Bristol Infirmary Inquiry: Healthcare Safety and Quality Case Study

This assignment presents a case study analysis of the Bristol Inquiry, which investigated failures in cardiac surgery at Bristol Royal Infirmary and Bristol Royal Hospital. The inquiry, initiated due to numerous deaths among children with congenital heart diseases, revealed critical issues such as poor monitoring, a deficient management system, and a lack of prioritization for very sick children. The hospital demonstrated a lack of transparency in disclosing information to parents and stakeholders, contributing to a loss of trust. Incompetent healthcare professionals, characterized by a lack of teamwork and leadership, further exacerbated the problems, alongside poor service offerings and inadequate staffing. The assignment summarizes the inquiry's findings, highlighting the systemic failures and their devastating outcomes, while referencing key sources that informed the investigation.

HEALTH CARE SAFETY AND
QUALITY- BRISTOL
Introduction Findings and outcomes
• Following numerous failures in cardiac surgery among children
and adults with congenital heart diseases (in which half of the
babies born with this complication need much attention for them
to survive) in Bristol Royal Infirmary and Bristol Royal Hospital,
the secretary of state for Health announced that an inquiry be
conducted to establish specific causes, action taken, and
recommend the best solution to be adopted (Billett et al,. 2008).
• Bristol Royal Infirmary and Hospitals were teaching hospitals
associated with Bristol University Medical School.
• The two centres were among the few centres that Department of
Health and Social Security had centralized funding of Paediatric
Cardiac Surgeries to children under the age of 1 year.
• They dealt in both open and closed heart surgeries that failed
frequently even after some recommendations were put in place
like not to carry open heart surgeries and appointment of a
paediatric cardiac surgeon to operate only on children. This led to
public and professionals who worked in the unit raising a lot of
complains hence the formation of an inquiry team chaired by
Professor Ian Kennedy and other three members (Aylin et al.,
2001).
• It took the inquiry team three years between 1998 and 2001 to
come up with a report about the findings and recommendations.
The team divided its work into two parts in which the first part
investigated the current situation and the second part research was
all about the future (what should be done in future to avoid such
incident from occurring again)
The following is a list of the findings and outcomes that
were discovered by the inquiry team during their
research:
 Poor monitoring. It was found that there was no single
mechanism that was used to monitor the performance of the
paediatric cardiac surgeons. Due to lack of close monitoring,
they just worked to enjoy themselves for example in the case of
two surgeons who were found guilty after follow ups were made.
There was no one who was concerned with healthcare standards
since they assumed the more you do the more experienced you
become. This led to paediatricians focusing on quantity rather
than quality.
 Poor management system. The kind of system that was used to
manage Bristol’s activities was very poor in that when a concern
was raised, no matter how urgent it is, it took a lot of time to be
responded to. This is a fact from balancing of power in Bristol
where operations were controlled by few individuals. This
compromised efficiency of operations in the units thus impacting
the hospital negatively.
 Priority of very sick children. One thing Bristol never payed
attention to was priority of the children who were very sick.
They just took them as normal patients. By so doing, about 35
children died between 1991 and 1995 after they were operated
open heart surgery. Even though it was recommended that a
paediatrician be appointed to operate on children, it took years
for it to be implemented. Also the safety of the sick children was
not guaranteed.

HEALTH CARE SAFETY AND
QUALITY- BRISTOL CONT…
Findings and outcomes cont…
 No openness to information. The hospital new that there was
a problem but still it never shared this to parents and
concerned stakeholders. It knew that children were dying but
were not willing to disclose this to parent. Hiding this
information led to parents trusting in them yet the kind of
services they offered was poor. If parents could access such
information, they could have opted to seek help elsewhere
making Bristol lose customers.
 Incompetent healthcare professionals. They lacked insights
and their behaviour was flawless in that they lacked
teamwork and leadership. They were poorly organized since
they discovered that there is no one who was keeping a record
of their works hence not accountable to anyone.
 Poor service offering. Bristol was split into two units with few
beds and trained healthcare nurses. There was no dedicated
paediatrician in charge of both open and closed heart
surgeries that were done in the two sites. Also there was less
manpower in the facility to handle sick children (Weick and
Sutcliffe, 2003).
References
Aylin, P., Alves, B., Best, N., Cook, A., Elliott, P., Evans, S. J., ... & Spieǵelhalter, D. (2001). Comparison of UK paediatric cardiac surgical
performance by analysis of routinely collected data 1984–96: was Bristol an outlier?. The Lancet, 358(9277), 181-187.
Billett, J., Cowie, M. R., Gatzoulis, M. A., Muhll, I. V., & Majeed, A. (2008). Comorbidity, healthcare utilisation and process of care measures in
patients with congenital heart disease in the UK: cross-sectional, population-based study with case–control analysis. Heart, 94(9), 1194-1199.
Weick, K. E., & Sutcliffe, K. M. (2003). Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary. California Management
Review, 45(2), 73-84.
Conclusion
The presentation starts with an introduction which gives us a
picture of the situation at two hospitals that deal with sick
children. The hospitals serve people from South West of
England and South wells. There has been a lot of failures for
a long period as many children have died from the surgeries
performed in the hospitals. The failures raise State’s health
secretary concern who call for an inquiry into the issue. The
second part oversees findings that were discovered by the
team of inquiry assigned the task of investigating the issue
together with the possible outcomes that resulted from the
findings.