Thursday, August 24, 2006


Equipment rule-breaking plus anaesthetist incompetence kill a healthy kid. And why did a cut finger need a general anyway? I have often had plastic surgery on my face done under a local! And no-one was penalized of course -- AND the abuses continue

Earlier this month, leading orthopaedic surgeon Simon Moyes, who put patients at risk of infections by re-using surgical equipment, escaped punishment after it was claimed such practices are widespread in the NHS due to cost cutting. It was news that shattered the Clowes family, whose nine-year-old son Tony died exactly five years ago this month after breathing apparatus was reused in what should have been a minor operation. Here, Tony's father George Clowes, 49, who works for a pharmaceutical company and lives in Dagenham with his wife Carol, a housewife and children Dion, 22 and Andrew, 13, explains why it's vital that lessons are learned.

He says: "After reading about Simon Moyes in the newspaper last week, I was left feeling as though I'd been run over by a truck. July is always a difficult month for my family and I because it marks the end of another year without our son Tony. And to hear at the same time that the very practices that killed our son are still going on was shattering. After Tony's death, we were promised that lessons would be learned, which, given this latest investigation, we find difficult to believe.

One of the consultants who gave evidence in support of Mr Moyes said it was common practice to reuse equipment because the NHS is so short of funds. To us, the thought of doctors still risking people's lives for the sake of a little penny pinching feels like a slur on Tony's memory. All fathers dote on their eldest son, and Tony was the apple of my eye. He was a caring boy, who enjoyed things like cooking and playing on his bike. He also had a thirst for knowledge, and I'd forever be finding him curled up on his bed with a book. At the time of his death, he was in perfect health. He wouldn't have ended up in hospital at all had he not lacerated his right index finger while trying to repair the chain of his bike.

I remember him coming rushing in from the garden that afternoon, in tears and covered in blood. After running his finger under the tap and seeing how deep the gash was, I decided to take him to our local A&E department at the King George hospital in Goodmayes, Essex. Tony cried all the way there but soon perked up at the sight of the hospital and the doctors. Because his wound was bleeding so heavily, we were rushed straight through to see a doctor and Tony was given a painkilling injection. When the doctors said they wanted to transfer Tony to the a specialist reconstructive department at the nearby Broomfield hospital in Chelmsford in an ambulance, he could barely contain his excitement and forgot all about his cut. He'd always wanted to go in an ambulance and thought the whole thing was a fantastic adventure. We arrived at Broomfield at about 5.30pm. At that point, I was expecting they'd stitch Tony's finger back up and we'd be home in time for dinner.

But because there was no surgeon on duty, it was decided Tony would stay the night and be operated on the following morning. I offered to stay with him, but he'd spotted he had a computer and toys in his room, and confidently told me he'd be fine on his own. The next morning, I returned to the hospital while Carol stayed at home and looked after our grandson. Of course she would have been there too had we imagined anything serious would happen but we thought it was just a case of a Tony needing a few routine stitches. By the time I got there at around 8am, Tony was his usual chatty self, sitting up in bed and asking the doctor lots of questions about the anaesthetic. Then he asked me if I'd buy him the latest CD by Shaggy, to which I said yes. Tony went off for his operation at 9.30. I stayed with him in the theatre holding his hand until he was given the anaesthetic.

I said to him "See you in a hour son", kissed him on the forehead, then went off to get a cup of tea. Sitting on the chair next to Tony's bed in the ward, I had no idea that almost as soon as I'd left the room, he had encountered difficulties. I had no idea that as I flicked casually through magazines, doctors were struggling to save Tony's life. I thought in a couple of hours, Tony would be ready to go home and would be chatting away about the welcome back dinner his mother was making him. The first I knew anything was wrong was about an hour later, when a doctor and his assistant came and found me and ushered me into a side room. He looked at me and said "I don't know how to tell you this but there's been an absolute disaster."

Then he said that Tony had died. It was impossible to take in what they told me next. I listened in total disbelief as they told me that they'd discovered Tony wasn't getting any oxygen through the breathing tube they'd put down his throat while he was under the general anaesthetic. At first, after checking the breathing equipment and discovering it was all fine, they'd thought he'd had an allergic reaction to the anaesthetic drug. So they'd started injecting him with a cocktail of other drugs, including adrenaline, in order to counter the anaesthetic.

It was only after other senior anaesthetists had rushed in to examine Tony, that one of the doctors finally lifted Tony's mask and discovered one of the connectors inside it had slipped into the tubing and was blocking the airflow. Tony had suffocated to death.

I can't even begin to describe how I felt in that moment. For a start, I couldn't take it in. How could he have died as a result of a simple operation to put a few stitches in his finger? How was it possible that just an hour ago, Tony was his usual chatty and relaxed self and now he was dead? And how could they have not noticed a tube was blocked and suffocating? I don't know whether I screamed or shouted or cried. But I do remember struggling to breathe. All I wanted to do at first was see Tony. The doctors wanted to phone Carol, but I told them I'd go home and tell her myself after I'd seen my son. I remember walking along a corridor in a total haze.

I felt like pushing aside all the doctors and nurses we passed on the way so I could just get to my son, but everyone stood aside to let me walk through. I think they all already knew what had happened. Looking at Tony lying on the bed, it was impossible to believe he was gone. He looked as though he was just asleep. I half expected him to jump up, put his arms around my neck and tell me it the whole thing was some sort of joke. But it was obvious from the way the two doctors were acting, staying right by my side the entire time, ushering me up back stairs away from all the other patients and not even giving me a moment alone to gather my thoughts, that this wasn't a joke.

I could tell straight away that they knew they'd done something terribly wrong. Looking back on it, I think they were worried I'd run into the wards screaming "These two have killed my boy!" which is why they were keeping such a close eye on me. They senior doctor and his administrator even came in the taxi with me home, and stood right by my side as I walked into the house and told Carol what had happened. Like me, she also struggled to believe anything had gone so wrong. When I said to her that something awful had happened, her first thought was that they'd cut Tony's finger off, not that he was dead. Stunned, Carol and I returned to the hospital, taking Andrew and Dion with us too. We went to see Tony again. We were all too shocked to even cry and just felt totally numb.

I was also taken to see the hospital coroner, who explained to me that the police had already sealed off the operating theatre and started an investigation. His words were a blur to me though - it was far too soon for me to start thinking about a possible medical negligence case. That night, after telling the rest of our family, we sat at home and sobbed. Tony should have been back there with us chatting away about his bike and his books as usual. Instead, we were now thinking about burying him. Tony's funeral took place two weeks after his death. There was a great turn out - everyone from his headmaster to his shocked school friends and we played two tunes from the Shaggy CD Tony had asked for just before his death.

As well as grief, I think everyone there was united by a total sense of disbelief. Tony's death led to a major police operation, Operation Orcadian, during which detectives looked at 13 similar but non-fatal cases all over the country involving blocked oxygen tubes. Three members of hospital staff were arrested over the incident and a file was submitted to the Crown Prosecution Service, but in July 2002 detectives said the boy's death was not the result of a criminal act. Instead they blamed sloppy working practises by NHS staff.

In each of these 14 cases including Tony's, a tiny piece of plastic used to connect anaesthetic tubing to a patient's face mask had become wedged inside the point where the two connect where it was difficult to see. Apparently this resulted from the equipment being washed and then left jumbled up in drawers. This is despite strict guidelines issued in 2000 by the Medical Devices Agency (MDA) that breathing equipment should be used only once and then binned.

In May 2003, a jury inquest at Chelmsford Coroner's Court returned a verdict of `accident contributed to by system neglect'. The foreman of the jury cited factors including `inadequate guidelines, failure to ensure the patency of all ancillary equipment and failure to follow guidelines concerning single-use medical devices' as causes. David Scott, the consultant anaesthetist who investigated the case, told the inquest that Tony would probably have lived if doctors had disconnected the equipment and given him mouth-to-mouth resuscitation. It devastated us that his life could have been saved so easily.

Although the inquest did condemn the hospital, both Carol and I would have been happier had the individuals who attended to Tony on the day been held accountable. We still can't believe not only did they break guidelines but they didn't do something as basic as mouth-to-mouth which would have saved his life. And no verdict could really offer us consolation for Tony's death. At the time, we were told by spokes people from the hospitals concerned that changes would be put in place and equipment would no longer be reused. It was the hope that lessons had been learned that gave us some comfort and consolation during those dark days and months that followed Tony's death. That is why the recent case matters to me so much. If doctors continue to get away with such behaviour, then there will be little incentive for them to change their ways and more people will die as a result of NHS budgetary constraints.

Even five years on, we still miss Tony desperately. There is still a gaping hole in this family and although we have days now when we're able to laugh, we will never be as happy as we once were. That is why I will carry on the fight to see doctors give up their shoddy cost-cutting ways. If I don't, then Tony's death will have been in vain and he'll become just another statistic."

Source. (HT Bizzy Blog).


Below is an email received from a reader who is an anesthesiologist in a U.S. public hospital:

Local anesthesia can also be dangerous, or fatal, in the wrong hands. This boy was in the wrong hands. We have separate "ambu bags" to ventilate patients. If the machine malfunctions, we reach for the ambu bag, ventilate the patient, and then troubleshoot the machine. We have "pulse oximeters" to measure oxygen in the skin, and "end tidal carbon dioxide" to measure ventilation. Alarms are set to go offf if these become abnormal, as would occur if the ventilation circuit was blocked. In addition, the anesthetist should be observing the patient - obviously not the case here. The time of neglect must have been significant. A healthy patient has enough "reserve" oxygen that it would take a number of minutes to die even if the oxygen supply was cut off. In the USA, this would be negligence - plain and simple - and a multi million dollar out of court settlement.


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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