It reported in 2001,[4] concluding 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.
[5] The same expert estimates that 25–30 children suffered permanent brain damage after cardiac surgery by the Bristol surgeons over the same 10-year time span.
[6] The NHS Plan 2000, published a year earlier, included the establishment of the Commission for Health Improvement which was intended to tackle such problems.
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".