A "Club Culture" of powerful but flawed surgeons at a major child heart unit led to one-third of its patients receiving inadequate care, according to a long-awaited report published yesterday. A "poisoned" atmosphere between management, surgeons and other staff meant people who raised concerns about the scandal at the Bristol Royal Infirmary were ignored and threatened.
Responding to the report of the independent inquiry, the British Health Secretary, Mr Alan Milburn, told MPs more action was needed to prevent a repeat of the "tragedy" at Bristol. He said he would be appointing a new national director of children's healthcare services, Prof Al Aynsley-Green, to improve standards of children's services in hospitals.
In line with the report's recommendations, he also announced a new independent Office for Information on Healthcare Performance to coordinate the collection and publication of medical data.
Up to 35 babies under a year old died unnecessarily at the infirmary between 1991 and 1995 as a result of sub-standard care, said the inquiry chairman, Prof Ian Kennedy.
Prof Kennedy said surgeons were able to cover up high death rates by claiming they were on a "learning curve", and their powerful positions both on the wards and at management level meant no one was able to question them.
Parents were given "partial, confusing and unclear" information and were kept in the dark about major concerns about the heart unit at the hospital.
The report attacked the NHS as a whole for "general failings" which allowed the scandal to happen. It criticised individuals from senior Department of Health officials to the Bristol surgeon Mr James Wisheart and nursing director Ms Margaret Maisey for their role in the scandal. They were accused of lack of "insight, leadership, respect and candour".
Prof Kennedy recommended that in the future hospitals should be licensed and "revalidated" every five years by checking that success rates in operations and other standards were acceptable.
The report said: "This is an account of a hospital where there was a club culture, an imbalance of power, with too much control in the hands of a few individuals. It is an account in which vulnerable children were not a priority, either in Bristol or throughout the NHS.
"The circumstances of Bristol and the NHS, at the time, led to the system for providing paediatric cardiac surgery being flawed. All these flaws, taken together, led to around one-third of all the children who underwent open-heart surgery receiving less than adequate care."
The inquiry has taken 2 1/2 years and has been the biggest investigation in the history of the Britain's NHS. It was ordered by the then Health Secretary, Mr Frank Dobson, in 1998 after the General Medical Council found Mr Wisheart and fellow surgeon Janardan Dhasmana guilty of serious professional misconduct in relation to 53 cases of child heart surgery, in which 29 patients died.
Mr Wisheart was struck off the medical register and Mr Dhasmana was prohibited from operating on children for three years. The hospital's chief executive, Dr John Roylance, was also found guilty of serious professional misconduct for failing to respond to concerns and was struck off the medical register.
Prof Kennedy's inquiry looked at the cases of more than 2,000 patients between 1984 and 1995. Many of the deaths occurred as the surgeons began performing a new "switch" operation on children with heart defects.
Death rates rose at all hospitals as the operation was introduced but while they levelled off in other areas, deaths at the Bristol Royal Infirmary remained high.