Summary
1988 to 1995 – The van Velzen Years
21. On 20 March 1987 the Foundation
for Sudden Infant Death (FSID) made an offer of £250,000 over a
five-year period to fund a new Chair in Fetal and Infant Pathology
in the Department of Pathology. The sum was to provide salaries
for two clinical lecturers, a research technician and a secretary.
Support from FSID was on the understanding that a substantial part
of the research effort would be devoted to the problem of cot death.
The offer was accepted.
22. Professor Wigglesworth,
one of the external assessors, did not believe that the planned
resources were sufficient to underpin the successful provision of
a clinical service and felt that the Chair would fail on that ground.
23. There was a feeling within
the selection committee that Dr van Velzen was to be appointed despite
the fact that he had only published about 27 papers, 20 of which
were in Dutch although English is the language of choice in international
publications. Even his supporters identified him as a risky appointment.
He was 38 years old. He told the interview committee that he had
been to see Miss Malone, the Unit General Manager of Alder Hey,
to discuss the clinical service. This was a lie.
24. The appointment was against
a background of almost unanimous concern for the resources available.
The premises and equipment were inadequate. The clinical resource
amounted to 1–1 1 /2 days per week. The University authorities
ignored all convincing advice and informed warnings.
25. The post of Senior Lecturer
was not filled apart from Dr Chan at lecturer level between late
1989 and early 1991 and a locum, Professor Ronald Kaschula, throughout
1994. The two clinical lecturers' positions were only filled with
one clinical lecturer, Dr Khine, and only after 14 October 1991.
26. Within a week of taking
up the Chair in 1988, Professor van Velzen issued an instruction
in the Unit of Fetal and Infant Pathology that there was to be no
disposal of human material. The store of material began to grow
and due to his practice and need for samples, this meant whole organs.
The decision not to dispose of any material was taken before any
backlog developed and indicates that lack of resource was not the
overriding motive for retention of organs.
27. Shortly afterwards, Professor
van Velzen stopped histological analysis of organs as part of his
routine clinical analysis. Instead, he prepared lengthy and apparently
detailed reports based upon naked eye findings at the time of evisceration.
28. In 1989 a computer system
was installed at Myrtle Street and Professor van Velzen started
using a template for post mortem reporting which he amended himself
in each case.
29. Professor van Velzen submitted
preliminary reports without histological analysis. A backlog of
preliminary post mortem reports built up, as well as a backlog of
post mortem histology and final reports.
30. Professor van Velzen made
no secret of the fact that he was no longer providing post mortem
histology which had been provided by his predecessors.
31. Research became the main
activity of Professor van Velzen, particularly into SIDS with the
main research being into the consequences of intra-uterine growth
retardation. He used the research tool of stereology which required
whole organs.
32. By the spring of 1991 at
the latest, the Executive Board at Alder Hey knew that post mortem
histology was not being carried out.
33. By the autumn of 1992 at
the latest, the University knew that Professor van Velzen was not
fulfilling his contract for clinical sessions.
34. A joint NHS and University
audit in 1992/3 was ineffectual.
35. A joint NHS and University
review in June 1993 failed to identify and act upon the shortcomings
of the Department as a unit when it was known to both parties that
post mortem histology was still not carried out.
36. The management vacuum at
the University caused by the retirement of Professor Heath as Head
of the Department of Pathology was not effectively filled until
1994 upon the arrival of Professor Christopher Foster.
37. Professor Foster was the
first person to provide proper supervision, appraisal and a job
plan for Professor van Velzen in early 1995, which should have been
the result of the joint University and Alder Hey review in 1993.
38. During the course of his
period in Liverpool, Professor van Velzen was guilty of the following
activities:
- immediately upon his arrival, Professor van Velzen ordered the
unethical and illegal retention of every organ in every case for
the overriding purpose of research;
- falsifying records, statistics and work output;
- falsifying research applications;
- falsifying post mortem reports;
- falsely representing that SIDS diagnoses were supported by histological
examination and presenting peer reviewed papers on the basis that
the subject-matter was based upon authenticated SIDS cases when
no histology had been carried out;
- ignoring written consents to limited post mortem examination;
- lying to parents about his post mortem methods and findings;
- misleading the Chief Executive at Alder Hey, Miss Hilary Rowland,
about his clinical practice at post mortem examination;
- failing to respond to the exhortations of clinicians and management
for the timely provision of post mortem reports and histology;
- delaying reporting on post mortem examination and histology
to such an extent that in at least one case a second child was
born with the same genetic condition as an earlier child of the
family;
- failing to provide a fetal pathology service in the early years
and later an effective service;
- causing an unnecessary excessive, illegal and unethical build
up of organs following post mortem examination, ostensibly for
research but with no likelihood that the bulk of the organs stored
in containers would ever be used for research;
- failing to keep a proper catalogue or record of the stored organs;
- failing to keep a proper record of access to the stored organs
for research purposes;
- encouraging staff to falsify records and statistics;
- failing to maintain proper accounting procedures in his Department;
- absenting himself from clinical practice without any or proper
cause;
- practising deceit upon the Foundation for Sudden Infant Death,
the University and Alder Hey;
- denying clinicians the opportunity of providing proper clinical
advice to their patients and the opportunity to consider referrals
for genetic counselling; and
- taking with him complete medical records from Alder Hey when
he left and leaving the Department with a budgetary deficit of
more than £70,000.
39. 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.
