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

Fairness

1 We stress at the outset that, to a very great extent, the flaws and failures of Bristol were within the hospital, its organisation and culture, and within the wider NHS as it was at the time. That said, there were individuals who could and should on occasions have behaved differently. In the final stages of the Inquiry, each was advised that the Inquiry was minded to comment adversely on some particular aspect of his or her conduct or behaviour that we identified, whether a particular incident or a pattern of behaviour, and was told of the evidence on which the Inquiry relied. Each had an opportunity to make representations. Those representations were taken account of by the Inquiry in reaching its conclusions. We also emphasise that such adverse comments as we make must be seen against the background of the Report as a whole, in which we also have occasion to make favourable comments.