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Final Report > Chapter 1: Introduction > Introduction

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Hugh Ross, present Chief Executive of the United Bristol Healthcare (NHS) Trust, in his closing submission to the Inquiry:

`... on behalf of United Bristol Healthcare Trust and its predecessor bodies, I should like to say sorry to the children and families of those who used the paediatric cardiac services in Bristol in the past. It is clear to me that a substantial number of parents and children did not receive the standard of care they were entitled to expect. I have seen at first hand how painful and distressing it has been for many parents to remember and reflect again on the events of the past. I would like to pay tribute to their bravery and composure under the most extreme circumstances.' [1]

Counsel for the Department of Health, in his closing submission to the Inquiry:

`... the Department of Health accepts that it is responsible and is accountable for any failings of the systems that were in place during the period covered by the Inquiry. Ultimate responsibility rests with the Department of Health and the Secretary of State.' [2] `... it now seems clear that there was confusion and therefore systemic failings with regard to the way in which the Supra Regional Services Advisory Group dealt with the specialty of neonatal infant cardiac surgery. Sir, may we say that there is no doubt that the diligence of the Inquiry team has uncovered this confusion and the systemic failing which was previously not known to the department. All these are accepted and are a cause of great regret.' [3]

Janardan Dhasmana, consultant cardiac surgeon at the UBH/T, [4] at the end of his oral evidence to the Inquiry:

`All these things, what have they done to me? They have ruined me professionally, financially, my family life has gone and I have lost confidence in myself. This is the first time in the last two years that I have been able to speak to any audience for three days. I was not sure on Monday whether I would be able to really stand up to these questions. Thank God Almighty for giving me the courage. All this courage has really come from support which I had from my close relatives, and there are still patients and parents who have continued to support me, making me feel that I am still trusted in some corners. Again, I emphasise, whatever suffering I have gone through, and I am going through, is no match to the suffering which you had with the loss of your child, and I wish I could turn the clock back. I cannot say any more.' [5]

James Wisheart, consultant cardiac surgeon at the UBH/T, at the end of his oral evidence to the Inquiry:

`I wish this evening to repeat and to offer again my deepest regret and sympathy to all parents whose children died at the time of or after their operation. In saying this, my sympathy and regret go to parents and families on all sides of this particular debate. ... the lowest point of a surgeon's life is when a child dies under his or her care.' [6]

Dr Stuart Hunter and Professor Marc de Leval in the 1995 report of their external inquiry wrote:

`It is not possible to determine the cause of these poor results [of the neonatal Arterial Switch operation]. To blame surgical skill as the sole reason would be shortsighted. It is most likely a multifactoral and multidisciplinary problem.' [7]

Susan Francombe, mother of Rebecca, at the end of her oral evidence to the Inquiry:

`... we did have a few hours of that joy that you get with your first born baby, and I think it was important for my husband and I to try and remember her like that.' [8]


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[1] T96 p.131-2 Mr Ross

[2] T96 p.54 Mr Pirani

[3] T96 p.56-7 Mr Pirani

[4] We use the term `UBH/T' to refer to that group of hospitals in Bristol which, prior to 1991, comprised the United Bristol Hospitals, and, since 1991, have been known as the United Bristol Healthcare (NHS) Trust. Included within this group of hospitals are the BRI and the BRHSC

[5] T87 p.118 Mr Dhasmana

[6] T94 p.195 Mr Wisheart

[7] UBHT 0052 0268; the first of two drafts of the Hunter/de Leval Report

[8] T68 p.28 Susan Francombe