news focus: The Bristol inquiry report was measured in tone - even bland - but it still provoked a colourful press response.The facts, Lyn Whitfield reports, may not have been as simplistic as the headlines but they were just as shocking

Predictably, babies dominated the papers last Thursday - although chancellor Gordon Brown's knocked the Bristol tragedy off the front of at least half the tabloids.

But reporting of the inquiry report was at odds with the tone of the document. For the report is actually measured to the point of blandness. One criticism of former United Bristol Healthcare trust chief executive Dr John Roylance is that he 'lacked awareness of and insight into the potentially negative effects [of] his 'silo' style of management'.

Inquiry chair Professor Ian Kennedy told journalists that:

'When blame and critical comment are called for, we have not shrunk from it.

'But we have not elevated it into a virtue, such that the force and strength of the report could only really be measured by the extent and scale of the criticisms.'

So the report does not say, as The Sun had it, that 'useless surgeons covered up failures'. What it does say is that Bristol Royal Infirmary should probably never have been designated as a supra-regional centre for paediatric cardiac surgery. Its surgeons were inexperienced and no visits were made to see what it had to offer.

Its designation in 1984 was 'made on the basis of geography' and the hope, Sir Terence English, former president of the Royal College of Surgeons, told the inquiry, that it 'had the capacity to develop - if the will was there'.

Unfortunately, as Professor Kennedy said last week, Bristol 'was simply not up to the task. [It] was not a place in which paediatric cardiac surgery could thrive and, sadly, it did not'.

One problem was split-site working. The infirmary had no dedicated paediatric intensive care beds and 'the intensive care unit was poorly managed'.

Furthermore, the infirmary was run down. Professor Kennedy's report, Learning from Bristol, says the inquiry team was 'shocked' by the 'sense of dilapidation'when in July 1999 it visited sections of the hospital involved in the tragedy.

'Our overall, lasting impression was that wards 5A and 5B were cramped, overcrowded, overheated, dirty and neglected. It was a tribute to the staff that they were prepared to work there.'

In addition, the inquiry heard there were critical shortages of staff and money. Paediatric cardiac surgery 'had a low priority in the everlasting struggle for funds', and paper policies to end split-site working were 'thwarted by lack of capital funding'.

And the individuals working within the system were struggling.

The report says that James Wisheart - struck off by the General Medical Council in 1998 - 'believed that outcomes would improve as his experience improved' but he should have 'recognised his own lack of objectivity' and 'instituted some check' on his results.

It is less critical of Janardan Dhasmana, currently suspended by the GMC from performing surgery on children, and only able to perform surgery on adults under supervision. The inquiry says he stopped operating when his results failed to improve.

Who should have spotted it?

The inquiry asked who was responsible from outside the trust for picking up the problems at Bristol and taking action.It concludes that nobody was.As health secretary Alan Milburn put it: 'We cannot say that the external system for assuring and monitoring the quality of care was inadequate - there was, in truth, no such system.'

But the report criticises the actions of Dr Norman Pryde Halliday, former medical secretary of the supraregional services advisory group, who 'was in error'to discount information passed on to him that suggested poor performance back in the late 1980s.

It says it is 'unfortunate'that Sir Terence English 'did not advise'the SRSAG (of which he was a member) 'that he was concerned about poor outcomes'- except informally.

And it says it was a 'seriously inappropriate response'for Dr Peter Doyle, a Department of Health senior medical officer, to put a dossier of evidence he was given by consultant anaesthetist Dr Stephen Bolsin in July 1994 into a filing cabinet without reading it.Dr Doyle, who continues to work at the Department of Health, is on leave and his position is to be reviewed when he returns.

What of the whistleblower?

Dr Stephen Bolsin is not 'lionised'in the report in the way he has been 'by those critical of the [paediatric cardiac service]'.

The report describes an approach Dr Bolsin made to Dr John Roylance about concerns over death rates in 1990 as 'oblique'- Dr Roylance thought it was about trust status - and says it 'antagonised both senior management and senior medical figures at an early stage'.

It also says that although it was obviously difficult to approach Mr Wisheart 'it is less clear why [Dr Bolsin] did not approach Mr Dhasmana'.In short, his actions 'may not always have been the wisest'although he 'persisted and was right to do so'.

Managing disaster: divide and rule coupled with a lack of strategic vision If the surgeons were 'too ambitious'then management at Bristol was 'flawed'.

Professor Kennedy paints a mixed picture of former chief executive Dr John Roylance (left), who began work in Bristol in 1963.He was one of only 15 clinicians to be appointed to a district general manager post during the Griffiths reforms and he 'provided a valuable element of continuity during the transition to trust status'.He was 'equipped to develop a management system built on clinical directorates', which was 'not unusual at the time'.But the report says Dr Roylance lacked strategic vision and allowed the directorates to become 'isolated from each other'.This 'silo effect'made it difficult for managers to learn of problems, and even when they did, the 'club culture'at Bristol made it nearly impossible to call attention to them.

'The most dangerous management style of all is that of the exercise of power without strategic vision, accompanied by 'divide and rule''it concludes.'Dr Roylance's style of management could be so characterised.'

Yet the report suggests that a managerial approach which 'could be categorised as wilful blindness'might be justified by trends in management at the time.

'If, by seeming to insist that clinicians solved problems for themselves, he empowered doctors to get on with looking after patients, it was clearly reasonable.

Moreover, it was entirely within the spirit of the reforms proposed by the Griffiths repor t.'

Indeed, asked whether he blamed the Griffiths report for the culture behind the tragedy, Professor Kennedy agreed that the failure to properly implement the Griffiths reforms had some part to play in giving power without the training in how to use it.

'The Griffiths report was an important and seminal report.In my view, it worked towards the involvement of clinicians in the management of hospitals.The problem was that it was not properly supported.There was. . . very little in the way of training for clinicians taking on such a role.That wasn't the way to manage it - that was quite wrong, but that wasn't a fault of the report.'

And the report implies that Dr Roylance's managerial failures should not have been taken into account when he was struck off by the GMC in 1998.'We are aware that Dr Roylance was also a doctor.We do not, however, regard this fact alone as warranting an assumption of responsibility for the care of every child admitted to the United Bristol Healthcare trust. . . To this extent, it follows that we do not agree with the decision of the Privy Council in Roylance v GMC, to the extent that it decides otherwise.'

Professor Kennedy told HSJ it was 'just too onerous'for a nurse or doctor who moved into management to continue to hold their clinical responsibilities.

The Bristol report also criticises the way power at UBHT was concentrated in the hands of too few people, including Dr Roylance's 'adjutant', Margaret Maisey, (trust director of operations and nursing adviser) and Mr Wisheart (who was also medical and clinical director).It says nursing staff were 'let down'by Mrs Maisey, the self-proclaimed 'Rottweiler of the trust', while Mr Wisheart's management style was 'autocratic'.