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The Bristol Royal Infirmary inquiry has also heard evidence about the development of cardiac surgery at the hospital.

Dr Norman Pryde Halliday, former medical secretary to the supra regional services advisory group, said the idea of designating specialist services as 'supra-regional' was a response to funding problems. Nine centres were designated for paediatric cardiac surgery in 1984. Bristol was one, though it only performed three such operations that year.

Dr Halliday said: 'In the case of Bristol, the case was weak, but there was an important point, and that was the geographical cover.'

The SRSAG hoped that with designation and support from the royal colleges referrals would increase and outcomes improve. But London hospitals, such as the Brompton and Hammersmith, ran clinics in the south-west, and surgeons continued to refer to them.

And in 1986, the Welsh Office agreed in principle to set up a paediatric cardiac unit in Cardiff.

Dr Halliday said Bristol was 'always a worry' and he could 'never understand why referrals were not increasing'. He acknowledged that the SRSAG monitored numbers of cases, but not the quality of outcomes.

Dr Gareth Crompton, former chief medical officer at the Welsh Office, said he detected an 'evident undercurrent of dissatisfaction' with the Bristol centre.

He said he raised concerns 'in the margins of another meeting' with Sir Donald Acheson, the then chief medical officer at the Department of Health, who referred him to Dr Halliday, who said he could not recall this.

Finance director Graham Nix painted a picture of ongoing problems in meeting demand for cardiac surgery, against a backdrop of financial problems. In 1984, Bristol was doing 374 open heart operations a year. By 1990, the figure was 900, with surgeons working 'excessive' hours, and waiting times were rising as intensive-care beds filled with children.

With the trust still losing referrals, it was decided to move children's heart surgery to the Bristol Children's Hospital, a move discussed since the mid-1980s for clinical reasons.