Urgently investigate paediatric cardiac surgery units for unsafe low patient volumes

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

Government responseNot tracked (historical inquiry)

DeliveryDHSC and NHS England say in progress (Feb 2026)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

An investigation should be conducted as a matter of urgency to ensure that PCS is not currently being carried out where the low volume of patients or other factors make it unsafe to perform such surgery.

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 in progress · 27 Feb 2026

In 2001, the Kennedy Report recommended the need for fewer specialist centres for children’s heart surgery. In response to this recommendation the national Safe and Sustainable review of children's heart surgery services was established to ensure that babies, children, young people and their families receive the best possible outcomes. In 2015 the New Congenital Heart Disease Review reported to the NHS England Board. This confirmed that the main recommendations of the review will be accomplished through commissioning and major service reconfiguration can be avoided. The Congenital Heart Disease Standards and Specifications set out the required standards.

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 “Implemented – Closed (review); commissioning arrangements are ongoing”. Table row: section 6.2 No. 198, PDF page 159.

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 Government agreed with this recommendation. In its January 2002 response, the Department of Health said a thorough review of services was underway.

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. 198, PDF page 136.

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.