Abstract
In July, 2001, Ian Kennedy chaired a public inquiry into an excessive death rate in children undergoing open-heart surgery in Bristol, UK. 1 Kennedy I. The Kennedy Review. Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984–1995. Command Paper: CM 5207. Bristol Royal Infirmary Inquiry, 2001 Google Scholar His report is an account of a service split between two sites, with no dedicated paediatric intensive-care beds, no full-time paediatric cardiac surgeon, and too few trained children's nurses. “It would be reassuring to believe that it could not happen again. We cannot give that reassurance. Unless lessons are learned, it certainly could happen again, if not in paediatric cardiac surgery, then in some other area of the care of children”, his report concluded.
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