Final Report > Chapter 12: Responses to Concerns and Actions Taken, and Whether Such Actions were Appropriate and Prompt > Concluding observations

Concluding observations

60 Concerns were expressed and data were collected and discussed, though not all data were discussed by all those involved. Indeed, it could be said that Bristol was awash with data but was, at the same time, singularly uninformed. Procedures existed for review, although there was no agreement as to what was meant, or even what was being referred to, as `high-quality care', nor where the responsibility lay for ensuring that it was provided. At the time covered by our Terms of Reference, surgeons were powerful, and cardiac surgeons associated with, and part of, senior management particularly so. `Management' stayed out of what were defined as `clinical matters'. There was no clear focus of responsibility for the care of patients. Audit was still an educational tool rather than a means of assessing and assuring quality. A central misfortune was that a key figure in the centre of the web, Mr Wisheart, was a man who worked hard and long for PCS, but was not able to reflect effectively or critically on his work. As Mr Baird said, when asked how the system dealt then with the competence of a consultant, `the difficult area arises where the individuals lack insight'. [52]

61 In Bristol too few people had too much power. Unhappily, if the people have flaws, the organisation becomes vulnerable. An organisation offering a service must, of course, have dedicated staff. But that is not enough. It must also have in place within it systems that allow it to learn, develop and prosper, quite apart from any external mechanisms. A key feature of such systems is that all involved must feel able to be open about their work and the work of colleagues. This is a central message which emerges from Bristol. This is what we must take into Section Two of our Report in due course.

Footnotes

[52] T29 p.41 Mr Baird