15 November 2007 - Afternoon session
7 (The short adjournment)
8 (1.30 pm)
9 (Jury present)
10 LORD JUSTICE SCOTT BAKER: I call Professor Pavie.
11 You can hear us, can you, in Paris?
12 THE INTERPRETER: Yes.
13 LORD JUSTICE SCOTT BAKER: Thank you.
14 MR HILLIARD: Could you please either affirm or take
15 the oath?
16 PROFESSOR ALAIN PAVIE (affirmed)
17 (Evidence via videolink, interpreted)
18 Questions from MR HILLIARD
19 MR HILLIARD: Are you Professor Alain Pavie?
20 A. Yes.
21 Q. Professor, my name is Nicholas Hilliard and I am going
22 to ask you some questions first of all on behalf of
23 the Coroner.
24 In 1997, were you a professor of thoracic and
25 cardiovascular surgery at the Pitie-Salpetriere Hospital
59
1 in Paris?
2 A. Yes.
3 Q. I think you qualified in cardiac surgery in 1976. Is
4 that right?
5 A. It must have been 1977.
6 Q. Right.
7 A. And I was a doctor in medicine in 1976.
8 Q. As at 1997, had you been practising at that hospital for
9 something like 20 years?
10 A. Yes, since 1977.
11 Q. And as at 1997, did your work involve you operating on
12 heart, lungs and blood vessels?
13 A. Yes.
14 Q. Then I think in 1998, is this right, were you elected by
15 your peers as president of the French College of
16 Cardiovascular Surgeons?
17 A. Yes. I am president of the society now.
18 Q. I think you made a statement to the police on
19 11th March 1998.
20 A. Yes.
21 Q. In the same year, I think you were interviewed by
22 Professors Lecomte and Lienhart. Is that right?
23 A. Yes.
24 Q. Then did you make another statement to the police on
25 9th March 2005?
60
1 A. Yes, with the English.
2 Q. English officers were present at the same time?
3 A. Yes exactly.
4 Q. Professor, I think that for the weekend of 30th to
5 31st August of 1997, you were on call at your home for
6 your area of specialisation; is that right?
7 A. Yes, exactly.
8 Q. And on Sunday 31st August of that year, at about
9 10 past 2 in the morning, did you get a telephone call
10 from your department?
11 A. Yes.
12 Q. Were you asked to attend the hospital as a matter of
13 extreme urgency?
14 A. Exactly.
15 Q. Was it for the purpose of treating the Princess of
16 Wales, who had just been admitted to recovery at
17 the hospital?
18 A. Yes.
19 Q. Did you know that she had also been involved in a road
20 traffic collision? Were you told that?
21 A. Yes.
22 Q. Is this right, you were also told that she was
23 presenting an extremely serious right haemothorax?
24 A. I cannot remember whether it was at that time or ...
25 Q. All right. I am looking, just so you know -- if you
61
1 have your statement of 11th March 1998, so the first
2 one, and if you look at the start of the --
3 A. (Answer not interpreted) You are right.
4 Q. Well, that is what it says there. You don't have
5 a clear memory of that now though?
6 A. Well, what was important was to get to the hospital as
7 quickly as possible. The fact that the haemothorax was
8 on the right- or left-hand side did not really matter as
9 much as to get there.
10 Q. Right. Just so that we understand the position about
11 being on call, I think your obligation, is this right,
12 was that you had to be capable of getting to
13 the hospital within a reasonable time compatible with
14 the degree of urgency?
15 A. It is the French definition.
16 Q. I think at that time you lived 12 kilometres or so from
17 the hospital.
18 A. Yes.
19 Q. I think you estimate that it took you in the order of
20 about 12 minutes or so, is this right, from the call to
21 get to the hospital?
22 A. Yes, at that time of the day, yes.
23 Q. You came in your own car; is that right?
24 A. Yes.
25 Q. For what it is worth, you did not in fact keep to
62
1 the speed limits, I think you said. Is that right?
2 A. Yes, that is right.
3 Q. In the course of the journey, did you speak to the
4 recovery department on your telephone to confirm that
5 you were on your way?
6 A. Yes, I called them with my phone, telling them I was
7 arriving.
8 Q. Did they once again indicate the urgency of the
9 situation?
10 A. Yes, the nurses, because the physicians were too busy,
11 told me that the situation was serious.
12 Q. When you got to recovery, I think you spoke to
13 Professor Riou, who we heard from this morning.
14 A. Yes, he was on duty as the resuscitator.
15 Q. And also, is this right, to Dr Dahman?
16 A. Yes, who was the digestive or general surgeon, according
17 to the way you wish to call him, who was on duty on site
18 at the hospital.
19 Q. Did they tell you what had been done so far?
20 A. Well, as soon as I arrived, they told me they had done
21 a right-hand-side thoracotomy, which I could see anyway.
22 Q. And -- sorry, you carry on.
23 A. They told me that because obviously the reason for
24 performing the thoracotomy was to try to get to
25 the source of the bleeding, try to find out if there was
63
1 a very clear and easily accessible source of the
2 bleeding in the right-hand side of the thorax.
3 Q. Were you told that the x-ray had shown a right-sided
4 haemothorax?
5 A. Yes. The x-ray showing a right-hand thorax, it was
6 logical to proceed to thoracotomy in the right-hand
7 side.
8 Q. Can you help us? As far as that procedure was
9 concerned, did the incision in fact go round to the back
10 of the body? Did it extend, do you remember, as far
11 round as that?
12 A. Well, the thoracotomy was called "antero-lateral"
13 because we could not move the Princess. She was lying
14 on her back and trying to turn her body could have
15 aggravated her condition.
16 Q. I think you have had an opportunity, is this right, to
17 see a passage from a post-mortem examination report that
18 was prepared by Dr Chapman. Is that right?
19 A. Who is English? Because there was no post-mortem in
20 France and I have never been given that report.
21 Q. Ah. I hoped that two pages had come out to you before
22 you began which is a passage from Dr Chapman's report
23 and a sketch. Have you not seen those?
24 SECRETARY TO THE INQUEST: Not received here, I am afraid,
25 Mr Hilliard.
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1 A. Well, the first thoracotomy was lateral, on the
2 right-hand side, but after having performed that,
3 we could realise that the bleeding came from behind and
4 from the left-hand side. We decided to extend the
5 thoracotomy and, to do that, we decided to transfer
6 the Princess to an operating theatre because we needed
7 instruments that we did not have available where we
8 were. It is possible, through lateral thoracotomy, by
9 pushing the ribs apart to really go very deep, and I do
10 not know that post-mortem report, but maybe that is
11 the source of the agreement.
12 MR HILLIARD: It is simply this. I am sorry it has not come
13 to you, but just so you understand, we are going to be
14 hearing from Dr Chapman a week on Monday. He is an
15 English pathologist.
16 A. Yes, but I guess he is not a specialist in thoracic
17 surgery.
18 Q. No. I just want you to have a chance to deal with his
19 findings.
20 A. Yes, but I do not have it.
21 Q. I know. I am just going to tell you it.
22 A. Okay.
23 Q. He describes an almost horizontal thoracotomy wound.
24 I will pause so we can break it up. An almost
25 horizontal thoracotomy wound.
65
1 A. We started this right-hand-side thoracotomy and that is
2 of the antero-lateral kind. We decided to extend it
3 towards the middle of the body, and finally, in
4 the operating theatre, to proceed to a shorter left
5 thoracotomy in order to get to the pericardium and also
6 to be able to cut the sternum. The aim obviously was to
7 get to the place where the bleeding came from.
8 Q. I just want to finish describing, if I may, what
9 Dr Chapman found. So if you can just listen to
10 the description and then I will ask you about it.
11 A. All right.
12 Q. He described an almost horizontal thoracotomy wound that
13 extended from 12 centimetres to the right of the
14 mid-line -- so mid-line of the back -- passing around
15 the right side -- if I can just finish -- passing around
16 the right side and mid-line of the chest to finish below
17 the left nipple.
18 A. Yes, I agree.
19 Q. So I just want to understand: that accords with your
20 recollection of the procedure or procedures that were
21 carried out?
22 A. Yes.
23 Q. Now I think you had indicated that after Dr Dahman's
24 procedure, the source of the bleeding still needed to be
25 ascertained. Is that right?
66
1 A. Yes.
2 Q. You told us that you decided to extend the thoracotomy
3 for that very reason.
4 A. Yes.
5 Q. Was the Princess of Wales taken to an operating theatre
6 for you to perform that procedure?
7 A. Yes.
8 Q. When you had done it, were you able to identify where
9 the bleeding was coming from?
10 A. Yes.
11 Q. If we can just put for our benefit up our picture of the
12 heart on the screen [INQ-PLAN-0014 - link to follow].
13 Professor, is this right, that bleeding was from
14 a tear at the junction of the left superior pulmonary
15 vein at the point where it joins the left atrium of the
16 heart; is that it? Is that right?
17 A. Yes, but your drawing is not very precise. It is not
18 anatomic --
19 Q. I did not do it.
20 A. But that was where the bleeding came from.
21 Q. Right. Having found the bleeding, Professor, what did
22 you do?
23 A. Well, considering the place, the very location of that
24 left pulmonary vein behind the left ventricle and that
25 gets into the left atrium, to try to repair it, to
67
1 repair the tear, we have to in a way push the heart;
2 we have to lift it up.
3 Q. What did you actually do with the tear itself?
4 A. Well, once I had seen the tear, I put the heart back in
5 its place and by the time I (overspeaking), and so
6 I lift the heart up again to try to stitch the wound in
7 an X fashion. In this kind of circumstance, the heart
8 having stopped beating, we ensured the circulation
9 thanks to an internal heart massage. So with your left
10 hand you have to, at the same time, try to mitigate
11 the bleeding and, very quickly with right hand, lifting
12 the heart up with the left one, you try very quickly to
13 do the stitches, the two X stitches, to try to put
14 the heart back in its place again very quickly.
15 After that, when the wound had been closed, I tried
16 to continue with the resuscitation and make the heart
17 start running again as the bleeding had stopped. So
18 it is joint work that is done with the resuscitator,
19 Mr Riou, who at the same time transfuses and does
20 a filling to try to get back to a reasonable level of
21 volume of circulation, at the same time, using very --
22 well, the strongest medications in terms of stimulating
23 the heart once again with an aim to make it start
24 running again.
25 Q. So if we summarise it: you managed to stitch up the tear
68
1 first of all?
2 A. Yes.
3 Q. You then continued the efforts at resuscitation?
4 A. Yes.
5 Q. But the heart did not restart, is that right?
6 A. Yes, unfortunately.
7 Q. I think you continued efforts at resuscitation for
8 a considerable period of time. Is that right?
9 A. Yes.
10 Q. Then, at 4 o'clock in the morning, you certified her as
11 dead. Is that right?
12 A. Yes, after more than an hour of efforts, we discussed
13 the matter with the team. We had used all of the
14 medications and techniques that were available to us and
15 we most probably continued beyond reasonable limits
16 because we were taking care of a VIP.
17 Q. Right. You explained to us earlier that in view of what
18 Dr Dahman knew the x-ray was showing, the right-sided
19 haemothorax, he had opened the chest from the right
20 side?
21 A. Yes, which is a totally logical approach. You cut the
22 side where you think the bleeding comes from, not
23 the other side.
24 Q. Is it possible to say, had he opened the chest from the
25 front and located the source of the bleeding sooner, in
69
1 your view, would that have made any difference to
2 the prospects for survival? Do you understand?
3 A. Do you mean if we had done it through the middle? That
4 is what is called a "sternotomy". Well, the reason why
5 we choose to do a lateral thoracotomy is that it is
6 the quickest and easiest form to get to the thorax if
7 we had only used a knife, the surgical knife, scalpel;
8 whereas if we had done it in the middle, you need to go
9 through the sternum and, to do that, you need a saw. It
10 takes time and it means you lose chances from
11 the outset. Also, to do that, you have to be in an
12 operating theatre and that is why I chose to transfer
13 the Princess to an operating theatre to extend
14 the thoracotomy.
15 Q. Can you help with this, Professor? Had she arrived at
16 the hospital earlier, suppose she had arrived, for
17 example, half an hour earlier at the hospital -- just
18 assume that -- in your view would that have made any
19 difference to the prospects of survival or not?
20 A. Probably not because if she had arrived there earlier,
21 she would have arrived there dead, because the time it
22 took to get her to the hospital was taken advantage of
23 to transfuse her and use medications to improve
24 the working of the circulatory system.
25 You have to bear in mind that Princess Diana
70
1 suffered from what was called a "closed" thorax wound or
2 trauma. For the physicians that were taking care of her
3 right after the crash, they had reasons to think that
4 she was bleeding somewhere, but it could have been
5 anywhere; in the brain, in the abdomen region, in
6 the thorax.
7 It is totally different from the cases where you
8 have what is called a "penetrating wound" by a bullet or
9 knife because according to the direction of the shot or
10 of the blade going in, you can assume which organs have
11 been affected by the bullet or the knife.
12 Q. Are you aware of any or many examples of a tear to
13 the pulmonary vein being treated successfully?
14 A. To my knowledge, there was not in the literature a case
15 relating to massive bleeding and a tear in the superior
16 left pulmonary vein that could have been treated
17 successfully. There were some cases relating to
18 the superior right pulmonary vein, but it is a totally
19 different case because it is in front so the access is
20 much easier and it was always in relation to patients
21 that were relatively stable, relatively compensated and
22 were not undergoing massive bleeding.
23 LORD JUSTICE SCOTT BAKER: Professor, I would just like to
24 ask you a question on this. In your 30 years'
25 experience, on how many occasions have you tried to
71
1 repair a tear between the left superior pulmonary vein
2 and the atrium of the heart?
3 A. Never, because, to my knowledge, such patients do not
4 make it to the hospital. They are normally examined at
5 later stage by a post-mortem physician, which gives you
6 an idea of the seriousness of that pathology.
7 LORD JUSTICE SCOTT BAKER: Thank you.
8 MR HILLIARD: Thank you.
9 Now, can you help us with this please? Had
10 the Princess of Wales undergone any test, to your
11 knowledge, for pregnancy?
12 A. To my knowledge, no. I am trying to think that if it
13 had been done, considering the seriousness of her
14 condition, that would have been a radical professional
15 fault. It was not at all part of our concerns in that
16 especially urgent case.
17 Q. Did anyone mention to you, whilst you were there at
18 the hospital, that there was any indication or that it
19 looked as if she was pregnant for some reason? Did
20 anyone ever say anything like that to you?
21 A. No, not at all. I actually heard or read about these
22 allegations in the press or TV, just like anyone, at
23 a later stage.
24 Q. In the days, weeks and months that followed, did any
25 member of the hospital staff ever come up to you later
72
1 and say that they had noticed that she was pregnant?
2 A. No, nobody.
3 MR HILLIARD: Thank you very much.
4 LORD JUSTICE SCOTT BAKER: Mr Mansfield?
5 Questions from MR MANSFIELD
6 MR MANSFIELD: Good afternoon. Can you hear adequately? Is
7 it clear?
8 A. Yes.
9 Q. I represent Mohamed Al Fayed, whose son was killed in
10 the crash. Just a few questions please.
11 If it had been possible to alert you at an earlier
12 stage than Princess Diana's arrival at the hospital,
13 that would have been desirable, would it not?
14 A. Well, to be called earlier, the people who called me
15 would have had to know that the bleeding came from
16 the thorax. You cannot call the specialist at an early
17 stage because otherwise you would have to call all
18 surgeons, all physicians, of all disciplines, which is
19 not very often the case. To know that they had to call
20 me, they had to wait until she was in hospital and be
21 able to examine her.
22 Q. Yes. The question was whether it would have been
23 desirable to alert you before she arrived.
24 A. Well, to my knowledge and according to the information
25 that I have, the resuscitators at the hospital,
73
1 including Mr Riou, did not see any sign from the outset
2 that the issue was related to the thorax. Actually when
3 I arrived at the hospital, they had just performed the
4 right thoracotomy, so no time was lost whatsoever.
5 Q. So are you saying that there is no benefit in alerting
6 you in advance so that you don't have to rush to the
7 hospital, break the speed limit, dress quickly, make
8 quick assessments? You think it is not more desirable
9 that you are alerted first? Is that what you are
10 saying?
11 A. In absolute terms, yes, but if I go to the hospital,
12 then all of the different specialists of different
13 disciplines have to go to the hospital also.
14 Q. I am sorry, I am going to intervene. I am not talking
15 about going; I am talking about alerting first of all.
16 A. What I said is it means you have to go to the hospital,
17 otherwise what is the interest of being alerted? Then
18 it would mean that of the all of the surgeons of all
19 disciplines would have to be there at the hospital; take
20 into account the frequency of the different kinds of
21 wounds and of the different wounds relating to different
22 disciplines.
23 The choice that was made at the Pitie-Salpetriere
24 Hospital, where you have in Paris -- it is not at all in
25 Paris -- where all of the surgical specialists are
74
1 represented, the disciplines that are not needed on
2 a daily basis, like the digestive or orthopaedist
3 discipline are, for those disciplines, there is
4 a resident physician who is there at the hospital and
5 the seniors are on call.
6 Q. The hospital that you were attending, we are told, was
7 the best hospital or one of the best hospitals in Paris
8 for dealing with multiple injuries; in other words,
9 it is not talking about other hospitals, your hospital.
10 A. Yes.
11 Q. Yes?
12 A. Yes, that is right, because there is a specialist in
13 each of the disciplines that is reachable 365 days
14 a year.
15 Q. Do you accept that blunt trauma thoracic injury commonly
16 arises in car crash incidents?
17 A. Yes.
18 Q. So if someone who is medically qualified is attending
19 the scene of a very serious car crash, two people dead,
20 two others seriously injured, there is a very high risk
21 that someone of the survivors at that point may have
22 a thoracic internal injury. Do you agree?
23 A. Yes, possible, but they may have other injuries.
24 Q. Of course.
25 A. Thoracic injuries are not the most frequent.
75
1 Q. No, but where there are thoracic injuries, they commonly
2 arise out of car crashes, don't they?
3 A. Yes.
4 Q. Were you aware that the SAMU doctor who attended some
5 time between half past 12 and 20 to 1 had already made
6 that general assessment? Did you know that?
7 A. That she had a thoracic trauma and that she had suffered
8 a cardiac arrest, yes.
9 Q. You did know that?
10 A. Yes, or I learned about it later obviously.
11 Q. Going forward to the injury itself, it may seem obvious
12 but there are three stages, are there not? Firstly,
13 assessing that there is internal bleeding of some kind;
14 secondly, identifying the source that internal bleeding;
15 and thirdly, trying to administer a remedy for that
16 situation.
17 A. Yes. I totally agree.
18 Q. You agree. Two of those stages, that is the last two --
19 identifying the source and bringing about a remedy --
20 really can only be done in a hospital under operating
21 conditions?
22 A. Yes.
23 Q. It is not something that can be done in a mobile
24 hospital unit, is it?
25 A. No.
76
1 Q. Therefore it is important not to lose any time, if you
2 can -- do you agree time is important here?
3 A. I agree, but I am going to repeat what I said earlier.
4 You should not be confused between the necessities of
5 being quick and "hurry up". That reasoning is correct
6 when you have a penetrating wound in the thorax from
7 a stabbing or a gunshot and that you suspect that
8 the heart or another important vessel was on the journey
9 of the bullet or of the knife; whereas when you have
10 trauma in the thorax, you cannot know where the bleeding
11 comes from. When you know what is the end of the
12 story -- and that is unfortunately the case in this
13 particular -- it is quite tempting to reverse-engineer
14 the procedure.
15 If we had known that Princess Diana was suffering
16 from a tear in the superior left pulmonary vein with
17 a right haemothorax, obviously we would have proceeded
18 to the left thoracotomy, but we did not know that and
19 that is why, bearing in mind that we have the x-ray
20 showing us bleeding on the right-hand side, we proceeded
21 to a right thoracotomy.
22 Q. Now I understand that. I am not asking for there to be,
23 as it were, hindsight on this matter. I am looking at
24 it on the ground.
25 On the ground on the night, Princess Diana was
77
1 removed from the car --
2 A. Yes.
3 Q. -- before 1 o'clock.
4 A. Yes.
5 Q. She suffered a cardiac arrest of some kind, but it was
6 very temporary and was rectified within two minutes.
7 A. Yes.
8 Q. The doctor at the scene assessed the situation as being
9 satisfactory; heart rate, pulse, breathing.
10 A. Yes, and they used a drip.
11 Q. If she had been put into, as I suggest she was,
12 the ambulance, the mobile hospital unit, straightaway
13 and brought to the hospital slowly, she might have
14 arrived at the hospital one hour sooner. Do you follow?
15 A. Yes, she might have arrived at the hospital an hour
16 earlier, but as I said earlier, most probably she would
17 have been dead. The French system in this kind of
18 situation in relation to car crashes that were quite
19 frequent at the time, especially because speed
20 limitations were not enforced as much as they are today,
21 there was a consensus between the resuscitators and
22 surgeons and all medical teams that that was the
23 procedure to follow to repeatedly have the highest odds
24 to give the patient a chance to survive, not in relation
25 to one particular case.
78
1 Q. Well, that was going to be my point. I am not asking
2 about a policy. Each case has to be looked at
3 individually, doesn't it?
4 A. Yes, of course every case is looked at individually, but
5 applying the same rules that we apply in order to give
6 the patient best chance to survive. That is the system
7 in France, that you try to stabilise the patient before
8 you transfer him or her to hospital.
9 Q. Yes. If you do that and you do it too much, you arrive
10 at the hospital with somebody who is nearly dead, having
11 waited an hour. Do you follow?
12 A. Yes, but we consider that if you "hurry up" too much,
13 you can be sure that the person is going to be dead by
14 the time he or she arrives at the hospital.
15 Q. That is the question I want to put to you now.
16 If she had left at 1 o'clock in a slow-moving mobile
17 hospital unit that was stabilising her breathing and all
18 the other things that have to be done to stabilise her,
19 you are not saying that she would have arrived at
20 the hospital an hour earlier in the same state in which
21 she arrived an hour later, are you?
22 A. I do understand your reasoning, but if your theory is
23 right, then we would have, in the literature, clinical
24 cases of patients being taken care of according to
25 the American way, the American system, that would
79
1 survive, but there is none.
2 Q. The particular injury here to the left pulmonary
3 superior vein, according to a medical opinion consensus,
4 is very rare, is it not?
5 A. It is very rare for a surgeon who deals with living
6 people, but I think it is not as rare for post-mortem
7 physicians who see that case much more often because
8 they deal with cases that are much more serious than
9 ours.
10 Q. Yes I understand that. But in terms of operating on
11 someone who is alive, it is extremely rare?
12 A. With that kind of injury?
13 Q. I am so sorry?
14 A. With this kind of injury?
15 Q. Yes, with this kind of injury.
16 A. Yes, but we knew about the injury afterwards. It is not
17 possible to change the whole system for an exceptional
18 case of which we did not know anything about before
19 we could discover what it was at a later stage in
20 hospital.
21 LORD JUSTICE SCOTT BAKER: But Professor, surely, other
22 things being equal, the sooner you could start operating
23 to repair the injury, the better?
24 A. Theoretically, yes, but it is not possible to reason
25 afterwards in relation to something if we had known this
80
1 or that piece of information. It is such a rare case.
2 MR MANSFIELD: Yes, the point I think that is being made is
3 this --
4 LORD JUSTICE SCOTT BAKER: That is why I said "other things
5 being equal".
6 MR MANSFIELD: Other things being equal, yes.
7 The point is this: that you cannot plainly operate
8 on an exceptional basis and, therefore, it is better to
9 have a policy that ensures that you get to the hospital
10 as quickly as you can in case it is an exceptional
11 position. Do you follow?
12 A. But every case is different.
13 Q. Yes, but at the --
14 A. The choice that we made in France is the one of the
15 system that we consider gives the highest chances of
16 survival to the patient. You never know beforehand
17 which kind of injury you are going to cover.
18 Q. That is why I suggest that the quicker you move, with
19 regard to safety, the better.
20 A. Subject to the patient arriving still alive at
21 the hospital. All of the French medical community
22 considers that the best way that a patient is going to
23 arrive at the hospital alive is first of all to
24 stabilise the patient on the site and to try to
25 stabilise his condition and then to transfer him or her
81
1 to the hospital.
2 If we have chosen this method, it is because we have
3 considered that the frequency of crashes was superior
4 for the time being to the number of penetrating wounds
5 in France. That is why the work of the resuscitators
6 and the SAMU actually was created according to these
7 principles.
8 Q. You see, I just want to summarise the position somewhere
9 between 10 to 1 and ten past 1, in that 20-minute
10 period. There was a time when she was breathing
11 normally, her pulse rate was fine and strong, she had
12 a Glasgow coma reading of somewhere between 12 and 14.
13 I am suggesting to you that is when she had the best
14 chance of a removal to hospital in an operable
15 condition.
16 A. But it was the beginning of -- she was bleeding in her
17 thorax and, you know, it is just like a bath tub. If
18 it is being emptied, then you have to fill it up again.
19 Q. I understand the point, but you can do that -- first of
20 all, it is a low-pressure system that is bleeding, is it
21 not? It is not like a bath.
22 A. Yes, it is a low-pressure vein, but the left ventricle
23 is still running and there is only 5 litres of blood
24 that can be used, so the condition can deteriorate quite
25 rapidly.
82
1 Q. Is that something that cannot be administered in
2 a slow-moving mobile hospital unit?
3 A. You have to fill the patient as much as you can. They
4 had to stop once again to try to stabilise her before
5 they could transfer her to the hospital.
6 Q. I am going to ask the question again. Is it possible,
7 in a slow-moving mobile hospital unit, to conduct
8 intubation or blood transfusions or whatever that are
9 needed to sustain the stability of the patient? Are you
10 saying that that is not possible?
11 A. But actually I think she was intubated even before she
12 was transferred to the ambulance after the cardiac
13 arrest.
14 Q. Yes, that is my point. She was in an operable
15 condition, therefore, to be transported to the hospital
16 between the 10 to 1/10 past 1 time slot?
17 A. I do not understand the question. She was stable at
18 that very moment, but she had a tear in the left
19 pulmonary vein and she was bleeding in her thorax and
20 they could not have known that.
21 According to my knowledge, they did everything that
22 was needed; that is, they intubated her, they used
23 the drip, et cetera, and even then, after a while, they
24 had to stop again because her condition started to
25 deteriorate again.
83
1 Q. That is much later. I do not go through that journey
2 again. My point to you is that the journey itself could
3 have started an hour earlier. That is all I am putting
4 to you.
5 A. Well, I do not agree.
6 Q. I appreciate you don't agree.
7 One final matter. Are you aware of what x-rays were
8 done before you got to the hospital?
9 A. Well, an x-ray of the thorax, that is what they had time
10 to do, and dosing of the haemoglobin. Then she suffered
11 a cardiac arrest and they started massaging her.
12 Q. Part of the initial procedure on admission involved
13 a pelvic x-ray, a chest x-ray and an abdominal
14 echograph.
15 A. Yes, if we had enough time to do all that, whereas
16 Princess Diana suffered a cardiac arrest in the very
17 first minutes after she arrived at the hospital, so
18 we were not dealing with the possibility of performing
19 other examinations; we were trying to save her life.
20 Q. Yes, I appreciate that.
21 A. We had an obvious case of bleeding. The situation was
22 extremely serious. The only chance we had was to find
23 the origin of the bleeding and that this cause could be
24 easily accessible. Sometimes a haemothorax can be
25 related to the bleeding of the intercostal artery and
84
1 then it is just enough to put the finger on the wound to
2 stop bleeding.
3 Q. The suggestion is simply this: when she comes in, nobody
4 knows exactly where the bleeding is, do they?
5 A. Yes.
6 Q. You agree?
7 A. Yes.
8 Q. So there has to be, at that stage, some initial quick
9 assessments done to ascertain where the bleeding is. Do
10 you agree?
11 A. Yes.
12 Q. That involves two x-rays and an echograph just to see
13 where the bleeding is, doesn't it?
14 A. No, most probably the resuscitator first of all took his
15 stethoscope and listened to what was going on in the
16 thorax and could tell that it was not going well, so he
17 had an x-ray of the thorax taken. He realised then that
18 the abdomen was soft, but before you take any x-rays,
19 the first thing is a quick clinical examination of
20 the patient. You listen to the thorax with a hand on
21 the belly to try to understand if the abdomen is soft or
22 not and a very quick examination of the limbs to try to
23 see if there is nothing happening in that area,
24 (inaudible) or something else taking place on the limbs.
25 LORD JUSTICE SCOTT BAKER: Mr Mansfield, I think we have
85
1 reached the point where we have to have the afternoon
2 break for the shorthand writers.
3 MR MANSFIELD: I have one more question.
4 Can I put to you something that Professor Riou said
5 in 2006? For reference, it is [INQ0007720 - read out in court]. This is
6 what he said about the process at the hospital:
7 "This initial examination process involved two
8 x-rays as part of the routine procedure. The first of
9 the chest area to check for haemothorax; the second was
10 a pelvic x-ray to check for pelvic bone injury. Also
11 part of the routine initial examination procedure was an
12 abdominal echography, also done by the radiologist.
13 Professor Riou believes that this procedure was
14 conducted but cannot be certain because the Princess of
15 Wales' injuries were so severe and evident."
16 A. I think that what he describes to you is a standard
17 procedure that seems to be applicable to stable or
18 a stabilised patient, but I think that considering
19 the instability of the condition of the Princess when
20 she arrived, concerned by the blood tests that had been
21 performed that gave a result of 5/5.8 grammes of
22 haemoglobin, that was not very good.
23 So the situation was such that it was not at all
24 a circumstance in which one would have asked
25 a radiographer to come to perform an ultrasound scan,
86
1 whereas we were proceeding to heart massage and then to
2 a lateral thoracotomy. It was not one of our concerns
3 to take that sonogram that takes time.
4 From what I know of the post-mortem report, there
5 was no injury in the abdominal region that we had not
6 discovered. It was brain damage due to deceleration,
7 but that could not have been assumed.
8 MR MANSFIELD: Perhaps I should have asked it after
9 the break.
10 Thank you very much.
11 LORD JUSTICE SCOTT BAKER: Can we have an assessment of how
12 long we are likely to be with this witness?
13 MR KEEN: I have no questions.
14 MR CROXFORD: The same.
15 MR MACLEOD: 15 minutes.
16 LORD JUSTICE SCOTT BAKER: Professor, we are going to break
17 off now for a short time now because the shorthand
18 writer has to have a break, but I do not think that we
19 will be very long; just perhaps 15 or 20 minutes or so
20 after we resume.
21 (3.00 pm)
22 (A short break)
23 (3.15 pm)
24 (Jury present)
25 LORD JUSTICE SCOTT BAKER: Can you hear us again in Paris?
87
1 SECRETARY TO THE INQUEST: Yes, we can, sir. Thank you.
2 LORD JUSTICE SCOTT BAKER: Yes, Mr Macleod?
3 Questions from MR MACLEOD
4 MR MACLEOD: Professor Pavie, my name is Duncan Macleod and
5 I ask questions on behalf of the Commissioner of Police
6 for London.
7 The first thing I would like to clarify with you is
8 the time it took to get the patient, Princess Diana,
9 from the point where she was taken from the car to
10 the hospital.
11 A. I totally agree to answer you, but I was not concerned
12 by this time, by the way.
13 Q. I appreciate that. We know certain times from
14 the records of the SAMU and the hospital. Now, first of
15 all, it has been put to you, and it is agreed, that
16 Princess Diana was taken from the wreckage of
17 the Mercedes at about 1.00 am or a minute or so before.
18 Do you understand? We know that she arrived at your
19 hospital at 6 minutes past 2.
20 A. Yes.
21 Q. So she was taken from the wreckage to the hospital in
22 one hour and six minutes.
23 A. Yes.
24 Q. It has been suggested to you by Mr Mansfield that she
25 may have got to the hospital one hour earlier if the
88
1 staff responsible had acted more promptly.
2 A. Which means that if we strike one hour from this time,
3 it would have taken six minutes to go from the crash
4 location to the hospital?
5 Q. Yes, and that is an impossibility, isn't it?
6 A. Totally impossible.
7 Q. Can we take it in stages --
8 LORD JUSTICE SCOTT BAKER: Professor, can you wait for
9 the question, please?
10 MR MACLEOD: The second thing we know, Professor, is that
11 the Princess, when she was removed from the wreckage,
12 suffered a cardiac arrest. The first question I want to
13 ask you, is that a life-threatening condition?
14 A. Yes, of course. That is why she was in need of the
15 treatment.
16 Q. How important is it, when a person with multiple
17 traumatic injuries has suffered a cardiac arrest at
18 the scene of the crash, to stabilise that patient and
19 secure the arterial blood pressure before removal to
20 hospital?
21 A. As far as I know, she made a short cardiac arrest when
22 she was out of the wreckage. If my information is
23 correct, she laid down on the floor of the car, in
24 between the front seat and the back seat, and her legs
25 were above her head. She was up -- I mean the legs were
89
1 up.
2 The first thing you do when you have such a patient
3 is to lay the patient down so that you can stabilise
4 the condition. So we had to have her legs down --
5 Q. Can I ask you to pause there, please, Professor? Can
6 I ask you to pause? I want to ask you only about
7 the treatment that she received once she was extricated
8 from the Mercedes.
9 A. That is what I am trying to explain to you and that is
10 why I would like to end my explanation.
11 Q. Very well.
12 A. When you have a patient and then you have to lay down
13 the legs of the patient and you have a heart arrest,
14 then the first assumption is that you have a stop of the
15 heart function because when your legs are up, all
16 the blood goes to the heart and to the brain. When you
17 lay the legs down, part of the volume of blood is
18 perfusing the legs.
19 That is the first thing you do when you have
20 a patient. You usually put the legs up in order to
21 favour the heart massage. That is what the same people
22 did, they dripped her and then they noticed that
23 the heart rate and the vital organ rate were okay, were
24 correct --
25 Q. Before you go on, Professor --
90
1 A. -- and at that time the assumption was there that she
2 had made a short cardiac arrest, she was easily treated
3 and she was easily stabilised.
4 Q. Can you pause there please? I want to ask you this one
5 question about the cardiac massage. Given that
6 the Princess had suffered a cardiac arrest at the scene,
7 was it essential to her prospects of recovery that she
8 was given cardiac massage at the scene?
9 A. According to my knowledge, the heart re-beated
10 afterwards, so maybe she had one or two massages. When
11 the heart is re-beating naturally, you should not at all
12 do any kind of massage on the heart.
13 LORD JUSTICE SCOTT BAKER: Professor, do you think you could
14 listen rather carefully to the question and answer
15 the question that is asked and not go into great detail
16 on other matters because it would help us to get on
17 a bit quicker.
18 A. Sorry. I thought I was answering your questions.
19 MR MACLEOD: Can I move on to the next aspect of
20 the treatment?
21 In order to stabilise the patient at the scene, is
22 it your understanding that she was both ventilated and
23 intubated at the scene, following her cardiac arrest?
24 A. I did not look at that in detail because it was not my
25 responsibility, but according to me it was quite obvious
91
1 that she was ventilated and intubated.
2 Q. We also know that a drip was set up to administer
3 treatment to the Princess. Was that to your knowledge?
4 A. Yes.
5 Q. I think that --
6 A. It is part of the treatment.
7 Q. This is right, isn't it, that she was also given
8 a transfusion of plasma?
9 A. I am not so sure that she was infused because I do not
10 know in the SAMU vehicles they had all this stuff, but
11 I am sure that she was filled with colloids or
12 crystalloids.
13 Q. Was she also --
14 A. It is difficult for me to have all of this in the
15 (indistinct) because it is not my speciality.
16 Q. Is it also your understanding that she was administered
17 catecholemines in order to assist her?
18 A. It seems logical enough to me.
19 Q. Now the question I would like to ask you is this: how
20 long would all those stages of treatment, do you
21 estimate, take to carry out at the scene?
22 A. I do not know. I know that all the operations which
23 were performed are time-consuming because time to
24 ventilate, to intubate, to put the drip and to put
25 the patient within the vehicle, it is about 20 to
92
1 30 minutes, I would say. I do not know.
2 Q. We understand that the Princess was placed in
3 the ambulance from the police record at 18 minutes
4 past 1.
5 A. But to be put in the ambulance does not mean that you
6 are ready to go to the hospital.
7 Q. Yes. Would an 18-minute period of treatment be
8 a reasonable amount of time for the physicians of SAMU
9 to spend stabilising the patient at the scene in the
10 manner in which I have described?
11 A. She was in the vehicle. I am not so sure that she had
12 received all the treatments that we have mentioned
13 because, first of all you have to put the patient out of
14 the car, then second you have to put on the special bed
15 where you can stabilise the patient in order to prevent
16 for (indistinct) or something like that. According to
17 me she was probably intubated and put on the drip and
18 ventilated and put in this bed before joining
19 the vehicle.
20 Q. Exactly. Do you agree that it is appropriate, when
21 transporting a patient in the Princess's condition to
22 hospital, that the ambulance should proceed slowly?
23 A. Yes, because we know that each time you have
24 accelerations or decelerations, all these are very
25 negative for the reasons of bleeding, for the grounds of
93
1 bleeding and also for the brain. It is even worse when
2 you have slopes, that you have to go down or up slopes.
3 Q. Is that because there is a risk that the patient may
4 suffer a profound loss of arterial blood pressure?
5 A. Yes.
6 Q. In that event, is that a life-threatening condition?
7 A. It is life threatening, but it is because their
8 condition is very serious that it is life threatening,
9 but the conditions should not be aggravated.
10 Q. We know that the journey to the hospital took
11 25 minutes. Now, we also know that that included
12 a five-minute stop because that very occurrence occurred
13 to the patient. She had to be stabilised owing to
14 a profound drop in arterial pressure.
15 A. Yes.
16 Q. Given that the journey to the hospital took 25 minutes,
17 it appears as if the treatment of the patient took
18 18 minutes from retrieval from the wreckage to being put
19 into the ambulance. That would amount to a total time
20 expended of 43 minutes; that is in treatment and
21 transportation. Do you agree?
22 A. I think that you are following the correct calculation.
23 Q. If the patient had arrived at the hospital 23 minutes
24 earlier, would that have made any difference to the
25 treatment she was given or the outcome that occurred?
94
1 A. It would have made no difference to the way we treated
2 her and, unfortunately, on the outcome.
3 Q. In your professional opinion, is it better to get
4 the patient to the hospital quickly at all costs or is
5 it better to take the precaution that the patient's
6 arterial blood pressure is maintained so that she does
7 not suffer cardiac arrest before she reaches hospital?
8 A. I already said clearly that the patient, according to
9 me, had to reach the hospital being alive --
10 Q. Thank you. I am sorry, Professor Pavie, to hurry you
11 along, but the final matter that I would like and
12 welcome your opinion about is the possible complication
13 of a gaseous embolism.
14 If that could be simply translated to the witness at
15 the moment.
16 The question I want to ask is this: given the nature
17 of the patient's injuries and given that she was treated
18 with a thoracotomy, and indeed that was extended with
19 a sternotomy, allowing air to enter, what were
20 the prospects that the complication of gaseous embolism
21 might occur?
22 A. It is not the size of the cut which changes any
23 attention regarding this assumption of the air embolism
24 to the brain. Anyway there was injury in the brain and
25 these would have been lethal too.
95
1 The gas embolism is something that we are really
2 afraid of in any cardiac surgical operation. It is --
3 for the surgeon's jargon, it just fills with the left
4 side of the heart, which is the left ventricle and
5 the left arteries. When you have a wound in the left
6 area and when you have high arterial pressure, the blood
7 is exiting the heart.
8 Q. Professor Pavie --
9 A. When you have a low pressure, a low arterial pressure,
10 when you have the thorax being opened, then you may have
11 air which can enter and mix with the heart --
12 Q. Can I stop you there, Professor Pavie, please? I just
13 want to ask you two short questions about this process.
14 Is it correct that there was a high risk of
15 a complication of a gaseous embolism given the nature of
16 the injury and the treatment?
17 A. The risk was connected to the nature of the wound and
18 not to the nature of the treatment because we had no
19 other choice.
20 Q. But was there a high risk of that occurring?
21 A. This risk would have turned into a complication only if
22 the patient had been alive, but then, if she had been
23 alive, the brain would have been dead.
24 MR MACLEOD: Thank you, Professor Pavie.
25 MR HILLIARD: Thank you very much indeed.
96
1 LORD JUSTICE SCOTT BAKER: Have you no further questions?
2 MR HILLIARD: No.
3 LORD JUSTICE SCOTT BAKER: Thank you very much indeed,
4 Professor. We are extremely grateful to you for giving
5 up your time to assist us. That will be all we require.
6 Thank you.
7 A. Thank you.
8 LORD JUSTICE SCOTT BAKER: As far as Monday is concerned,
9 I think the two witnesses are Professor Lienhart and
10 Professor Treasure. Is Professor Lienhart scheduled for
11 half past nine?
12 MR HILLIARD: As I understand it, he is.
13 LORD JUSTICE SCOTT BAKER: He is by videolink from France?
14 MR HILLIARD: That is right.
15 LORD JUSTICE SCOTT BAKER: We will adjourn now, members of
16 the jury, and we will resume at half past nine on Monday
17 morning, as far as you are concerned.
18 MR MANSFIELD: Sir, may I detain you for a second?
19 LORD JUSTICE SCOTT BAKER: Certainly, yes. Thank you very
20 much. We can close down the videolink. Thank you.
21 (Jury out)
22 Yes, Mr Mansfield?
23 Submissions by MR MANSFIELD
24 MR MANSFIELD: I was just apologising to Mr Hilliard. I
25 had not actually warned him about this. It has arisen
97
1 overnight.
2 I wonder if we could raise one matter quickly. This
3 is because matters are going relatively speedily as far
4 as witnesses are concerned and I want to, if possible,
5 circumvent this situation arising again.
6 The simple point is this: we were provided overnight
7 with more material under the categories of "other
8 documents and messages".
9 Now I will not go through the details, but on the
10 face of these documents they were plainly relevant at
11 a much earlier stage. I appreciate that people can
12 overlook such matters. But, on the other hand, because
13 there are risks like this of people overlooking material
14 or taking decisions that they are not relevant, at least
15 for the purposes of the reader who is making the
16 selection, may I just return to a request that we made
17 in fact many months ago -- and letters have been sent --
18 that we have a list of all the messages.
19 So in other words, we are not asking for all of the
20 messages; we are asking for a list. Now, the message
21 that was revealed -- again, I am not going into
22 the detail -- but a message numbered 730 was revealed
23 overnight. It has plain prima facie relevance to an
24 issue that I have canvassed today about the possibility
25 of radiology and so on, with particular names -- and you
98
1 are probably aware of what is in these documents.
2 LORD JUSTICE SCOTT BAKER: I think I too saw them last
3 night.
4 MR MANSFIELD: Yes. Of course we are grateful for them, but
5 in fact, had we had this list, which we have asked for
6 before -- this is in relation to messages -- then
7 we could have identified because -- for example, M730
8 could have had in the margin "DS Easton re radiology"
9 and the name "Dion" would have come up and of course
10 other names would of course come up in that same
11 document. That would have been, on the face of it,
12 relevant to inquiries as well as questions.
13 So may I just ask that if it is not too late,
14 because of witnesses that are coming up in the ensuing
15 weeks, that we be provided with a master list so at
16 least we can identify anything that has potential
17 relevance that may have either been overlooked or
18 wrongly categorised?
19 As far as other documents are concerned, again there
20 was a document that was provided overnight. It has an
21 "OD" number on it. Now, we were given a list of some of
22 these, but this one, this particular one, which relates
23 to enquiries that the same officer was making, this time
24 not of the radiology, but of the source of a name that
25 was put into the public domain by a journalist, there
99
1 are clearly various matters that arise with that
2 journalist and information that was gleaned which
3 we could have certainly had at a much earlier stage.
4 What I imagine may have happened here is that
5 the person has decided that this either was irrelevant
6 or did not have evidential value or whatever. Once
7 again, if we could have a list of the other documents,
8 then a better assessment can be made so that we don't
9 get it the night before, we have time to prepare and
10 consider the significance or otherwise -- there may be
11 none -- in this. It only came about because I made
12 enquiries in relation to a particular name and said
13 "Could we have more information?" and then this material
14 was forthcoming. Up to then, we were unaware that it
15 existed.
16 So it is really that request: a list in both cases
17 if we could have it. I am sure by now -- I hope I am
18 speaking with a reasonable request -- that those lists
19 must exist somewhere.
20 LORD JUSTICE SCOTT BAKER: I do not know about that. It may
21 be that the time preparing the list is time taken away
22 from looking out the documents.
23 MR MANSFIELD: Absolutely.
24 LORD JUSTICE SCOTT BAKER: We are doing our best. One of
25 the difficulties here is that there has been such a vast
100
1 amount of what I would call "peripheral discovery", for
2 perfectly understandable reasons, that it is not always
3 inevitable that we can see the wood for the trees.
4 MR MANSFIELD: Yes, I understand.
5 LORD JUSTICE SCOTT BAKER: We have a limited number of
6 people who can deal with this and we are doing the best
7 we can. I will find out what the explanation is for
8 the particular points you raised.
9 MR HILLIARD: The position is that the name was only
10 mentioned at a relatively late stage, so that material
11 came to light when it did. One is bound to observe,
12 I suppose, that the bulk of it, as it were, which was
13 demonstrating that something which was suggested did not
14 appear to be right, I am not sure on the face of it, as
15 it were, what the sensitivity would be about that. That
16 is what that material came to, that something in fact
17 came to nothing.
18 As I understand it, there is a review going on of
19 material in any event at the moment. I understand my
20 learned friend's point, but it is probably right to say
21 that it is more important that the process is done and
22 done properly because if it is done properly, that
23 obviates the need for a list and it is, as you have
24 observed, a question really of competing resources;
25 assuming a list does not already exist, whether it is
101
1 worth spending the time preparing the list or looking at
2 the documents.
3 LORD JUSTICE SCOTT BAKER: Well, Mr Mansfield, I think all
4 I can say is that we will do our best and bear in mind
5 what you have said. Obviously we are particularly
6 conscious of those witnesses who are coming up in
7 the near future that anything that is potentially
8 relevant to them is important to get out sooner than in
9 relation to witnesses who are not giving evidence for
10 some time.
11 MR MANSFIELD: I make an obvious point: if, in fact,
12 the original information was wrong about a particular
13 radiologist, then one would be interested to know
14 whether the others that are mentioned in one of the
15 messages have been identified or asked or questioned
16 or --
17 LORD JUSTICE SCOTT BAKER: You might be interested to know
18 that I raised the very point at the midday break and
19 that is being looked into.
20 MR MANSFIELD: Then, sir, you are obviously extremely
21 sensitive to how it can develop or not develop.
22 LORD JUSTICE SCOTT BAKER: Yes.
23 MR MANSFIELD: I would have thought -- I may be wrong --
24 that electronically it would be possible to raise a list
25 relatively quickly without taking too many people away
102
1 from essential work.
2 LORD JUSTICE SCOTT BAKER: We will see what we can do. I do
3 not know if there are any lists at the moment, but we
4 will do the best we can.
5 I know that there are a number of documents that
6 come into the pre-statement material that I think are on
7 their way within the next 48 hours or so.
8 MR MANSFIELD: Yes. We have been told that. I will leave
9 it for the moment and we will see if progress can be
10 made.
11 LORD JUSTICE SCOTT BAKER: Very well. Half past nine on
12 Monday.
13 (3.50 pm)
14 (The hearing was adjourned until 9.30 am
15 on Monday, 19th November 2007)
16
17
18
19
20
21
22
23
24
25
103
103
1 INDEX
2
3 PROFESSOR BRUNO RIOU (sworn) ................. 1
4
5 Questions from MR HILLIARD ................ 1
6
7 Questions from MR MANSFIELD ............... 30
8
9 Questions from MR MACLEOD ................. 46
10
11 Further questions by MR HILLIARD .......... 54
12
13 PROFESSOR ALAIN PAVIE (affirmed) ................. 59
14
15 Questions from MR HILLIARD ................ 59
16
17 Questions from MR MANSFIELD ............... 73
18
19 Questions from MR MACLEOD ................. 88
20
21 Submissions by MR MANSFIELD ...................... 97
22
23
24
25
104
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