Final Report > Summary

Summary

Terms of Reference

1 Our Terms of Reference were:

To inquire into the management of the care of children receiving complex cardiac surgical services at the Bristol Royal Infirmary between 1984 and 1995 and relevant related issues; to make findings as to the adequacy of the services provided; to establish what action was taken both within and outside the hospital to deal with concerns raised about the surgery and to identify any failure to take appropriate action promptly; to reach conclusions from these events and to make recommendations which could help to secure high-quality care across the NHS.

2 The Public Inquiry was conducted between October 1998 and July 2001. The Panel was chaired by Professor Ian Kennedy. The other members were Rebecca Howard, Professor Sir Brian Jarman and Mavis Maclean. The work of the Inquiry was divided into two phases. In Phase One, the focus was on events in Bristol. Evidence from 577 witnesses, including 238 parents, was received in writing. The Inquiry also received 900,000 pages of documents, including the medical records of over 1,800 children. Oral evidence of selected witnesses was taken over 96 days. The focus of Phase Two was the future. One hundred and eighty papers were submitted to seven seminars in which 150 participants from the NHS, and the public and private sectors took part. In May 2000 the Inquiry produced an Interim Report on the Removal and Retention of Human Material.