Final Report > Chapter 2: The Conduct of the Inquiry > Understanding and interpreting the past: the dangers of hindsight

Understanding and interpreting the past: the dangers of hindsight

23 We recognise the dangers of retrospective vision. We recognise also that what we have examined has only been a selection of what went on. Properly to understand and take a view on the events of Bristol require that we see them in their context. Not only do we look back at the period 1984 to 1995 from a distance, but we must recognise there was much change during that period. Even to apply the view of 1995 to 1984 would be a distortion. As regards hospitals and those who worked in them, the context was one of changing knowledge and ways of behaving over time.

The reality of the time was not the picture of it which we are able to create. We reconstruct the past from the building blocks left to us. But these can only ever give a partial picture. For example, through the forensic process, events and exchanges are brought into sharp focus. At the time that they happened, however, they were part of the blur of daily activity which characterises a large and busy organisation. By dissecting them out, we see them in isolation, distinct from the hundred and one things happening at the same time. But they never existed in isolation. We must remember that.

24 In addition to the formal written statements which we received, we have taken account of documents and records obtained from the United Bristol Hospitals and the United Bristol Healthcare (NHS) Trust (UBH/T) [9] and those who worked in it, not only as evidence in themselves, but often as the basis for the oral evidence of witnesses called to help the Inquiry. It might be said that they, at least, are immune from the dangers of hindsight. They are the same now as they were then and so can reveal what was going on. Again, this is only partly true. Indeed, if pressed too far, it actually becomes untrue. Documents and records can only tell part of the story. By their clarity, they suggest an ordered and readily identifiable progression of events. But their order is an order imposed by us. We have selected them, and thus have singled them out from what Mrs Thatcher once memorably described as a `snowstorm' of paper [10] which busy organisations dealt and deal with all the time. By selecting them, we have given them an importance and coherence which is the product of hindsight and may not have been as evident at the time. Moreover, documents which appear to record facts may have been written in fact to advance an argument. Furthermore, documents record that which is recorded. But large organisations also function by word of mouth. Decisions are taken all over the place, in meetings, conferences and conversations. They may not always be recorded. If they are not, they become a matter of memory. It is a natural tendency, in such circumstances, to rely on the certainty of what is written down, when set against the gloss suggested by a fallible memory. But this is to produce an illusory and, to a degree, unfair picture of the reality of the time. This is particularly true in Bristol where there was a managerial commitment to what was described in evidence as an `oral culture'. [11]

25 As regards the evidence of parents, it is equally important to recall the context. For the parents who came into contact with the organisation, the context varied hugely: there were long-term relationships, as a child was cared for through a series of procedures, contrasted with short, agonisingly sad encounters ending in the tragedy of death or disability. To each parent, these were times of the highest intensity. This was their child and their child's life. Each moment was an eternity and yet everything passed in a dizzying whirl. Each word and gesture were noted and repeatedly weighed and assessed for significance. But, paradoxically, sometimes words might be forgotten and gestures disregarded if hope lay elsewhere. We recognise this.

26 Finally, in this brief recital of caveats about reconstructing the past, we draw attention to (and took account of in our deliberations) a further reality. The events which we were asked to enquire into had been subject to lengthy exposure in the media over a number of years, and to a major investigation by the GMC, before we began our Inquiry. While it is impossible to evaluate the impact of this degree of attention, we were aware that interpretations had long since been placed on events, which understandably would tend to become entrenched, thereby influencing the evidence which we received.

Footnotes

[9] We use the term `UBH/T' to refer to that group of hospitals in Bristol which, prior to 1991, comprised the United Bristol Hosptials, and, since 1991, have been known as the United Bristol Healthcare (NHS) Trust. Included within this group of hospitals are the BRI and the BRHSC

[10] The Inquiry into exports of defence equipment to Iraq, 1996 (Cmnd HC 115)

[11] See Annex A, Chapter 8