Inquiry highlights failures in NHS

After a two-year investigation, bereaved parents will finally have some answers to their children's deaths

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We lost our baby, my partner killed himself. So how can I forgive those surgeons now?

The head of the General Medical Council yesterday admitted that the tragedy of the Bristol heart babies scandal could happen again elsewhere.

The findings of the inquiry into the paediatric cardiac unit, dubbed the "killing fields", at Bristol Royal Infirmary, will be published finally on Wednesday.

The largest inquiry into the NHS is likely to highlight a number of systematic failures that led to the deaths of too many babies, operated on by two surgeons later found guilty of serious professional misconduct. Sir Donald Irvine, president of the GMC, the doctors' regulatory body, told The Independent on Sunday: "I do feel I have let patients down in the sense that the regulatory system has failed and people have been hurt.

"We just have to candidly acknowledge the health service's regulatory bodies and systems as a whole have not been geared for modern medicine."

Sir Donald conceded he could not rule out a recurrence of the tragedy: "I think there is no such word as 'never'." But he stressed that a series of measures either had been or were being put in place to monitor doctors' performance more carefully.

"The NHS does not have a good track record for the capacity to collect data on performance," said Sir Donald. "It has not made that kind of investment and has not considered that appropriate [in the past] and now it has to."

Publication of the report this week is expected to unleash more recriminations against the poor performance of the hospital's paediatric heart unit. A new study, published last week by The Lancet ahead of the inquiry result, reveals that for babies under one year old undergoing open heart surgery, the death rate at Bristol was around double that of other centres. Statistical analysis by an independent team from the Imperial College School of Medicine shows 19 "excess" deaths among 43 children who died in one set of figures, and 24 "excess" deaths among 41 deaths in another study.

Mr James Wisheart, one of the cardiac surgeons at the centre of the public inquiry, contacted The Independent on Sunday yesterday and said he was "apprehensive" about the inquiry's findings. Earlier this month, he apologised for the first time for the "torment the families have suffered".

His supporters say Mr Wisheart and another surgeon, Janardan Dhasmana, had been made scapegoats for wider NHS failures, including underfunding of the paediatric cardiology unit. The unit has since been transferred to the children's hospital at Bristol and now has one of the best success rates in the country.

John McLorinan, secretary of the Bristol Surgeons Support Group, said: "They were both wonderful men with a great presence on the ward and a great sense of healing around them." His son Joe, now aged 11, survived two heart operations performed by Mr Wisheart in 1990 and 1991.

But Helen Rickard, whose daughter Samantha died on the operating table, said: "I don't understand how Mr Wisheart could justify it to himself to continue operating when there so many babies dying."

Wednesday's report is the culmination of a two-year inquiry, started in March 1999, which looked at the cases of 500 families and 1,900 operations from 1983 to 1995.

An interim report published last May criticised the hospital for routinely removing and retaining the hearts of babies without parents' consent. Professor Ian Kennedy, who is chairing the public inquiry, said at the time: "It was an arrogance born of indifference. We must recognise that the practice of the past was a product of the culture of the past."

Parents whose children died at the hospital have received £20,000 payouts. Compensation payments are still being negotiated for children who suffered brain damage during heart surgery that went wrong.