BRIS-193

Stipulate minimum paediatric cardiac surgery procedure volumes for hospitals to ensure outcomes

Bristol Heart Inquiry · Bristol Heart Inquiry — Final Report · Issued 18 July 2001

Government responseNot tracked (historical inquiry)

DeliveryDHSC and NHS England say partially delivered (Feb 2026)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

With regard to paediatric cardiac surgery, the standards should stipulate the minimum number of procedures which must be performed in a hospital over a given period of time in order to have the best opportunity of achieving good outcomes for children. PCS must not be undertaken in hospitals which do not meet the minimum number of procedures. Considerations of ease of access to a hospital should not be taken into account in determining whether PCS should be undertaken at that hospital.

Bristol Heart Inquiry, Bristol Heart Inquiry — Final Report · 18 Jul 2001 Source PDF →

Government response

●No formal government response recorded

The Index has not yet recorded a verbatim government response to this recommendation.

Delivery

●DHSC and NHS England say partially delivered · 27 Feb 2026

This recommendation is supported by various frameworks, including:

• The NHS England Paediatric Congenital Heart Disease Specification published in May 2016.

• Royal College of Surgeons guidance on standards of care for children’s surgery. Clinical network service specifications as set out in our response to Recommendation 175, including: ▪ Congenital Heart Disease (including paediatrics) ▪ Neonatal critical care ▪ Paediatric clinical care ▪ Surgery in children

The RCN additionally provides guidance on optimum standards for the nursing care of infants, children and young people with congenital heart disease. It includes recommendations for education and training, underpinned by competency frameworks and career pathways.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Partially Implemented –Closed”. Table row: section 6.2 No. 193, PDF page 157.

What other bodies have found

In their own words. These do not change the delivery statement above.

●Thirlwall Inquiry legal team · 15 May 2024

The Paediatric and Congenital Cardiac Services Review Group published its report in December 2003. The report contained a number of standards. However, it rejected the need for the standards to stipulate the minimum number of procedures that should be performed by a centre over a given period of time, saying there was limited evidence to support such a standard or to help determine what the minimum level should be.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024)

Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 6.2 No. 193, PDF page 134-135.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.