The public inquiry into the Bristol Royal Infirmary heard evidence throughout last year and will make recommendations for the future management of the whole NHS in its final report expected in the autumn. In addition to being affected by the wider implications of the inquiry, other NHS organisations should take heed and learn from Bristol's experience.
The resource implications for any trust involved in a public inquiry are enormous, in terms of management and clinical time. It is not usual for public bodies to be able to recover their costs, which must be met out of annual budgets.
The Bristol inquiry itself has been innovative in a number of ways: in its handling of documentation, its procedures, the use of technology in the hearing chamber and by its use of the Internet to publish its activities as it went along. It was to be a paperless inquiry and to a large extent that was achieved.
The chair and panel have statutory powers and wide discretion as to the procedures adopted.
They can subpoena witnesses to give evidence and bring documents. They can take evidence on oath. They can refer for criminal prosecution anyone who obstructs their work or fails to respond to their formal demands.
The ground rules for cross-examination, re-examination, and written rebuttal comment were laid down in formal directions at the outset. There was no formal cross-examination, although for any witness facing testing questions, the distinction was not obvious. Re-examination was limited to a few minutes to clarify key points. The process of written rebuttals provided an opportunity to correct facts, make or acknowledge criticisms, and explain misunderstandings.
Although the inquiry panel consists of people with relevant knowledge and experience, their main role is to receive, analyse and assess the evidence before them.
The inquiry appointed a panel of independent experts, answerable directly and only to them. This contrasts with the adversarial process of litigation, where each party has its own experts. The experts' discussions have been held in public, moderated by counsel to the inquiry.
It remains to be seen whether those whose work may be criticised will see this as having been a fair and effective process.
The inquiry's first task was to call for all relevant documentation for review, to identify the key issues and key players, and to plan its work for 1999. The inquiry wanted to review all medical records for every patient who had undergone open or closed paediatric cardiac surgical procedures in Bristol during the 12-year period of its remit. Around 2,400 sets of medical records were retrieved and passed to the inquiry for scanning. The inquiry took the responsibility for preserving patient confidentiality. To ensure that no relevant records were inadvertently destroyed, the trust's document destruction policy was suspended, with inevitable pressure on archive space.
Core documentation had already been identified by the trust to assist the General Medical Council investigation and to deal with pre-action disclosure in the litigation. The inquiry's remit was wider and no stone was to be left unturned. The key question was:
what documents did the inquiry itself consider to be relevant? The process was iterative, as knowledge and understanding of the issues evolved.
The task of recovering documents was complicated by having to go back over such a long period of time. In all, the trust provided the inquiry with over 300 folders of documents, comprising more than 75,000 pages, all of which were scanned into the inquiry's document management system.
CD-ROMs containing the scanned 'core documents' were produced for the interested parties, so avoiding enormous volumes of photocopied paper, often of poor quality. The inquiry hearings used a document retrieval system, with video screens, so that everyone present could see the same document at the same time.
The handling of documentation has been unique in other ways.
The familiar constraints of commercial confidence, legal privilege, general sensitivity, or sheer embarrassment, simply did not apply.
It was only with respect to documents raising issues of patient confidentiality that the public inquiry was scrupulously careful to avoid publishing anything without the consent of the family. Patient confidentiality has been respected and preserved to the greatest extent possible.
Indeed, the personal details of all witnesses, such as home addresses, were kept private.
Based only on the clinical records of 80 selected cases, the public inquiry identified teams of experts to review case notes and grade the quality of the work. This has highlighted how difficult it is to make notes which are full enough for meaningful subsequent critical review, when there may have been many pressures on time for note making. Claims experience shows this is not peculiar to clinical practice in Bristol.
There has been a high cost to the organisation in management and clinical time - costs that are never recovered.
For bereaved families, the ordeal of giving evidence is unimaginable. But being a witness is a daunting experience for anyone. So witnesses need time to prepare properly before giving evidence - to read relevant papers and cast their minds back and to talk through the issues. The support of an accompanying relative, friend or colleague is valuable.
Afterwards, witnesses will need time to reflect, and sometimes to recover their confidence and composure sufficiently to be safe to treat patients. This puts a still greater strain on colleagues maintaining the service.
The public interest in a public inquiry is not only in finding out what happened and why, but also in making sure that similar mistakes are not made in the future. The changes and improvements an organisation makes in response to the problems and the investigation are watched closely.
In a large organisation such as the NHS, the issues which lead to one trust being closely scrutinised could equally apply, to some degree and with local variations, elsewhere. Of all the issues to emerge from this inquiry, perhaps the most significant is the importance of active listening.
Practical implications The most immediate and obvious practical implications for any NHS organisation about to be involved in a public inquiry, are:
The financial and opportunity costs, which are unlikely to be recoverable.
To know where all relevant documentation is, and be able to recover it quickly.
Deciding how documents are to be managed, including providing access to all who need to see them, and making sure nothing potentially relevant will be lost.
Identifying relevant and key individuals who will need immediate information, advice and support.
Making arrangements for those asked for statements to refer to documents and receive appropriate advice and help with the drafting process.
Supporting individuals attending to give oral evidence.
Recognising and planning from the outset who will manage and lead the preparatory work, instruct lawyers, deal with the inquiry team, handle media queries and inform staff.
Establishing from the start what assistance the inquiry team expects to receive.
Establishing a trusting working relationship with the inquiry team.
Informing and reassuring all staff as to what is happening, what will be happening, and what it means for them individually - a continuing process.
Close liaison with professional organisations and trade unions, who may be involved in advising and supporting individuals whose professional reputations may be in question.
Recognising and managing any potential conflict of interest between the trust as employer and its employees - could someone be referred to the General Medical Council or the UK Central Council for Nursing, Midwifery and Health Visiting, or even the Director of Public Prosecutions?
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