The inquiry was sparked by the death of 11-month-old Samantha Rickard, who died in 1992 while undergoing open-heart surgery at Bristol Royal Infirmary (BRI). In 1996, four years after Samantha's death, her mother Helen Rickard learned of the allegations of excessive mortality rates for children's heart surgery at the BRI. Rickard demanded a copy of her infant daughter's medical records from the hospital and found a letter from the pathologist who performed the post-mortem to her surgeon, stating that he had retained Samantha's heart. Confronted with this evidence, the hospital promptly returned the heart in 1997. Rickard quit her job in order to find out exactly what had happened to her daughter; she set up a support group with other parents and ran a free phone helpline to cater to the many other families affected as well.