Hospital's neglect led to death of boy, rules inquest

THE father of a nine-year-old British 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 today 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," he said.

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

By the time doctors discovered the fault, Tony had stopped breathing and could not be revived. Jurors heard that since Tony's death, angle pieces had been used once and thrown away.

The inquest heard a safety notice from the Medical Devices Agency (MDA) in 2000 said all single-use devices should never be reused under any circumstances.

The jury heard 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.

Bruce Emerson, a consultant who was head of anaesthetics at the plastic surgery and burns unit where Tony underwent surgery, said: "We were truly all devastated."