Annex A > Chapter 1 - The Background to and Conduct of the Public Inquiry > Commissioned work > The Clinical Case Note Review (CCNR)

The Clinical Case Note Review (CCNR)

82 There was no template against which the adequacy of the service provided at Bristol could readily be measured. The Inquiry, therefore, had to make its own assessment from a variety of sources. These included a statistical review of the main data sources which might inform the Inquiry of comparative outcomes at Bristol, both relative to other units and to its own performance over time; evidence of individuals of their contemporaneous views; evidence given with hindsight (with its limitations); contemporaneous documentation; the inferences properly to be drawn from the documentary and oral evidence given to the Inquiry; and the knowledge base of clinicians at the relevant time.

83 Additionally, the Panel asked clinical experts to review a sample of the clinical case notes of children whose care fell within the Terms of Reference. The purpose of the CCNR was to provide the Panel with a qualitative perspective on what the notes revealed about the overall pattern of care, and to highlight areas where it appeared, from the notes, that services were adequate or less than adequate. [29]

84 Teams of clinicians drawn from the Expert Group undertook the exercise. The teams reviewed a weighted sample, initially, of the clinical case notes of 80 children; these included children who had died within 30 days of surgery and children who were alive at that time. The weighting of the sample was designed to reflect the principal issues of concern to the Inquiry. Due consideration was given to any distortions caused by the process of weighting when the final conclusions were advanced.

85 The clinicians were grouped into six multidisciplinary review teams, and each team was asked to review a set of clinical case notes.

86 Each review team consisted of five members:

• paediatric cardiac surgeon;
• paediatric cardiologist;
• paediatric anaesthetist/intensivist;
• paediatric pathologist; and
• paediatric nurse or intensive care nurse.

87 The Inquiry's approach to the CCNR was deliberately qualitative and acknowledged that, for the years from 1984 to 1995, there were no clearly set down, nationally agreed standards for paediatric cardiac surgical services. Therefore, the members of each review team were asked, as far as possible, to apply their best clinical judgement drawing on their understanding and knowledge of received professional standards at the time at which the care was delivered. In determining the most appropriate method for the review, the Inquiry took the advice of members of the Expert Group and then tested that advice in a pilot exercise.

88 The CCNR consisted of four stages: reading; reaching a tentative independent view; discussing those views at a multidisciplinary meeting; and reporting on the outcome of the discussions.

89 All members of a review team were given access to the clinical notes. To the extent that they could be located, relevant perfusion and Intensive Care Unit (ICU) charts, echocardiograms and angiograms, and X-rays were made available to the clinicians on each team as necessary. Each expert read the notes and developed a tentative view of what they showed, from the perspective of his or her own clinical expertise.

90 Each team held review meetings, where case histories were discussed, following a short introduction. Each member of the team contributed from his or her own expertise, drawing on an understanding and knowledge of professional practice at the time. The team collectively reached a view about the adequacy of care in relation to specific aspects of care, as well as in relation to the overall management of the case, including cases in which two or three operations took place.

91 The Inquiry was mindful that differences of approach between the review teams could occur. In order to make any such differences transparent, and to help with the overall interpretation of the exercise, the Inquiry distributed a number of the same case notes across the teams. Teams were not aware when looking at case notes that another team may have already considered them.

92 It needs to be emphasised that the CCNR was a review of that which the notes showed. Accordingly, evidence extraneous to the notes that tended to support or falsify a view taken of the quality of treatment which the notes showed, did not, and could not, itself invalidate conclusions reached as to what the notes themselves showed. It was the pattern of care revealed by the notes, rather than the appropriateness of its conclusions when a case was examined by using evidence extrinsic to the notes, that was of importance.

<< previous | next >> | back to top

Footnotes

[29] See Annex B for an explanation of the methodology employed in the CCNR