QUESTIONS AND ANSWERS
THE FOLLOWING IS A LIST OF ANSWERS TO SOME OF THE QUESTIONS MOST FREQUENTLY PUT TO THE INQUIRY TEAM.
The Secretary of State for Health announced to Parliament the setting up of this Inquiry into children's heart surgery at the Bristol Royal Infirmary on June 18, 1998. Ministerial Statement
The Inquiry was set up under Section 84 of the National Health Service Act 1977 which gave the Chairman, Professor Ian Kennedy, the power to require witnesses to attend the Inquiry; to give evidence on oath; and to order the production of documents. Criminal penalties could be imposed on anyone refusing to comply with these requirements. Announcing the Inquiry, the Secretary of State said it would examine all aspects of what happened at Bristol, identifying any professional, management or organisational failures.
Yes it was. The Chairman, the Panel members and those managing and supporting the Inquiry were independent of any of the individuals or organisations involved. The Inquiry was independent of the Department of Health and of any health authority or medical organisation. It was an independent Inquiry team working to comprehensive terms of reference.
The Inquiry started in September 1998. The first stage, during the first few weeks, consisted of developing a procedure for the Inquiry and issuing requests for relevant papers from organisations or individuals who had an involvement or a direct interest in the Inquiry's work. The time was also used to begin the search for offices in both Bristol and London.
The Inquiry team made an initial request for papers in September 1998. That allowed the team to begin the process of collecting papers and files which may have been relevant to its work. The Chairman issued a further call for information during his opening statement at the preliminary hearing.
The first formal stage of the Inquiry was the preliminary hearing which was held in Bristol on October 27, 1998. The Chairman made a statement to explain the Inquiry's procedure and purpose and he heard applications to be legally represented at the Inquiry at public cost. The Chairman's opening statement is available on this website on the "Preliminary Hearing" page.
The objectives were to understand what happened in Bristol, why it happened, and what lessons could be learned for the benefit of the NHS as a whole. The Inquiry team started with a clean sheet and there were no preconceptions. It was fair and impartial.
All cases of children receiving complex cardiac surgical services at the BRI between 1984 and 1995 were taken into account in the Inquiry. While part of its work involved looking at the quality of clinical decision making. It was not the role of the Inquiry, nor was it possible, to make a judgement about the standard of care in each and every case. Where it was necessary for the Inquiry to choose a case to look at in more detail, then the reasons for choosing that case were made known. The Inquiry did its very best to get at the truth of what happened in Bristol and suggested ways forward for the future.
No. The Inquiry looked at a wide range of cases at the BRI including those in which children died or where they suffered permanent disability, such as brain damage.
The Inquiry was concerned with the full range of services including, for example, how children were referred for surgery, what parents were told about their child's care, and the management of post-operative care.
It is not the intention to actively to seek information about children's heart surgery services before 1984 or after 1995 or about adult surgery. However, if any information came to light during the investigations which was relevant to the terms of reference then it was considerd. Anyone who had anything to say on these matters was invited to write to the Inquiry.
No, it was not. The Chairman stated that the process must be as bearable as possible given the sensitive nature of much of the evidence involved. No one was on trial at this Inquiry. It was not a trial, nor a court, nor a disciplinary hearing. It was not about winners and losers, there were no parties and no sides. It was not the purpose of the Inquiry to sit in judgement. The approach was inquisitorial and not adversarial. When announcing the Inquiry, the Secretary of State said he hoped everyone involved would co-operate fully.
No. Issues of professional registration are a matter for the General Medical Council.
It was not the Inquiry's role to act as a professional disciplinary body. What other organisations did, or may do, is a matter for them and had no bearing on how the Inquiry proceeded and what it concluded.
No it did not. This is an entirely separate matter, not connected with the Inquiry. The issue of compensation is being handled by the United Bristol Healthcare NHS Trust and the National Health Service Litigation Authority (NHSLA) which is the Special Health Authority that deals with these matters on behalf of NHS organisations.
The Inquiry Chairman was Professor Ian Kennedy, Professor of Health Law, Ethics and Policy at the School of Public Policy, University College, London. He holds degrees in law from universities in the UK and USA and is a Barrister and Honorary Bencher of the Inner Temple. Until December 1996, he had been Dean of the Law School at King's College, London, for ten years and was Director and then President of the Centre of Medical Law and Ethics which he founded in 1978. He has a long involvement in public service including membership of the Medicines Commission and the Department of Health's Expert Advisory Group on AIDS. He chaired the Secretary of State for Health's Advisory Group on Xenotransplantation and, most recently, the Minister of Agriculture's Advisory Group on Quarantine. He is Chairman of the Nuffield Council on Bioethics and serves on the Archbishop of Canterbury's Advisory Group on Medical Ethics and the International Forum on Transplant Ethics. The Reith Lecturer in 1980, Professor Kennedy has taught and lectured throughout the world. He is the author of texts on medical law and ethics, co-editor of the leading journal on medical law and a member of the editorial board of ten national and international journals.
He was assisted by Professor Sir Brian Jarman OBE, Rebecca Howard and Mavis Maclean. Professor Jarman is Emeritus Professor at Imperial College School of Medicine at St. Mary's Hospital in London. Rebecca Howard is the Director of Nursing at the Alder Hey Children's Hospital, Liverpool. Mavis Maclean is Director of the Oxford Centre for Family Law and Policy, Oxford University.
Oral hearings began in Bristol on 16 March 1999.
Phase Two Questions
In his opening statement to the Inquiry’s preliminary hearing on 27th October 1998, the Chairman explained that the Inquiry would be in two Phases. Phase One examined paediatric cardiac surgical services in Bristol between 1984 and 1995. Phase Two, which took place between January and March 2000, was an examination of relevant wider issues.
The objectives of Phase Two were:
a. to assist the Inquiry Panel in meeting the requirement in their terms of reference, "to make recommendations which could help to secure high quality care across the NHS";
b. to help to ensure that the Inquiry’s recommendations are relevant to the NHS of the future, practical and achievable, all within a realistic level of resources.
The Panel focused on current and potential future policy initiatives to help them to make recommendations to improve the quality of care in the NHS. They took a national perspective, informed by learning from the evidence presented in Phase One of the Inquiry.
The Panel commissioned "position papers" from a wide range of organisations and individuals. For each theme, these were supplemented by public seminars to address topics of particular interest to the Panel. Further short papers ("points for discussion") were commissioned from some of those invited to attend the seminars. All position papers and points for discussion were published on the Inquiry’s website under the heading 'Phase Two' and copies sent to libraries and Community Health Council offices.
The first seminar was held on 12 January 2000.
Participants, drawn from the public and private sectors and from academic and voluntary organisations, were invited to attend the seminars to raise points for discussion and to share their relevant expertise. The Panel were advised by members of the Inquiry Counsel on points of law and members of the Inquiry Secretariat attended to manage administrative matters. The seminars were open to the general public and the media.
No. A summary of each discussion was prepared and published on the Inquiry website and made available through libraries and Community Health Council offices.
At the conclusion of Phase Two, the Inquiry Panel withdrew to consider all the evidence and information presented to them during the course of the Inquiry and began the task of writing the Inquiry’s full report. In addition, at the request of the Chief Medical Officer for England, the Panel also prepared an interim report on the subject of tissue removal and retention following post-mortem examination. The Interim Report was published on 10 May 2000.
It was in the interests of everyone concerned to try to complete the Inquiry within a reasonable period. This was crucial so that those affected by these tragic events could find a place for them and be helped to get on with their lives. It was also important that any lessons learned could be translated into action within the NHS as soon as possible. The estimated final cost of the Inquiry was £14 million.
Phase One (oral hearings) Questions
The Inquiry heard oral evidence in blocks, according to the issues and following the themes as laid down in our terms of reference. However, it must be remembered that a great deal of evidence was in writing and that this written evidence was also put before the panel.
The Inquiry was in two phases. The first phase focussed on services at the Bristol Royal Infirmary between 1984 and 1995 and looked at the full range of services for the care of children who received complex heart surgery. It examined the context, both national and local in which these services were delivered. The Inquiry also examined how concerns about surgery were raised and handled, both within and outside the hospital. In addition, the Inquiry examined the information available on which any conclusions as to quality of care could be based. The second phase of the Inquiry examined wider issues and allowed the Panel to make recommendations for the benefit of the whole NHS. This second phase began in January 2000 and lasted through the Spring of 2000.
The Inquiry's terms of reference were broad. Any individual or organisation, including the Department of Health, the Bristol Royal Infirmary, Royal Colleges, health authorities, doctors, nurses and managers, and others with a relevant interest, were among those invited to assist the Inquiry.
Yes. Witnesses who had given oral evidence were recalled to give further evidence.
Their job was to listen and also to ask questions. Having assessed and evaluated the evidence they assisted the Chairman in preparing the Inquiry report.
Counsel to the Inquiry was Brian Langstaff QC. His role was strictly impartial. It was to assist the panel in its investigation of the facts and its search for the truth. It was not his role to prosecute nor to prove a particular case. The Inquiry began with a clean sheet and the Panel read and heard evidence given by witnesses. The role of the Inquiry Counsel was to present all the oral evidence thoroughly and rigorously and to advise the Inquiry Chairman and the panel members on matters of law and evidence. He was assisted by Eleanor Grey and Alan Maclean. The solicitor to the Inquiry was Peter Whitehurst who was appointed from the Treasury Solicitor's department. Peter was assisted by Charlotte Martin and they were responsible for investigating the documentary material, liaising with witnesses and arranging the hearing programme.
Yes, it did. In 1999 a team of experts was announced; they were qualified in a variety of areas of expertise such as paediatrics, cardiology, surgery, intensive care, anaesthesia, statistics and management. Experts’ formal evidence was also made public. For a list of the team of experts please see Expert Group.
The Inquiry was not a trial. Phase One followed an inquisitorial procedure rather than that of a court. Questioning of witnesses was normally conducted by Inquiry Counsel. The legal representatives of individuals and relevant organisations had a crucial part to play in assisting in obtaining written statements and suggesting to Inquiry Counsel lines of questioning. If anyone wished to raise an issue to be addressed by a particular witness, they did this through their legal representative, if they had one, who would in turn request Inquiry Counsel to include the matter in the questions to be put to the witness. Alternatively, they could contact the Inquiry’s solicitor. Any person not represented could contact the Inquiry direct either in writing or by e-mail. All witnesses who appeared before the Inquiry were entitled to equal treatment and a fair hearing.
The Inquiry legal team aimed to look at each statement within two days of receiving it. If any individual or organisation was criticized, they were offered a chance to respond. The work was undertaken behind the scenes by a team made up of solicitors, paralegal staff and administrators. The statement was considered by the Panel with all relevant comments that had been received. The statement was published on the Inquiry website and distributed to libraries and Community Health Councils. Oral hearings concluded in December 1999. The Chairman and Panel decided, from among all those who had submitted formal written statements, whom they would like to hear from further at the public hearings.
The staff of the Inquiry were there to help and to provide immediate support to anyone visiting the Inquiry. They were easily identifiable as they wore a badge – "Inquiry Staff". Where necessary, the staff provided information and advice about how to get in touch with other sources of longer-term support and assistance. On certain days professional counsellors were available but the Inquiry was unable to provide long-term support, or one-to-one counselling.
Anyone who wished was, of course, welcome to attend the public hearings in person. There was no need to contact the Inquiry in advance. However, for those who were not able to travel, or did not want to travel long distances, arrangements were put in place which enabled as many people as possible to follow the proceedings. Video links were established to transmit live pictures direct from the Inquiry to Community Health Council Offices in Cardiff, Barnstaple and Truro. Video screens were also installed within the Inquiry Chamber itself and in the dedicated press room. The Daily transcripts were placed on the Inquiry website every evening. Copies of the transcript were available in the Inquiry Offices, Community Health Councils and public libraries (a list of libraries and CHC's receiving hard copy transcripts can be found under Daily transcripts.)
Phase One hearings concluded on Thursday 16 December 1999. Those witnesses who had previously given oral evidence were given the choice to make a short final presentation, either by themselves or through their legal representatives. This could be presented orally, at the discretion of the Chairman, or in writing.
The Inquiry Report was published on 18 July 2001. It is available on this site. Further information about the Inquiry's procedures can be found in Chapter 2 of the Report and in Annex B.