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Dr. Liam Fox (Woodspring): I thank the Secretary of State for his statement today and for making a copy of it available to the Opposition in advance. I also thank the inquiry team for making the report available to us in advance and for all its hard work in producing such an excellent report. It would be verging on insulting its great effort to try to make any pretence of a definitive response this afternoon, yet very major issues are involved, and parents and professionals will rightly want them to be fully explored in Parliament. So I begin by asking the Secretary of State whether he will give an undertaking now that, having had time to reflect on those issues during the summer, the Government will make time available soon after the recess to debate them fully in the House in Government time.

The report says that learning from error, rather than seeking someone to blame, must be the priority to improve safety and quality. That is a much easier concept for hon. Members to accept than it is for many of the parents who have lost their children so tragically; but however understandable a part of human nature wanting to attach blame may be, it is our job to ensure that we minimise the risk of such events being repeated elsewhere. We need to determine which errors came from individuals, which came from specific systems and conditions in Bristol and which were endemic in the culture of the NHS. Of course, it very easy for us to do that with the benefit of hindsight.

The report says:

"At the time while the paediatric cardiac service was less than adequate, it would have taken a different mindset from the one that prevailed on the part of the clinicians at the centre of the service and senior management to come to that view. It would have required abandoning the principles which then prevailed, of optimism, of 'learning curves' and of gradual improvements over time. It would have required them to adopt a more cautious approach rather than muddling through. That this did not occur to them is one of the tragedies of Bristol."

We must not be too hasty in our judgment of them, or judge them by the massive advances in medical culture that have occurred in the past decade.

Clearly, however, some problems could and should have been recognised. Effective teamwork did not always exist at the BRI. The report says:

"All the professionals involved in the PCS service were responsible for this shortcoming.


Those in positions of clinical leadership must bear the responsibility for this failure."

We also had the problem of the split site, which meant that cardiologists, as opposed to cardiac surgeons, could not be effectively involved in intensive care. It is worth

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pointing out to the House that the cardiologists in Bristol were extremely well regarded by their fellow professionals and by parents throughout the south-west.

As the Secretary of State pointed out, it was not simply the outcomes in Bristol which should have raised the alarm, but the growing gap between Bristol and other centres. Between 1988 and 1994 the mortality rate at Bristol was roughly double that elsewhere in the UK for five out of seven years. That mortality rate failed to follow the downward trend in other centres. The Secretary of State mentioned statistics relating to children under one; the excess death rate was even higher for children under 30 days. It is clear from the evidence that there was no excuse for that on a case-mix basis. Around 35 more children died than might have been expected, and each individual was a tragic and irredeemable loss.

We will reflect on the responses that the Secretary of State has made today. Will he publish the job specification for the national director of children's health care services, so that we can all see exactly what is expected of him?

Will the Secretary of State think again about his proposals on consent and information, and go further? The report says that

"the sense is gained that informing patients and gaining their consent was regarded as something of a chore by surgeons."

I believe that that has changed dramatically in recent years, but surely in an ever more protocol-driven medical world, there is a strong case for introducing standardised consent forms at least for non-emergency procedures so that all patients and their parents will know in advance what to expect from surgery, what to expect after the operation, what the complications may be and what the likely outcomes are. As individual users of the health service, surely we have a right to know what to expect of it.

Will the Secretary of State consider going even further with his plans for a health care performance office? This country requires a truly independent academic institute able to develop a standardised methodology of determining outcome. If we cannot properly measure outcomes, we cannot make rational choices in health care in this country as in any other western country.

We will need more time to consider some of the more contentious recommendations: the abolition of clinical negligence litigation and the common terms of employment for doctors, nurses and managers, to name but two. It is worth the House bearing in mind the fact that, in the words of the report,

"The story of the paediatric cardiac surgical service in Bristol is not an account of bad people. Nor is it an account of people who did not care, nor of people who wilfully harmed patients.


It is an account of people who cared greatly about human suffering, and were dedicated and well-motivated. Sadly, some lacked insight and their behaviour was flawed. Many failed to communicate with each other, and to work together effectively for the interests of their patients."

Finally, in paying tribute to the courage and steadfastness of the parents of those patients—some in my constituency and many nearby—the greatest service that we can do them is to take Professor Kennedy's report away and reflect on it not in anger, but with the determination to make sure that those precious and irredeemable losses are not repeated elsewhere.

Mr. Milburn: I thank the hon. Member for Woodspring (Dr. Fox) for the content and tone of his

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response. He is correct to say that the report is large. As he knows, the body of the report runs to some 500 pages and the annexes are much longer still. There are 198 recommendations. Some are small recommendations; some are fundamental and far reaching. They require proper scrutiny, and time is needed to enable us to study them as we should.

On the possibility of a debate, I welcome the hon. Gentleman's comments. I have no objection, but it is a matter for the business managers. If we can arrange a debate, clearly we should.

The hon. Gentleman makes an important point about looking back with the benefit of hindsight. Professor Kennedy and his panel reflect much on that in their report. With the benefit of hindsight, it is clear that the norms and behaviour that were accepted then are at variance with the current position. It is also true that mistakes were made even within the norms prevailing then. As we discuss these issues, it is important to recognise how far things have moved on in just a short time. I welcome the attitude of individual doctors and the medical profession, and the recognition that the culture of the past can no longer pertain in the NHS of today.

With regard to cardiologists, the situation was even worse than the hon. Gentleman describes. At the time, no single paediatric cardiac surgeon specialising in that discipline was available. That may explain some of the difficulties that many of the parents subsequently encountered.

On the job specification for the national director, I am happy to write to the hon. Gentleman and let him know the details. On consent forms, we have already developed a model consent form which has been out for consultation. By 1 October this year we expect to have a finalised version in place. That is needed not just in some hospitals in the NHS, but across the entire NHS.

Mr. Frank Dobson (Holborn and St. Pancras): I join my right hon. Friend and the shadow Secretary of State in expressing my sorrow about what happened to the children, my concern for the parents, and my admiration for the steadfastness of the parents who struggled long and hard for the inquiry. I hope that they will find the outcome in some way satisfactory.

As both previous speakers have said, what happened was not the product of bad people. It involved good and caring people. That is a measure of just how awful the arrangements in the NHS were at the time for setting and monitoring standards of performance. There was no setting of standards nationally, locally, managerially or professionally, nor was there any monitoring of standards. That is largely why those events occurred. My right hon. Friend is no doubt as pleased as I am that the report states that there is cause for optimism because of changes that have subsequently been made to start establishing and monitoring standards.

My right hon. Friend rightly gave great prominence to the problem of the blame culture. The report makes it clear that if improvements are to be made, all the professionals and managers must be open and willing to report when things go disastrously wrong or when near-misses occur. They must accept that they may have been at fault, and they must apologise for what has happened and publish outcomes. All that will be

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necessary, but I am convinced, as the inquiry was clearly convinced, that it will not happen while the possibility of litigation for clinical negligence continues to exist.

I hope that when the Government have completed their consideration of the report, they will agree with the inquiry recommendations and rid the national health service of the threat of clinical negligence litigation, which does much harm and encourages the blame culture.

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