§ Mr. Patrick Jenkinasked the Secretary of State for Social Services if he will publish a report of the inquiry into the case of Elizabeth Shewan; and if he will make a statement.
§ Mr. EnnalsThe committee of inquiry into the case of Elizabeth Shewan was set up by the Kensington and Chelsea and Westminster Area Health Authority (Teaching). The findings of the committee are that the accident arose from the transposition of two medical gas hoses and resulted in Miss Shewan being given nitrous oxide instead of oxygen. The tragic consequences were due to a combination of circumstances, responsibility for which was shared among a number of people. The report makes 22 recommendations, nearly all concerning patient safety in operating theatres generally.
220WA report of the committee is being published by the Authority today and I have arranged for a copy to be placed in the Library of the House. Copies are also being made available to the parties concerned and to the Press.
In accordance with established departmental guidance and practice the published report does not identify by name the parties concerned. There are matters brought to light by the inquiry which may be the subject of litigation. In any litigation, the courts could of course order disclosure of the full report made to the Authority, or any part of it.
The area health authority has accepted the findings of the committee and its recommendations. My Department is also considering them urgently. Action on many of the points raised has already been taken. I assure the House that all necessary action will be taken to avoid, as far as is humanly possible, any recurrence of this tragic event.