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Spring 2001 Issue 13


Previous issues -

Issue  1 - December 1998

Issue  2 - February 1999

Issue  3 - March 1999

Issue  4 - April 1999

Issue  5 - May 1999

Issue  6 - June 1999

Issue  7 - August 1999

Issue  8 - October 1999

Issue  9 - November 1999

Issue 10 - March 2000

Issue 11 - May 2000

Issue 12 - Autumn 2000



Message from the Chairman

“I wanted to bring you up to date with progress on the Inquiry’s Report. Since the conclusion of Phase Two of the Inquiry at the end of March 2000 and the publication of the Interim Report “Removal and retention of human material” in May 2000, I have been working with my colleagues on the Panel and the Inquiry’s team to analyse the evidence, reach our conclusions and write our recommendations. As you can imagine, we recognise the significant responsibility placed on us.

We have applied ourselves to the first part of our Terms of Reference:

“To inquire into the management of the care of children receiving complex cardiac surgical services at the Bristol Royal Infirmary between 1984 and 1995 and relevant related issues; to make findings as to the adequacy of the services provided; to establish what action was taken both within and outside the hospital to deal with concerns raised about the surgery and to identify any failure to take appropriate action promptly”

But, we recognise also, the importance for the future of the NHS of the second 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”

Reaching conclusions across such a broad area is a lengthy process and has taken longer than we originally anticipated. For this I apologise. We all want to bring the Inquiry to a close as quickly as possible. But we also know our task cannot be rushed.

We would like to thank all the parents and other individuals and organisations who have contributed evidence to the Inquiry. To those most affected by the Inquiry’s work, we would like to say thank you for your patience in waiting for our Final Report.

May I also reinforce earlier statements made by the Inquiry. This is, and has always been, an independent Inquiry, carried out openly throughout. We will continue to keep everyone informed of our progress in the usual way through our website, our newsletter and news releases.

As soon as the Inquiry’s Report is completed it will be passed to the Secretary of State, and a broad indication given as to the likely timing of publication.

This has been a long journey for everyone involved; a great deal of hard work has been done and we are nearly at the end. I am confident that the Final Report will reflect the scale and importance of the task.”

Professor Ian Kennedy



Inquiry welcomes CMO’s Report

The Inquiry welcomes the publication of the Chief Medical Officer’s (CMO) Report: ‘The Removal, Retention and Use of Human Organs and Tissue from Post-mortem Examination’, published on 30 January 2001.

Last year, in response to a request from the CMO, the BRI Inquiry Panel completed their study on this matter:  ‘Removal and retention of human material’, * published in May 2000. 

The study was an additional piece of work undertaken by the Inquiry, not contemplated within the original Terms of Reference.

This report was produced so that the CMO was able to consider the BRI Inquiry’s recommendations before putting his own recommendations to the Secretary of State. 

The Inquiry’s Panel was pleased to see that many of their recommendations had been taken into account and incorporated into the CMO’s Report.  

The BRI Inquiry Panel does not expect to revisit this subject in their Final Report.

* Copies of the Inquiry’s Interim Report and Annexes

“Removal and retention of human material” can be found on the Inquiry’s website at

Printed copies are still available by contacting the Inquiry offices in Bristol.

Please contact:

Becky Jarvis,

Head of Communications

on:  0117 938 8716.


New material presented to the Inquiry

Several major pieces of work have been concluded and submitted to the Panel over the past few months.

These papers and reports have been published on the Inquiry’s website (on the Statistical Evidence, Expert Group and Clinical Case Review pages) and together with all other evidence submitted to the Inquiry will be taken into account by the Panel in developing their conclusions and recommendations.

No comment will be made on the evidence, conclusions or recommendations until the publication of the Inquiry’s Final Report later this year.


Final Report

It will be published in printed form and on CD. The Report will be accompanied by a Summary and two annexes, both on CD.

The Report itself will have two sections:

*          The Bristol Story, and

*          The Future


Annex A will be an account of the evidence about Bristol presented to the Inquiry during its first phase;  Annex B will include expert reports on statistics, the clinical case note review and other expert commentaries.

The Report and its annexes will also be published on the Inquiry’s website, which we expect will remain indefinitely as a source of information following the conclusion of the Inquiry.

Inquiry’s Website

Prior to the publication of the Inquiry’s Final Report, work has been going on behind the scenes to ‘revamp’ the Inquiry’s website to allow easy access to the Final Report and Annexes.

 The overall design of the website will not change. The familiar layout with the use of buttons and links will remain the same. However, once the new site is launched, later this year, visitors will notice a few changes.

 Much of the information currently available on the website, which has been published during the course of the Inquiry, is being incorporated into the Annexes of the Final Report. Therefore, it is necessary to re-group this material under different headings.

Visitors will still be able to view all of the existing material by selecting either: ‘Interim Report’, ‘Evidence’, ‘Inquiry Seminars’ or ‘About the Inquiry’. The ‘Search’ facility remains and assistance with navigating the site can be found on a new ‘Help’ page.

For example, under the heading ‘About the Inquiry’ visitors will be able to access topics such as:

           the Inquiry’s Terms of Reference;

           Issues list;

           Who’s who

 This work is necessary in order to ensure that the Inquiry website will remain as a useful archive resource for the future. The Inquiry is currently discussing the means of maintaining the website permanently.


Inquiry facts and figures

            96 days of Oral Hearings

           417 hours of hearing time

           238 witness statements submitted by parents (553 witness statements submitted in total)

           40 parents gave oral evidence (127 witnesses gave oral evidence in total)

           674,000 pages of medical records were received in total comprising:

    2056 childrens’ records  (some of these cases fell outside the years of the Inquiry’s Terms of Reference)

           42,071 documents were received from 30 different sources

           7 Phase Two Seminars

                       More than 150 participants

                       180 papers submitted

           Over 50 expert papers on a variety of topics

           150 page Interim Report and Annexes


Published by the Bristol Royal Infirmary Inquiry, July 2001
Crown Copyright 2001