Final Report > Conclusions
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1 With regard to the systems in place to seek to secure the provision of adequate care, there were elements both in the arrangements at Bristol, particularly aspects of management, poorly developed teamwork, and split service, and more widely beyond Bristol, for instance, the respective roles of the SRSAG, the Royal Colleges, the Regional Health Authority, the District Health Authority, the Trust (after 1991), and the DoH in quality assurance, that were conducive to the PCS service being less than adequate on occasions. But it is crucial to recognise that, at that time, some of these factors, in particular the split service, which was heavily implicated in affecting adversely the quality of care, were regarded as a challenge to be overcome rather than as an obstacle or barrier warranting the cessation of the PCS service. The thinking seems to have been that things would get better in time, once the plans to consolidate the service at the BRHSC were realised. In the interim, the tradition in the NHS of overcoming the odds drowned out any messages that things were worse than they should be.
2 In addition to the shortcomings in the systems underpinning the PCS service, there is the separate question of whether there was sufficient evidence at that time that the service as a whole, whatever the outcome in particular cases, was less than adequate. On balance, we take the view that, had there been a mindset to carry out the necessary analysis, the figures for 1987, 1988 and 1989 could have alerted the clinicians in Bristol by 1990 that there was a need to stop and take stock of their results. The absence of such a mindset may have allowed them to wish away their poor results because of the improvements shown by the 1990 data. But certainly, at least by 1992, notwithstanding the false assurance of the 1990 data, there was evidence sufficient to put the Unit on notice that there were questions to be answered as regards the adequacy of the service.
3 At the time, however, there was a temptation for the clinicians to persuade themselves, even in the face of such evidence, that any poor outcome could quite plausibly be explained away. They could equally plausibly speak in terms of an expectation of improvement over time, notwithstanding the failure of Bristol's performance to improve in comparison with improvements reported in other units. Indeed, Mr Dhasmana spoke in terms of the `inevitability' of a `learning curve', by which it was meant that results could be expected to be poor initially, but would improve over time with experience.  They could argue that the small numbers of children who were treated meant that their figures looked worse when expressed in percentage terms, that they treated children who were more sick (albeit that there was no evidence to support this assertion) and that, once the hoped-for new surgeon was appointed, the pace of improvement would quicken. All of these arguments had sufficient plausibility at that time that they could be believed, and they could not readily be refuted, though they might be doubted.
4 It could be argued that there was a duty on the clinicians to challenge their own rather easy explanations. But they were working in a tradition and against a background in which, sadly, there was no system in place which could provide reliable and meaningful information which could be analysed and which could not be explained away. Only they could effectively challenge their results. They did discuss their data: Mr Dhasmana did seek help from the team in Birmingham. But, with hindsight, they were too easily persuaded that their poor results were a run of bad luck or that things would improve. To some in Bristol the cup was dangerously empty, to others it was half full, and neither could be proved wrong.
5 Turning to the concerns expressed by parents, parental dissatisfaction with the PCS service may well have existed throughout the period of our Terms of Reference. It only really surfaced, however, in any significant sense after 1995. Indeed, we note that during the entire period of our Terms of Reference the UBHT records show only two formal complaints regarding PCS.  Certainly, any parental dissatisfaction did not, at that time, serve as a reason for stopping all or some PCS, or even for re-evaluating the programme. Of course, this is no surprise since parents could never get an overall perspective, concentrating as they naturally were on their own child. Furthermore, there was no system in existence to discover their feelings and views so as to respond to them.
6 We conclude that the PCS service for children who received open-heart surgery was, on a number of criteria, less than adequate. The statistical evidence allows us to reach this conclusion as regards children under 1 who had open-heart surgery between 1988 and 1994. The rest of the evidence, including for example that of the parents, the clinicians in Bristol and the Clinical Case Note Review, allows us to go further and say that the service was less than adequate over the whole period of our Terms of Reference and as regards open-heart surgery on all children, whether under or over 1. But this judgment, to the extent that it is based on reliable and verifiable evidence, relies heavily on hindsight. At the time, while the PCS service was less than adequate, it would have taken a different mindset from the one which prevailed on the part of the clinicians at the centre of the service and senior management to come to this view. It would have required abandoning the principles which then prevailed, of optimism, of learning curves, and of gradual improvements over time, and adopting what may be called the precautionary principle. This did not occur to them. This is one of the tragedies of Bristol.
7 We reach one conclusion which owes nothing to hindsight. It relates to what we described earlier: the problem of poor teamwork and the implications this had for performance and outcome. The crucial importance of effective teamwork in this complex area of surgery was very widely recognised. Effective teamwork did not always exist at the UBHT. There were logistical reasons for this: for example, the cardiologists could not be everywhere. But the point is that, knowing this, they carried on. Also, relations between the various professional groups were on occasions poor. All the professionals involved in the PCS service must bear responsibility for this. But, in particular, it demonstrates a clear lack of effective clinical leadership. Those in positions of clinical leadership must therefore bear the responsibility for this failure and the undoubted adverse effect it had on the adequacy of the PCS service.
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 WIT 0084 0115 Mr Dhasmana
 The Inquiry asked the UBHT to check all complaints made by patients (or carers) between 1984 and 1995. The UBH/T received a total of 1,703 complaints. Of these, two related to concerns of patients following the death of their child admitted for paediatric cardiac care, one in 1986 and the other in 1993. UBHT 0345 0001