Professor van Velzen lied to parents, he lied to other doctors, lied to hospital managers, he stole medical records, he falsified statistics and reports, and he encouraged other staff to do the same

Alan Milburn

And Health Secretary Alan Milburn told the House of Commons: "Those who did wrong will now be held to account."

Under van Velzen's guidance, the bodies of all children going under post-mortem were "systematically stripped" of all their organs.

The number of organs increased dramatically in the years he was employed at the hospital, 1988 to 1995.

Managers at the hospital, says the report, failed to prevent Professor van Velzen's "worst excesses".

"His practices were totally unacceptable," said Michael Redfern QC, who chaired the inquiry.

"The prevailing attitude seems to have been that following death it is far better to carry out research for the common good than bury or cremate organs, which would be a terrible waste of potential research material. This completely misses the point of the inquiry."

The pathologist, says the report, was guilty of the following activities:

• Falsifying records, statistics, research applications, and post mortem reports
• Lying to parents about post mortem findings
• Encouraging staff to falsify records
• Failing to even carry out post mortems properly in some cases
• Leaving his department with a budget deficit of more than £70,000

Michael Redfern chaired the inquiry

A close examination of a tissue "stockpile" in the city - many taken even before the arrival of van Velzen - revealed some gruesome finds.

Parts taken included brains, eyes from foetuses, 1,500 stillborn foetuses, and, most shockingly, a number of entire children's heads and bodies.

Most disturbingly, one specimen taken in the 1960s was of the severed head of an 11-year-old child.

The report reveals a catalogue of management failings at Alder Hey which allowed van Velzen to gather the huge number of organs.

Opportunities were missed to investigate and discipline him, says the report.

Four NHS staff, including the chief executive of Alder Hey, Hilary Rowlands, have been suspended.

The trust chairman has left the board, and two non-executive directors have resigned.

The report suggests that several hundred families have faced the trauma of finding out that the hospital had kept organs.

'Systematically stripped'

The pathologist should never be allowed to practice again, says the report.

It calls for changes to the law governing the taking of tissues and organs to include criminal sanction for those who breach regulation.

And a standard national consent form should be introduced, says the report, so that parents are treated the same throughout the country.

Mr Milburn told the House of Commons: "There was a lack of respect, and a failure to appreciate the cirucumstances which led to the taking of human material."

Professor van Velzen's investigations into the root cause of cot death had not been advanced "one iota" by his organ stripping.

He told the House: "This was unethicial and illegal stripping of every organ from every child. He ignored parents wishes, even when they told him specifically that they did not want a full postmortem, let alone the retention of any of their child's organs.

"Professor van Velzen lied to parents, he lied to other doctors, lied to hospital managers, he stole medical records, he falsified statistics and reports, and he encouraged other staff to do the same."

Total never known

Both the Hospital and van Velzen's co-employer, Liverpool University, says the report, will never be able to tell parents accurately what happened to every organ or every child.

Mr Milburn said: "Hospital authorities and the University of Liverpool failed to monitor his practices and failed to take action to stop them.

The report is highly critical of the response of the hospital and university once the scandal broke.

Mr Milburn said: "These failures were compounded by incompetence and insensitivity of both the hospital and univeristy once truth did begin to emerge."

The university, said Mr Milburn, had simply "turned its back" on the desperate parents, some of whom faced the prospect of carrying out four different funerals of their children's bodies and organs.

The pain caused, he said, was "unforgiveable".