,

70:25, 73:23

week [13] - 7:6,

8:24, 10:8, 10:19,

22:14, 23:3, 23:6,

24:8, 30:19,

154:12, 173:16,

191:13

welcome [3] -

4:5, 158:7,

158:11

welcomed [1] -

40:18

West [1] - 5:27

whatsoever [7] -

34:16, 39:25,

50:2, 56:1, 59:26,

166:20, 172:11

Wheeler [33] -

28:7, 34:18,

35:28, 36:5,

48:11, 48:14,

49:14, 53:22,

56:4, 101:4,

102:7, 103:7,

123:22, 124:16,

124:28, 125:16,

125:26, 156:17,

156:19, 160:10,

177:3, 181:27,

194:12, 194:17,

194:18, 195:5,

195:11, 195:26,

198:14, 200:26,

200:27, 208:21,

209:21

wheeler [7] -

50:22, 102:9,

102:19, 113:24,

194:9, 197:11,

201:22

wheeler's [2] -

156:25, 208:18

Wheeler's [4] -

96:25, 166:21,

206:19, 209:2

whereas [2] -

27:29, 177:21

whereby [1] -

157:15

whilst [5] -

51:26, 64:29,

69:14, 88:21,

151:19

White [3] - 14:3,

14:7, 14:9

WHO [3] -

175:28, 203:22,

203:23

whole [4] -

111:17, 115:8,

150:3, 175:8

wholly [1] -

210:9

wields [3] -

113:24, 113:25,

114:20

willing [3] -

63:5, 142:6,

153:10

willingly [1] -

38:10

Willis [4] -

16:20, 16:21,

17:4, 18:15

Wilms' [2] -

56:26, 99:7

window [1] -

53:15

wish [12] -

104:26, 110:28,

111:1, 134:2,

144:22, 152:22,

166:9, 169:2,

170:22, 177:8,

186:12, 186:20

wished [4] -

28:17, 53:14,

114:26, 169:1

wishes [1] -

114:22

withdrawn [1] -

4:14

WITHDREW [1] -

185:26

Withdrew [3] -

189:27, 194:3,

214:14

witness [17] -

49:4, 54:3, 54:9,

62:20, 107:9,

155:15, 174:6,

185:19, 185:29,

194:6, 195:8,

195:17, 198:17,

199:1, 200:24,

201:5, 214:29

Witness [3] -

189:27, 194:3,

214:14

WITNESS [3] -

3:4, 5:4, 185:26

witness...(

INTERJECTION

[1] - 201:8

witnessed [1] -

26:3

witnesses [6] -

49:1, 185:9,

185:17, 186:3,

186:25, 215:1

wonder [8] -

8:16, 20:2, 22:12,

107:7, 133:7,

184:7, 185:14,

199:5

wonderful [1] -

213:15

wondering [4] -

130:4, 175:20,

181:28, 212:18

word [7] - 84:20,

111:16, 111:20,

149:18, 174:15,

174:18, 175:9

wording [1] -

98:29

words [6] -

82:10, 101:24,

134:17, 142:1,

146:22, 175:15

workload [3] -

24:22, 72:22,

180:8

workloads [1] -

138:17

works [6] -

10:12, 36:24,

157:15, 189:5,

189:16, 201:5

workshop [3] -

7:26, 165:11,

166:8

world [3] -

96:20, 102:20,

102:23

world's [1] -

6:11

worry [1] -

213:20

worse [2] - 68:7,

213:28

worthwhile [1] -

166:8

wound [2] - 42:8

write [6] - 28:22,

122:28, 174:14,

174:18, 174:27,

175:15

writes [1] -

70:21

writing [7] -

28:24, 86:29,

89:6, 122:14,

174:20, 183:22,

206:15

written [19] -

2:27, 31:29,

62:11, 72:2,

88:11, 92:2,

106:6, 106:10,

127:25, 172:16,

174:12, 175:9,

198:18, 198:21,

198:26, 198:27,

200:8, 205:16,

205:24

wrongly [1] -

12:24

wrote [12] - 18:2,

27:22, 70:16,

87:8, 88:10,

122:29, 172:12,

174:21, 175:2,

180:27, 206:16,

207:2

X

x-ray [30] -

12:23, 14:10,

14:11, 14:13,

19:19, 20:6, 20:9,

20:12, 20:16,

20:27, 20:29,

21:9, 21:12,

27:17, 27:18,

27:19, 35:9,

50:16, 50:17,

50:18, 51:3, 53:3,

63:18, 64:29,

69:10, 70:26,

160:6, 162:7

X-ray [4] - 19:25,

20:5, 21:6,

102:25

X-rays [6] -

89:15, 97:5,

102:24, 104:24,

104:26, 212:17

x-rays [47] -

19:17, 19:27,

19:28, 20:11,

20:13, 20:15,

20:18, 20:22,

20:27, 21:8,

21:13, 21:22,

21:24, 22:2,

25:13, 27:17,

32:22, 32:25,

32:28, 33:12,

34:14, 35:13,

50:26, 51:16,

51:17, 51:18,

51:20, 52:25,

63:4, 63:6, 64:13,

64:19, 64:25,

71:13, 71:18,

71:19, 71:22,

75:1, 75:2,

113:28, 162:5,

162:9, 175:3,

176:15

XY [5] - 92:29,

94:15, 94:19,

117:3, 117:8

XY's [1] - 92:22

Y

Yeap [4] - 32:7,

32:20, 143:27

year [28] - 5:11,

5:27, 6:16, 6:22,

6:25, 8:2, 8:14,

9:2, 9:4, 32:11,

39:17, 40:11,

40:16, 69:17,

69:26, 75:9,

84:13, 100:2,

105:3, 165:3,

172:21, 172:22,

176:3, 205:24,

205:25, 206:4

years [34] - 6:13,

9:22, 10:3, 15:11,

15:21, 15:25,

18:9, 19:26, 20:4,

24:19, 39:21,

69:3, 71:20, 72:3,

103:15, 104:28,

155:3, 159:2,

159:6, 159:8,

172:10, 173:8,

190:18, 190:21,

190:22, 191:29,

192:12, 196:19,

196:24, 196:26,

197:2, 197:4,

203:24

yesterday [21] -

4:6, 34:18, 35:28,

47:27, 48:11,

54:15, 56:3,

64:15, 102:3,


34

104:6, 113:12,

113:24, 125:16,

126:1, 148:15,

156:18, 156:28,

160:10, 160:25,

174:5, 174:13

York [1] - 159:5

Youngson [4] -

8:15, 165:3,

165:20, 165:28

Youngson's [1]

- 166:10

your...(

INTERJECTION

[1] - 9:12

yourself [18] -

5:3, 8:27, 10:9,

10:28, 30:3,

38:13, 38:28,

43:13, 44:13,

55:8, 100:28,

122:28, 134:1,

158:27, 169:21,

182:24, 183:9,

189:7

Z

Zaidi [1] - 32:18

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