Bristol inquiry

Between 30 and 35 children undergoing heart surgery at Bristol Royal Infirmary died between 1991 and 1995 who would probably have survived if treated elsewhere, the long awaited report into children's heart surgery at Bristol has concluded. These “excess” deaths took place in a unit where mortality at the time for children aged under 1 was probably double that for England as a whole, and even higher for neonates. Around a third of children who underwent open heart surgery received less than adequate care. The inquiry report, published last week, painted a picture of a flawed system of care with poor teamwork between professionals, “too much power in too few hands,” and surgeons who lacked the insight to see that they were failing and to stop operating. But the failings were not those of the surgeons alone. An expert review of 80 cases carried out for the inquiry showed inadequacies at every point, from referral to diagnosis, surgery, and intensive care. The physical setup was “dangerous,” with surgeons on one site—at the Royal Infirmary—and paediatric cardiologists several hundred …