Key figures who played a management and supervisory role in paediatric care at Bristol Royal Infirmary were bracing themselves for a damning report as HSJ went to press.

The public inquiry, chaired by Professor Ian Kennedy, was due to publish its findings yesterday, bringing to an end its three-year inquiry. Its report was expected to criticise former chief executive Dr John Roylance and cardiac surgeon James Wisheart, both struck off two years ago, and surgeon Janardan Dhasmana, currently banned from performing surgery on children.

But given the inquiry's broad remit, it was sure to pay close attention to systems failures across the trust and the wider NHS, which meant poor performance went unchecked, and successive attempts to expose high death rates failed. High-level failures to properly supervise performance at the trust and ambiguities about where responsibility for clinical failure lay nationally emerged during the hearings.

The inquiry took evidence from Dr Norman Pryde Halliday, medical secretary of the supraregional services advisory group until 1994, Catherine Hawkins, former regional general manager of South West regional health authority, Sir Terence English, former president of the Royal College of Surgeons, and Sir Kenneth Calman, former chief medical officer, on the issue of who should have taken action over the trust's high death rates.

Dr Halliday told the inquiry that, before the Conservative government reforms, responsibility for picking up concerns lay with health authorities. After the reforms there was 'some ambiguity', but responsibility probably lay with the Department of Health unit in charge of trusts, he said.He denied that responsibility for quality lay with the services advisory group, arguing that it had a funding role with no responsibility for collecting outcome data. Dr Halliday also denied that Sir Terence had warned him in 1992 that outcomes at Bristol were so poor it should be de-designated.

But Sir Kenneth said responsibility did lie with the advisory group, as did Ms Hawkins, who described Bristol as a 'rumbling appendix' but said she never had enough evidence to act.

On Monday health secretary Alan Milburn met representatives from Bristol Heart Children's Action Group to ask what he could say to the House of Commons that could give comfort to bereaved parents. BHCAG said: 'The health secretary must acknowledge the sheer commitment of the parents in bringing this to the public's attention.'They told Mr Milburn that they 'never wanted to see an operation which resulted in brain damage being referred to as a successful outcome'.

Official figures released days before the report showed death rates among babies under one year old were nearly twice as high at BRI as at other cardiac centres between 1991 and 1995. The paper, drawn up by Dr Paul Aylin of Imperial College School of Medicine, showed 19 excess deaths among 43 deaths following open surgery recorded on the cardiac surgery register. Hospital episodes statistics showed 24.1 excess deaths among 41 deaths recorded.

The final clinical case review, published by the Bristol inquiry last October, suggested that about 160 babies and young children could have been damaged or died as a result of poor standards of care between 1984 and 1995.

For more on the Bristol inquiry findings, see www. hsj. co. uk See news focus pages 11-17; comment, page 19.