Summary
Management Failings
40. Alder Hey and the University
failed properly to resource the Chair of Fetal and Infant Pathology
from the outset.
41. Alder Hey and the University
ignored warnings from independent assessors about the essential
requirements of the post not being available.
42. Alder Hey and the University,
knowing of the risks inherent in the appointment of Professor van
Velzen to the Chair of Fetal and Infant Pathology, failed to supervise
and performance manage the new unit.
43. Alder Hey and the University
failed in conjunction with the Mersey Regional Health Authority
to provide resources for the perinatal pathology service in response
to Professor van Velzen's cries for help in 1988 and 1990.
44. The University failed at
any stage to recognise their responsibility to resource the Chair
of Fetal and Infant Pathology.
45. Alder Hey and the University
failed to implement the job plan and additional supervision laid
down by their Joint Review in 1993.
46. The Chief MLSOs were complicit
in Professor van Velzen's falsifications and the Service Manager
at Alder Hey allowed himself to be sidelined.
47. Alder Hey and the University
failed to ensure that histology was reinstated when they became
aware that Professor van Velzen had abandoned the service from spring
1991 in the case of Alder Hey and June1993 in the case of the University.
48. Alder Hey and the University
failed to monitor and follow up complaints about delay in providing
post mortem and histology reports.
49. Alder Hey and the University
permitted Professor van Velzen to abdicate his clinical duties and
responsibilities.
50. Alder Hey and the University
missed numerous opportunities to discipline Professor van Velzen
for justifiable reasons from 1989 onwards.
51. Alder Hey and the University
failed to investigate Professor van Velzen's post mortem practice
in the period 1988 to 1995 which would have revealed the retention
of every organ in every case.
52. Alder Hey and the University
failed to apply or follow up proper audit procedures and management
systems to Professor van Velzen's Unit of Fetal and Infant Pathology
throughout his tenure when there was reason for continuing audit.
53. Alder Hey failed to institute
proper cataloguing of organs and left them to the University without
establishing a proper audit trail in the event of future inquiry.
54. The University failed to
institute a proper system for cataloguing organs.
55. The University consistently
ignored its conflict of interest with Alder Hey and FSID.
56. Alder Hey and the University failed
to prevent Professor van Velzen's excesses, thereby imperilling
patient care.
