Final Report > Chapter 1: Introduction > This Report

This Report

16 This is the Final Report of the Inquiry. It has two sections. In Section One we set out our understanding of the events which took place at Bristol in the period 1984-1995. It begins by setting the scene, at both a national and a local level, against which the events of Bristol must be understood. There follow three chapters in which we set out the concerns which were expressed at the time and what, if any, action was taken. Finally, we respond to that element in our Terms of Reference which requires us to reach conclusions about the adequacy of care provided to children who underwent PCS.

17 In Section Two we look to the future and the lessons that can be learned from what happened at Bristol. This responds to our duty, set out in the final part of our Terms of Reference: `to reach conclusions from these events and to make recommendations which could help to secure high quality care across the NHS'.

18 The evidence received by the Inquiry is in the public domain. A full account is set out in Annex A. Papers by our Experts and various submissions made to the Inquiry are set out in Annex B.