For over a year, an unprepossessing office block on a thundering arterial road through Bristol has been home to the biggest and most public inquiry the National Health Service has ever known. Up its anonymously businesslike steps have streamed some of the most powerful people in medicine, along with disgraced doctors and families whose deep hurt at the death of their children has no chance of healing while the hearings continue.
This is the Bristol Royal Infirmary public inquiry, ordered by the health secretary in June last year after two children's heart surgeons, James Wisheart and Janardan Dhasmana, and the chief executive of the United Bristol Healthcare Trust, John Roylance, were disciplined by the General Medical Council. The GMC looked at the cases of 29 babies and toddlers who died in two separate open-heart operations and decided that the doctors should have realised the death rate was higher than in other hospitals and sent their small and very sick patients to units where they did the operations better.
The public inquiry was a response to the anguish of the parents. Any parent whose child died or was brain-damaged in or after heart surgery at the BRI in the late 80s or early 90s was desperate to know whether he or she could have been saved. Chaired by Ian Kennedy QC, the inquiry has the widest possible brief, investigating not only standards of care in all types of heart surgery in Bristol but also how Bristol compared with other hospitals and what organisation was in place to prevent standards badly slipping.
It will cost about £15m. About 100 witnesses have so far given evidence, while 339 witness statements and 226 comments on them have been received, with more to come. Some 674,000 pages of medical documents and 175,000 other pages have been scanned in as evidence. About 100 people have given oral evidence. In the new year, seminars of experts will discuss public sector performance and management culture. The proceedings are simultaneously relayed by video to three west country cities, while the transcript of each day's proceedings is put on the inquiry website each night.
The scale of the thing is phenomenal, but there are mutterings within the profession as to what will be achieved. It is becoming clear that the burden of blame for the poor performance in babies' open-heart surgery must be distributed across far more shoulders than those of the unfortunate trio who came before the GMC. But does it take a juggernaut of this description to run down that fairly obvious truth?
This week the inquiry is back in the news. In the witness seat whistle-blowing anaesthetist Stephen Bolsin has broken down over the deaths of babies who might have been saved had they gone elsewhere. Now the surgeons are taking centre stage, beginning with Dhasmana. They will be asked why they did not stop operating when they must have been aware they were not as good at some procedures as surgeons elsewhere.
The audience is bound to swell considerably, but for months this massive inquiry has been playing to a fairly empty house. Parents who felt sidelined by the GMC hearings and campaigned for the inquiry, and supporters of the surgeons turn up every day. But in the absence of newspaper, radio or TV reports, most people could be forgiven if they had forgotten that the inquiry is still going on.
Day after day, Brian Langstaff QC, counsel for the inquiry, has probed the actions, beliefs and motivation of the medical establishment which let the Bristol tragedy happen. It has become clear that many knew standards were not what they should be - particularly in heart surgery on babies under one year old - years before the scandal became public.
Many knew, but either shrugged off responsibility or hoped things would get better. Bolsin's view was that the surgeons were just not good enough at complex surgery on tiny hearts. They weren't fast enough, and babies spent too long on bypass machines. But if that was so, one of the reasons should have been glaringly obvious to everybody - they were not doing enough operations to become highly competent at them.
This worried some on the Supra Regional Services Advisory Group (SRSAG). The inquiry has heard evidence from past members of the group responsible for deciding which hospitals should be "designated" for open-heart surgery on children, attracting funding for that purpose from the department of health.
There was telling evidence from Sir Terence English, former president of the Royal College of Surgeons, who was a member of SRSAG from 1990 to 1992. In those two years, he said, they considered de-designating Bristol because they did not do enough operations. But without Bristol, children from the west country would have to travel to London or Birmingham for surgery. So SRSAG was willing to hope that more patients would be referred, from Wales for instance, and the surgeons would thus become more skilled with practice.
Still Sir Terence was worried, he said, and at the end of 1991 or beginning of 1992 he wrote a letter to Dr Norman Halliday, medical secretary of SRSAG, saying that he felt geography was not a sufficient reason to allow a hospital to be designated. In July 1992 he got a letter from Dr Halliday asking the college to review heart services for infants and neonates (babies under four weeks old). Halliday specifically asked for recommen dations from the college on whether some operations could be exempted from supra-regional status - so that babies would have to be sent elsewhere for them - and whether certain hospitals should be de-designated.
By that time, said Sir Terence, his personal feeling was that Bristol should be de-designated. Before the report went to SRSAG, Sir Terence received a letter from Dr John Zorab, medical director at Frenchay Hospital in Bristol, expressing serious concerns at the quality of children's heart surgery at the BRI.
Sir Terence spoke to Professor David Hamilton, the chairman of the group set up in the college to write the review, and they agreed to recommend that Bristol lose its designation. Halliday would inform SRSAG at its next meeting (which Sir Terence could not attend because he was on holiday). But before the meeting, Professor Hamilton and the review group changed their minds, deciding to leave Bristol untouched. Finally, at the meeting itself, the group decided to ignore the report and de-designate the whole service, so that children's heart surgery would be funded according to patient numbers in the normal way.
What this episode suggests is that mechanisms in place to stop standards slipping were at best flaky - and that those at the top of the profession could not agree what to do for the best. Sir Alan Langlands, head of the NHS Executive, told the inquiry that after 1991, with the reforms to set up trusts, there was confusion over roles and responsibilities for the delivery of care. Should the department of health have intervened? Dr Peter Doyle, one of its senior medical officers, suggested that it was the local health authority, not government, which was responsible for standards at that time.
And so it goes on, with nobody willing to accept the blame. The inquiry is revealing about the way the medical establishment used to work; but in a way, none of that matters. The Bristol scandal was the catalyst and justification for major reforms in the way the profession is monitored and policed. It has allowed the government to bring in clinical governance, audits of doctors' results, appraisals and inspections, with hardly a murmur from a profession that used to pride itself on its independence.
Ian Kennedy's report next autumn may recommend more radical changes, but the longer and more impressive the inquiry is, the better the government will be pleased - because with Bristol in the public eye, nobody is going to argue with health secretary Alan Milburn's agenda.
But what about the parents who fought for the inquiry? They may in the end be satisfied that they know what went wrong. But there will never be the answers each parent really wants. The inquiry is not there to investigate each individual case; over 200 families have contacted solicitors. At the end of the day, there are bound to be many who still do not know whether their child really should not have died.
