Hospital's neglect led to boy's death

THE father of a nine-year-old boy who died during a routine operation last night criticised the hospital after an inquest jury found "system neglect" contributed to his death.

George Clowes, 46, said he was "appalled and angry' with medical staff following the death of his son Tony and hoped the Crown Prosecution Service would reconsider criminal charges.

A jury at Chelmsford Coroners Court yesterday returned a unanimous verdict of accident contributed to by system neglect following Tony's death last July.

The youngster, from Dagenham, Essex, died while he was being prepared for surgery at Broomfield Hospital, Chelmsford, after trapping his finger in a bicycle chain.

He was denied oxygen because a piece of connecting tube forming part of the anaesthetic apparatus was blocked by a tiny plastic cap from another piece of surgical equipment which had become lodged inside it.

After the inquest, Mr Clowes, a process operator for a pharmaceutical company, read from a statement in which he criticised hospital staff for not observing medical guidelines.

"We are satisfied that the full facts of the event that led to our son's death have been fully investigated before the coroner. We are appalled and angry, however, that his death was due to a failure on the part of senior members of staff and management of the hospital to observe clear guidelines and safety notices that were intended to protect patients.

"Those failures which amounted to neglect resulted in the death of our nine-year-old son Tony, whose life we entrusted into the hands of the professionals who failed in their duty towards him.'

Mr Clowes said the family would report the matter to the General Medical Council.

Returning the verdict, the foreman of the jury said: "Tony George Clowes died as a result of an accident and the cause of death was contributed to by system neglect, inadequate guidelines, failing to ensure the patency of all ancillary equipment, failure to disseminate important safety information to relevant personnel, and failure to follow guidelines concerning single-use medical devices.'

The five-day inquest heard how a nurse had found an "angle piece' of tube - which links a patient's face mask to the breathing tube - tucked away in the back of a drawer on a surgical trolley.

The jury heard that the two-inch angle piece was designed to be used once and thrown away but staff at the hospital often washed and reused them.

One member of the medical staff said that this was common practice throughout the country. By the time doctors discovered the fault, Tony had stopped breathing and despite resuscitation efforts, could not be revived.

Dr David Scott, a consultant anaesthetist and medical-legal expert who investigated the case, told the inquest doctors should have been able to save Tony.

He said surgeons should have been able to pick up the fault and that their training should have been enough to get them out of the situation.

Dr Scott said Tony would probably have been saved if doctors had disconnected the equipment and given him mouth-to-mouth resuscitation instead of concentrating on what they thought was a problem with the machinery.

Jurors heard that since Tony's death, angle pieces had been used once and thrown away. A safety notice from the Medical Devices Agency (MDA) in 2000 said all single-use devices should never be reused under any circumstances.

The MDA also said in 2001 that hospitals must check all components of breathing systems as incorrect fitting could cause patients problems and there had been instances of blockages and poorly-fitted equipment. Some members of medical staff from the hospital told the inquest that they were never aware of these notices.

Hospitals have national guidelines for checking anaesthetic equipment, but the inquest heard checking was "not absolute at that stage".

Speaking following the verdict, Det Supt Win Bernard said: "No verdict today is consolation for Tony's family who were devastated by the sudden and untimely loss of their son, and only those who have suffered a similar loss can even begin to understand what they must be going through.

"I have total admiration for the dignified way in which the Clowes family have conducted themselves throughout the last two years and would like to take the opportunity to publicly pay tribute and thank them."

A police investigation codenamed Operation Orcadian, set up after Tony's death looked at 28 similar but non-fatal cases.

Three members of hospital staff were arrested by police in connection with the incident, and a file was submitted to the Crown Prosecution Service. In July 2002 detectives said the boy's death was not the result of a criminal act.

Mr Bernard said detectives worked with the Health and Safety Executive, took advice from experts, submitted medical exhibits for forensic analysis, and took part in tests to look at the possibilities of foreign objects inadvertently blocking components of anaesthetic breathing systems.

He said detectives will continue to work with the HSE while they consider what action to take.

Speaking following the inquest Andrew Pyke Chief Executive of Mid Essex Hospital Services NHS Trust expressed the hospital's sadness to the Clowes' family about what had happened.

He said staff had been upset about the events and that major changes had been put in place since the tragic event.