1990 Dr Stephen Bolsin, consultant anaesthetist at Bristol Royal Infirmary, writes to chief executive Dr John Roylance raising concerns over the hospital's mortality levels in cardiac surgery.
Dr Roylance later tells the General Medical Council the letter said levels were only 'undesirable' in the context of the hospital's application for trust status, and 'this image of a festering discontent, an anxiety, about paediatric cardiac surgery extending over a period of five years and ignored by everybody, is a fiction'.
May 1992 Dr Phil Hammond uses one of his first anonymous columns for Private Eye to draw attention to BRI's reputation as 'the killing fields, ' and claims it has a mortality rate of 'between 20 and 30 per cent - 'hardly the stuff of commendations'.
1992 Heart surgeon James Wisheart is appointed medical director of United Bristol Healthcare trust.
July 1994 Dr Bolsin hands Dr Peter Doyle, Department of Health senior medical officer and secretary of the National Specialist Commissioning Services Advisory Group, a sealed envelope containing data about surgical outcomes at BRI. Dr Doyle does not open the envelope, later telling the inquiry: 'I did not have the skills or expertise to come to a judgement, ' but writes a strongly worded letter to professor of cardiothoracic surgery Gianni Angelini, saying the allegations should be investigated.
Dr Doyle receives a letter from Dr Roylance confirming 'this trust board's awareness of this problem'.
January 1995 A 'switch' operation goes ahead on 18-month old Joshua Loveday, despite 11th-hour concerns raised by Dr Bolsin and the DoH's Dr Doyle. Joshua is the last of nine children to die out of 13 given a 'switch' operation by Janardan Dhasmana.
1995 Dr Roylance retires.
1996 Parents write to the GMC asking for an investigation into the professional conduct of Mr Wisheart, Mr Dhasmana and Dr Roylance.Mr Wisheart suspends all surgery and steps down as medical director.
1997 Mr Wisheart retires.
June 1998 The GMC finds Mr Wisheart, Dr Roylance and Mr Dhasmana guilty of serious professional misconduct.Mr Wisheart and Dr Roylance are struck off, Mr Dhasmana is banned from operating on children for three years.Health secretary Frank Dobson orders a public inquiry, and promises a system of clinical governance, with a Commission for Health Improvement and National Institute for Clinical Excellence.
March 1999 Start of the public inquiry.
April 1999 The NHS introduces clinical governance, under which trust chief executives are held liable for for quality of care, as well as holding financial responsiblity.