Final Report > Chapter 20: Understanding and Assessing the Quality of Clinical Care in Bristol > The Clinical Case Note Review
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25 Statistical data are only one way of assessing performance. At the very least they should give rise to questions as to whether there is a problem concerning the outcomes of care. They can tell us little, however, about the reasons for these outcomes. Thus, to examine in detail the clinical care provided, we commissioned a further retrospective analysis, the Clinical Case Note Review (CCNR).  A random stratified sample of 80 cases was selected from the case notes of 1,827 children who underwent open- or closed-heart surgery at Bristol between 1984 and 1995. The sample was weighted so as to reflect the concerns which gave rise to the Inquiry. Thus it was weighted towards younger children, towards those who had open-heart surgery and towards those who died. The case notes of each of the 80 cases were reviewed by multidisciplinary teams of clinical Experts (doctors and nurses). Each group of Experts was asked to assess the adequacy of care provided to the child, both in overall terms and at various stages in treatment. Where they reached the view that a child had received less than adequate care, the Expert team was asked to assess whether this might have had an impact on the outcome for that child. The results of the CCNR suggested that for 70% of the children, care was thought, overall, to have been adequate, but for 30% care was thought to have been less than adequate to varying degrees. In 9% of cases, the less than adequate care might have, or could reasonably be expected to have, affected the outcome for the child.
26 We acknowledge a number of possible caveats. First, our Experts were anxious to point out that their study did not involve comparison with other centres performing PCS at that time. We take the view, however, that the wide range of expertise among the reviewers does offer an indirect comparison with practice at other institutions. Moreover, the adequacy of the care in Bristol falls to be judged on the basis of our Experts' views as to what could properly have been expected of clinicians at the time, wherever they were. Secondly, our Experts also accept that the case notes cannot tell the whole story of a child's care. There are many discussions and actions which do not appear in the notes. That said, the notes convey a sufficiently clear picture of the care provided to allow a view to be taken. Thirdly, it must be true that all centres are likely to have cases where treatment was less than adequate and that such shortcomings might have affected outcome. But we are concerned with the adequacy of care in Bristol. Thus we accept our Experts' findings that for three in ten of the children care was less than adequate to varying degrees. 
27 In reaching this conclusion, it is extremely important to understand what the CCNR actually found. Problems rarely arose, according to the CCNR, from the particular activity of any individual clinician. In most cases, the case notes suggest that problems arose from the management of care as a whole. Our Experts identified a number of factors. They included: delays between diagnosis and treatment; shortcomings in the cardiological input both before and after surgery; some weaknesses in surgery; shortcomings in the organisation of intensive care; and difficulties in delivering care across two sites. Their findings are validated by the degree of agreement among and between the various teams of Experts reviewing the cases.
28 Among the detailed comments made by the Experts who conducted the CCNR were the following.  Professor John Deanfield wrote that his team had identified as a common feature that: `There was often considerable delay between primary referral and appropriate investigation by the cardiologists. In some cases, despite adequate diagnosis, surgery was delayed to an extent which jeopardised outcome (e.g. AVSD). Furthermore, further delays often occurred between referral to the surgeon and conduct of the surgery itself.' He went on that: `Intensive care at the Bristol Royal Infirmary appears to have been fragmented and insular in approach. For example, failure to anticipate clinical problems, delayed response to post-operative problems and failure to involve other team members (eg. cardiology, surgery and other disciplines) contributed to poor overall performance.' Dr Barry Keeton drew particular attention to the concern: `about the lack of evidence of regular input and involvement by members of the paediatric cardiology team in the post-operative management of the patients'. The team of which he was a member felt: `that the split nature of the sites for care of children's cardiology was clearly hampering the communication between the various professionals within the team and perhaps the co-ordination of the child's care'. Dr David Hallworth's team wrote that: `the feeling is of children being cared for by staff who are much more used to dealing with adult patients'.
29 In addition, in his evidence during the hearings in Phase One, Professor de Leval told us of the impact on the outcome of surgery of multiple minor errors. He told us that, taken together, and without the technique or experience to develop defensive mechanisms against them, they were far more likely to endanger the success of any procedure than a single major error.  The arrangements at Bristol were almost calculated to produce such minor errors, given the split site, the lack of cardiological input in the operating theatre and ICU, the lack of trained nurses, and the lack of co-ordination in the ICU. Mr Dhasmana described the benefits of a dedicated paediatric cardiac surgical assistant or well-trained theatre nurses, as he saw in place in Birmingham.  Moreover, it was clear from disagreements among our Experts that some of the problems identified were not unique to Bristol and still remain to be resolved. For example, Dr Eric Silove and Dr Alan Houston disagreed about the relative responsibilities of the surgeon and the cardiologist in the care of a child at various stages.  Furthermore, on the question of who is in charge in the ICU, our Experts showed that confusion still appears to be the order of the day. The nurse identified the intensivist, the cardiologist said that no one is in charge but everyone is responsible, the intensivist said that there must be one person in charge without identifying whom, and the surgeon while suggesting a procedure identifying the cardiologist as the person in charge pre-operatively, the surgeon during surgery and the intensivist post-operatively, indicated that fundamentally the surgeon remained in charge, even in the ICU.
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 We also accept that we can validly extrapolate from the sample of 80 cases. Details of the process of selecting and weighting the sample are given in the annexes to the CCNR Report. See a supplementary technical note from Professor Stephen Evans, Annex B, 12d