The inquiry will examine why babies who underwent heart surgery at the infirmary in the late 1980s and early 1990s died when they might have been saved had they been operated on elsewhere. That bald fact, which covers a well of human sorrow, has so far resulted in findings of serious professional misconduct against two senior surgeons and the hospital's former chief executive, shaken the public's confidence in their doctors and sent shock waves through the profession.
Are other doctors in other hospitals sending patients quietly, unknowingly and unnecessarily, to their deaths? Sir Donald Irvine, president of the General Medical Council, said after the council's own investigation concluded last June, that there can be no guarantee that similar disasters are not happening, unrecognised, elsewhere. As Sandy Rundle, mother of Matthew, a Bristol baby who died aged 10 months in April 1994, said: "Someone must have the power to stop a surgeon. I find it hard to believe no one did."
The General Medical Council's eight-month examination of the case, the longest and most emotive in its history, cast a spotlight on the three principal players, surgeons James Wisheart and Janardan Dhasmana and former hospital chief executive John Roylance. The focus was narrow because the GMC functions like a criminal court and the case revolved around specific charges relating to specific patients where the evidence was strongest. It could not look at the wider picture, though that caused distress to many of the parents, who complained their stories had gone unheard.
The public inquiry will switch the focus from the individuals to their institution. Ian Kennedy, the inquiry's chairman and professor of health law and ethics at University College, London, will try to peer behind the cloak of professional secrecy that shrouded events at Bristol, and in doing so shine light on what Sir Donald Irvine described as the "defensive, protective, inward-looking culture" in which doctors work. Professor Kennedy will attempt to prise from witnesses details of the tensions, the rivalries and the "corridor gossip" that kept the disaster covered up for so long.
A hint of what may emerge has already been provided by a detailed analysis of the GMC case by Rudolf Klein, an expert on NHS policy. His diagnosis is that the BRI was a hospital suffering from an "institutional malaise" in which no one was ready to confront evidence of poor practice.
According to Professor Klein, whose account of the case is published by the King's Fund in Health Care UK, the infirmary emerged as an "introverted and complacent institution" dominated by long-established consultants who were reluctant to question the performance of one of their number. "The evidence strongly hints that the institutional ethos was such that anyone who criticised his colleagues was stereotyped and dismissed as a troublemaker."
Responsibility for what went wrong begins with the individuals who took no action or ignored what they saw. Professor Klein writes: "The cardiologists continued to refer to the two surgeons, the anaesthetists continued to assist at the operations ... so too did the nurses. If there is a collective team responsibility for maintaining standards ... then it is surprising that only the two surgeons and the chief executive appeared before the GMC."
It was not only individuals who kept silent about what was going on. The board of the United Bristol Hospitals NHS Trust apparently took no action, even after rumours about babies dying surfaced in Private Eye. Warnings were also ignored by the regional health authority, the Royal College of Surgeons and the Department of Health.
The inquiry, which has amassed 600,000 pages of information so far, is not due to report until the summer of next year. It has already triggered a sea change in attitudes within the medical establishment, with the royal medical colleges and the General Medical Council agreeing for the first time that checks on doctors' skills are necessary throughout their careers.
Critics of the inquiry, however, question whether it is too large in scope and too cumbersome and that its report will be too long in coming to be effective. As an indication of what can go wrong, consider an almost identical inquiry which concluded in Canada last September. It examined the cases of just 12 children from among 100 who died following heart operations at the Manitoba Health Sciences Centre in Winnipeg from the 1980s until the programme was stopped in December 1994.
Despite its limited scope, the inquiry ran for almost three years, heard evidence from more than 100 witnesses, produced 50,000 pages of testimony and has cost C$2.2m (pounds 900,000) so far. Judge Murray Sinclair now has to sift through the mountains of evidence, decide what happened and make recommendations.
Jan Davies, a consultant an-aesthetist from Calgary, Alberta, and an expert witness in the case, said she cited the Bristol disaster in her report on the Manitoba case. "The biggest lesson is that these deaths were organisational accidents," Professor Davies said. "We have to recognise that most doctors try to do their best. They don't go into the operating theatre and say: `I'm going to kill someone today'. We need to stop pointing the finger and look at fixing the system. Otherwise patients will go on dying."
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