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Bristol Royal Infirmary Inquiry

3.31 pm

The Secretary of State for Health (Mr. Alan Milburn): With permission, Mr. Speaker, I wish to make a statement about the Bristol Royal infirmary inquiry.

The report of the inquiry into the care and management of children receiving complex heart treatment between 1984 and 1995 is being published today. It is now available in the Vote Office. I am grateful, Mr. Speaker, for your agreement that the parents and their representatives should also have advance access to copies of the report.

The inquiry was established in 1998 by my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson). I want to express my thanks to Professor Ian Kennedy and his panel members, Professor Sir Brian Jarman, Mrs. Rebecca Howard and Mrs. Mavis Maclean, for doing a quite outstanding job in delivering a well considered and far-reaching report.

Words in a report can never be enough for those families whose children died or were damaged. When I met representatives of some of the parents earlier this week I think that I was speaking for the whole House when I expressed my profound sorrow for the pain and loss the families have endured. I hope that the report at least provides an explanation, and that those families are able to take some small comfort from it.

The report and its annexes run to some 12,000 pages. We will study the findings and the 198 recommendations with care. Today, I can outline the thrust of the inquiry's findings and some of the Government's initial responses. Our substantive response will be made in the autumn. It is right that this House and the public should have the opportunity to study the report in detail. It will be available from this afternoon on both the inquiry's website and through the Department of Health's website. I would welcome views from the public and those working in the NHS to inform our full response.

In examining events at the Bristol Royal infirmary between 1984 and 1995, the report recognises that a great deal has changed since then. It also, quite rightly, commends NHS staff in Bristol and throughout the country for their dedication and commitment in providing care and treatment to hundreds of thousands of patients every day.

I hope that today, above all other days, all of us—across the House, in the media and among the public—remember one simple truth: the NHS is full of good doctors, not bad ones, and of good people who are doing their best for patients, sometimes in difficult circumstances. The report rightly reminds its readers that between 1984 and 1995 staff at Bristol carried out heart surgery on 1,827 children. The great majority of those children are alive today because of the efforts of those NHS staff. As the report puts it:

In discovering what happened at Bristol, the report describes

The senior NHS staff concerned got things wrong, not least because they assumed that in time they were bound to come right. As we now know, they never did. Between

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1991 and 1995, the report makes it clear that between 30 and 35 more children aged under one year died after open-heart surgery in Bristol than was typical of similar heart units elsewhere in England. The report says that that was not due to differences in the severity of the cases. While mortality rates fell throughout the rest of the country as time went on, this did not happen in Bristol.

The report paints a picture of a hospital short of resources and short of specialist staff. Cardiac care was split between two sites; children's services played second fiddle to adult services. Power was concentrated in too few hands. The hospital was a closed world. The report describes a "club culture" in which problems were neither identified nor resolved. Paternalism towards patients sat side by side with rivalries between professions.

Concerns about paediatric open-heart surgery at Bristol were first raised as early as 1986—first inside the hospital, then outside, then with the Department of Health and Social Security, as it was at the time. Concerns continued to be raised but no one acted effectively to protect the welfare of the children who were patients there.

There was a tragic combination of key clinicians failing to reflect on their own performance, senior management failing to grasp the seriousness of what was going wrong, and people in various official capacities—including in the Department of Health—failing to act. Uncertainty about who was responsible for sorting out problems meant that they were never sorted out. In the meantime children were dying who should not have died. It was left to a whistleblower, an anaesthetist in the hospital, Dr. Stephen Bolsin, to trigger the chain of events which led eventually, in 1995, to the suspension of children's heart surgery. As the report says, Dr. Bolsin is owed a debt of gratitude for what he did.

The report is directly critical of certain individuals, including the senior doctors concerned. As the House is aware, Dr. Roylance, Mr. Wisheart and Mr. Dhasmana have already been the subject of action by the General Medical Council, but the inquiry panel made clear its determination to avoid simply pointing the finger of blame at a few individuals. I commend this approach, because the Bristol tragedy was born of deeper causes than the actions of a handful of senior clinicians and managers, wrong though they were to act as they did. The children who died and who were damaged were failed by a few people in senior positions in the hospital but, even more so, they were failed by the very system that was supposed to make them well and keep them from harm.

If the NHS is to learn from when things go wrong, it must move beyond a culture of blame. The tenor of the Bristol inquiry report is, in my view, a significant step towards a more open and honest health service. Medicine is not a perfect science. Even the best people can make the worst mistakes. Putting right what can sometimes go wrong relies on the NHS being able to acknowledge error and having systems in place to minimise error. The absence of such an approach at Bristol, and in the wider NHS at the time, contributed directly to the tragedy that cost dozens of children their lives.

Bristol was designated a specialist regional centre for children's heart surgery. It probably never should have been. It never performed sufficient operations to ensure safe outcomes for patients. Monitoring was virtually

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non-existent. Accountability was confused. There were no national standards in place. The inquiry report puts the position starkly:

That was the norm for the NHS then. The events at Bristol have been a major catalyst for change since. As the report repeatedly acknowledges, since those years the NHS has moved on. Earlier this year the new Bristol Royal Children's hospital opened. The United Bristol Healthcare trust has a new, strong management team with extra cardiac staff.

As elsewhere in the NHS, problems remain—of course they do—but it is worth noting that today's survival rates for children's heart surgery at Bristol are among the best in the country. The energy and commitment that the staff, the managers and the trust board have shown in turning the service around deserve recognition and praise. I hope that the whole House will join me in doing so today.

The NHS today is a very different health service, too. As the report acknowledges, the under-resourcing that was such a feature of the NHS then is beginning to be addressed now. The events at Bristol have spurred the Government and the medical profession to work together to put in place new standards and structures to improve quality in care. As the Kennedy report says,

The report welcomes the establishment of the National Patient Safety Agency to run a single reporting system for all adverse health events. The report welcomes annual appraisal and revalidation for doctors; it recognises that a new contract for hospital consultants is being negotiated and that joint training for health professionals is being introduced. The clinical negligence system, which the report rightly criticises, will be the subject of a White Paper to be published early next year. Many of these changes, and other reforms contained in the NHS plan, are welcomed or endorsed by the report.

As the report highlights, however, further action still is needed if we are to prevent another tragedy on the scale of Bristol's. Between now and the autumn, the Government will give the report's recommendations careful consideration. Today I can tell the House that I am taking the following steps immediately in response to the Bristol report.

First, the report laments the lack of priority given to children's services in the NHS. It calls for the appointment of a national director of children's health care services. I have therefore appointed Professor Al Aynsley-Green, Nuffield professor of child health at Great Ormond Street hospital, to take up the post with immediate effect. His priority will be to spearhead the faster development of the first ever national standards for children's health services. Standards for children in hospital, including children with congenital heart disease, will be ready next year.

Secondly, the report calls for patients and parents to have a greater say in the NHS and in their own care. Informed consent must be a cornerstone of a modern health service. Today we are publishing information for

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patients and specifically for parents about the questions that they should ask before consenting to treatment for themselves or their children. Next month we will invite views on our proposals for increased public involvement in the NHS. By April next year, every trust will have a specialist patient advocacy and liaison service in place to help patients who are experiencing problems with treatment, as part of a wider programme to inform and empower patients within the NHS.

Thirdly, the report identifies a failure to act on concerns about services, not through a lack of data, because Bristol was awash with data. There was however, no single point where data were brought together for analysis, evaluation, dissemination, and, most important, follow-up action. For data on surgical outcomes to be published, of course, they need to be robust, rigorous and risk-adjusted. That will inevitably take time. The report does, however, recommend publication to give both NHS staff and the public accurate information. It recommends the establishment of a new independent office for information on health care performance within the Commission for Health Improvement to co-ordinate the collection and publication of data. We will action those two recommendations. In so doing, we will ensure that the new office works in tandem with the medical organisations that have been pioneering improvements on data collection about clinical outcomes.

Fourthly, the report criticises confusion in regulation and accountability in the NHS. It recommends the establishment of an overarching body—the council for the regulation of health care professions—to ensure that the individual professional regulatory bodies act in a more consistent manner. That is in line with a similar commitment that we made last year in the NHS plan. We will action that recommendation, following consultation, alongside our proposals to reform the General Medical Council in the NHS reform and decentralisation Bill later this year.

Fifthly, the concern is expressed in the report that NHS managers should also have responsibility for maintaining standards and protecting patients. It recommends the establishment of a new regulatory body for NHS managers. We will consider that proposal, but in the meantime, we will seek to develop a new code of professional conduct for NHS managers in conjunction with their professional associations. I will announce the further steps that we will take to strengthen safeguards for patients when we publish our full response in the autumn.

Professor Kennedy and his panel have provided us with a report that builds on what is now being achieved, but the ambition is bigger still: to build a new culture of trust, not blame, in the NHS—an NHS where there is greater partnership between patients and professionals; where lines of accountability are clear; where there is openness about mistakes; where services are designed from the patients' point of view; and where safety for patients always comes first.

None of that can ever make good the loss experienced by the Bristol parents. Throughout the inquiry, they have acted with great dignity and purpose. Their determination has been, as ours must now be, to see some good come out of the events at the Bristol Royal infirmary. As one parent put it to me earlier this week, "There are no winners from Bristol. We are all losers. I just hope that future generations can be the winners." I hope that through this report the families will gain at least some

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consolation from the knowledge that, over time, the lessons learned from what went wrong for their children will help us to prevent it from happening again to any other children.

In framing its recommendations, the inquiry panel said that its aim was

It is for us—all of us—to ensure that is indeed the case. I commend the report to the House.

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