Hospital admits oxygen pipe fault

Det Supt Win Bernard and Nigel Offen face the media

A hospital has admitted breaking manufacturers' guidelines by re-using an oxygen pipe for an operation in which a nine-year-old boy died.

A police investigation has been launched into the death of Tony Clowes at Broomfield Hospital, Chelmsford, on 18 July, after the pipe became blocked.

The inquiry is also looking into a second incident in which an oxygen pipe became obstructed, this time at Basildon Hospital, also in Essex, on 2 August.

Both occurred while the patients were under anaesthesia but no harm was caused in the second case.

Tony, from Dagenham, died in the pre-operation room after being admitted to Broomfield Hospital to have the top of his finger sewn back on following a bike accident.

Tony Clowes, who died at Broomfield Hospital

Speaking at a news conference at Essex Police headquarters, Nigel Offen, head of clinical quality for the eastern region of the NHS, confirmed that the oxygen pipe involved in Tony's operation had been used more than once.

He also confirmed that the packaging on the pipe recommended single use only.

When asked why the pipe had been re-used, Mr Offen responded: "I think it's probably become custom and practice over the years."

The hospital is run by Mid Essex Hospital Services NHS Trust, which has denied an allegation made in a newspaper that cost-cutting led to the death.

Normal practice

Mr Offen said procedures were being reviewed at Broomfield Hospital in the case of the re-use of single use equipment.

He said it would be normal practice to throw such equipment away after one use.

It's just absolutely heart-stopping, shattering news

George Clowes, father

In a statement, hospital managers said: "The trust has not instructed and would not instruct medical staff to breach manufacturers' guidelines."

Professor Peter Hutton, president of the Royal College of Anaesthetists, said: "If the manufacturers recommend pipes for single use and they are used more than once by a hospital, then the hospital becomes responsible for the kit and the outcome."

Once staff were aware the tube was blocked, they and other medics fought for nearly two hours to revive the boy.

'Beyond comprehension'

Speaking on Wednesday, Tony's father George recalled: "I accompanied the bed up to the anaesthetic room and once they had administered the anaesthetic and he had gone to sleep, I went back down to the ward.

"They came and told me he had died.

Tony (rear) with mother Carol, brother Andrew and father George

"It's just absolutely heart-stopping, shattering news."

At the time, a relative said: "To go into hospital to have the end of a finger stitched back and to die because of a blocked tube is beyond comprehension."

Essex coroner Caroline Beasley-Murray called in police after the death was referred to her.

Essex Police widened the investigation after last week's incident at Basildon Hospital.

Detective Superintendent Win Bernard said similar pipes had been used in both cases.

Internal report

The second incident involved a man in his 40s who was in the pre-operation anaesthetic room when the blockage took place.

Mr Bernard said: "The medical team present was able to deal with the situation and continue with a successful operation without any adverse affects to the patient.

"This incident was reported internally and was subsequently referred to Essex Police by the Eastern Region Office of the NHS for further investigation."

Both incidents were being examined under one investigation which was being carried out in conjunction with the Health and Safety Executive.