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When a major failure happens in a healthcare organisation in the British NHS an inquiry of some kind usually ensues, tasked with finding out what happened, diagnosing the problems or causes of the failure, and making recommendations for changes in policy or practice which would prevent or make such a failure less likely in the future.1 The inquiry is akin to an organisational post-mortem, intended to move beyond a simple description of the symptoms and effects of the failure and to provide a more insightful analysis of its pathology and aetiology. While the symptoms of failure are often clinical in nature—poor standards of care, avoidable mortality and morbidity, distressed patients and their families, and so on—the pathology of failure is usually organisational, concerned with things such as organisational leadership, management structures and systems, organisational culture, interprofessional relationships and teamwork. This paper presents an analysis of a recent and tragic example of failure at an acute hospital in the south west of England, and explores what lessons it offers for those involved in quality improvement and clinical governance in health care.
Events at the Bristol Royal Infirmary
The Bristol Royal Infirmary is a renowned hospital with a long and distinguished history. It has served the healthcare needs of people in Bristol and the south west of England for over 270 years and is a national and international centre for clinical research and innovation. Regrettably, its name is probably now best recognised in the UK and elsewhere for a tragic sequence of events in paediatric cardiac surgery in the late 1980s and early 1990s in which many young children lost their lives (box 1).
In the late 1980s some clinical staff at the Bristol Royal Infirmary, particularly a recently appointed consultant anaesthetist named Stephen Bolsin, began to raise concerns about the quality of paediatric cardiac surgery undertaken …
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