Welcome...
... to the tenth edition of Inquiry News. This issue contains information
about the conclusion of Phase one evidence, about Phase Two and the interim
report on the retention and use of tissue.
There is also information about the Phase Two page on the Inquiry’s
Website (www.bristol-inquiry.org.uk/)
If there is anything you would like to see in Inquiry News or if you
would like further information on any topic then please contact Becky
Jarvis, Media Relations Manager on 0117 938 8716 or e-mail R.Jarvis@bri-inq.org.uk.
TISSUE RETENTION REPORT
The Interim report from the Inquiry on tissue retention is still scheduled
for publication this spring, probably shortly after Easter.
Inquiry Chairman, Professor Ian Kennedy, announced in December last year
that the Chief Medical Officer had accepted his offer to produce an interim
report dealing with the retention and use of tissue following post-mortem.
The Inquiry will report on all the evidence heard, addressing issues
such as the complexity of the law and what may be proper or good practice,
and make recommendations for the future.
Inquiry receives final submissions
in Phase One
The Bristol Royal Infirmary Inquiry heard final oral presentations at
a hearing in Bristol in February.
Witnesses who gave oral evidence during Phase One, which lasted from
March to December 1999, were invited to put in a short, final presentation.
Final submissions were also presented by legal representatives on behalf
of:
- Bristol Heart Children Action Group;
- Bristol Surgeons’ Support Group;
- Department of Health;
- United Bristol Healthcare NHS Trust (UBHT);
- Dr John Roylance, former Chief Executive, UBHT;
and personally by
- Mr Hugh Ross, Chief Executive, UBHT.
Written submissions were also made by Mrs Margaret Maisey, former Director
of Operations and Nurse Advisor, UBHT; British Paediatric Cardiac Association;
Avon Health Authority; UBHT cardiologists Drs Hyam Joffe, Stephen Jordan
and Robin Martin; Mr James Wisheart, former Medical Director and consultant
cardiothoracic surgeon, UBHT; and Mr Janardan Dhasmana, former consultant
cardiothoracic surgeon, UBHT.
All of the final submissions and a transcript of the day’s proceedings
have been published on the Inquiry’s internet website. This concluded
the oral hearings from Phase One of the Inquiry.
Written statements still coming
in
Written statements are still being received at the Inquiry’s Bristol
office and new ones received are regularly published on the Inquiry website
and copied to libraries and community health councils.
As well as publishing statements under blocks of evidence we will shortly
be providing an alphabetical listing (by surname) of all those people
who have provided written statements to the Inquiry.
Farewell to the Remote Links
The technology, which enabled people to watch the Inquiry proceedings
from Community Health Council (CHC) offices in Barnstaple, Cardiff and
Truro, is being dismantled this month. We said goodbye and thank you to
the CHCs on 9 February at the end of the final submissions hearing.
The service, which was established to enable people to follow the Inquiry
hearings without having to travel to Bristol on a daily basis, has proved
useful for many families and individuals affected by the Inquiry.
As the Chairman stated, the Inquiry is very grateful to the three CHCs
involved for acting as ‘satellites’ for the hearings.
PHASE TWO UPDATE
The Inquiry team is concluding work on Phase Two. This second phase examines
wider issues and takes a broader, national view than the Inquiry’s
Phase One, which looked back at how services in Bristol were organised
between 1984 and 1995.
Phase Two consists of a series of seven seminars held in Bristol and
London between January and March this year. All seminars were open to
the public and media.Dates and venues of all the seminars were advertised
in local newspapers and national journals and published on the Inquiry’s
website.
The seven seminars look to the future and allow the Inquiry to fulfill
that part of its Terms of Reference to "make recommendations which
could help to secure high quality care across the NHS".
The seminar topics (listed below) were informed partly by lessons emerging
from Phase One. They also took account of the latest research and thinking
concerning the factors which determine the level of performance of organisations,
both within the public sector and beyond. The seminars have explored the
following themes:
Acute Healthcare Services for Children.
Determinants of Performance - The factors which determine the level of
performance of organisations including the public sector generally and
healthcare in particular.
Culture - professional and managerial cultures and their impact on the
quality of service.
Leadership - Vision, Change and Learning from Experience.
People – education, training, development and governance.
Systems – safety and risk management, quality and information.
Service – empowering the public in the healthcare process.
Phase two on the website
Details of all seminars are published on the Inquiry’s website.
Information about seminar participants, programmes and venues together
with position papers and points for discussion can be found by visiting
the ‘Phase Two’ page. A summary of the discussions from each
seminar is also made available a few days after the seminar.
PHASE ONE
During Phase One the Panel sat for 417 hours of actual hearing time spread
over 95 days and heard from nearly 150 different witnesses (plus our experts).
We have so far received over 500 formal written statements and these have
generated over 400 written comments. Of these statements, more than 220
have been given by parents.
Evidence scanned into the Inquiry’s computer database consists of
almost 850,000 pages. That is 674,000 pages of medical documents and 175,000
of other evidence.
ASSESSMENT OF ADEQUACY – Update on statistical
and other reviews
Over the past year the Inquiry has heard evidence from a wide range of
sources including: parents, Bristol clinicians and managers and independent
experts.
In addition, the Inquiry commissioned independent analytical work on
statistics and a sample of children’s case notes:
* Reports to the Inquiry on the results of the review, analysis and
synthesis of key statistical sources were published by the Inquiry
on 3 November 1999.
* A preliminary report on the results of the clinical case note review
exercise were published on 4 November 1999.
The Inquiry has now commissioned further analytical work to supplement
its assessment of the adequacy of paediatric cardiac services at Bristol.
Further work includes:
- a review of published research evidence on the effectiveness and outcomes
of paediatric cardiac surgery;
- consolidation of the Inquiry’s statistical review, analysis and
synthesis work through further validation of mortality data and some
additional analysis of existing data sources and
- consolidation of the clinical case note review exercise.
The Inquiry expects to publish reports on the results of this supplementary
analytical work in May 2000.
Update on the Clinical Case Note Review (CCNR)
The Clinical Case Note Review is an important contribution to the Inquiry’s
understanding of the adequacy of paediatric cardiac services at Bristol
from 1984 to 1995. A weighted sample of 80 cases was selected at random
from more than 1,800 cases of children who had heart surgery in Bristol
during this period. Teams of clinical experts drawn from the Inquiry’s
Expert Group then considered the 80 cases. Each review team consisted
of a paediatric cardiac surgeon; a paediatric cardiologist; a paediatric
anaesthetist/intensivist; a paediatric nurse or intensive care nurse and,
a paediatric pathologist.
The review was completed in October 1999. A preliminary report of the
CCNR exercise, bringing together the findings from all 80 cases reviewed,
was presented to the Panel during the oral evidence to the Inquiry on
4th November 1999. A number of cases from
the CCNR were also discussed during oral evidence to the Inquiry in November
and December 1999.
Work continues on the CCNR. Parents and clinicians involved in cases,
who considered that all the matters in the case notes may not have been
taken into account, had an opportunity to refer the matter to the Inquiry
Panel. The Panel agreed that a new team drawn from the Expert Group should
look at some cases and these reviews are currently being completed. Also,
individuals with an interest in a particular case had the opportunity
to make a formal written comment to the Inquiry. The Inquiry has continued
to keep in touch with parents of children who are included in the CCNR
sample.
A report on the CCNR will be completed in May 2000. This report will
be published on the Inquiry’s website, along with those CCNR forms
that the Inquiry has been given permission by parents or next of kin to
make public and any other formal written comments on the CCNR.
If you have any questions or would like further information please contact
Claire Bache, Medical Records Assistant on 0117 938 8727 or call our local
call number 0845 3000 613.
WHAT HAPPENS NEXT
Following the final Phase Two Seminar on 28 March, the Inquiry Panel
will focus on its remaining task to write a report of events in Bristol
and to make findings and recommendations as required by the Inquiry’s
Terms of Reference.
The Inquiry office will remain in Bristol until at least the summer.
While it is too soon to give a precise date of publication of the Inquiry’s
report, every effort is being made to complete it in the autumn.
There will be a further Inquiry Newsletter in June with information about
the interim report on tissue retention and an update about progress on
the final report.
Up to Contents
Back to top
|
