Final Report > Summary > The adequacy of the paediatric cardiac surgical service in Bristol

The adequacy of the paediatric cardiac surgical service in Bristol

21 We concentrate on open-heart surgery on children under 1. We adopt a `systems' approach to analysis, by which poor performance and errors are seen as the product of systems which are not working well, as much as the result of any particular individual's conduct. We acknowledge at the outset that in a number of ways the service was adequate or more than adequate. The great majority of children who underwent PCS in Bristol are alive today.

22 Our overall conclusion, however, is that the PCS service for children who received open-heart surgery was, on a number of criteria, less than adequate.

23 To the extent that it is based on reliable and verifiable evidence, this is the judgment of hindsight. At the time, while the PCS service was less than adequate, it would have taken a different mindset from the one that prevailed on the part of the clinicians at the centre of the service, and senior management, to come to this view. It would have required abandoning the principles which then prevailed: of optimism, of `learning curves', and of gradual improvements over time. It would have required them to adopt a more cautious approach rather than `muddling through'. That this did not occur to them is one of the tragedies of Bristol.

24 We reach one conclusion which owes nothing to hindsight. There was poor teamwork and this had implications for performance and outcome. The crucial importance of effective teamwork in this complex area of surgery was very widely recognised. Effective teamwork did not always exist at the BRI. There were logistical reasons for this: for example the cardiologists could not be everywhere. The point is that everyone just carried on. In addition, relations between the various professional groups were on occasions poor. All the professionals involved in the PCS service were responsible for this shortcoming. But, in particular, this poor teamwork demonstrates a clear lack of effective clinical leadership. Those in positions of clinical leadership must bear the responsibility for this failure and the undoubtedly adverse effect it had on the adequacy of the PCS service.

25 The Experts to the Inquiry advised that Bristol had a significantly higher mortality rate for open-heart surgery on children under 1 than that of other centres in England. Between 1988 and 1994 the mortality rate at Bristol was roughly double that elsewhere in five out of seven years. This mortality rate failed to follow the overall downward trend over time which can be seen in other centres. Our Experts' statistical analysis also enabled them to find that a substantial and statistically significant number of excess deaths, between 30 and 35, occurred in children under 1 undergoing PCS in Bristol between 1991 and 1995. As our Experts make clear, `excess deaths' is a statistical term which refers to the number of deaths observed over and above the number which would be expected if the Unit had been `typical' of other PCS units in England. The term does not refer to any particular child's death. The mortality rate over the period 1991-1995 was probably double the rate in England at the time for children under 1, and even higher for children under 30 days. This higher mortality rate in Bristol was not restricted to the neonatal Switch and Atrio-Ventricular Septal Defect (AVSD) operations. Even without taking these two higher-risk groups into account, there was considerable evidence of divergent performance in Bristol. Further, differences in mortality rates in Bristol could not be accounted for on the ground of case mix (an explanation which some clinicians both then and even now have adopted). We note a failure to progress, rather than necessarily a deterioration in standards.