The Inquiry was set up in 1998 "To inquire into the management of the care of children receiving complex cardiac surgical services at the Bristol Royal Infirmary between 1984 and 1995 and relevant related issues; to make findings as to the adequacy of the services provided; to establish what action was taken both within and outside the hospital to deal with concerns raised about the surgery and to identify any failure to take appropriate action promptly; to reach conclusions from these events and to make recommendations which could help to secure high quality care across the NHS." The Inquiry finds a paediatric open-heart service with high aspirations (including at one stage the ambition to become a centre for heart transplantation) overreaching itself, given its limitations, and failing to keep up with the rapid developments elsewhere in paediatric cardiac surgical care (PCS) during the late 1980s and early 1990s. It reports a mortality rate up to double that elsewhere at certain times, with some 30-35 deaths more than would have been expected. Individual failings, poor teamwork and communication locally, coupled with general failings in the NHS, combined to create an unsafe environment for PCS in Bristol. The Inquiry makes some 200 recommendations, designed to advance the central notion of a patient-centred healthcare service committed to continuous improvement. The need for a change in the culture of the NHS is of prime concern.The recommendations cover: needs of very sick children; safety; competence of healthcare professionals; organisation within hospitals; standards of care; openness; monitoring of clinicians. The Inquiry recommends the development of national standards for all aspects of the care and treatment of children with congenital heart disease (CHD).