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CCNR Report and associated documents

Clinical Case Note Review

BRISTOL ROYAL INFIRMARY INQUIRY

PRELIMINARY REPORT ON THE

CLINICAL CASE NOTE REVIEW

Prepared for the Inquiry by

Mr Leslie Hamilton, Consultant Paediatric Cardiac Surgeon and

Dr Eric Silove, Consultant Paediatric Cardiologist

with support from the Inquiry Secretariat

 Executive Summary

1. The Bristol Royal Infirmary Inquiry commissioned clinical experts to review the cases of 80 children covering 100 procedures of cardiac surgery.
2. This review is only one of a number of sources of evidence and information available to the Inquiry on the adequacy of paediatric cardiac surgery in Bristol.
3. The sample of 80 cases was selected at random from over 1800 children who received either open or closed cardiac surgery at Bristol between 1984 and 1995. The sample was deliberately weighted towards younger children who had open heart surgery, and towards children who died.
4. Each case was reviewed by multi-disciplinary teams of clinical experts who were asked to assess the adequacy of care overall, as well as the adequacy of pre-operative, surgical and post-operative care. Reports were prepared to a standard format.
5. Initial analysis of the overall assessments shows that the care received by 50% of children in the sample was adequate. For a further 20% of the children, care was assessed as less than adequate, yet different management would have made no difference to outcome. In the cases of the remaining 30% of children, (24 out of 80 cases), reviewers concluded that care was also less than adequate, but different management might have made, or would reasonably be expected to have made, a difference to outcome.
6. In only 9 of the 100 procedures assessed was it considered that different conduct of the surgical procedure might have or would probably have made a difference to outcome.
7. Where care was assessed as less than adequate, aspects of pre-operative care, surgical care, and post operative care were all mentioned. Reviewers also commented on problems of communication in the team and difficulties arising from way the Bristol service was organised.
8. A retrospective review of cases where children died is always likely to be critical; by definition different care might have made a difference. In some cases where death or disability occurred, the reviewers identified aspects of care which were praiseworthy.

PRELIMINARY REPORT ON THE CLINICAL CASE NOTE REVIEW

 October 1999

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