'Neglect' factor in op death

George and Carol Clowes are going to the General Medical Council

An inquest jury has returned a unanimous verdict of accidental death "contributed to by system neglect" on a nine-year-old boy who died during minor surgery.

Tony Clowes died during a routine operation on his finger at the Broomfield Hospital in Chelmsford in July 2002.

His father George, 46, who was in Chelmsford Coroners Court with his wife Carol on Monday to hear the verdict, said he was "appalled and angry" with medical staff following his son's death.

He said he hoped the Crown Prosecution Service would reconsider criminal charges and the family intended to report the matter to the General Medical Council.

The youngster, from Dagenham, Essex, needed the surgery after trapping his finger in a bicycle chain.

Foul play was ruled out as a cause of Tony's death

But in the operating theature a breathing tube became blocked and he was starved of oxygen.

Hospital staff had not realised that a connecting tube forming part of the anaesthetic apparatus was blocked by a small plastic cap from another piece of surgical equipment.

A police investigation was carried out last year in which detectives looked at 28 similar but non-fatal cases - but foul play was ruled out.

After the five-day verdict, Tony's father, a process operator for a pharmaceutical company, criticised hospital staff.

He said: "We are satisfied that the full facts of the event that led to our son's death have been fully investigated before the coroner.

Tony Clowes died after a breathing tube became blocked

"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."

'Dreadful loss'

The Essex coroner expressed her sympathies to Tony's parents.

She described their son's death as a "dreadful loss".

Detective Superintendent Win Bernard of Essex Police said officers would continue to work with the Health and Safety Executive while they consider what action to take.

In a statement the Mid-Essex Hospital Services NHS Trust said: "The death of Tony Clowes is a tragedy.

'Learning lessons'

"The hospital and all its staff want to say once more how deeply sorry we are that Tony died whilst in our care.

"The Trust has co-operated fully with the exhaustive enquiries that have taken place over that last 22 months as part of our total commitment to learning lessons when things go wrong.

"Many systems and clinical practices have been reviewed and improved since this catastrophic and unique event.

"The Trust is wholly committed to creating a culture in which lessons can be learned from mistakes and accidents, as it strongly believes that this is the best way of ensuring that clinical practice will continue to become safer for patients."