Final Report > Chapter 10: Introduction to Concerns > Introduction

Introduction

1 In this section of the Report we respond to that element of our Terms of Reference which requires us `to establish what action was taken both within and outside the hospital to deal with concerns raised about the surgery and to identify any failure to take appropriate action promptly; to reach conclusions from these events ...'. We set out later in Chapters 13-20 our conclusions on the adequacy of the system and the paediatric cardiac surgical service. In this chapter we are concerned with the conduct of individuals. We have set out in Annex A, Chapters 20 to 30, a year-by-year account of the concerns raised, as indicated by the evidence received by the Inquiry. We begin here by identifying what we regard as the most significant events raised in that extensive account. Once we have set them out, we will then be in a position to express a view: to reach the conclusions asked of us.

2 We begin by acknowledging at the outset that it is the concerns of parents whose children died or suffered harm after cardiac surgery in the UBH/UBHT which have played a large part in bringing the issues in this Report into the public arena, and that these concerns are both heartfelt and longstanding. Those concerns were expressed and emerged after the end of the period of our Terms of Reference. They are dealt with in detail in later chapters. They relate, for example, to the split service, and the quality of communication, informed consent and counselling. The concerns dealt with in this chapter are those raised at the time by clinicians, managers and in the media, or those which, in the light of the information available, should have been raised at that time.