| Synopsis: |
This document presents the Government's response to the report of the Public Inquiry (CM 5207-I), into the management of children's heart surgery at the Bristol Royal Infirmary (BRI) between 1984 and 1995. The inquiry's report highlighted poor organization and communication, lack of leadership, paternalism and a "club culture" and a failure to put patients at the centre of care. It found that these problems were accompanied by general failings in performance standards and care assessments, at both the local level and across the NHS. These failures combined to create an unsafe environment for paediatric cardiac surgical care (PCS) in Bristol, which resulted in the unnecessary death of a number of very young children. The government agrees with the inquiry's analysis of the failures in organization and culture, not only at the BRI but in the wider NHS at that time. It accepts most of the recommendations made by the inquiry, which aim to advance the central notion of a patient-centred service, and address the need to establish a culture within the NHS of openness about mistakes and where safety is paramount.The document details the Government's programme of reforms to implement the recommendations, including: independent standard setting and inspection bodies; regulation and education of health care professionals; and policies to promote greater public involvement. |