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Monday, 15 March, 1999, 23:34 GMT
BRI Inquiry: The facts

The independent public inquiry into standards of heart surgery for children at Bristol Royal Infirmary - where 29 babies and toddlers died after operations performed by two doctors - began in March. It could be the longest-running and widest-ranging investigation into medical standards in the UK since the NHS was founded in 1948.

Why a public inquiry?

In June 1998 the doctors' regulatory body, the General Medical Council (GMC), concluded its longest-ever hearing.

The Bristol Heart Babies
The council had been investigating three doctors at Bristol Royal Infirmary - heart surgeons Mr James Wisheart and Mr Janardan Dhasmana and their boss, former chief executive Dr John Roylance.

It found all three of them guilty of serious professional misconduct - Mr Wisheart and Mr Dhasmana for continuing to operate on infants when the death rate was unacceptably high, and Dr Roylance for not intervening.

Between 1988 and 1995, Mr Dhasmana carried out 38 arterial switch operations in which 20 of the young patients died.

Mr James Wisheart was struck off the medical register
Between 1990 and 1994, Mr Wisheart carried out 15 atrio-ventricular septal defect operations. Nine of the young patients died.

Mr Wisheart and Dr Roylance were banned from practising medicine altogether while Mr Dhasmana was banned from operating on children for three years.

Then Health Secretary Frank Dobson was furious that the GMC did not ban Mr Dhasmana outright.

Mr Janardan Dhasmana was temporarily banned from operating on children
He established the inquiry in response to fears that doctors have too much power over the regulation of their profession and to investigate matters overlooked by the GMC hearing.

Parents of children who died or suffered brain damage at the hospital particularly wanted an independent public inquiry.

They criticised the GMC inquiry when it ended, saying it was not wide enough and did not look into all the cases of children who suffered severe brain damage following surgery.

Protesters outside the GMC hearing held up a list of 150 children they said had been affected by treatment at BRI.

Dr John Roylance was also struck off
The GMC hearing was also criticised for failing to examine the hospital's record on adult surgery.

Issues that were not addressed during the GMC hearing included the role of the Department of Health.

The department was alerted to problems with paediatric heart operations at Bristol nine years ago.

Yet it was not until bereaved parents wrote to the GMC in 1996 that any action was taken.

The case left many people disillusioned with doctors and the concept of professional self-regulation in tatters.

What can the inquiry do?

The inquiry can make recommendations as to how medical standards can be maintained.

Because there were failures at every level in this case - from the operating table to Whitehall - the inquiry has a wide-ranging remit to investigate the case from every angle.

Its full terms of reference are:
  • "To inquire into the management of care of children receiving complex heart surgical services at the Royal Bristol Infirmary between 1984 and 1995 and relevant related issues"

  • "To make findings as to the adequacy of the services provided"

  • "To establish what action was taken both within and outside the hospital to deal with concerns raised about the surgery and to identify any failure to take appropriate action promptly"

  • "To reach conclusions from these events and to recommendations which could help secure high quality care across the NHS'

In short, it will examine the role of anyone or any management structure related to events at Bristol Royal Infirmary.

It will also be able to look at the mechanisms in place at other hospitals and make recommendations to try and ensure that a similar tragedy could never happen again.

What has the government done since June?

Apart from launching the public inquiry, the Department of Health introduced several measures to ensure high standards in the NHS.

These included the use of the proposed National Institute for Clinical Excellence to set guidelines for best practice.

The proposed Commission for Health Improvement will ensure that practitioners meet the standards the institute sets.

The government also plans to publish league tables of the death rates at hospitals.

What have doctors done since June?

Doctors were swift to point out that "there could never be another Bristol".

In the wake of its ruling, the GMC issued improved guidelines to doctors advising them when and how they should report a colleague whose performance they thought was putting patient safety at risk.

In October 1998, the Senate of Surgery issued proposals to ensure doctors monitor their performance and are not allowed to carry out procedures which they are not fully competent to perform.

It also proposed "rapid response teams" of specialists to take over surgery at hospitals where death rates are unacceptably high.

Under the proposals, consultants will have to undergo regular appraisals to establish if they are still fit to practice.

Who is chairing the inquiry?

Professor Ian Kennedy was appointed chairman of the inquiry.

He is professor of health law, ethics and policy at the School of Public Policy, University College, London.

Professor Kennedy said he wants access to the inquiry to be as easy as possible, and has launched a website to this end.

He has chosen to conduct the inquiry in an inquisitorial manner - investigators will gather information rather than witnesses appearing and being cross-examined at the inquiry.

He said: "I have a duty to find the best possible procedure to help us get to the truth.

"I believe an inquisitorial approach is much better suited to our purpose than a complex process of cross-examination where each witness could be cross-examined by as many as seven or eight sets of barristers.

"That would be in no one's interest, not least because it would prolong the proceedings, and we have a duty to the parents and to everyone else to come to our conclusions as soon as we reasonably can."

How long will the inquiry last?

Phase one of the full public hearings began last March.

This section is due to last until the end of 1999, but due to the complexity of the issues and the broad remit, no one can accurately predict how long the entire inquiry will last.

Richard Green, spokesman for the BRI Inquiry Unit, said: "It's difficult to predict how long it's going to take.

"It's not in anyone's interests for it to take a long time but we have got to make sure that what we do is thorough.

"It's a question of making sure that we keep those two things in mind as we work through."

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