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Gillian Smallwood

Volume 124: debated on Wednesday 9 December 1987

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Motion made, and Question proposed, That this House do now adjourn.— [Mr. Neubert.]

11.49 pm

I am grateful to you, Mr. Deputy Speaker, and to Mr. Speaker for granting me this debate so quickly after I made my application.

I applied for the debate because I am deeply disturbed about the circumstances surrounding the death of Gillian Smallwood, aged five, while undergoing dental treatment at a clinic in my constituency. The Rochdale community health council is equally worried, as are senior medical staff at the Booth Hall hospital, Blackley, in Manchester. Requests have been made to the Rochdale health authority for an inquiry into the case to find out what went wrong, with a view to preventing similar tragedies in future.

Such requests were turned down locally and, in reply to my letter of 23 July, the Minister of State also turned down my request for a formal inquiry under section 84 of the National Health Service Act 1946. I believe that the Minister and the local health authority are both wrong. I hope that this debate will help to make them reconsider their earlier decision and agree to an inquiry to establish what went wrong in the Gillian Smallwood case and thus help to prevent any other child's death in similar circumstances.

The facts are these. On 21 August 1986, Gillian Smallwood, aged five, attended the Langley clinic, accompanied by her mother, for the extraction of three deciduous molar teeth. Mrs. Smallwood was informed that an additional tooth would need to be removed because it was mobile. Gillian was anaesthetised and had four teeth removed but, during the recovery period, she collapsed. Measures were instituted to resuscitate her. They were not successful and Gillian was transferred to the Booth Hall hospital, Blackley, where she was pronounced dead later that day.

An inquest was held by the Manchester city coroner, Mr. L. Gorodkin on 29 January 1987. He concluded that the cause of death was cardio-respiratory failure, hypoxia, dental anaesthesia, and tracheo-bronchitis, and that Gillian died of the aforesaid, sustained when she was having an anaesthetic for teeth extraction at the dental clinic, Borrowdale road, Langley, Middleton on 21 August 1986, when she had cardiac arrest. She was conveyed by ambulance to Booth Hall hospital, Blackley, where she died shortly after arrival.

Almost one year later, on 17 July 1987, Mr. A. J. Doyle, the district dental officer for Rochdale, wrote a long report defending the staff and the equipment used in the Langley clinic, but he concluded:
"Despite all the enquiries I have made, it has not been demonstrated that anything untoward happened which led to the death of this little girl, and the sad events of that day remain inexplicable."
His findings were submitted to the regional health authority meeting on 28 July 1987 as item No. 2.

I have given only the briefest of facts surrounding Gillian's death. However, the Rochdale community health council was so concerned about all the facts surrounding the death of this child that it wrote to the Rochdale area health authority asking for an inquiry into the events surrounding the case. There was a similar request from the child's parents, made through their solicitor. Unfortunately, the Rochdale health authority appears to have treated the receipt of a solicitor's letter as a major reason for discounting holding an inquiry, despite the fact that the letter related to the parents' wishes for a full inquiry and not to any prospect of legal action. This is a great pity, because the purpose of any inquiry is not simply to determine the cause of death. It can enable people to learn from an event and to take steps to try to prevent such tragedies recurring.

It is most regrettable that the health authority and the Minister appear uninterested in learning from this case. While I am aware that the health authority is almost certainly correct to assert that deaths from anaesthetics are rare, it misses the vital point—whether such rarities are preventable.

I have been told by an eminent doctor that such events are, at least in part, preventable. Dr. T. David, senior lecturer in child health and honorary consultant paediatrician at Booth Hall children's hospital, Blackley, Manchester—a man whom I salute as a dedicated and caring doctor—tells me that it is well known that all general anaesthetics, for whatever reason, carry a small risk of disaster and death. Some such events could be due to errors on the part of the medical staff and some represent unexpected adverse reactions to agents used in anaesthesia. In the latter context, it should be pointed out that Gillian had had several general anaesthetics previously, suggesting that her death was not for this reason.

Despite the smallness of the risk, it is a basic principle that one should plan for disasters and assume that the worst will happen. Yet general anaesthetics in dental surgeries outside hospitals are used not on this basis but on the premise that things rarely go wrong, and, when they do, it is bad luck.

Hospitals are geared up for emergencies such as cardiac arrest. To give an example, at Booth Hall children's hospital, as in any other hospital, cardiac arrests are an everyday event, with the result that all the medical and nursing staff have become well practised in all the procedures. Furthermore, plenty of staff are available.

At a cardiac arrest, the following staff are always called: the medical senior house officer on call, the two surgical SHOs on call, and the medical registrar on call. In addition to these six doctors, extra nursing staff are summoned, as is a porter. Not all these staff are required for efficient treatment, but one will usually need a couple of doctors for a cardiac massage, a doctor to intubate the patient and provide manual ventilation, a doctor to set up an intravenous line, and at least two nurses to assist with the intravenous line and drugs.

The situation in a dental surgery is quite different: a dentist, a dental nurse and an anaesthetist are there. The former may have had some training in resuscitation at some time in the past, but neither is likely ever to have dealt with such events. So there is little comparison with a trained, experienced and practised team.

Thus, there are two aspects of this case. One is the competence of the staff involved, but far more important is the principle whether it is any longer acceptable for children to have treatment under a general anaesthetic in a dental surgery. It is not easy for me to see the justification for such risky procedures in a dental surgery when proper facilities are available in hospitals.

This same Dr. T. J. David wrote to me about these matters, and also about the specific case of Gillian Smallwood on 17 July 1987. He told me that he first saw Gillian soon after her birth at the North Manchester general hospital because of the instability of her hip joint, and that he followed her up at Booth Hall hospital, where she subsequently required surgery to the hip and where she was also treated, under his care, for recurrent respiratory infections. By chance, he was the consultant paediatrician on call the day she died, and, with a consultant anaesthetist at Booth Hall, he supervised an unsuccessful attempt to revive her.

Dr. David told me:
"I think it is most regrettable that a request for an inquiry has been resisted by the Rochdale Health Authority. Their grounds appear to be twofold, that the Coroner has already examined the matter fully, and that deaths from dental general anaesthetics are rare."
He went on to say:
"It is questionable as to how detailed the Coroner's inquiries were. I submitted a short report, in the anticipation that as the Consultant in charge I would be called upon to give evidence, but I was never asked to attend".
On 3 December 1987 Dr. David also sent me a copy of a letter that he had sent to the hon. Lady, the Under-Secretary of State for Health and Social Security, in which he expressed his concern that the Minister had told me in her recent letter:
"You can be sure that the case was carefully studied to see if new lessons could be learned".
Dr. David's concern about the Gillian Smallwood case is precisely that it has never been carefully studied, and that he thinks it likely that there will be further, similar deaths unless it is studied.

Remembering that Dr. David was the consultant paediatrician looking after Gillian Smallwood from her birth and that he was the consultant in charge of the unsuccessful attempt to revive Gillian when she was brought from the dental surgery to Booth Hall hospital on the day of her death, I quote what he said:
"The fact is that at no time has anyone from Rochdale Health Authority or the Regional Health Authority, carefully studying Gillian's death, ever contacted me about her preexisting medical or surgical condition, her previous operations and anaesthetics or to obtain details of her final demise."
The consultant anaesthetist at Booth Hall hospital, who was assisting our attempts, has similarly never been contacted. The only people whom I have heard from are the Rochdale community health council, which has expressed its concern, and the parents' solicitors who, on behalf of the parents, have been pressing unsuccessfully for a full investigation. Thus, the suggestion that "careful inquiries" have been made is incorrect. The lack of desire to prevent a similar tragedy is the most depressing aspect of the case.

Having listened to Dr. David, I believe that any anaesthetic carries the risk of a serious adverse event, and possibly death.

It is self-evident that, if a disaster occurs and somebody sustains a cardiac arrest during anaesthetic, the facilities and staff are likely to be better in a hospital than in a dentist's surgery or in a community dental clinic, and if cardiac arrest occurs the patient stands a better chance of survival if the procedure is undertaken in hospital.

I draw attention to an editorial in Anaesthesia in 1979 —volume 34, pages 523–525—which makes it clear that anaesthetics in dental premises should be urgently phased out, and certainly should not be taking place in 1987.

I believe that Gillian's death was potentially avoidable, and I should like steps to be taken to bring about a rapid halt to general anaesthetics performed for dentistry on children outside hospitals.

I am sure that it will be appreciated that I am deeply concerned about the tragic death of Gillian Smallwood and am anxious to do all that can be done to establish, as quickly as possible, what happened to her and what measures need to be taken to prevent a similar tragedy.

I call on the Minister, and I am supported by Dr. David, the Rochdale community health council and Gillian's parents, to set up an inquiry into this sad and tragic case to see what lessons can be learned from it.

12.1 am

The Parliamentary Under-Secretary of State for Health and Social Security
(Mrs. Edwina Currie)

I congratulate the hon. Member for Heywood and Middleton (Mr. Callaghan) on his success in the ballot.

I should start with an apology for not responding to the hon. Gentleman's letter of 23 July 1987, which has never turned up. The delays since he wrote to me on 17 September were unsatisfactory, and I have expressed my dissatisfaction to officials. I expect that the muddle was in part due to confusing him with his illustrious and noble Friend, who had left the House at the time that my officials were trying to contact him. At the time, the office was dealing with about 1,000 letters a week. However, the hon. Gentleman drew attention to the non-reply on 26 November and received an answer the next day. He has my unreserved apology for the delay.

On 21 August 1986, Gillian Smallwood, a little girl of five and a half years, attended the Langley clinic at Middleton in Rochdale for the extraction of three teeth under general anaesthesia. She had previously attended the clinic in February 1986, when five deciduous teeth were extracted under general anaesthesia.

Gillian was generally well, but had suffered from a congenital dislocation of the hip and had been an inpatient at Booth Hall children's hospital during July 1986 for the removal of pins.

The anaesthetic history was that Gillian came into the surgery at approximately 2.25 pm, accompanied by her mother, who stayed during the induction. It was agreed that a mobile deciduous incisor would be extracted in addition to the three already designated. The anaesthetic was administered by Dr. Padmanabhan, who holds a consultant appointment with the Rochdale health authority. One hundred per cent. oxygen was administered for between one and two minutes before nitrous oxide at 6 litres per minute was turned on. The oxygen flow was reduced to 2·5 litres a minute and Halothane 0·5·1 per cent. added. A prop was inserted by the anaesthetist, the mouth packed by the dental officer, Miss Arnold, arid three of the teeth were extracted.

During the transfer of the prop to the left side, the child became restless and it was then noticed that the flow of nitrous oxide had ceased. This was re-established by the anaesthetist opening the valve further, the child settled and the remaining extraction was effected.

The extractions were described as uncomplicated and, at this stage, the child's colour was said to he good. The nitrous oxide and Halothane were turned off, but oxygenation was continued. It was then noticed that the child had urinated, that she was pale and had stopped breathing. Positive pressure ventilation was commenced using the rebreathing bag, an endotracheal tube, which first had to be shortened, was passed and connected to the anaesthetic machine and 2 to 3 ml of adrenaline 1:1,000 administered directly into the heart. The child was then moved on to the floor so that cardiac massage could be commenced and an ambulance and crash team were requested. Help was also summoned from the health centre. Dr. Philip Rowlands, a general medical practitioner attending a vaccination clinic, and three district nurses responded. Dr. Rowlands, acting under the direction of the anaesthetist, administered further adrenaline and commenced external cardiac massage. The child was transferred to hospital, where she was declared dead. At the inquest, Dr. Rowlands gave a clear indication that the child was already dead by the time he arrived.

The post mortem examination was conducted by Dr. Lindon, the consultant pathologist at Booth Hall children's hospital. She gave evidence that Gillian was well cared for and well nourished and confirmed the presence of an operational scar over her left hip. No evidence of any other congenital defect was found, nor evidence of any disease except for an upper respiratory tract infection of moderate severity. Dr. Lindon was unable to comment on the effect of the disruption in the flow of nitrous oxide, but when questioned on the effect of the administration of Halothane on three separate occasions in relatively quick succession, she stated that she found no evidence of Halothane toxicity.

I am glad that the hon. Gentleman has confirmed that.

The coroner concluded that there were four causes of death: cardio-respiratory failure, hypoxia — lack of oxygen—dental anaesthesia and tracheo-bronchitis. The finding was misadventure.

Therefore, we appear to have a child with a cold receiving general anaesthesia which appeared to have been less than sufficient at some point during the operation. The child collapsed soon afterwards.

I express my deepest sympathy for the parents in what was a totally unexpected death. I should like to draw attention to the excellent facilities and expert staff at the Langley clinic. That clinic is specially equipped to administer general anaesthetic. There are only three such clinics in Rochdale. Most of the general dental practitioners, at whom the hon. Member for Heywood and Middleton or Dr. David might be directing many of their criticisms, do not do general anaesthetics now in Rochdale. It is done in the special clinics.

The anaesthetic equipment was well maintained and in good working order. The anaesthetic was administered by a consultant anaesthetist, not a registrar or a senior house officer, who was employed precisely for that purpose. A full range of emergency equipment was available—and indeed, it is not unusual to have to shorten a tube as has been described. The staff were fully trained in the emergency treatment of a cardiac arrest and had recently attended a refresher course. Therefore, I reject all the criticisms that have been made.

I should comment on the response of the clinic staff to the child's condition. The consultant anaesthetist led the attempt to help the child. The drug adrenaline, recommended for use in such situations, was available and was used. The mother was not present while resuscitation was attempted and she has complained about that. However, that was because the staff were concentrating on treating the child. An ambulance was called and during the journey to hospital the child was still being treated by the consultant anaesthetist. The crash team was not included because the ambulance by itself was quicker. I know that the consultant concerned should have all the skills necessary for resuscitation if such resuscitation turned out to be possible.

Gillian died on 21 August. The matter was reported to the health authority on 26 August and it was agreed that if the inquest indicated a need, an inquiry would be held. In the light of the inquest, which, as the hon. Gentleman rightly says, set out clearly all the facts of the case, the health authority felt that a further inquiry would not be necessary. It published its own report on the events with commendable speed, and I know that the hon. Gentleman has a copy. Since then, there has been an exchange of correspondence with the Smallwoods' solicitor, the community health council and Dr. David, all requesting an inquiry. I can do no better than quote my reply to the hon. Gentleman of 27 November, in which I said:
"Having studied the report and taken advice, I have concluded that the report"—
I am referring to the report of the health authority—
"has adequately covered the sad events of this particular case, and that the case itself does not give rise to any general issues concerning the safety of dental anaesthesia. I have therefore decided that a further formal inquiry under section 84 of the NHS Act would not be justified."
That is the section of the law that we have used recently, for example, in the investigation of the outbreak of salmonella at Stanley Royd hospital and of Legionnaire's disease at Stafford hospital. We do not consider that it is appropriate or justified to hold an inquiry in the terms that have been requested.

Once Gillian collapsed, everybody acted with commendable speed and everything that could have been done was done. All the correct equipment was in use and working. All the correct guidelines were followed. All the facts are known.

I have received a letter from Dr. David from the department of child health at Manchester university. He was the consultant paediatrician who attended Gillian soon after she was born and subsequently because of her congenital hip problem. He says that he was never interviewed, but in all honesty I doubt whether he could throw any more light on the events in the clinic that surrounded her death, since he was not there.

I am sorry, I am responding to the hon. Gentleman, not to Dr. David, which I shall do in due course.

At the time, the child was under the care of a consultant anaesthetist who was well qualified for the job and who had been appointed precisely for that purpose. The family have taken legal advice and they also have the hon. Gentleman to advise them. I believe that they have access to all the papers from the authority that I have seen. They must decide how to proceed, but I am satisfied that the health authority has done everything that it can and should have done, and I see no reason for calling another inquiry.

I want specifically to reject Dr. David's assertion that all general anaesthesia on children should be done in hospital. That is not necessary or desirable. I draw the hon. Gentleman's attention to the rules of the General Dental Council as set out in its paper of April 1983, particularly to paragraph 5. That sets out rules that have been accepted throughout Britain and which have been a considerable improvement on the previous arrangements, which were the subject of some criticism.

Paragraph 5 says:
"A dentist who carried out treatment under general anaesthesia or sedation without fulfilling these conditions"—
which were set out in great detail in the notes for guidance—
"would almost certainly be considered to have acted in a manner which constitutes infamous or disgraceful conduct in a professional respect."
No such complaint has been made at any time, and I strongly believe that no such complaint could possibly be sustained.

As I read through the papers I found the case upsetting. I have two daughters of my own. I found myself wondering why Gillian was having her teeth out in the first place. She had lost five on a previous visit, also under general anaesthesia, and was about to lose four on this occasion. I have taken advice on that.

I understand that Gillian's dental extractions were necessary because of rampant caries of her deciduous dentition. A photograph of Gillian published in the Manchester Evening News on 29 January 1987 and 17 March 1987 showed her with very broken-down teeth.

The incidence of dental caries in young children in Rochdale has not fallen since 1980 and is much higher than the national average. A typical five-year-old in 1985 in Rochdale had 1·7 decayed teeth, 0·7 missing teeth and 0·8 filled teeth. The equivalent in England in 1983—the most recent figures that I have which are reasonable for comparison purposes—show 1·1 decayed teeth and 0·5 filled teeth. That is a big difference. The mean number of teeth extracted per child treated in Rochdale in 1985—I am talking about children aged between five and nine— was 0·74 and in England it was 0·45. One could put that rather crudely by saying that three-quarters of the children of that age treated at the dentist lost a tooth in Rochdale, whereas it was less than half in England as a whole. Rochdale's children have some of the worst teeth in the country. The record is not one to be proud of.

I also asked whether we had lost any other children like this. I am sad to say that the answer was yes. In 1986, there were two deaths of children associated with general anaesthesia for dental treatment. The other child was four years and four months old, and came from Halifax.

It is normal for children to eat sweets. I reflected on this little girl who had had nine teeth extracted before her sixth birthday through caries and on my younger daughter who loves sweet things and has now reached ten and a half without ever having a single filling or losing a single tooth from dental caries. She is typical of children in Birmingham, where she grew up. The difference is that one child lives in an area with fluoride in its water and the other lived in an area without fluoride. Furthermore, there is no fluoride in the water in Halifax, where the other death occurred.

I am aware that these comments are not entirely fair, because there have been deaths under general dental anaesthesia in Birmingham, too. However, it is possible to cut the risk of such terrible tragedies happening. It is possible to reduce the number of children who need general anaesthesia for necessary and painful dental treatment for bad teeth. I hope that, when the regional and district health authorities in the hon. Gentleman's area move to introduce fluoride — a move that we support and which we shall finance—he will give due thought to this terrible case. I know that some people resent being given what they consider to be unethical medication, but we should not pay for our principles with the death of a child. When the hon. Gentleman is given the opportunity to raise this issue, I hope that he will bear in mind that, had this child lived in a fluoridated area, she might not have died. I know that that does not help the family, but I have to put it on record.

I hope that I have answered the hon. Gentleman's points. The facts are all there and are available for further inspection. I suggest that the hon. Gentleman discusses the matter further with the Smallwood family and lets them decide whether they would like to take the matter further, and in what form.

Question put and agreed to.

Adjourned accordingly at sixteen minutes past Midnight.