Annex A > Chapter 30 - Concerns 1995 and after > Concerns 1996 and later
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Concerns 1996 and later
Professor de Leval's report
265 In November 1995, Professor de Leval was invited to write a report on the updated paediatric cardiac surgical results of the UBHT, which were included in the UBHT's final report on paediatric cardiac surgery published in January 1996. [326] Professor de Leval's report examined paediatric cardiac surgery at Bristol between January 1990 and March 1995. [327]
266 In his introduction to the report, Mr Hugh Ross, the new Chief Executive of the UBHT, wrote:
`... it is a matter of regret that there was not an earlier in-depth and objective investigation within the Trust to resolve the concerns expressed by senior personnel. Any such investigation would have established whether concerns that were expressed were justified.' [328]
267 In the report, Professor de Leval examined the results of open- and closed-heart operations in Bristol between 1990 and 1995. These were compared with the data in UK Cardiac Surgical Register. Professor de Leval wrote:
`The UK Cardiac Surgical Register used in this report as a gold standard has ... never been validated. The degree of reliability of the data is not known. Importantly, the confidence limits are not available; and last, but not least, the detailed results of individual units and individual surgeons are not known. It is quite possible that a number of institutions and/or surgeons have the same results for some conditions and that the worst Bristol results are actually similar to a substantial minority of their peers.' [329]
268 Professor de Leval's conclusion was:
`... the Bristol performance over the last three years in terms of mortality matches with the average UK results as published by the UK Cardiac Surgical Register, including open-heart surgery in infancy, with the exception of the results of atrioventricular septal defects and arterial switch procedures.
`I also believe that the Trust and those at the sharp end of the system have taken positive steps to improve those results'. [330]
269 On 23 January 1996, Mr Ross sent Professor de Leval's report to the regional director of the NHSE to enable him to give any final advice on its contents. [331] The final report was presented to and approved by the UBHT Board on 26 January 1996 and then presented at a public meeting on 31 January 1996. Copies were sent to the clinicians involved in the paediatric cardiac service, to MPs, to families and to other NHS bodies. [332]
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Footnotes
[326] WIT 0319 0002 Professor de Leval
[327] UBHT 0052 0097 - 0108 ; `Bristol Paediatric Cardiac Surgery 1990-1995', report by Professor de Leval
[328] UBHT 0052 0098 - 0099 ; report by Professor de Leval
[330] UBHT 0052 0102; see Chapter 3 for an explanation of clinical terms
[331] WIT 0128 0044 Mr Ross
[332] WIT 0128 0044 Mr Ross