Parents of children having heart surgery at Bristol hospital “were let down”

Babies and children who were treated for congenital heart problems at Bristol Royal Hospital for Children were put at “a clear risk of harm” on a ward staffed by too few nurses, an independent review has concluded.1

Bruce Keogh, medical director of NHS England, set up the “Bristol Review,” chaired by Eleanor Grey QC, to consider the safety and quality of children’s cardiac services in Bristol from March 2010. The review was launched in June 2014 after pressure from parents who believed that their children may have died unnecessarily after treatment at the hospital.

A large percentage of the patients on ward 32, to which children were admitted from intensive care, were babies or very young children with heart conditions, and the review found that “nursing numbers would have fallen below the recommended levels on a reasonably frequent basis.” It continued, “Further, heavy reliance on bank and agency nurses to maintain staffing levels is not consistent with providing an appropriate quality of care.”

The children’s hospital was built after a public inquiry, chaired by Ian Kennedy, reported in 2001 that between 30 and 35 children had died needlessly as a result of systemic failures in children’s heart surgery services at Bristol Royal Infirmary in the 1990s.

But 15 years later the new review, to which Kennedy was a consultant, has “reached the firm conclusion that there was no evidence to suggest that there were failures in care and treatment of the nature that were identified in the Bristol public inquiry of 1998-2001. The outcomes of care at the children’s hospital were broadly comparable with those of other centres caring for children with congenital heart disease.

“There was evidence that children and families were well looked after and were satisfied with the care their children received. There was, however, also evidence that, on a number of occasions, the care was less good and that parents were let down.”

In October 2012 the Care Quality Commission issued a formal warning to University Hospitals Bristol NHS Foundation Trust, which runs the children’s hospital, that it faced enforcement action unless it improved ward staffing levels. The commission found that “high dependency care was being delivered on Ward 32 without adequate staffing levels over a sustained period of time.”

The trust reduced the number of beds on the ward and created two high dependency beds in the intensive care unit. Another CQC inspection in November 2012 found that there were enough qualified, skilled, and experienced staff to meet children’s needs.

The review concluded that senior managers had failed to respond effectively to parents’ concerns and adopted an “unnecessarily defensive position,” leading to a “deeply regrettable breakdown in communication.”

Trust chief executive Robert Woolley said, “We are deeply sorry for the things we got wrong—for when our care fell below acceptable standards, for not supporting some families as well as we could have, and for not always learning adequately from our mistakes.”

The review made 32 recommendations for action by the children’s hospital, NHS England, and the Department of Health, ranging from reviewing staffing levels to better communication with parents and a nationwide review of paediatric intensive care units.

NHS England pledged “to take action to ensure a consistent level of care is available for every patient in every part of the country,” and to unveil an action plan in early July.