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In 2004-05, a survey of NHS acute, ambulance and mental health Trusts found 974,000 patient safety incidents (PSI's) were reported.
Hospital acquired infections were estimated to increase the PSI figures by around 300,000 incidents. It is estimated that about 50% of these incidents are preventable (National Audit Office 2005:1).

It is estimated from International studies that at least a quarter of these figures may relate to medically negligent PSI's, yet in 2005-06 there were only 5, 697 legal claims (NHSLA 2006) making about 2% of all possible claims.

The Evans Enquiry

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Background to The Royal Brompton & Harefield Hospitals (NHS Trust) Independent Inquiries: The Evans Report, April 2001

You can view more about this and in greater detail by visiting: www.sin-medicalmistakes.org
Read the article here Evans Enquiry Artcle.PDF 151KB

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In June 1999 an anonymous whistle blower, working at the Trust , contacted "Private Eye", alleging that paediatric cardiac surgical results at the Royal Brompton were worse than elsewhere and particularly so in the case off Down's Syndrome children. It was also claimed that the attitude of doctors towards children with Down's Syndrome was inappropriate. This prompted the setting up of the "Hunter Review" which was published in September 1999. This Review claimed to have found no evidence to uphold these allegations. However,in the course of the Review several families, both from the Brompton and the Harefield hospitals, had come forward to express concerns about the standard of paediatric cardiac care experienced by their children.

The Trust originally agreed to set up an "Independent Inquiry" to allay concerns of the Brompton families only. However, when the results of the paediatric cardiac surgery results were released from the Bristol Royal Infirmary Inquiry in November 1999, and showed that Harefield Hospital's performance was "worse than average in the case of children over one year" and indeed scored only better than the BRI, which was at the bottom with the highest mortality rate for children over one year, being double the national average. In the light of these statistics, the Trust agreed to extend the Inquiry to include families from Harefield.

A total of 49 families were represented in the Inquiry, 42 children had received cardiac treatment at Brompton and 7 at Harefield. Of these 49 cases, less than a third (14) represented Down Syndrome children, all of whom had been under the care of Brompton. The larger group of 35 children included all 7 cases from Harefield and the remaining 28 from Brompton. Most of these children died (26), 6 suffered severe brain damage, and 3 successfully survived.

The latter group set themselves up as "The Brompton and Harefield's Heart Children's' Action Group" (BHHCAG) which is chaired by MS Josephine Ocloo, who had made the original public demand for an Inquiry into the concerns of the aggrieved families. The Down Syndrome families were represented by "The Down's Heart Group" and "Down Syndrome Association".