Health Check: Why the Bristol babies died

I STOOD with about 400 others in the dank Bristol Council House last week remembering the Bristol babies. It was raining, the light was grey, and a few people were quietly crying. Professor Ian Kennedy, chairman of the public inquiry into the heart surgery disaster, had asked for a moment's silence before beginning what he admitted would be a harrowing investigation into what went wrong with children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995.

It was a deft performance which showed the professor of health law and ethics at University College, London, to be sensitive to the human as well as the intellectual issues. Yet some question the wisdom of holding this inquiry, after an emotive eight-month General Medical Council hearing which ended with findings of guilt against three doctors, and a flurry of activity by the Government and medical organisations aimed at imposing tougher checks on doctors. They fear that rival camps will try to apportion or deflect blame. What can the inquiry uncover that has not already come out?

The answer is a great deal. Babies with complex heart problems who had surgery at the Bristol Royal Infirmary in the late 1980s and early 1990s died when they might have been saved had they been operated on elsewhere. Or would they? Are doctors in other hospitals sending patients with other conditions to their deaths? The GMC inquiry focused on the role of the two surgeons and the former chief executive. The narrow remit was necessary because the GMC works like a criminal court. The public inquiry will take a wider view and try to peer behind the cloak of secrecy that shrouded events at Bristol. In doing so it will hope to shine a light on what Sir Donald Irvine, president of the GMC, has described as the "defensive, protective, inward-looking, culture" in which doctors work.

The Bristol tragedy is not about individual surgeons making errors. It is about a hospital suffering from an "institutional malaise". Professor Rudolf Klein, who has written the best account of the case in Health Care UK, published last week, describes it as an "introverted and complacent institution" dominated by a number of long established consultants who were reluctant to question each others' performance.

It was not only individuals who kept silent. Warnings were ignored by the hospital's board, the regional health authority, the Royal College of Surgeons and the Department of Health. And there was another force at work, dubbed "institutional imperialism" by Professor Klein. Why did the hospital get involved in complex heart operations? The answer seems to be that as a prestigious teaching hospital, it was determined to become a major player in the field - and it collected grants of at least pounds 2 million to develop the service.

We will have to wait until well into 2000 for Professor Kennedy's report. But an almost identical inquiry into the deaths of children following heart surgery in Canada which concluded taking evidence last month gives a clue to what he may find. Professor Jan Davies, a consultant anaesthetist from Calgary and an expert witness in the case, said: "Most doctors try to do their best. They don't go into the operating theatre and say `I'm going to kill someone today'. Often it is the system that impedes them. We must stop pointing the finger and look at fixing the system. Otherwise patients will go on being injured and dying."