Lessons learned from the public inquiry into children’s heart surgery at the Bristol royal infirmary and the English safe and sustainable cardiac review

Abstract

This chapter discusses the consequences of an episode in Bristol, UK in the 1980s and 1990s, in which there was an unacceptably high mortality in children undergoing open heart surgery. A major public inquiry followed and amongst many other recommendations, it was suggested that UK cardiac surgical services should be concentrated in a smaller number of centers. Subsequent service reviews came to the same conclusion. It did not happen. Eventually, a process called Safe and Sustainable Cardiac Surgery was established by the Department of Health, building on agreement of all centers to attempt once again to reduce the number of centers, using a standards-based approach. This chapter outlines, from the personal perspective of one lead care center involved, the process, its complexity, the scale of investment, the massive public consultation and, the final analysis that led to its ultimate failure. It contains salutary lessons for all those involved in pediatric cardiac service reform.