A senior Department of Health official was given a sealed envelope containing data about surgical outcomes at the Bristol Royal Infirmary during a taxi ride with 'whistleblower' Dr Stephen Bolsin, the inquiry into baby deaths at the hospital heard this week.
Dr Peter Doyle, a senior medical officer and secretary of the National Specialist Commissioning Services Advisory Group, said Dr Bolsin approached him after an unrelated audit meeting in Bristol on 19 July 1994.
Dr Bolsin handed over a 'brown paper envelope' with his audit results in it, which Dr Doyle did not open. He told the inquiry: 'I did not have the skills or expertise to come to a judgement.'
But he did write a strongly worded letter to Professor Gianni Angelini, who hosted the audit meeting, saying the allegations should be properly investigated.
Professor Angelini replied in August that the appointment of a full-time paediatric surgeon and an end to split site working should 'address the shortcomings pointed out in your letter'.
Dr Doyle then received an unprompted letter from United Bristol Healthcare trust chief executive Dr John Roylance confirming 'this trust board's awareness of this problem'.
Dr Doyle told the inquiry: 'This letter is crucial. . . Nobody, the secretary of state himself, could not have asked for better and clearer reassurance from the chief executive that the trust had analysed, understood the problem, taken effective management action.'
He also said he understood 'implicitly' that further risky procedures would not be undertaken until the new surgeon was in place. But on 11 January, he was told by Dr Bolsin and Professor Angelini that a non-urgent operation was being planned on an 18-month-old child.
Dr Doyle managed to telephone Dr Roylance 'early that evening' to discuss the case.
But on 12 January, he heard 'there had been a tragedy' and the child, Joshua Loveday, had died.
On 16 January, he alerted 'a large number of colleagues in the DoH' and ordered an external inquiry. 'It was apparent to all that they [the trust managers] had failed in an aspect of their management, ' he said.