Independent report

The Royal Liverpool Children's Inquiry Report

This document contains the following information: The Royal Liverpool Children's Inquiry Report.

Document

Detail

This document contains the following information: The Royal Liverpool Children’s Inquiry Report.

This investigation was prompted by evidence given to the Bristol Royal Infirmary Inquiry which spoke of the benefits of retaining hearts for the purpose of study and teaching and identified Alder Hey as holding the largest collection. Previously, the Director of the Association of Community Health Councils had expressed concerns about contraventions of the Human Tissue Act 1961 to the then Secretary of State for Health.

The investigation set out to investigate the removal, retention, and disposal of human tissue and organs at Alder Hey Children’s hospital following hospital post-mortem examinations and, the extent to which the Human Tissue Act 1961 (HTA) had been complied with. It involved examination of the professional practice and management action and systems, including what information, if any, was given to the parents of deceased children relating to organ or tissue removal, retention and disposal.

The inquiry received evidence of the practice of organ retention from about 1948. It studied the obligation to establish ‘lack of objection’ in the event of a request to retain organs and tissue taken at a Coroner’s post-mortem for medical education and research. Post-mortem examination and research involving the foetus was considered in the context of the Polkinghorne Report.

In particular, the inquiry considered the heart collection and the huge store of body parts which accumulated between 1988 to 1995 under the auspices of Professor van Velzen. A number of other collections were identified including foetal and eye collections and a store of children’s body parts.

The report centres around the actions of Professor van Velzen and categorically states that he must never be allowed to practice again. His conduct will be reported to the General Medical Council and the Director of Public Prosecutions. The hospital and University management is also heavily criticised for failing to prevent Professor van Velzen’s excesses and thus imperiling patient care. Their handling of the news of organ retention from September 1999 is also criticised.

The mistakes include failing to retain a paediatric pathologist to head a team to catalogue the retained organs and making four or five attempts to provide parents with accurate information, not learning from and compounding the mistakes made in each previous attempt. The management also failed to provide suitable advice, counselling and support necessary to the affected families.

A Consultant Psychologist should have been retained to assist in devising the best method for assisting parents. A large number of recommendations are made in the report. These cover: measures to avoid mishandling of such serious incidents in the future; relationships between Universities and Trusts; audit; management standards; legislation.

Recommendations are also made for clinicians, coroners and pathologists. The issue of consent is covered very fully with recommendations made on consent to post-mortem examinations of children, consent forms in the future, a new approach to consent, an NHS hospital post-mortem consent form for children. The concept and functions of a bereavement counsellor are also covered by the report.

This paper was laid before Parliament in response to a legislative requirement or as a Return to an Address and was ordered to be printed by the House of Commons.