The Bristol heart scandal occurred in England during the 1990s. At the Bristol Royal Infirmary, babies died at high rates after cardiac surgery. An inquiry found "staff shortages, a lack of leadership, [a] ... unit ... 'simply not up to the task' ... 'an old boy's culture' among doctors, a lax approach to safety, secrecy about doctors' performance and a lack of monitoring by management". The scandal resulted in cardiac surgeons leading efforts to publish more data on the performance of doctors and hospitals.
An investigation chaired by Professor Ian Kennedy QC was set up in 1998. It reported in 2001., It concluded that paediatric cardiac surgery services at Bristol were "simply not up to the task", because of shortages of key surgeons and nurses, and a lack of leadership, accountability, and teamwork.
The NHS Plan 2000 published a year earlier, included the establishment of the Commission for Health Improvement, which was intended to tackle such problems.
By 2010 the mortality rate within 30 days of a child's heart operation had fallen from 4.3% in 2000 to 2.6%. Plans to reduce the number of centres performing children's heart surgery have been opposed. A report to NHS England in July 2015 proposed a “three tier” model for all hospitals providing congenital heart disease care. It suggested that they would work within “regional, multi-centre networks, bringing together foetal, children’s and adult services” and noted that since 2001 there “have been subsequent reviews each making a series of recommendations, but no coordinated programme of change, and concerns have remained”.
Ten further children died at Bristol Royal Hospital for Children following heart surgery in 2013-5 and Ian Kennedy was again recruited to head an enquiry. The inquiry was ongoing in 2015.