Final Report > Summary > Synopsis

Synopsis

3 The story of the paediatric cardiac surgical service in Bristol is not an account of bad people. Nor is it an account of people who did not care, nor of people who wilfully harmed patients.

4 It is an account of people who cared greatly about human suffering, and were dedicated and well-motivated. Sadly, some lacked insight and their behaviour was flawed. Many failed to communicate with each other, and to work together effectively for the interests of their patients. There was a lack of leadership, and of teamwork.

5 It is an account of healthcare professionals working in Bristol who were victims of a combination of circumstances which owed as much to general failings in the NHS at the time than any individual failing. Despite their manifest good intentions and long hours of dedicated work, there were failures on occasion in the care provided to very sick children.

6 It is an account of a service offering paediatric open-heart surgery which was split between two sites, and had no dedicated paediatric intensive care beds, no full-time paediatric cardiac surgeon and too few paediatrically trained nurses.

7 It is an account of a time when there was no agreed means of assessing the quality of care. There were no standards for evaluating performance. There was confusion throughout the NHS as to who was responsible for monitoring the quality of care.

8 It is an account of a hospital where there was a `club culture'; an imbalance of power, with too much control in the hands of a few individuals.

9 It is an account in which vulnerable children were not a priority, either in Bristol or throughout the NHS.

10 And it is an account of a system of hospital care which was poorly organised. It was beset with uncertainty as to how to get things done, such that when concerns were raised, it took years for them to be taken seriously.

11 The circumstances of Bristol, and the NHS, at the time, led to the system for providing paediatric cardiac surgery (PCS) being flawed. All of these flaws, taken together, led to around one-third of all the children who underwent open-heart surgery receiving less than adequate care. More children died than might have been expected in a typical PCS unit. In the period from 1991 to 1995 between 30 and 35 more children under 1 died after open-heart surgery in the Bristol Unit than might be expected had the Unit been typical of other PCS units in England at the time.

12 Our Report contains close to 200 Recommendations. They include the following:

13 Children: the needs of very sick children in the 1980s and 1990s were not given a high priority. For the future, children in hospital must be cared for in a child-centred environment, by staff trained in caring for children and in facilities appropriate to their needs. A national director for children's healthcare services should be appointed to lead the development of child-centred healthcare.

14 Safety: the arrangements for caring for very sick children in Bristol at that time were not safe. There was too little recognition that the state of buildings and of equipment, and the training of the staff, could cause actual harm to the children. For the future, the NHS must root out unsafe practices. It must remove barriers to safe care. In particular, it must promote openness and the preparedness to acknowledge errors and to learn lessons. Healthcare professionals should have a duty of candour to patients. Clinical negligence litigation, as a barrier to openness, should be abolished. Safe care should be promoted and led by a non-executive member of every trust board.

15 The competence of healthcare professionals: there was no requirement on hospital consultants at that time (nor is there now) to keep their skills and knowledge up to date. Surgeons were able to introduce new techniques without any formal system of notification. For the future, it must be part of all healthcare professionals' contracts with a trust (and part of a GP's terms of service) that they undergo appraisal, continuing professional development and revalidation to ensure that all healthcare professionals remain competent to do their job.

16 Organisation: consultants enjoyed (and still enjoy) what is virtually a job for life. Their relationship with the trust that employs them makes it difficult to bring about change. All employees should be treated in a broadly similar manner. Doctors, nurses and managers must work together as healthcare professionals, with comparable terms of employment and clear lines of accountability, in order to provide the best possible care for patients.

17 Standards of care: parents taking their children to be treated in Bristol assumed that the level of care provided would be good. Their children were cared for in a `supra regional centre' designated as such by the Department of Health. They trusted the system. Few had any idea that there were no agreed standards of care for PCS or for any other specialty. For the future, there must be two developments. There must be agreed and published standards of clinical care for healthcare professionals to follow, so that patients and the public know what to expect. There must also be standards for hospitals as a whole. Hospitals which do not meet these standards should not be able to offer services within the NHS.

18 Openness: Bristol was awash with data. There was enough information from the late 1980s onwards to cause questions about mortality rates to be raised both in Bristol and elsewhere had the mindset to do so existed. Little, if any, of this information was available to the parents or to the public. Such information as was given to parents was often partial, confusing and unclear. For the future, there must be openness about clinical performance. Patients should be able to gain access to information about the relative performance of a hospital, or a particular service or consultant unit.

19 Monitoring: the clinicians in Bristol had no one to satisfy but themselves that the service which they provided was of appropriate quality. There was no systematic mechanism for monitoring the clinical performance of healthcare professionals or of hospitals. For the future there must be effective systems within hospitals to ensure that clinical performance is monitored. There must also be a system of independent external surveillance to review patterns of performance over time and to identify good and failing performance.

20 The aim of these and all our recommendations is to produce an NHS in which patients' needs are at the centre and in which systems are in place to ensure safe care and to maintain and improve the quality of care.