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Review finds 'poor care' and 'understaffed wards' in hospital where 11 children died

Video report by ITV News correspondent Rupert Evelyn

NHS England has admitted major changes are needed in children’s cardiac care, after a review into a Bristol hospital found evidence of understaffing and poor care.

The report was ordered two years ago by the health service’s Medical Director Sir Bruce Keogh and examined the deaths of 11 children at the Bristol Royal Hospital.

Luke Jenkins died at Bristol Royal Hospital in 2012, aged seven. Credit: Family handout

NHS England has admitted major changes are needed in children’s cardiac care, after a review into a Bristol hospital found evidence of understaffing and poor care.

The report was ordered two years ago by the health service’s Medical Director Sir Bruce Keogh and examined the deaths of 11 children at the Bristol Royal Hospital.

Luke Jenkins was just seven years old when he died there in 2012.

He had been expected to make a full recovery from heart surgery but suffered a cardiac arrest after being moved out of intensive care onto Ward 32.

Luke’s father Stephen told ITV News:

The ward was full of patients, approximately 16 children and babies, yet there were only two staff members for the whole ward.

We could hear the alarms going off on the monitors for other patients as well as Luke and you could just tell the staff couldn’t cope.

– Stephen Jenkins
Luke's father Stephen said the report failed to hold anyone to account. Credit: Family handout

The Trust later admitted the ward was short staffed and those on duty didn’t know where vital resuscitation equipment was kept.

But the independent inquiry concluded outcomes of care at the hospital were "broadly comparable" with those of other centres caring for children with congenital heart disease.

Eleanor Grey QC, who chaired the inquiry, found ward 32 was "routinely under strain" from 2010 to 2012.

The nursing numbers would have fallen below the recommended levels on a reasonably frequent basis. We felt that children were put at risk of harm as a result.

– Eleanor Grey QC

Mr Jenkins, from Cardiff, told ITV News the report was "a tick-box exercise that fails to hold anyone to account".

He has spent four years trying to get the truth about his son’s death. He is not a bitter man and doesn’t want the Trust’s money, channelling what is left of his energy into raising funds for the charities that helped Luke before his surgery.

But he says he can’t trust a report that gets even the date of his son’s death wrong.

Along with nine other families of the 237 involved, Mr Jenkins is taking legal action against the Trust.

The same hospital was the subject of the damning Bristol Public Inquiry of 1998 – 2001. Eleanor Grey QC concludes there is no evidence to suggest failings in care of the same nature, despite finding that - once again - parents concerns went ignored.

Chief executive Robert Woolley has said they are 'deeply sorry' for things they got wrong. Credit: PA

The Trust’s chief executive Robert Woolley has accepted the report’s findings in full.

He said: "We are deeply sorry for the things we got wrong – for when our care fell below unacceptable standards, for not supporting some families as well as we could have and for not always learning adequately from our mistakes."

The latest Care Quality Commission inspection has rated childrens’ heart services at the hospital as 'good'.

But the 32 recommendations in the report include a call for a national review of paediatric intensive care services.

Only 10 hospitals offer children's heart surgery and there have already been years of controversy over whether they should all keep operating in a highly specialised field.

NHS England has responded to the Bristol report by promising an announcement next week on major changes in the way heart services are provided across the country.