In 1998, the British medical regulatory body, the General Medical Council, severely disciplined 3 doctors after inquiring into the deaths of 29 infants and children at Bristol Royal Infirmary. The deaths had resulted from open-heart operations for atrioventricular septal defect or transposition of the great arteries. According to the Council’s adjudication, the 2 surgeons had continued to operate when their mortality rates were too high, and the medical chief executive, despite ample cause for alarm, had failed in his duty to intervene; the doctors left the hearing to cries of “murderer.”
The “Bristol scandal” generated enormous outrage and, since 1998, a public inquiry has been in progress under the chairmanship of Professor Ian Kennedy, a lawyer. His report, which has now been published (www.bristol-inquiry.org.uk/final_report), tells the story of an enterprise that began with high aspirations but failed to keep up with developments elsewhere; between 1988 and 1994, the mortality rate for open-heart surgery in children younger than 1 year at Bristol Royal Infirmary was about double that in England as a whole. Despite local expressions of concern and even adverse comment in the media, the surgeons pressed on, hoping for better things. No formal system existed for monitoring their work, and the chief executive chose to ignore the increasing unease of other clinicians. The program was suspended in 1995 when an infant died after a particularly controversial operation. Between 1991 and 1995, according to a statistical analysis conducted for the inquiry, ≈30 to 35 children younger than 1 year died after open-heart surgery in Bristol who would have survived if the unit had achieved results typical of others in England at the time.
Kennedy’s report concludes that a “club culture” existed at the hospital; there was an imbalance of power, with too much control in the hands of a few individuals. Disturbing local results could be kept under wraps. The information given to parents, when they considered the option of surgery for their child, was often partial, confusing, and unclear. When national bodies became aware of the poor results in Bristol, nothing was done because each thought it was the responsibility of another. The report goes far beyond pediatric cardiac surgery: Kennedy judges that the Bristol phenomenon reflects a malaise within the National Health Service itself. It was not, he says, a story of “bad people” but of individuals who failed to work together effectively for the interests of patients; leadership and teamwork were lacking. He calls for a more open and accountable health service in which patients are seen as partners in decision-making, physicians surrender their dominance and become team players, standards for clinical and hospital practice are set and monitored, and local success rates are published. Many of Kennedy’s proposal’s have been anticipated and acted on by the government; the Bristol affair has left the British medical profession almost helpless to resist curtailment of its freedom and power. But one piece of advice that is unlikely to be accepted by an administration with a taste for control is the recommendation that bodies who set and monitor standards should be independent of the executive (ie, the Department of Health).