“It’s easy to breathe a sigh of relief and act as though the problem has gone away when a dangerous incident has been dealt with, but Oxford raises concerns about the whole children’s heart care system that can only be resolved by introducing rigorous standards across the network. It would be wrong just to scapegoat Oxford.”

“A mother wants the best for her child and I trusted my baby to the hospital. What else could I do? I believed Nathalie was in good hands.”

“It just would not be acceptable to stop doing this sort of surgery in a big university centre like Oxford.“

“It appears that managers and clinicians in Oxford put empire-building ahead of the well-being of critically ill children and their very vulnerable parents. Ego and trust can make a lethal cocktail.”

“Do we need to have a second Bristol before we can actually make the cultural changes that are needed? We have continued to have avoidable deaths in surgery because the lessons that were so clearly set out in Sir Ian Kennedy’s report [into the Bristol Babies Scandal] have not been acted upon.”

“Behind closed doors, clinicians and managers speak up about the deficiencies in a sevice where there are only one or two surgeons, but in order not to undermine parents’ confidence, they are reluctant to speak publicly. Hopefully, by putting in place stronger protocols for sharing information and examining practice, which make transparency part of our medical culture, parents’ trust will be well-founded and Oxford will be the tipping point that saves us from another Bristol.”