'No crime' in blocked tubes cases

A supply of oxygen is vital during surgery

Police have ruled out foul play in the death of a nine-year-old boy whose oxygen tube became blocked during an operation.

Instead they believe the tube became accidently blocked by another piece of specialist equipment.

They have also reached the same conclusion about a series of similar incidents at hospitals around the country which narrowly avoided tragedy.

Tony Clowes, from Dagenham, Essex, died at Broomfield Hospital in Chelmsford, during routine surgery to his finger after a bike accident in July last year.

During the operation the pipe supplying him with oxygen became blocked, and he suffocated.

We must try especially hard to prevent any further tragedies

Sir Liam Donaldson
Chief Medical Officer

His mother has expressed unhappiness that no-one has been held accountable for her son's death.

Following the Clowes case, more than 100 incidents involving problems with anaesthetics came to light.

Of these, 12 involved similar problems to those identified in the Clowes case. They stretched back to 1988.

Police officers from 30 forces, together with experts from the Medical Devices Agency and the Health and Safety Executive, examined these in detail.

They found that the problems centred on a tiny piece of equipment - an angle piece - used to connect anaesthetic tubing to a patients' face mask or a tube fed down the windpipe.

This item should be discarded after a single use, but was sometimes washed and stored for use on other patients.

In some cases it was stored in a drawer with other equipment and apparently became accidently blocked by a cap from a device used to keep drips sterile.

Forensic tests revealed that it was very easy for the cap to find its way inside the angle peice, but once lodged it was not only difficult to dislodge, it was also extremely difficult to spot.

'Rare complication'

As a result of the investigation, health workers have been told only ever to use the angle piece once. It will also come individually wrapped.

Someone has got to be accountable for it somewhere along the line and no-one is being accountable and I want to know why not

Carol Clowes

They are also being warned about the importance of the proper storage of equipment and the need to carry out vigorous checks.

An expert group has been set up by the chief medical officer to take a further in-depth look at the 13 incidents investigated by police.

The National Patient Safety Agency will look at the further 100 or so incidents which came to light after the Clowes case.

Further research will also be commissioned into the threat from sabotage to operations.

Sir Liam Donaldson, chief medical officer, said: "Bearing in mind that there was a very tragic death we must try especially hard to prevent any further tragedies happening in the future.

"What we are looking to do is make a very rare complication of surgery even rarer."

Dr Peter Simpson of the Royal College of Anaesthetists, said: "It is important we make people aware of the fact that they must check every device and they must dispose of things properly."

It is estimated that there is a risk of complications related to anaesthesia in one in every 300,000 operations. The 13 cases investigated by police represent one in every five million operations.

No evidence

Commenting on the Clowes case on Monday, a spokesman for Essex Police said: "A lengthy and detailed investigation has produced no evidence to show that the series of blockages was as the result of criminal conduct.

"The linked police investigation is therefore at an end."

However, Tony Clowes' mother Carol said she was unhappy with the findings of the investigation.

"Someone has got to be accountable for it somewhere along the line and no-one is being accountable and I want to know why not.

"If it had of been one of Tony Blair's children, heads would have been rolling by now."

The other hospitals where incidents were investigated by detetectives were: Basildon, Watford, Royal Bournemouth, Nobles on the Isle of Man, Sunderland Royal, Bedford General, Rotherham General, Alder Hey Children's Hospital and two hospitals in the private sector who refused to be indentified.