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Independent review to be held into Bristol paediatric cardiac unit

An independent review is to be held into a hospital’s paediatric cardiac unit following concern about its treatment of newborn babies and young children who died or suffered complications.

Professor Sir Bruce Keogh, medical director of NHS England, confirmed the inquiry will take place at Bristol Children’s Hospital, which is accused of a catalogue of neglect and mistreatment of babies and children with heart problems.

He said Sir Ian Kennedy, a lawyer who specialises in the law and ethics of healthcare, has agreed in principle to oversee the review.

Sir Bruce said in a statement: “We have today had a very important meeting with the families of children who died at Bristol.

“My deputy medical director Mike Bewick and I have listened with great care to their concerns about the care their children received.

“I would like to thank them for the dignified and powerful way they have talked to us.

Sir Bruce Keogh

“We collectively concluded that the most effective course of action might be to put in place an independent review of the care at the trust’s paediatric cardiac unit.

“It was clear that, in the interests of everyone, such a review would need to be independent of the NHS. It must be led by the families involved. It must be their review.

“I have already taken soundings from Sir Ian Kennedy who has agreed in principle to take such a review forward should the families wish him to do. I will now ask Sir Ian to meet the families and to work with them to see if they can come to the scope and terms of reference that the families want.”

Last year it emerged around 10 families were believed to be taking legal action against the trust, including seven whose children died following treatment at the hospital.

Ian Kennedy

Ian Kennedy

Previously some had spoken out about the ”inept care” of the young patients and called for a public inquiry into what they considered to be ”chronically low standards”.

Among parents that have complained are Steve and Yolanda Turner, whose son Sean Turner died in March 2012 from a brain haemorrhage after previously suffering a cardiac arrest - six weeks after he underwent vital corrective heart surgery at the hospital.

Just last month at an inquest into his death they gave harrowing accounts of how they begged doctors and nurses on Ward 32 to help their desperately ill son.

Mr and Mrs Turner, from Warminster, Wiltshire, claim their son’s death was not isolated and other children with heart problems have died at the hospital.

They claim ward hygiene was poor, staff were incompetent and that Sean was neglected to the point where he had an avoidable cardiac arrest.

They came forward publicly after being struck by the similarities of Sean’s death to an earlier tragedy. Cardiff youngster Luke Jenkins, seven, was expected to make a full recovery after successful corrective surgery at the hospital, but died after suffering a cardiac arrest on a bank holiday within a week of his operation.

His heart stopped for 43 minutes before he was resuscitated, after which he underwent exploratory surgery. He died the following day.

His death in April 2012 was due in part to the duty surgeon having to be urgently called in from home on Good Friday when Luke collapsed, something admitted by hospital bosses.

Junior nursing staff lost vital time because they did not know where resuscitation equipment was kept, it later emerged.

The emergency team was also unfamiliar with the equipment because cardiac arrest was rare in the ward environment, the hospital claimed.

In both cases the children were transferred from the intensive care unit to Ward 32 too rapidly, according to their parents.

Both sets of relatives believe that, but for substandard after-surgery care on the ward, their children would be alive.

Both claim that once on the ward they were increasingly anxious at the reduced level of care they felt their children received.

But they said that in both cases rising concerns were dismissed by ward staff who appeared too busy and too few to care properly for patients.

A spokesman for University Hospitals Bristol Foundation Trust said it welcomed the review and hoped it would “restore trust and confidence in the service, which has learnt much from the experiences of these families”.

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Readers' comments (5)

  • Putting aside the CQC inspection visit in 2012 and the corner's inquests of 2013 and 2014 the fact of the matter is that the hospital did not operate a step up/step down High dependency Unit between ITU and Ward 32, parents were not listened to when they raised concerns,
    Guidelines by BACCN and RCN exist so hopefully the inquiry will ask the management of UBHT why there was a disregard for these guidelines.
    Questions need to be also asked of the Council of Governors as to why the children and their parents were not given the best possible care available as required by the best evidence practice/guidelines

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  • Basically this sounds like best practise was ignored, staffing levels and skill mix were not what they should be, and deterioration in the patients condition was not recognised quickly enough. Same old same old unfortunately.

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  • Have people forgot that the whole way Paediatric Cardiac surgery takes place in the UK today, is because of the shambles of Bristol back in the late 80's and 90's. But here we are again with the same hospital royally screwing everything up yet again. No lessons learned then!

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  • "In both cases the children were transferred from the intensive care unit to Ward 32 too rapidly, according to their parents"

    And here was I thinking that people with appropriate medical qualifications/experience and an understanding of priorities of care were the ones who should make the difficult decisions regarding when to transfer from ITU.

    I'm sure there will be lessons to be learned and where poor performance or sub-standard care is evident, I hope that corrective measures are put into place - It is clearly an emotive topic and the death of a child (however ill they may have been) is NEVER going to be easy to accept, but I think it is unfair to presume that the care was inadequate and led directly to the awful outcomes, until an independent and unbiased review of the service provided has been undertaken.

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  • In response to Anonymous 18th Feb 3:42 pm

    With the greatest of respect tell that to the parents of children who died, it is fair to say that being provided with care on a HDU with a patient to nurse ratio of 2:1 instead of 5:1 is more favourably to outcomes atfer be stepped down from ITU, THESE ARE GUIDELINES from BACCN/RCN, SHOULD Patients and parents expect any the less.

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