Alder Hey report condemns doctors, management, and coronerBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7281.255 (Published 03 February 2001) Cite this as: BMJ 2001;322:255
A catalogue of deception and malpractice by an unethical pathologist, compounded by severe management failings and an evasive and paternalistic attitude towards bereaved parents, are the main findings of the long awaited inquiry into Alder Hey Hospital in Liverpool.
Four members of the hospital staff, including the chief executive, were suspended from their jobs this week following the report's publication.
The report is every bit as scathing as described by the health secretary, Alan Milburn, with the bulk of its criticism aimed at pathologist Professor Dick van Velzen, who worked at Alder Hey between 1988 and 1995.
However, the report also contains caustic condemnation of coroner Roy Barter, Professor van Velzen's pathology colleagues, and the management teams of both Alder Hey Hospital and the University of Liverpool.
The report comes after a one year inquiry, chaired by Michael Redfern, QC, into how thousands of organs taken at postmortem examination—often without the parents' consent—were stored by Professor van Velzen, apparently without the knowledge of senior hospital and university officials.
The practice of obtaining organs without consent was exposed during the inquiry into paediatric cardiac surgery at Bristol Royal Infirmary. By the end of 1999 over 50000 organs, body parts, or fetuses were held by pathology services, according to a census published by the chief medical officer this week to coincide with the Alder Hey report.
Alder Hey began retaining human organs in 1948, but the practice increased dramatically with the appointment of Professor van Velzen in 1988. According to the report, Professor van Velzen's first deception came during his selection interview when he lied about having already discussed clinical services with the hospital's unit general manager.
The report goes on to list 20 different areas of malpractice carried out by Professor van Velzen during his seven years' tenure. These included the unethical and illegal retention of every organ in every case; falsifying records, research applications, and postmortem reports; ignoring written consents to limited postmortem examination; and lying to parents about his postmortem findings.
The General Medical Council has been waiting for the inquiry's findings before considering whether to discipline Professor van Velzen. The report's authors leave little doubt about their opinion.
“Professor van Velzen must never be allowed to practise again. We will report his conduct to the General Medical Council and the Director of Public Prosecutions,” states the report. Professor van Velzen, however, is not the only professional condemned by the report.
Coroner Roy Barter is roundly condemned for poor record keeping, lack of insistence on histological examination, and his decision to delegate the decision on whether to carry out a coroner's postmortem examination to the Coroner's Office.
“Slackness in Mr Barter's procedures undoubtedly contributed to the delay in identifying Professor van Velzen's abuse of post mortem procedures,” states the report.
The management teams of both Alder Hey and Liverpool University also come in for severe criticism. From the outset, senior managers ignored warnings from independent assessors that Professor van Velzen's post was underresourced. Lack of supervision and performance management allowed Alder Hey's problems to escalate unnoticed, claims the report, and Professor van Velzen's colleagues are castigated for not raising the alarm sooner.
Nor was management's performance any better once the scandal had come to light. The report describes an inadequate “dripfeeding of information to parents,” which ended with some parents having to reopen their child's grave on several occasions as their organs were returned “on a piecemeal basis over the past 14 months.”
“[Managers] adopted a policy of paternalism, namely restricting the freedom and responsibility of parents to object or consent to organ retention in their supposed best interest,” the report says.
The report can be accessed at: www.rlcinquiry.org.uk/
Full story in News Extra at bmj.com
Health secretary proposes reform
The secretary of state for health, Alan Milburn, told the House of Commons this week that the 1961 Human Tissue Act would be reformed “to enshrine the concept of informed consent.” He accepted in full the recommendations of the inquiry into tissue retention carried out by the chief medical officer, Professor Liam Donaldson, and published this week. Four proposals will be implemented:
A special commission will be established to oversee the return of organs and tissues from around the country to their families
The home secretary has begun a review of the coroner's system
The secretary of state for education and employment will establish a review of accountability and management arrangements between NHS trusts and universities
The health secretary pledged to “ensure that all NHS trusts provide support and advice to families at the time of bereavement”