James Wisheart and Janardan Dhasmana, heart surgeons at Bristol Royal Infirmary, were found guilty of serious professional misconduct by the General Medical Council last year.
Mr Wisheart was struck off the medical register. Mr Dhasmana was banned from operating on children for three years and later sacked by the infirmary after the GMC found they had continued to carry out heart surgery on young children when they should have known their death rates were too high.
Yesterday the public inquirywas told that a detailed review of 100 operations carried out on 80 children at the infirmary found only two operations in which the surgery was at fault and where, had it been performed better, the outcome would probably have been different. In a further seven operations the outcome might have been different.
However, the review of the 80 cases - randomly selected from about 1,800 at the infirmary between 1984 and 1995 - found that half the children had received inadequate care.
In almost one in three cases - 24 children, of whom 21 died - there was an avoidable feature that might have contributed to death or disability. Overall, the review concluded that 170 of the children - almost one in 10 - might have survived or had a better outcome had they been operated on elsewhere.
The review suggests much of the blame may be pinned on a wider institutional failure involving the organisation of care. It says: "When care was considered to be less than adequate in any patient there were a number of aspects that appeared to have an even greater influence on poor outcome than the actual operation."
Many of the problems occurred at the pre-operative stage and concerned inaccuracies in diagnosis, poor initial treatment and delays to surgery. There were also problems of communication among members of the team.
The findings underpin statistics presented on Wednesday showing that Bristol had twice the average death rate among the 12 specialist centres carrying out complex heart surgery on children. The reports paint a grim picture of the care at Bristol, but suggest responsibility should be spread wider than the two surgeons.
Dr Eric Silove, a paediatric cardiologist at Birmingham Children's Hospital who presented the clinical review to the four-member inquiry, said the pre-operative care "set the scene" for the whole management of patients thereafter. Aftercare provided in intensive care was also a "major determinant" of outcome.
Professor Stephen Evans, a consultant statistician, said all aspects of care contributed to the shortcomings. "I think it is clear that there is a pattern over the whole of care that was the problem, particularly in regard to open heart surgery."
The Bristol Surgeons Support Group, set up by families to campaign for Mr Wisheart and Mr Dhasmana, said the clinical review vindicated the surgeons. Spokesman John McLorinan said: "It is apparent that the whole thing was down to teamwork."Reuse content