The report of the Bristol heart babies inquiry team found:

• A third of children received "less than adequate care"

• Between 30 and 35 more children aged under one died between 1991 and 1995 than would have been expected in a "typical" unit

• The mortality rate between 1991 and 1995 was "probably double" the rate for England at that time for children under one

• It was probably even higher for children under 30 days

• Problems were not confined to the complex Switch and Atrio-Ventricular Septal Defect (AVSD) operations

• The kind of cases dealt with at the hospital cannot explain the difference in rates with other units

• There was a "failure to progress, rather than necessarily a deterioration in standards" at Bristol

• The arrangements for caring for very sick children at the hospital were "not safe"

• The systems for delivering children's heart services at Bristol were "not up to task"

• There was "real room for doubt" as to whether the hospital should have been designated as a centre for open-heart surgery for under-ones

• The unit "overreached" itself and failed to keep up with developments in the specialty happening elsewhere in the late 1980s and early 1990s

• A lack of staff and resources, which had been highlighted as a problem for the Bristol was "typical of the NHS as a whole" so does not solely explain what went wrong at the hospital

• The hospital had a lack of leadership and teamwork

• Healthcare staff were "victims of circumstances" which related to general failings in the NHS rather than individual faults

• Children's heart services were undermined by being split between two sites

• There was no way of checking on the quality of services or standards of doctors at the hospital

• At the hospital, there was a "club culture" with too much power concentrated in too few hands

• Vulnerable children were not a priority - at Bristol or across the NHS

• The hospital was poorly organised

• There was no requirement for doctors to keep their skills and knowledge up to date

• Bristol was "awash" with data, but none was available to patients or parents

• Systems problems were not confined to Bristol

• There was confusion as to who should monitor quality of care nationally