Tests to prevent 'another Bristol'

Health Secretary Alan Milburn has promised action

Hospitals and medical staff across the NHS could face rigorous testing to ensure they are up to standard after an inquiry into the scandal of baby heart deaths at Bristol Royal Infirmary.

The report, which blamed a "club culture" of "powerful but flawed" surgeons warned that similar tragedies could be repeated - and may even be happening now.

But Health Secretary Alan Milburn has promised action to ensure no parents have to go through such pain ever again.

This is the end of the age of the doctor is right

Trevor Jones

James Wisheart, the surgeon who was struck off the medical register after being found guilty of serious professional misconduct over his part in the scandal, welcomed the inquiry report.

He reiterated his "deep regret" over the tragic events which unfolded at Bristol.

Parents have welcomed the fact that the long-awaited report was not a whitewash.

It concluded that between 30 and 35 children who underwent heart surgery at the Bristol Royal Infirmary between 1991 and 1995 died unnecessarily as a result of sub-standard care.

And it said a series of flaws in the way the hospital worked meant around one third of all children who underwent open-heart surgery there received "less than adequate care".

'Greek tragedy'

The heart unit was split between two sites, with no dedicated children's intensive care beds, no way of monitoring quality and poor organisation.

It condemns a "club culture" among powerful, but flawed doctors at the unit, who adopted a paternalistic attitude to patients and were caught up in professional rivalries.

This lead to a "Greek tragedy" of events in which warning signs were not recognised and people who raised concerns were ignored and threatened.

Surgeons were able to cover up high death rates by claiming they were on a "learning curve" - and their powerful positions both on the wards and at management level meant no one was able to question them.

Report's recommendations

Periodic revalidation should be compulsory for all healthcare professionals.

The public, as well as employers, should be involved in the processes of revalidation.

Units providing open heart surgery on very young children must have two surgeons trained in paediatric surgery, who must conduct at least 40 operations a year.

Patients and the public must be able to obtain information as to the relative performance of trusts and consultant units within trusts.

The clinical negligence system should be abolished and replaced by an alternative way of compensating patients.

A Council for the Quality of Healthcare should be created along with a Council for the Regulation of Healthcare Professionals

However, it warns: "It is not possible to say, categorically, that events similar to those which happened in Bristol could not happen again in the UK, indeed, are not happening at the moment."

The multi-million pound inquiry was the biggest probe into the workings of the NHS ever carried out.

Its two-volume report runs to 500 pages, with 12,000 pages of back-up statistical data. It makes 198 recommendations.

It says what happened at Bristol was not about "bad people", nor was it about "people who did not care, nor of people who wilfully harmed patients".

Instead, the report says the healthcare staff were "victims of circumstances which owed as much to the general failings in the NHS at the time than to any individual failings".

It recommends measures to beef up regulation of the medical profession in the UK.

Speaking in the House of Commons, Health Secretary Alan Milburn said the Bristol children were "failed by the very system that was supposed to keep them safe from harm."

In line with the report's recommendations, he announced a new independent Office for Information on Healthcare Performance to coordinate the collection and publication of medical data, and the appointment of a national director for children's services.