Access to the full text of this article requires a subscription or payment. Please log in or subscribe below. Radical change is essential but hard to achieve Richard Smith , editor BMJ News p 181 Some will read the well written report of the Bristol inquiry into children's heart surgery as a "whodunnit?" 1 The answer is that "the system done it," but various named individuals behaved dishonourably. Some have been struck off by the General Medical Council. 2 All will have paid a heavy price with sleepless nights. The report is primarily, as Ian Kennedy, the chairman, says in his introduction, a tragedy. A great many well intentioned people worked hard to do good but did dreadful harm. Over 30 children under 1 year died unnecessarily, the report concludes. 3 Many more were severely injured. The most chilling thought in the report is that there could have been 50, perhaps 500, even 5000 similar reports about other parts of the NHS. The ingredients that led to the excess deaths in Bristol occur throughout the NHS. The report emphasises not only that the NHS had no system for monitoring quality and no reliable data but also there was no agreement on what constituted quality. "Thus the most essential tool in achieving, sustaining, and improving quality of care for the patient was lacking ... clinicians had to satisfy only themselves [the report's italics] that the service was of sufficient quality." Bristol (and we must accept, as does the inquiry, that Bristol