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Report findings at a glance
James Wisheart
Surgeon James Wisheart was struck off
The report of the inquiry into the Bristol heart babies scandal has made a number of hard-hitting findings.


The report of the Bristol heart babies inquiry team found:

  • A third of children received "less than adequate care"

  • Between 30 and 35 more children aged under one died between 1991 and 1995 than would have been expected in a "typical" unit

  • The mortality rate between 1991 and 1995 was "probably double" the rate for England at that time for children under one

  • It was probably even higher for children under 30 days

  • Problems were not confined to the complex Switch and Atrio-Ventricular Septal Defect (AVSD) operations

  • The kind of cases dealt with at the hospital cannot explain the difference in rates with other units

  • There was a "failure to progress, rather than necessarily a deterioration in standards" at Bristol

  • The arrangements for caring for very sick children at the hospital were "not safe"

  • The systems for delivering children's heart services at Bristol were "not up to task"

  • There was "real room for doubt" as to whether the hospital should have been designated as a centre for open-heart surgery for under-ones

  • The unit "overreached" itself and failed to keep up with developments in the specialty happening elsewhere in the late 1980s and early 1990s

  • A lack of staff and resources, which had been highlighted as a problem for the Bristol was "typical of the NHS as a whole" so does not solely explain what went wrong at the hospital

  • The hospital had a lack of leadership and teamwork

  • Healthcare staff were "victims of circumstances" which related to general failings in the NHS rather than individual faults

  • Children's heart services were undermined by being split between two sites

  • There was no way of checking on the quality of services or standards of doctors at the hospital

  • At the hospital, there was a "club culture" with too much power concentrated in too few hands

  • Vulnerable children were not a priority - at Bristol or across the NHS

  • The hospital was poorly organised

  • There was no requirement for doctors to keep their skills and knowledge up to date

  • Bristol was "awash" with data, but none was available to patients or parents

  • Systems problems were not confined to Bristol

  • There was confusion as to who should monitor quality of care nationally
Full coverage of the Bristol heart babies inquiry report

Government response

Key stories

Key figures

Parents' stories

Background briefing

Analysis

Bristol year by year
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