Final Report > Foreword

Foreword

It is my privilege to present this Report, as Chairman of the Inquiry. I do so in the hope that it will achieve two principal aims. First, I hope that it will allow a better understanding of what happened in relation to paediatric cardiac surgery in Bristol in the 1980s and 1990s. There were failings both of organisations and of people. Some children and their parents were failed. Some parents suffered the loss of a child when it should not have happened. A tragedy took place. But it was a tragedy born of high hopes and ambitions, and peopled by dedicated, hard-working people. The hopes were too high; the ambitions too ambitious. Bristol simply overreached itself. Many patients, children and adults benefited; too many children did not. Too many children died.

A Public Inquiry cannot turn back the clock. It can, however, offer an opportunity to let all those touched by the events, in our case Bristol, be heard and to listen to others. Through this process can come understanding. We tried to provide this opportunity. The understanding we formed is set out in Section One of our Report. It speaks of an organisation which was not up to the task; of confusion and muddle as to where responsibility lay for making sure that the quality of care provided to children was good enough; and of a system of care blighted by being split between two sites, by shortages of trained staff and by inadequate facilities.

It would be reassuring to believe that it could not happen again. We cannot give that reassurance. Unless lessons are learned, it certainly could happen again, if not in the area of paediatric cardiac surgery, then in some other area of care. For this reason we have sought to identify what the lessons are and, in the light of them, to make recommendations for the future. This is the second of our aims. It is what Section Two of our Report addresses. We offer our view of the way forward for the NHS: an NHS fit for the 21st century. The scale of the enterprise is considerable. So are the time and resources which will be needed to achieve the necessary changes. We make close to 200 recommendations. They are the recommendations of all of us. This is a unanimous Report. Our job is done. It is up to others to decide how to take things forward.

For the Panel it has been a long journey. I pay tribute to the support Rebecca Howard, Brian Jarman and Mavis Maclean have given me throughout. They have tolerated the burdens which I have placed on them with exemplary patience and goodwill. We have worked harmoniously. Throughout, we have had the benefit of a quite outstanding team. It has constituted a rich array of talents: the architects and designers who created the hearing chamber and facilities in Bristol; the teams supporting us in areas such as analysis, administration and IT; the managerial abilities of the Deputy Secretary Zena Muth; the tireless efforts of Becky Jarvis in the final stages of publication; and my personal assistants who in turn managed not only me but such things as trains and hotels with great skill and good humour. Warm thanks are also due to the Inquiry's legal team: the solicitors and paralegals led by Peter Whitehurst and Counsel led by Brian Langstaff QC. They all worked prodigiously hard. I mention also our team of Experts. They helped us enormously. Their work was of the highest standards and often groundbreaking. I single out one person for particular thanks. The Inquiry was fortunate beyond words in having Una O'Brien as its Secretary. I cannot praise her too highly. Her ability, dedication and sheer unremitting hard work represent the finest traditions of public service. Without her we could not have achieved half of what we did. She is owed a singular debt of gratitude.

I hope I can be forgiven for adding an entirely personal note. During the Inquiry's hearings my brother Stuart died. He had contracted hepatitis while operating on a patient. He was a good man and a good doctor. He taught me much. I dedicate any contribution I may make to the future of the NHS to his memory.

Ian Kennedy

July 2001