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"
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Between 30 and 35 more children aged under one died between 1991 and 1995 than would have been expected in a "typical" unit
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The mortality rate between 1991 and 1995 was "probably double" the rate for England at that time for children under one
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It was probably even higher for children under 30 days
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Problems were not confined to the complex Switch and Atrio-Ventricular Septal Defect (AVSD) operations
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The kind of cases dealt with at the hospital cannot explain the difference in rates with other units
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There was a "failure to progress, rather than necessarily a deterioration in standards" at Bristol
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The arrangements for caring for very sick children at the hospital were "not safe"
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The systems for delivering children's heart services at Bristol were "not up to task"
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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
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The unit "overreached" itself and failed to keep up with developments in the specialty happening elsewhere in the late 1980s and early 1990s
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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
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The hospital had a lack of leadership and teamwork
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Healthcare staff were "victims of circumstances" which related to general failings in the NHS rather than individual faults
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Children's heart services were undermined by being split between two sites
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There was no way of checking on the quality of services or standards of doctors at the hospital
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At the hospital, there was a "club culture" with too much power concentrated in too few hands
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Vulnerable children were not a priority - at Bristol or across the NHS
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The hospital was poorly organised
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There was no requirement for doctors to keep their skills and knowledge up to date
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Bristol was "awash" with data, but none was available to patients or parents
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Systems problems were not confined to Bristol
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There was confusion as to who should monitor quality of care nationally