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Inquiry chief's 'blame culture' warning
Professor Ian Kennedy
Professor Ian Kennedy said Bristol "over-reached" itself
The Bristol heart inquiry chairman has pleaded for the NHS to steer clear of a culture of "blame and shame" when implementing his findings.

At the heart of the report were 198 recommendations to prevent a repeat of the scandal.

Professor Ian Kennedy spoke of his duty to find out the truth for parents as he outlined some of the key proposals to reporters.


If it were happening [again] we would only have a slight chance of knowing

Professor Ian Kennedy
But he said the obvious question after the publication of the report was: "Could it happen again, could it be happening now?".

He admitted: "The honest answer is that it could and if it were happening we would only have a slight chance of knowing."

Prominent among the proposals were moves to make sure that parents made more informed consent, armed with knowledge about the performance records at the relevant hospital compared to other trusts.

Critical comment

But he insisted: "We have sought to be fair to everyone, in particular we have tried hard to avoid the judgments of hindsight, it is all to easy for all of us to be wise after the event.

"We have set our face against what has come to be called a culture of blame and shame.

"When blame or critical comment was called for we haven't shrunk from it but we haven't elevated it into a virtue."


We don't prevent mistakes in the future if we simply blame and remove one set of individuals only to replace them with another set [who have] precisely the same difficulties

Professor Kennedy
He said society had often take the "easy way out by singling out someone to blame".

He maintained that doctors who were in constant fear for their careers might be more inclined to cover up mistakes.

"We don't prevent mistakes in the future if we simply blame and remove one set of individuals only to replace them with another set [who have] precisely the same difficulties."

"It is not a story of bad people [at Bristol] - the clinicians were dedicated hard working professionals - harming children was the last thing in their mind."

His recommendation that the current system for dealing with clinical negligence be replaced is likely to cause controversy.

"[One of the] biggest barriers is fear of being sued ... [leading to an] impetus to deny, to hide, to obfuscate and delay."

He was quick to highlight the personal and institutional problems and unhelpful cultures that the report had identified.

Flawed management

He said Bristol was a hospital that had "over-reached itself", where clinicians only had "limited experience" at the time it became a regional centre.

"Clinicians were ambitious to expand - the ambitions were too ambitious.

"The management of the hospital was flawed - too much power was in too few hands.


The management of the hospital was flawed - too much power was in too few hands

Professor Kennedy
"There was a club culture where it was hard to raise matters of concern and harder to get anything done."

And he said wider problems in the NHS were also to blame.

"There were no agreed national standards as to what amounted to good quality care for paediatric cardiac surgery - no agreed measure or benchmark.

"Bristol was awash with data ... [but] there was confusion in the NHS from top to bottom as to where responsibility lay for monitoring the quality of paediatric cardiac surgery."

Professor Kennedy said he was delighted that the health secretary had accepted his recommendation and appointed a national director for children's health care.

He said: "Children are not merely patients who need little beds. Children have their own particular needs."

Full coverage of the Bristol heart babies inquiry report

Government response

Key stories

Key figures

Parents' stories

Background briefing

Analysis

Bristol year by year
See also:

18 Jul 01 | Health
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