Final Report > Chapter 2: The Conduct of the Inquiry > The approach of this Inquiry

The approach of this Inquiry

27 In our Preliminary Statement, [12] we committed ourselves to certain values. They included openness, transparency in our working, inclusiveness, the avoidance of a confrontational approach, and fairness. By adhering to these, our task has been made easier and, we hope, the ordeal of others has been made more bearable. We are aware that from the outset there have been many sets of expectations about the outcome of the Inquiry. There are parents who hope for a clearer explanation of what happened to their child. Others seek to defend those who have been criticised in other arenas. There are also expectations, shared by many, that we will be able to suggest ways of helping to secure care of high quality in the future throughout the NHS. We are conscious that in addressing our task we may satisfy some to some degree, but inevitably disappoint others.

28 Conscious of the pitfalls of hindsight, we took a number of decisions from the outset of the Inquiry about the way in which we would proceed, designed to insulate the Inquiry as far as possible from looking at the past with the eyes of the present. They included:

• The order in which evidence was heard was planned so as to begin by examining the wider context in which PCS services were provided in Bristol and then gradually to focus on the events in Bristol. Some may, indeed, have been surprised that we did not wish at the outset to hear from the Bristol clinicians. Our decision to hear from them quite late in the oral hearings was deliberate. We were anxious to ensure that we appreciated and took account of the various layers of context and background, before seeking to understand the particular circumstances and events at Bristol.
• We did not have any regard to the result of the disciplinary hearings conducted by the GMC against Dr Roylance, Mr Wisheart and Mr Dhasmana. We began with a clean sheet.
• We established a Group who acted as Experts to the Inquiry. In this way, they gave their evidence on behalf of the public interest, rather than for any particular individual or group. Many members of the Expert Group were in clinical practice during the period 1984-1995, and thus were able to assist the Inquiry by placing evidence in its historical context. They were also able to indicate to the Inquiry the norms of practice that prevailed at the time. The Group also contained Experts in management, audit, counselling, and statistics.
• We gathered together all the available data on PCS at Bristol, both that which was available to clinicians and the hospital at the time, and that which was available nationally, and subjected it to independent and rigorous analysis by independent experts.
• We then commissioned an independent detailed review of a sample of these case notes. Having made it clear in our Preliminary Statement that we would take account of all operations and all children operated on at Bristol during the period of our Terms of Reference, we did so, both in the statistical analyses and so as to form the basis for the sample chosen for the Clinical Case Note Review (CCNR). The CCNR was based on an appropriately constructed sample of cases. It was designed and carried out by panels drawn from the Expert Group. After an exhaustive search by the United Bristol Healthcare (NHS) Trust (UBHT), the clinical notes of the vast majority of children who received heart surgery at the BRI and the BRHSC between 1984 and 1995 were included in the group from which the sample was chosen. The design of the sample meant that, after making proper adjustments, we were able to reach a view on the care of all of the children treated during the relevant period.
• We sought to ensure that the process of receiving evidence remained as open and inclusive as possible throughout the Inquiry. By making public the evidence seen by the Panel as we went along, witnesses affected by any evidence were able to comment as the Inquiry went on. Thus the Inquiry might have a single statement, accompanied by several formal written comments from others, thereby lending depth and texture to the evidence. Furthermore, in keeping with our duty to obtain as extensive a picture of Bristol as possible, we continued to seek out anyone who might be able to help us until the end of the Inquiry.

29 In the course of the Inquiry, we adopted a number of initiatives, both procedural and practical, some of which were innovative and had not been tried before in a Public Inquiry. Full details are set out in Annex A; [13] the initiatives included:

• the use of information technology, particularly an Inquiry website, as a means of publishing witness statements and oral evidence throughout the course of the Inquiry;
• the live transmission of the Inquiry's hearings to remote locations;
• the establishment of a panel of people who were available to serve as Experts to the Inquiry;
• the extensive use of academic research and review;
• the role of Counsel to the Inquiry and other legal representatives in participating in an inquisitiorial approach to the evidence;
• the way in which evidence was taken from Experts, so that they could interact with each other and with the various clinicians from Bristol who we heard from;
• the provision of counselling and support for witnesses and others attending the hearings;
• the statistical analyses and the CCNR; and
• the physical environment and practical arrangement of the hearing chamber and adjoining rooms.

30 Lastly, as befitted the nature of the Inquiry which we were engaged with, we began and ended with the evidence of parents.

31 There is one thing, in particular, which we have not done. We made it clear at the outset that we would not seek to reach a determination as to the adequacy of care received by each individual child. We explained why at the beginning of the Inquiry. We repeat that explanation here. Our Terms of Reference required us to conduct a Public Inquiry, not a series of clinical negligence trials. We were not constituted as a court of law, nor were we capable of acting as one. Given the number of procedures and the number of children involved, and given how long it takes for a court to try a complex case of clinical negligence, it would have taken us many, many years to try every case, even had we been required to do so and capable of doing so, which we were not. Issues of blame, fault, negligence and compensation under our current system are for the courts, to be investigated with all the necessary procedural safeguards. They were not for us. We make these points again here because it is clear that, despite our best efforts, some still thought that we would provide an answer to every child's death or disability. We regret this and that they may therefore feel disappointed. We hope that they will join us in believing that, if something good, by way of changes in the care of children in the NHS, can come from this Inquiry, the death or disability of their child, whatever the cause, was not in vain.

32 As we said in our Preliminary Statement in October 1998, the Inquiry cannot put the clock back. We cannot put all the broken pieces of history back together. What we can do is offer through this Report the basis for reflection, understanding, and moving forward with concern for the interests of all. We hope that we do not aim too high in believing that our Report may serve both as a memorial and as a milestone on the way to improved care.

33 We add one final word. Throughout the Inquiry we were helped by parents: some who were part of the Bristol Heart Children Action Group (BHCAG), some who came together to form the Bristol Surgeons Support Group (BSSG), and some who belonged to neither group. We were helped by the co-operation of the UBHT. We were helped by our Expert witnesses. And we were helped by those doctors, nurses and others who were intimately involved in the events of Bristol. We would be failing in our duty if we did not recognise the dedication, commitment and hard work of the healthcare professionals. That things were done which should not have been done will become clear. But the Bristol story is one of a flawed organisation and systems. It is also a story of some people whose behaviour was flawed but who cared greatly about human suffering. It is not a story about bad people.

Footnotes

[12] Chairman's Preliminary Statement, 27 October 1998. See Annex B, 1b

[13] Annex A, Chapter 8