Learning from Bristol

1 The Report of the Public Inquiry into children s heart surgery at the Bristol Royal Infirmary 1984-1995 Learning from BristolProduced for the Bristol Royal Infirmary Inquiryby COI CommunicationsCM 5207(I) Bristol Royal Infirmary Inquiry Learning from BristolPublished by The Stationery Office Limitedand available from:The Stationery Office(Mail, telephone and fax orders only)PO Box 29, Norwich NR3 1 GNGeneral enquiries 0870 600 5522 Order through the Parliamentary HotlineLo-call 0845 7 023474 Fax orders 0870 600 5533 Email Stationery Office Bookshops123 Kingsway, London WC2B 6PQ020 7242 6393 Fax 020 7242 639468-69 Bull Street, Birmingham B4 6AD0121 236 9696 Fax 0121 236 969933 Wine Street, Bristol BS1 2BQ0117 9264306 Fax 0117 92945159-21 Princess Street, Manchester M60 8AS0161 834 7201 Fax 0161 833 063416 Arthur Street, Belfast BT1 4GD028 9023 8451 Fax 028 9023 5401 The Stationery Office Oriel Bookshop18-19 High Street, Cardiff CF1 2BZ029 2039 5548 Fax 029 2038 434771 Lothian Road, Edinburgh EH3 9AZ0870 606 5566 Fax 0870 606 5588 Accredited Agents(See Yellow Pages)and through good booksellersPresented to Parliament by the Secretary of State for Healthby Command of Her MajestyJuly 2001CM 5207(I) 32 (inc.)

2 VAT) The Report of the Public Inquiry intochildren s heart surgery atthe Bristol Royal Infirmary1984 1995 Learning from Bristoli BRI InquiryFinal ReportSection OneForeword Foreword It is my privilege to present this Report, as Chairman of the Inquiry. I do so in the hope that it will achieve two principal aims. First, I hope that it will allow a better understanding of what happened in relation to paediatric cardiac surgery in Bristol in the 1980s and 1990s. There were failings both of organisations and of people. Some children and their parents were failed. Some parents suffered the loss of a child when it should not have happened. A tragedy took place. But it was a tragedy born of high hopes and ambitions, and peopled by dedicated, hard-working people. The hopes were too high; the ambitions too ambitious. Bristol simply overreached itself. Many patients, children and adults benefited; too many children did not.

3 Too many children Public Inquiry cannot turn back the clock. It can, however, offer an opportunity to let all those touched by the events, in our case Bristol , be heard and to listen to others. Through this process can come understanding. We tried to provide this opportunity. The understanding we formed is set out in Section One of our Report. It speaks of an organisation which was not up to the task; of confusion and muddle as to where responsibility lay for making sure that the quality of care provided to children was good enough; and of a system of care blighted by being split between two sites, by shortages of trained staff and by inadequate would be reassuring to believe that it could not happen again. We cannot give that reassurance. Unless lessons are learned, it certainly could happen again, if not in the area of paediatric cardiac surgery, then in some other area of care. For this reason we have sought to identify what the lessons are and, in the light of them, to make recommendations for the future.

4 This is the second of our aims. It is what Section Two of our Report addresses. We offer our view of the way forward for the NHS: an NHS fit for the 21st century. The scale of the enterprise is considerable. So are the time and resources which will be needed to achieve the necessary changes. We make close to 200 recommendations. They are the recommendations of all of us. This is a unanimous Report. Our job is done. It is up to others to decide how to take things forward. ii BRI InquiryFinal ReportSection OneForeword For the Panel it has been a long journey. I pay tribute to the support Rebecca Howard, Brian Jarman and Mavis Maclean have given me throughout. They have tolerated the burdens which I have placed on them with exemplary patience and goodwill. We have worked harmoniously. Throughout, we have had the benefit of a quite outstanding team. It has constituted a rich array of talents: the architects and designers who created the hearing chamber and facilities in Bristol ; the teams supporting us in areas such as analysis, administration and IT; the managerial abilities of the Deputy Secretary Zena Muth; the tireless efforts of Becky Jarvis in the final stages of publication; and my personal assistants who in turn managed not only me but such things as trains and hotels with great skill and good humour.

5 Warm thanks are also due to the Inquiry s legal team: the solicitors and paralegals led by Peter Whitehurst and Counsel led by Brian Langstaff QC. They all worked prodigiously hard. I mention also our team of Experts. They helped us enormously. Their work was of the highest standards and often groundbreaking. I single out one person for particular thanks. The Inquiry was fortunate beyond words in having Una O Brien as its Secretary. I cannot praise her too highly. Her ability, dedication and sheer unremitting hard work represent the finest traditions of public service. Without her we could not have achieved half of what we did. She is owed a singular debt of hope I can be forgiven for adding an entirely personal note. During the Inquiry s hearings my brother Stuart died. He had contracted hepatitis while operating on a patient. He was a good man and a good doctor. He taught me much. I dedicate any contribution I may make to the future of the NHS to his KennedyJuly 2001 iii BRI InquiryFinal ReportContents Contents Summary 1 SECTION ONE: THE Bristol STORY Chapter 1:Introduction21 Chapter 2:The Conduct of the Inquiry29 Chapter 3:The Care and Treatment of Children with Congenital Heart Disease43 Chapter 4:The Changing NHS 1984 199549 Chapter 5:Management in Bristol61 Chapter 6:Quality, Standards and Information73 Chapter 7:The Audit and Monitoring of the Paediatric Cardiac Surgical Service in Bristol87 Chapter 8:Paediatric Cardiac Surgical Services97 Chapter 9:The Paediatric Cardiac Surgical Service in Bristol111 Chapter 10: Introduction to Concerns129 Chapter 11: The Expression of Concerns by Individuals and Reaction to Those Concerns133 Chapter 12.

6 Responses to Concerns and Actions Taken, and Whether Such Actions were Appropriate and Prompt153 Chapter 13: Introduction to Adequacy of Care177 iv BRI InquiryFinal ReportContents Chapter 14: External Assessment and Monitoring of the Quality of Care in Bristol185 Chapter 15: The Culture and Management at the UBH/T195 Chapter 16: The Organisation of the Paediatric Cardiac Surgical Service in Bristol205 Chapter 17: Parents Experiences217 Chapter 18: The Designation of Bristol as a Centre for Neonatal and Infant Cardiac Surgery225 Chapter 19: Observations on the Organisation of the PCS service229 Chapter 20: Understanding and Assessing the Quality of Clinical Care in Bristol233 Conclusions 247 SECTION TWO: THE FUTURE Chapter 21: Introduction251 Chapter 22: The Culture of the NHS263 Chapter 23: Respect and Honesty279 Chapter 24: A Health Service which is Well Led301 Chapter 25: Competent Healthcare Professionals321 Chapter 26: The Safety of Care351 BRI InquiryFinal ReportContents v Chapter 27: Care of an Appropriate Standard375 Chapter 28: Public Involvement Through Empowerment399 Chapter 29: The Care of Children413 Recommendations 433 APPENDICES Appendix 1: List of Acronyms used in the Report and Annexes 463 Appendix 2: Details of Individuals who Gave Oral and Written Evidence to the Inquiry and Individuals who are Mentioned in the Report or Annex A 471 Appendix 3: Guide to the Annexes of the Final Report 499 Appendix 4: Expenditure of the Bristol Royal Infirmary Inquiry: September 1998 July 2001 525 Appendix 5.

7 Staff Employed on the Inquiry 527 vi BRI InquiryFinal ReportContents BRI InquiryFinal ReportInformation vii Information about reference material, sources of evidence and footnotes (a) Reference material Explanation of acronyms: A list of acronyms commonly referred to in the text can be found at the end of the Report in Appendix 1. People: A list of the full names and titles of those individuals referred to in the text can be found at the end of the Report in Appendix 2. Further reading: A bibliography of published works which have informed the Panel s work can be found in Annex B. (b) The Annexes to the Report There are four Annexes to the Report. They comprise the equivalent of 12,000 pages of text and are available in CD format, attached to the back of the Annexes are:A more detailed list of contents of the four Annexes is in Appendix 3. Annex A A factual account of the evidence heard and received during Phase One (oral hearings) of the Inquiry.

8 Annex B A variety of papers including the following: The procedures of the InquiryPapers by Experts to the InquiryThe Clinical Case Note ReviewPapers on statistics. Annex C The Inquiry s Interim Report: Removal and retention of human material . Annex D The transcript of the oral hearings: a verbatim account of 96 days of evidence. viii BRI InquiryFinal ReportInformation (c) Footnotes The footnotes in the Report refer to sources of evidence, or provide an explanation, for a particular point. The types of footnote, and the routes for further exploration, are as follows: (d) The Inquiry s website The Inquiry s website will remain available for the forseeable future. The website includes the full text of the Summary, Final Report, Annexes A D and all background papers for Phase Two. The website is the only route of access to the statements received from 577 witnesses and to all the formal written comments made about those :the prefix WIT denotes a witness statement.

9 WIT 0578 0003 Mr White is a reference to page 3 of Mr White s statement. All statements can be found on the Inquiry s website T:the prefix T refers to the transcript. T24 p. 16 refers to day 24, page 16. The full transcript is in Annex D. It is also available on the Inquiry website. Other acronyms:A variety of other acronyms occur in the footnotes, particularly in Section One. An example would be UBHT 0065 0027. This refers to a paper given to the Inquiry by the United Bristol Healthcare NHS Trust (UBHT); the number is a unique page reference number assigned by the Inquiry. A full list of all the footnote acronyms can be found in the notes to Annex acronyms are: UBHT United Bristol Healthcare NHS TrustDoH Department of HealthRCSE Royal College of Surgeons of England The vast majority of the documents referred to in Section One are available in Annexes A and B on the accompanying CD. 1 BRI InquiryFinal ReportSummary Summary Terms of Reference 1 Our Terms of Reference were: To inquire into the management of the care of children receiving complex cardiac surgical services at the Bristol Royal Infirmary between 1984 and 1995 and relevant related issues; to make findings as to the adequacy of the services provided; to establish what action was taken both within and outside the hospital to deal with concerns raised about the surgery and to identify any failure to take appropriate action promptly; to reach conclusions from these events and to make recommendations which could help to secure high-quality care across the NHS.

10 2 The Public Inquiry was conducted between October 1998 and July 2001. The Panel was chaired by Professor Ian Kennedy. The other members were Rebecca Howard, Professor Sir Brian Jarman and Mavis Maclean. The work of the Inquiry was divided into two phases. In Phase One, the focus was on events in Bristol . Evidence from 577 witnesses, including 238 parents, was received in writing. The Inquiry also received 900,000 pages of documents, including the medical records of over 1,800 children. Oral evidence of selected witnesses was taken over 96 days. The focus of Phase Two was the future. One hundred and eighty papers were submitted to seven seminars in which 150 participants from the NHS, and the public and private sectors took part. In May 2000 the Inquiry produced an Interim Report on the Removal and Retention of Human Material. Synopsis 3 The story of the paediatric cardiac surgical service in Bristol is not an account of bad people.