Professor Ian Kennedy, who yesterday announced the list of issues that the inquiry will cover, said the aim was to find out what happened in Bristol and what lessons could be learnt by hospitals elsewhere, rather than to pin blame.
"We are not seeking to focus on individuals but rather we are looking at the whole system which was responsible for the management and care of children needing heart surgery services. It will not be a court, it will not be a trial," he said.
The inquiry, which is set to be one of the most detailed ever undertaken by the NHS, follows an investigation by the General Medical Council into the deaths of 29 babies at Bristol Royal Infirmary.
The GMC found three doctors, two surgeons and the hospital's chief executive, guilty of serious professional misconduct after they allowed complex heart operations on babies to continue, despite warnings from colleagues about their poor success rate.
The GMC acts like a criminal court, so it could investigate only specific charges relating to specific patients where the evidence was strongest.
It did not, and could not, look at the wider picture which caused distress and anger to many of the parents who complained their stories had gone unheard.
The inquiry will investigate all types of heart operations, including cases of children who suffered disabilities as well as those who died.
The main issues proposed for phase one of the inquiry are:
The national and regional context in which heart services were delivered;
A detailed investigation into the paediatric cardiac unit at the Bristol Royal Infirmary;
Comparisons between the Infirmary and other hospitals;
How children were referred to the hospital for treatment;
Management of surgery and post-operative care;
How families of babies and children were treated;
Training of staff;
The role of post-mortem examinations;
How and when concerns were expressed and dealt with.
Parents of children who died after heart surgery at the hospital welcomed the announcement but supporters of the three doctors said the inquiry had been biased from the start.Reuse content