Surgeons 'should have saved boy'

Tony Clowes was put under under general anaesthetic

Doctors should have saved a boy who died while under general anaesthetic prior to a minor operation, an inquest has heard.

But consultant anaesthetist and medical-legal expert Dr David Scott said surgeons caring for Tony Clowes, 9, of Dagenham, Essex, had made an understandable mistake not "disregarded their duties".

Tony died at Broomfield Hospital, Chelmsford, Essex in July 2001 while being prepared for surgery on a finger he had injured when he trapped it in a bicycle chain.

He was denied oxygen because unbeknown to anaesthetists 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.

Tony's parents, George and Carol Clowes, arrive at the inquest

Anaesthetists found that they were unable to ventilate Tony after putting him to sleep - and could not work out why.

By the time one of the surgeons had found the blockage in the "angle piece" of the pipe, Tony had stopped breathing and could not be revived despite desperate resuscitation attempts.

Dr Scott, who was based in Edinburgh, was asked by Coroner Caroline Beasley-Murray if he thought there had been "gross failure" in the anaesthetists' management of Tony.

Should have seen fault

"I think that the evidence was there. They should have been able to pick up this fault," he said.

"Their anaesthetic training should have been enough to take them out of the ruts they were in.

"I can understand fully how they were not able to do that and they were in a mind-set.

"I don't think they did deliberately disregard any aspect of his care but unfortunately they didn't manage to detect the problem.

Not performed sufficient checks

"It is a failure that ordinary anaesthetists should have been able to pick up but I don't think they were disregarding their duties sufficiently for it to be considered anything more serious than that."

Dr Scott said Dr Patricia Richardson, the consultant anaesthetist in charge of preparing Tony for the operation had not performed sufficient checks on the equipment - a failure she accepted.

But he added that even if she had performed the checks, the blockage might not have been spotted.

The hearing continues and is expected to end on Monday.