Learning from Bristol: the public inquiry into children's heart surgery

Professor Sir Ian Kennedy · work from 1998 · published 2001

What this was

Public inquiry into the care of children undergoing heart surgery in Bristol between 1984 and 1995. It found a service with poor outcomes that families and some clinicians could not get the organisation to face.

Why it sits in the hub

Bristol set the modern template for NHS inquiries: publish outcomes, regulate the service rather than only the individual, and give patients information that is honest.

Findings

Finding 1
Death rates in the service were high for years, and the organisation did not act on what the figures showed.
Children and safeguarding Data and early warning Leadership and boards
Finding 2
Parents were not given a fair account of the risks, and the clinical culture made challenge difficult.
Candour Culture and conduct Listening to patients and families

Recommendations in this hub

Paraphrase of the public recommendations, not the official text.

1Partly doneNHS and regulators
Publish comparable outcomes and act when a service is an outlier.
Outcome publication grew after Bristol. Later inquiries still find outlier signals ignored.
Data and early warning Regulation and oversight
2Partly doneClinical services
Give families clear information and a real part in decisions about their child's care.
Children and safeguarding Listening to patients and families
3AcceptedGovernment
Regulate the quality of the service, not only the conduct of individual professionals.
This direction of travel shaped the later system of service regulation.
Regulation and oversight