A British inquiry recently uncovered serious deficiencies within a pediatric cardiac surgery program in Bristol, England. The reasons it was called are eerily similar to those for an inquest held in Winnipeg in the mid-1990s, when an inquest looked into 12 infant deaths following heart surgery (Sibbald B. Why did 12 infants die? Winnipeg's endless inquest seeks answers. CMAJ 1998;158[6]:783-9). The Bristol inquiry, which started in 1998, was investigating 3 times as many deaths. Dr. Gabriel Scally, the regional director of public health in South West England, submitted this report to CMAJ.
The landscape of British medicine has been changed irrevocably by the discovery of serious deficiencies in pediatric cardiac surgery in Bristol.
The long-awaited report of the public inquiry into the situation in the Bristol Royal Infirmary in the late 1980s and early 1990s was published July 18. The inquiry, established in 1998, heard evidence from a wide range of witnesses and produced almost 200 recommendations. The main body of the report runs to 500 pages and — with appendices included — totals 12 000 pages. Professor Ian Kennedy, an academic lawyer with particular expertise in health issues, chaired the inquiry. He had already shown himself to be an incisive critic of the culture and structure of British medicine in a series of lectures in 1980, so it was no surprise that the inquiry recommendations were aimed at producing fundamental change.
Expert analysis of pediatric cardiac surgery data from Bristol and other centres showed that between 1991 and 1995 there were between 30 and 35 more deaths among children who underwent operations in Bristol, compared with the average of all UK centres.
The report's most damning aspect is its description of the “club culture” that was pervasive among the hospital's senior staff. The report (www.bristol-inquiry.org.uk/final_report/report/Summary2.htm) states that the system of hospital care was poorly organized and “it was beset with uncertainty as to how to get things done, such that when concerns were raised it took years for them to be taken seriously.”
“The story of the paediatric cardiac surgical service in Bristol is not an account of bad people,” it concludes. “Nor is it an account of people who did not care, nor of people who willfully harmed patients.
“It is an account of people who cared greatly about human suffering, and were dedicated and well-motivated. Sadly, some lacked insight and their behaviour was flawed. Many failed to communicate with each other, and to work effectively for the interests of their patients. There was a lack of leadership, and of teamwork.”
The report criticizes 8 doctors, including 2 who worked at the Department of Health in London and the then president of the Royal College of Surgeons of England, and says that children's services were given a lower priority than adult services.
The shock waves from Bristol have already rocked medicine in the UK from top to bottom: TV networks showed images of tiny coffins being laid out by aggrieved parents outside the General Medical Council's (GMC) offices in London, and of Bristol doctors who were found guilty of professional misconduct requiring police escorts to get out of the GMC building.
The Bristol Royal Infirmary Inquiry also heralded a sea change in the relationship between the medical profession and the British public. The GMC has committed itself to a routine process of revalidation of doctors' competence and has strengthened its own processes for dealing with poor medical performance. Perhaps the biggest change in recent years has been the introduction of a system of clinical governance in the National Health Service (NHS). This has been prompted not only by the events in Bristol but also by a number of other high-profile clinical failures.
Because of this inquiry, the responsibility for taking a consistent and universal approach to the improvement of the quality of clinical care has been placed firmly with the NHS. The process is supported by the creation of a jigsaw of statutory bodies, including the Commission for Health Improvement and the National Patient Safety Agency. As part of the process of renovation, regular professional appraisal and routine participation in clinical audits have been made universal requirements within the NHS.
(The Bristol Inquiry also led to the uncovering of scandalous organ-retention practices that had been taking place in the Alder Hay Children's Hospital in Liverpool [see CMAJ 2001;164(8):1199].)
There are undoubtedly parallels between the events in Bristol and Winnipeg. The combination of the stark nature of the crude outcomes — survival or death, the highly complex nature of the surgery and the patient group involved —all contribute to making this an area of clinical practice that inevitably engenders massive public and political feeling.
However, the changes now taking place in the NHS in England because of the Bristol inquiry are based on the premise that quality of clinical care cannot be taken for granted in any specialty or location. As for pediatric cardiac surgery in Bristol, new clinical staff and managers have produced remarkable improvements, and the mortality rate is now less than half the national average. — Gabriel Scally lives and works in Bristol.