The Royal Liverpool Children's Inquiry

Terms of reference: To inquire into the circumstances leading to the removal, retention and disposal of human tissue, including organs and body parts, from children at the Royal Liverpool Children's NHS Trust (and its predecessor NHS organisations) who have undergone post mortem.

To inquire into the extent to which the Human Tissue Act 1961 has been complied with

To examine professional practice and management action and systems, including what information, and in what form was given to the children's parents, or where relevant, other family members, in respect of the removal, retention and disposal of tissue.

To examine the role of the NHS and other persons or bodies involved.

To consider such other issue relating to the above matters as necessary.

To report to Secretary of State by end of March 2000 and make such recommendations as are appropriate.

Chair: Michael Redfern QC

Panel Members: Dr Jean Keeling, Consultant Paediatric Pathologist, Royal Hospital for Sick Children, Edinburgh; Mrs Elizabeth Powell, Chief Officer, Liverpool (Central & Southern) Community Health Council.

Dates:

· Established 3 December 1999

· Inquiry formally opened on 9 February 2000

· Oral evidence heard between 11 May 2000 and 14 July 2000

· Report 30 January 2001

Link to website and or download report:

http://www.rlcinquiry.org.uk/index.htm

Description of the events which caused the public concern:

In evidence to the Bristol Royal Infirmary Inquiry, a leading clinician gave evidence as to the benefits of retaining hearts for the purpose of study and teaching referring to collections at various hospitals around the country. He identified the largest collection at Royal Liverpool Children’s NHS Trust (Alder Hey Children’s Hospital). The practice of removing and retaining organs following post-mortem examination was found to be widespread. Concerns were raised as to compliance with the Human Tissue Act 1961. Alder Hey was identified as having particular problems, due to a systematic full-scale removal of organs which occurred in period 1988-1995. Most the retained organs were not subject to histological examination, but were retained by the hospital.

Litigation

In re Makin, decd (2002) 6 Ecc LJ 414

R (Woods) v General Medical Council [2002] EWHC 1484

A v Leeds Teaching Hospitals NHS Trust [2005] QB 506

Summary of report’s recommendations:

· A procedure to be put in place for dealing with serious incidents, such as the discovery of the organ retention practice in this case

· Improved communications between Universities and Trusts, including joint investigations where failings are identified

· Improved management standards. Clinicians should not be appointed to managerial roles within hospitals without having relevant clinical experience for the position and hospital managers should seek medical advice where necessary.

· Clinicians should receive training on the role of coroners

· Specific clinical practices in respect of dealing with human tissue were identified

· Specific guidance for coroners in respect of their role

· Instruction to the medical profession on the Human Tissue Act 1961

· Following examination of the organ there should be a meeting with the family and specialist advice available

· Local ethics committees to be given supervisory role to police research