Frank Dobson, Secretary of State for Health, responded to the General Medical Council's verdict by announcing a public inquiry into what has become known as the Bristol cardiac disaster. Of 53 cases investigated by the GMC, 29 children died and four were left brain damaged after operations between 1988 and 1995.
James Wisheart, 60, a senior surgeon and former medical director of the Bristol Royal Infirmary and John Roylance, former chief executive, were struck off the medical register and Janardan Dhasmana, Mr Wisheart's junior colleague, was restricted to operating on adults for three years, after the council's professional conduct committee found they had failed to protect children undergoing surgery for heart defects from unacceptably high risks.
The decision to allow Mr Dhasmana to continue working outraged parents who packed the public gallery to hear Sir Donald Irvine, president of the GMC, deliver the verdicts. One shouted "murderer" and another accused the GMC of "protecting working doctors". Mr Wisheart and Dr Roylance are retired and their pensions will be unaffected by the GMC's decision.
Outside there were scuffles as two parents lunged at Mr Dhasmana.
Mr Dobson told the Commons that the inquiry, to be chaired by Ian Kennedy, professor of medical ethics at University College, London, would "cover all aspects of what went wrong at Bristol". He said he hoped the parents of the children concerned "would gain at least some small consolation from the knowledge that the lessons learnt from what their children had suffered should mean that nothing like it ever happens again".
The GMC's verdict strikes at the heart of the medical establishment. In its judgement, the council said the three doctors were "caring and dedicated" and had given long service to the NHS which had made the need for the inquiry "all the more tragic". In addition to the doctors' individual failings, the council identified "institutional failures at the BRI and beyond" and listed more than a dozen issues that needed addressing, including the need for training, the monitoring of performance and how doctors should explain risks.
The case, which has lasted eight months and cost the council pounds 2.2m, has sent a collective shudder through government and medical organisations which have belatedly recognised that there are no clear standards against which the performance of doctors can be judged.
Ministers announced last week that hospitals will be required to publish death rates and all doctors will be required to submit details of their performance for checks.