A review finds low staffing levels left the Bristol hospital ward under strain, putting young patients at risk.
Parents of children who died on a children's cardiac ward were let down, according to an independent review.
Despite making 32 recommendations, the report said the outcomes of care at Bristol Royal Hospital for Children were "broadly comparable" with other specialist units for children with heart conditions.
The chair of the review, Eleanor Grey QC, said: "What we've tried to do, in order to be accountable and transparent, about our work is not only publish the main report - which tries to look at the system on a systemic basis - but also to produce 27 individual reports for families to try and answer their concerns and questions personally."
Stephen Jenkins is the recipient of one of those reports.
His son Luke died four years ago, aged seven, whilst receiving treatment for congenital heart disease.
Mr Jenkins told Sky News that the response to their son's cardiac arrest was panicked and disorganised and that had he received better care, he may still be alive.
He described the report as "very poor" and Luke's individual report as "really weak".
He said: "It's just disheartening really - from looking at this individual report it seems to be that they've just collated evidence that was already supplied through the inquest and not as independent as I thought it would be.
University Hospital Bristol NHS Foundation Trust which manages the hospital said that it accepted the recommendations.
Chief Executive Robert Woolley said: "I would like to say to say how sorry I am to those families where the review has found that our care fell below acceptable standards were we didn't listen to their concerns and we didn't give them the information that they needed in a full and timely fashion.
"We haven't waited for the review to come out today, we've invested millions in new medical and nursing staff over the last three years, new facilities and equipment."
In 2001 a separate review at the same hospital exposed a failing system which lead to children unnecessarily dying.
The latest review found that there was no evidence to suggest failing in care on the same scale.
Recommendations include: recording conversations with clinicians, implementing a framework for dealing with child deaths and carrying out a nationwide review into paediatric intensive care units.
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