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Joshua Loveday, an 18-month old "switch" patient of Janardan Dhasmana, died on the operating table.
Hospital management had been advised not to go ahead with the operation by Dr Peter Doyle from the Department of Health, but after a meeting, nearly all the doctors involved had agreed there was no reason to delay it.
Now the switch programme was stopped entirely, and the decision is taken to get outside advice about the state of the unit.
While data is scarce about success rates at other units, leading surgeons elsewhere have quoted a figure of 5% mortality for the switch.
Marc De Leval, a surgeon from Great Ormond Street, and Stewart Hunter, a cardiologist, visited Bristol - and got hold of Steve Bolsin's audit.
Their report for trust managers, which is eventually published, concludes that Bristol is a "high risk" centre, and there has probably been "excess mortality".
Worried and angry parents joined together to form the Bristol Heart Babies Action Group, which began campaigning to learn the true extent of problems at the hospital.
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