(Circulation. 2001;104:e9014.)
© 2001 American Heart Association, Inc.
Bristol Scandal
In 1998, the British medical regulatory body, the General Medical Council, severely disciplined 3 doctors after inquiring into the deaths of 29 infants and children at Bristol Royal Infirmary. The deaths had resulted from open-heart operations for atrioventricular septal defect or transposition of the great arteries. According to the Council’s adjudication, the 2 surgeons had continued to operate when their mortality rates were too high, and the medical chief executive, despite ample cause for alarm, had failed in his duty to intervene; the doctors left the hearing to cries of "murderer."
The "Bristol scandal" generated enormous outrage and, since 1998, a public inquiry has been in progress under the chairmanship of Professor Ian Kennedy, a lawyer. His report, which has now been published (www.bristol-inquiry.org.uk/final_report), tells the story of an enterprise that began with high aspirations but failed to keep up with developments elsewhere; between 1988 and 1994, the mortality rate for open-heart surgery in children younger than 1 year at Bristol Royal Infirmary was about double that in England as a whole. Despite local expressions of concern and even adverse comment in the media, the surgeons pressed on, hoping for better things. No formal system existed for monitoring their work, and the chief executive chose to ignore the increasing unease of other clinicians. The program was suspended in 1995 when an infant died after a particularly controversial operation. Between 1991 and 1995, according to a statistical analysis conducted for the inquiry, 
30 to 35 children younger than 1 year died