Final Report > Chapter 1: Introduction > Interpreting the Terms of Reference

Interpreting the Terms of Reference

15 The Terms of Reference given to the Inquiry constituted a significant challenge. First, we had to conduct a factual inquiry into events, and to reach conclusions about those events. The events took place over a period of 12 years, ending more than three years before the start of the hearings. Second, arising from the conclusions we reached, we were asked to make proposals for improving the quality of care in the NHS: to engage, in other words, in an analysis of how the lessons of Bristol might be applied to the NHS in the future. To achieve these objectives the Inquiry had to constitute itself in different forms, hence the Oral Hearings of Phase One and the Seminars of Phase Two. As well as hearing from parents, the Inquiry also had to consider two quite distinct types of evidence and be assisted by two categories of witness: those involved in caring for children in Bristol and Experts who commented on this care on the one hand, and those with expertise on the wider issues facing the NHS. The challenge was made much greater by the fact that any advice we might give on improving the quality of care, our second task, while informed by the events in Bristol, was not limited to either Bristol or to PCS, but rather ranged across the acute sector of the NHS. We saw the requirement placed on us as being to address fundamental issues of policy going to the core of the NHS as a whole. We also had to ensure lessons could be learned and appropriate action taken promptly. This was our task.