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How the scandal developed
BBC News Online charts the events which led to the Bristol babies heart scandal.
When 18-month-old Joshua Loveday died on the operating table in the Bristol Royal Infirmary in January 1995, a storm broke over the heart unit.
Professor Ian Kennedy and his inquiry team have spent record amounts unravelling the events which led to one of the worst medical crises ever to strike this country.
Where the GMC examined only the circumstances of only a few dozen cases - and found fault in the handling of only a fraction of these, the inquiry was tasked with looking all the way back to 1984, at every paediatric case to pass through the infirmary.
Surgeon James Wisheart, at the epicentre of the eventual scandal, had been in post since the mid 1970s, and the unit had been working at full capacity ever since.
After all, this was a region which was labelled the worst in England for heart surgery provision by a study in the British Medical Journal in the early 1980s.
The storm which engulfed Bristol had been brewing since the mid 1980s.
In 1988, anaesthetist Dr Steve Bolsin arrived at Bristol after working at hospitals in London.
He said the first curious thing he noticed about Bristol was the sheer length of time that operations were taking.
This meant that babies were potentially spending much longer periods on heart bypass machines, and, while there was no direct evidence that said these babies should do worse, he suspected that this might be the case.
Another anaesthetist, Dr Andy Black, said that his colleagues were refusing to take on afternoon cases with James Wisheart simply because they knew there was no chance of getting out of the operating theatre at a reasonable hour.
His initial concerns soon crystallised into wider worries about death rates in certain types of paediatric heart surgery at Bristol.
He decided to embark on his own audit of results with Dr Black.
At this point, the only surgeons carrying out heart surgery on very young babies at Bristol were James Wisheart and Janardan Dhasmana, recruited in 1985.
Rather than approach the surgeons directly and ask for their figures, he used sources as diverse as the anaesthetists own operating logs, and the records of the Bristol Heart Circle, a charity providing support to parents of children undergoing heart surgery there.
And the results were startling - showing a significant "excess mortality" in two types of operation, compared to what passed for the national "average" at the time.
Bolsin's audit would prove a partial catalyst for the full exposure of Bristol's operating record.
The existence of the figures appears to have been an "open secret" within the unit, with some doctors seeing the entire document.
Bolsin had already written a letter to trust chief executive Dr John Roylance, prior to the completion of the audit, which mentioned his worries about mortality.
He had also spoken to an official from the Department of Health, who in turn raised it with the clinical director of surgery at Bristol, Dr John Farndon.
In 1994, the year after the first audit was completed, Bolsin decided to look further into a sequence of operations by James Wisheart, uncovering more figures suggesting that death rates may be too high.
After an anaesthetists meeting at the infirmary, he shared a cab back to the city's Temple Meads station with Dr Peter Doyle, from the Department of Health, and passed him details of his investigations to date.
While Dr Doyle didn't read the document, he spoke to Dr Roylance - who reassured him that steps were being taken.
At this point events are progressing without much publicity, although the satirical magazine Private Eye has been running occasional derogatory pieces about the unit.
However, events finally came to a head with the operation on 18-month-old Joshua Loveday in January 1995.
Whether this operation should have gone ahead turned out to be one of the key issues in the GMC hearing against all three doctors.
Managers had been told to halt the operation by Peter Doyle, but, following a team meeting, doctors had decided to go ahead.
Following Joshua's death, the infirmary decided to get outside help, calling in a surgeon and cardiologist from other hospitals to look at their work.
Their report concluded Bristol was a "high risk" centre, and that it was likely that more babies had died than would be expected at other units.
A press storm erupted around the infirmary, and local parents, many of whom lost children in operations there, formed the Bristol Heart Babies Action Group, pressing to find the true extent of problems.
Dr Bolsin, claiming his career was under threat following his whistleblowing, resigned later in 1995 and went to live and work in Australia.
James Wisheart and Janardan Dhasmana had by this time stopped operating, and eventually, after pressure from parents, the General Medical Council (GMC) launched the longest and most expensive investigation in its history.
A little over two years later, both surgeons, and Dr Roylance, were found guilty of serious professional misconduct.
Roylance and Wisheart were struck off, while Dhasmana was banned from operating on children for three years.
He was later sacked by the trust, although Wisheart and Roylance had already retired, keeping their pension rights, and in Wisheart's case, thousands of pounds in a merit award conferred for "excellent practice".
The GMC decided that both surgeons should have realised their results were bad and stopped operating sooner than they did.
They were also criticised for misleading parents as to the likely success rates of the operations their children were about to undergo.
As soon as the GMC announced its verdicts, the pressure for a public inquiry became irresistible, and it opened in Bristol in 1999.
All three doctors still insist they did nothing wrong - or at least did not perform badly enough to merit being punished by the GMC.
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