bristol inquiry:

An open, thorough inquiry which will make tough recommendations to curb sub-standard medicine, or expensive psychotherapy for bereaved parents? Opinion differs widely on the Bristol Royal Infirmary inquiry at it reaches the halfway stage in a two-year investigation of the tragedy which left at least 29 children dead and four brain-injured.

The inquiry hearings leave the visitor in no doubt it is being run by a painstaking, innovative team. For example, it is the first to use technology to display key documents on screen during hearings, the first to create a pool of expert witnesses acting only for the inquiry - not for the parties involved - and the first, probably, to have a playroom. The inquiry team is in touch with 500 families, and children's facilities, which include a nappy-changing room and a microwave oven to heat milk, make attendance easier.

The chair, Professor Ian Kennedy, was 'very keen that we had a whole range of features which reflected the way we wanted to run the inquiry and the wish that it should be open, accessible and inclusive', says inquiry spokesman Richard Green. 'Anybody and everybody should feel free to take part in the way that makes them feel comfortable. The facilities aim to put people at their ease. It's not a court. It's not a trial. Therefore, it should not feel like one.'

The inquiry is operating from three floors, only a few streets away from Bristol Royal Infirmary, where the tragedies under investigation unfolded.

The public areas have the feel of a modern hotel. In the chamber, the Changing Rooms television series team might have been at work on the traditional trappings of witness stands, public galleries and press benches. Carpets, curtains and comfortable chairs in turquoise and grey create a more peaceful atmosphere than the average public building.

In the centre of the room is an important-looking desk and chair, which everyone assumes belongs to Professor Kennedy. In fact, it is the witnesses' seat: they are the important people in the hearing and, so the logic goes, they take centre stage. Public seating is opposite the witness. But people who do not want to watch the proceedings directly can use one of two other rooms equipped with screens relaying the action. Even the playroom has a screen.

The facilities in the press room are good, reflecting the inquiry team's view that the media's close interest in the inquiry is legitimate. But journalists are asked to wear red badges. A small group of reporters from the local media and press agencies are becoming inquiry veterans. One, from the local evening paper, is covering every day of the hearings.

The images and words of people speaking are picked up and relayed by voice-activated equipment to screens in the hearing chamber, other rooms in the inquiry offices and the remote offices in Barnstaple, Truro and Cardiff (see box, page 27).

An adjacent screen displays documents under discussion. The inquiry team estimates that instant access to documents could cut the hearing time by about 25 per cent. Wide access to the letters and reports also helps to achieve the aim of making the inquiry as open as possible. Scrupulous care is taken to remove confidential material from documents.

Fast access to the inquiry's proceedings is achieved with a system called Live Note, which produces an almost simultaneous transcript. Transcripts appear on the inquiry website about two hours after the end of each day's hearings and linked documents are on the site within 24 hours. Hard copies can be read at the hearing and inquiry offices and copies are sent weekly to many libraries and community health council offices in South Wales and the South West.

Listening to the inquiry is an interesting experience for anyone used to the courts' adversarial approach or the aggressive questioning of those giving evidence to parliamentary select committees.

The inquiry process means that issues, rather than individuals, are examined. So, for example, when former United Bristol Healthcare trust chief executive Dr John Roylance gave evidence last month, we were treated to an account of the introduction of general management, a trip in the time machine for those of us who remember the 'first-wavers'.

Unasked questions about what he knew about the surgeons' mortality rates - and when he knew it - hung in the air. The inquiry should return to the issue later in the block of evidence devoted to concerns about surgery at the hospital between 1984 and 1995 and any failure to take action appropriately.

North Devon solicitor Mervyn Fudge, of the legal team acting for the Bristol Heart Children's Action Group, says: 'All the parties are used to the adversarial system. Everybody has had to adjust their style. The objective is to unearth information and facts, rather than to prove who is right and who is wrong. Everybody took time to get used to that.'

A protocol has been reached which allows all parties to provide questions to the inquiry's team of lawyers, who then put them to the witnesses. If the questions are not asked, or not explored in sufficient depth, an application can be made to the inquiry panel to cross-examine.

'It's going slowly,' says Mr Fudge. 'The prevarication and avoidance of the direct question is obvious. Groups one to five (of the evidence - see box, below) are pretty much scene-setting for what will happen in block six.'

Two years is not an extraordinary timespan for an inquiry. The Stephen Lawrence inquiry took 20 months and the BSE inquiry, still underway, is due to last for two years and three months. 'Obviously what they (the families) want is for this never to happen again and for a structure to be put in place where, if the situation arises again, those involved will be stopped and re-trained,' says Mr Fudge.

Michaela Willis, chair of the action group, confirms the parents are finding the pace of proceedings quite slow and the questioning 'somewhat lacking'.

Ms Willis, whose baby son Daniel died at the BRI in 1993, says: 'We always realised it was going to be non-adversarial, but we don't think it's got enough bite. We don't think they are being as inquisitorial as they might be with the main witnesses.'

The parents are waiting and watching carefully to see whether the harder questions are pressed home in later blocks of evidence. 'It's a bit like a jigsaw. We've only got the outside frame and it isn't falling into place yet,' she says. 'Morale is quite low. It took so long to fight for this.We need to make sure it works for us. It's not about the timescale. It's the fact that they don't feel a great deal has come out of it yet.'

Everyone watching the inquiry closely will be seeking, in particular, firm guidance on exactly how sub-standard performance can be stopped.

As broadcaster Dr Phil Hammond writes in his book, Trust Me, I'm a Doctor: 'When I left Bristol at the end of 1992, I was told the matter was in the hands of the Department of Health and was reassured it would be sorted. The operations continued until 1995 because, as a DoH official told the General Medical Council inquiry, even the health secretary would have difficulties intervening to override a trust's decision to let surgery continue. Trusts had been given their independence and there was no stopping them.'

Steven Bolsin, the BRI consultant anaesthetist credited with bringing the tragedy to light with his persistent questioning and diligent data gathering, is impressed with the inquiry's openness. Feeling frozen out by the Bristol surgeons, he moved in 1996 to Australia, where he follows the inquiry closely on the Internet. The evidence on the club culture of management and clinical freedom without a clinical framework interests him greatly. 'We're beginning to see a process of management with a lack of accountability,' he observes.

Asked if it is possible to overcome such closed, inward-looking attitudes, Dr Bolsin replies: 'What you have to do is put in place structures that ensure these attitudes are not supported and, if these attitudes are encountered, that they are dealt with.'

A more sceptical note is sounded by Rudolf Klein, professor of social policy at Bath University. The inquiry is 'an extraordinarily expensive method of providing psychotherapy for the parents', he told HSJ. 'For pros like myself in the business it will be interesting to read the Kennedy Report, but I don't expect any revelations.'

Is it possible to fulfil the parents' demand that such a tragedy should never happen again? 'Of course not,' he says. 'You can lessen the risk but you are always going to have the awful possibility of horrors happening. One hopes that in the future it will not be possible for something to go on so long.'

Professor Klein says cases such as those at the BRI are the most difficult to prevent because they involve conscientious people working beyond their competence. The risk could be lessened with greater awareness and judicious use of audit. The inquiry could help a little by providing a second impetus behind efforts already being made in this direction.

Even the cronyism of the club culture presents the paradox that people work best where they trust each other and get along with one another, he points out. But in the context of the inquiry, his impression is the BRI was a 'peculiarly inbred institution'.

'If you have a situation where everyone is looking at what others do wrong, it's ghastly. You have to strike a balance between creating trust between colleagues and vigilance.'

Inquisitorial though the approach may be, there is a strong awareness of the need to produce a report that will address the questions raised by the Bristol tragedy effectively and openly.

As a recent Financial Times article put it: 'For witnesses who fear their professional reputation will be traduced, the line between fact-finding and apportioning blame can seem blurred.'

It is a difficult line to tread and one that is now a matter of debate between civil rights groups and those defending senior officials and others who find themselves giving evidence to inquiries.

Mr Green spells out a firm message: 'The inquiry must provide the opportunity to bring people to account where it is proper to do so. We don't see an adversarial process as being necessary to achieve this, but our process will be rigorous and thorough, and, when the time comes to write the report, if tough things have to be said, they will be said.'