Bristol Royal Infirmary Enquiry

Learning from our mistakes: Clinical Governance and the Bristol Royal Infirmary Enquiry 12th October 2001


The aims of the Conference were to identify the crucial issues which arise from a series of disasters in the NHS which have compromised public faith in the quality of care provided and to identify the way in which lay people can participate in decision making about clinical governance and quality assurance.

Report of the conference by Andrew Manasse

1. Lessons for Clinical Governance from the Bristol Royal Infirmary. Dr Kieran Walshe, Senior Research Fellow, Health Services Management Centre, University of Birmingham.

Dr Walshe spoke about Quality Improvement. He started with a brief history of the events at BRI with regard to paediatric cardiac surgery and then addressed the issues of lessons to be learned.

Context: Nationally there was little formal assessing of quality before 1985. One of the earliest initiatives was ‘What sort of Doctor?’ from the RCGP. In 1989 Medical Audit was introduced and this underwent a series of developments culminating in Clinical Governance in 1997.

Experience at Bristol during this period: There was nothing in the audit reports to indicate that there were any problems. (Dog that didn’t bark: Conan Doyle). In fact the audit activity diminished as the problems increased.

Why the (audit) system did not work there:

Leadership: Passive, traditional doctor to doctor; little power; no links to management; focus on conciliation, support and advice. Those on the committee were also involved protagonists (interested parties).

Resources: Adequate – in fact lots. ? where did it go? ?wasted? No records of how used etc.

Methods and Process: Traditional – numerous interests – but not related to quality. Much irrelevant activity. Some directorates were good but there was no mechanism for spreading good practice within the hospital.

Confidentiality/Secrecy: Restrictive. It was a barrier. UBHT was uncooperative and, in fact, produced no reports.

Monitoring and reporting: Monitoring regular – but did not work. No returns. No pursuit of non returns. Information gathered not used. RHA realised this and reported on it.


  • Need for strong clinical leadership – a very difficult job
  • Need for clear corporate responsibility and central corporate function i.e. ownership – being responsible.
  • Need for wise (appropriate) resource use. (definition of priorities etc.)
  • Need to monitor progress

Concluding comments:

Quality of ( audit/clinical governance) programme is related to quality of the organisation and is a good marker of wider organisational health or Quality improvement holds up a mirror to the organisation.

2. The Challenge of Accountability Donna Covey, Chief Executive ACHCEW

Donna Covey

Points from her talk:

In relation to the NHS there are 3 types of stakeholder relationship:

  • Users
  • Tax payers
  • Voters

Good accountability leads to better services. NB re Expert patients: Expert with regard to illness etc. but also expert with regard to local community needs. She referred at length to the Kennedy Report and noted that the Govt. was mis/ab-using some of the recommendations. She spoke about the present discussion document about involving patients, said it was an improvement on the NHS Plan but at the focus was the wrong way round: See Para1.5 -emphasis on replacing CHCs and going on from there rather than on starting from scratch with the emphasis on defining what is actually needed.

In this context, ACHCEW criteria for any new structures must:

  • Be Independent and seen to be independent
  • Have statutory powers and adequate financing
  • Be accessible: CHCs are a one-stop shop and this ids very important
  • Be integrated – work together. e.g. patients’ forums within the same area/city etc.
  • Be accountable to lay people at all points

Here she compared the Govt. proposals in this context to the Kennedy Report and commenting on the present document noted:

  • A 6 week discussion period compared with the normal 3 months for even far less significant changes. [NB Kennedy: ‘A fait accompli gives rise to dissociation and cynicism’].
  • No lay involvement above patient forum level and these are within the Trusts. ‘Voices’ ? no lay involvement – seems to have no teeth and be a talking shop. Local ‘Voices’ are not local – they are at strategic HA level – a huge area.
  • Lack of integration e.g. between local patients forums. Confusing for patients: where to go? etc.
  • No mechanism for continuous scrutiny.
  • Local Authority Scrutiny currently set up to cherry pick issue on a regular basis when what is needed is the facility for continuous scrutiny including inspection/visiting rights.

NB Importance of (independent) Lay involvement outside the system – as made clear in the Kennedy Report and misinterpreted in the Govt. document.

One of the measures of any system is: How do the patients know where to go for their needs, questions etc.? (Mrs Archibald test).

3. Managing cultural change 1 Guy Routh, NHS Consultants Association.

NHS Consultants Association, of which he is chair, represents about 2% of consultants and is at the pro NHS liberal end of the spectrum of views. BUT it was important to realise that political/social views do not determine performance.

50% of consultants are = to or < average in their performance. It is nonsense for people or the media to expect all consultants to be above average!!!

He spoke about the culture of the NHS in the context of managing change.

  1. Tribalism: e.g. doctors; nurses; porters etc., OR clinical teams. Criticism strengthens tribalism and makes for defensiveness.
  2. Hierarchy of power: Consultants are the most powerful tribe. Also, the consultant is the most powerful member of any group.
  3. Resource shortage: Fighting for resources unites the tribe Resource shortage is also an excuse for poor performance.

At Bristol in 1984 management was the problem; in 1995 market forces were paramount. It is important to recognise and include business drivers and needs into any equation about change and quality.

He felt that the Kennedy Report was a good report which did fairly reflect the situation as it was. He had surveyed all his local consultants about the 198 recommendations and most were in favour of most of them.

There were reservations over only 14 of them of which most concerned

  1. Tape recording consultations and giving patients a copy of the consultant’s letter
  2. Making information about quality of care available (?related to league tables and morale)
  3. Supervision of doctors carrying out a procedure for the first time.

Good points included

  1. i. A single body for regulation and for quality
  2. ii. Revision of distinction awards.

He noted that 5 things may happen to consultants who do not function properly

  1. Local disciplinary action
  2. (Very) Public GMC challenge
  3. Risk of criminal prosecution
  4. Civil prosecution
  5. Trial by media (much more than happens with normal civil or criminal cases)

Points in relation to Management of Change:

  • Necessary to recognise that change is needed
  • It is not possible, long term, to make people do what they do not want to do
  • Delegation is necessary and needs to be appropriate
  • Essential to work within budgets and to have a little over (as a sweetener)

To achieve change it is necessary to

  1. Identify the real problems
  2. Enable others to recognise the problems and therefore the need for change/action.
  3. Identify and support champions of change.
  4. No public confrontation otherwise the tribes just close up.

4. Managing cultural change 2 Maria Shortis, Director of Constructive Dialogue for Clinical Accountability (CDCA).

Maria Shortis

She spoke from her experience of having had an infant at Bristol early on in the period under question. Her experience showed her that one of the main issues was consultant communication failure and that others included indifference and complacency. Following this, she founded Constructive Dialogue for Clinical Accountability. She had been an NHS catering manager and had considerable experience of the management of change.

‘What is needed to implement the Kennedy Report is a change of culture in the NHS’

CDCA is a charity on which are parents, health professionals and members of the public. The mission statement is concerned with creating a constructive dialogue between health care professionals, building trust, enabling working in partnership and two-way communication between patients/carers and health professionals.

Key objectives:

  • Balanced patient/clinical relationship including mutual respect (difficult)
  • Patient safety and clinical excellence
  • Clinical audit on the internet:
  • Other issues: risk management, communication skills training, active partnerships

Much of this is to be found in the Kennedy Report

Workshops Changing hospital culture: What is needed

The group consisted of 15 people lead by a hospital consultant. Points:

  • Putting patients first
  • Respect: them and us
  • Equal partnership
  • Welcome complaints (i.e. an opportunity not a threat)
  • No-blame culture – admission of failure.
  • Important relevant issues:
  • Personal responsibility
  • Corporate responsibility
  • (problems arising from) Top down pressure from Govt.

5. Learning and applying the lessons at the coal face. Nick Bishop, Medical Director UBHT.

The Kennedy Report: Openness and transparency in all the NHS does.

Patient information.

Clearly understood systems of responsibility and accountability

No-blame culture essential

He then highlighted a few of the recommendations:

43. Provision of time, space and tools to do the job. Consultants work on average 55 hrs./wk. and are paid for 35 – 38 hrs./wk.

26. Informed consent. The difficulties involved in this at times in relation to what patients want and appropriateness of describing all risks etc.

57. Training health care professionals:

  • Communication with patients and colleagues
  • Organisational and management skills and information
  • Teamwork
  • Shared learning across professional boundaries
  • Clinical audit and reflective practice
  • Leadership



  • Good management is as important as good doctoring
  • Pay is an issue all round: % of GDP too low for expectations
  • ?Measurability of ‘feel good’ aspects of a culture
  • Shared professional training
  • Need (for all) to accept honest failure.

It was a good honest meeting. There were a number of CHC chief officers and a range of others. There were many good points in amongst all the words although many of them are not new to members of Sheffield CHC.

Andrew Manasse 17th October 2001

BMA statement on improved regulatory systems

Enquiry website