Summary of the report into Alder Hey organ scandal

By IAN HERBERT

LONDON - A string of authorities proved incapable of tackling the pathologist at the centre of the Alder Hey organ storage scandal, who has been branded as a liar and an incompetent who should never be allowed to practise medicine again.

The report of Michael Redfern QC into the scandal revealed that managers at Liverpool University and Alder Hey, Europe's largest children's hospital, knew of Professor Dick van Velzen's activities but failed to act.

Such was the chaos he left behind when he departed Alder Hey in 1995, that when news of the organ store became public the hospital made four or five abortive attempts to inform some parents about organs, causing further multiple attempts at burial.

Although the scandal came to light 16 months ago, the cataloguing of organs still did not begin until June last year, the inquiry found.

In Professor van Velzen's seven years at Alder Hey from 1988, he lied consistently to his employers and bereaved parents. His conduct will be reported to the General Medical Council and the Director of Public Prosecutions – the latter, for consideration of a criminal case against him.

Doubts about Professor van Velzen's ability had been aired before his appointment, but he was still recruited to a Liverpool University chair at the hospital, for which there were clearly inadequate funds.

Within a week of taking up the chair in foetal and infant pathology, he issued an order that no human material kept for examination was to be disposed of – allowing the creation of a colossal store of organs for his own research purposes.

A combination of Professor van Velzen's professional incompetence and a lack of internal resources was to create a stockpile of body parts from more than 800 children, which he was too busy to deal with, as he wrongly diverted his time and money into research instead of examinations on the parts.

Consequences

The report revealed that one mother, who had suffered a stillbirth in mid 1989, was desperate for a post-mortem report from the professor, fearing a similar tragedy if she conceived again. She became pregnant again two months after the post-mortem examination was initiated but still had not received her first baby's body for burial by the time the second, a healthy boy, was born in 1990.

The hospital's assertion, in response to a letter of complaint from the mother, that the professor had "reorganised his priorities'' was inadequate and untrue, the report found.

In a further case, a delayed post-mortem examination caused a mother's second child to be born with the same genetic condition as an earlier child in the family.

The children's organs, and others like them, gathered dust in a Liverpool laboratory, forming part of a collection that dated back to 1948, which the inquiry revealed to be bigger than many had expected.

The most shocking item in the collection, according to the inquiry, dated to before Professor van Velzen's time: the head of an 11-year-old boy. There were also 13 post-natal heads and parts of heads from children as young as a few days old, all from the 1960s, and 22 heads from premature and fully formed foetuses.

Mr Redfern's team was shocked by the cavalier way the organs had been dealt with, citing the case of foetal material labelled with the words: "neck deeply lacerated. Pull to pieces some time and reject.''

The report dismissed the argument that stockpiling organs without consent – in contravention of the 1961 Tissue Act – was justifiable on the basis that doctors were acting in parents' best interests.

Van Velzen's deceit

Doubts about the professor's ability centred on the fact that he had published only 27 papers, 20 of which were in Dutch, not English, the usual language of international publications. But he persuaded Alder Hey to recruit him anyway.

Once appointed, his frequent returns to the Netherlands helped to cause the mounting backlog of post-mortem examinations. Every other week he would return to his native country, the inquiry found, leaving Alder Hey on Friday mornings and returning on Monday afternoons. Occasionally, he did not return until Wednesdays.

Soon he was incapable of carrying out complete post- mortem examinations based on organ analysis, basing his conclusions on naked eye examinations instead. He begansubmitting preliminary post- mortem reports without analysis as he focused on his research into Sudden Infant Death Syndrome (Sids) instead.

He lacked even elementary secretarial support so he was soon falsifying records and statistics – one of 20 activities the inquiry found him guilty of.

He also falsified research applications in an attempt to procure money. Meanwhile, he ignored written requests for prompt post-mortem reports, lied to parents about his post- mortem methods and findings, falsified post-mortem reports and encouraged staff to falsify records on stored organs.

Management failings

Alder Hey and the university were aware of some of his practices but failed to act, the inquiry found. The Alder Hey executive board knew by 1991 that the professor had stopped providing detailed post-mortem reports and by 1992 was aware that he was not fulfilling his contract for clinical work.

But a joint audit of his department by the NHS and the university was ineffectual and a joint review published by them in 1993 took no action against him. The inquiry held both hospital and university accountable for failing to follow up patient complaints about post-mortem examinations and failing to "prevent Professor van Velzen's excesses, thereby imperilling patient care''.

Both hospital and university provided inadequate resources to fund his position from the start, despite warning of the fact from independentassessors. The professor's premises and equipment were both inadequate.

Only when Professor Christopher Foster became the head of university pathology in 1994 was Professor van Velzen tackled. Professor Foster complained bitterly to the university vice-chancellor of "repeated failure by the hospital administration to discipline Professor van Velzen'.'

Coroner's failings

The scandal was further compounded by failings on the part of the former Liverpool coroner, Roy Barter, the inquiry found. Rather than decide which of the professor's post-mortem requests to grant, he "wrongly delegated'' the decision to junior officers. Mr Barter, the inquiry found, also had no system for specifying those cases in which detailed post-mortem examinations were needed and on several occasions accepted Sids as a cause of death without demanding a post-mortem examination.

Mr Barter, therefore, "must have recorded an inaccurate cause of death in a number of cases'', the inquiry found. "Slackness in Mr Barter's procedure ... contributed to the delay in identifying Professor van Velzen's abuse.''

Inadequate handling

Alder Hey and the university should have appointed an officer to catalogue the retained organs and tissue, when the scandal broke. Its failure to do so further delayed an inevitable conclusion: that there was no way of telling parents what had happened to the organs of all children who had died between 1988 and 1995.

The inquiry also found Alder Hey guilty of failing to provide adequate face-to-face communication, suitable advice or counselling to parents.

Recommendations

A new approach to the issue of parental consent in organ donation is the inquiry's main recommendation. "Full informed consent'' is necessary and it should include a programme of health education, informing the public of the medical need for further organ retention.

But "it is not enough for clinicians to tell the next of kin that they would like to examine the body after death and this might involve taking some tissue'', the report said. Though securing "informed consent'' might be an unpleasant task for clinicians, who would need to provide detailed information, the responsibility could not be avoided, the report said.

A more complete organ donation consent form was necessary and, to assist relatives through the painful details, bereavement advisers should be introduced at every hospital.

The inquiry demanded improved audit systems at hospitals, management standards to ensure that no clinician could be appointed to authority without the relevant experience and procedures to prevent a repeat of the mishandling of the scandal as it broke at Alder Hey. Coroners should also receive clear instructions, preventing a repeat of Liverpool's flaws.

- HERALD CORRESPONDENT