The boy's name was Tony. But he liked to call himself "Alfredo" just because. He baked banana bread. He daydreamed so often that his teachers worried. His mom would catch him kneeling by his bed praying, but he never talked about it. That was his secret. And his bike -- oh, did he love that bike. On Christmas morning in 2000, he hopped on it for the first time, teetered and chirped in delight, "Whoohey!"
That moment they still have. It's on home video. Tony's mom and dad don't watch it much anymore, not since July 17, 2001. That's the day Tony severely cut the tip of his right index finger on the chain of the bike. He was supposed to get stitched up. It was supposed to be routine. Except by the next morning, Tony was dead at the age of 9.
The cause of Tony Clowes's death was "irreversible cerebral anoxia," oxygen starvation of the brain, according to hospital records. His parents believe their son was the victim of cost cutting.
The hospital where Tony was to undergo minor surgery had reused oxygen tubes designated as single-use devices, according to police, government investigators and a coroner's jury. Asleep on the pre-operating room table, Tony could not breathe because the cap of another device had accidentally lodged itself inside his oxygen tube. A nurse had found that reused tube stuffed in the back of a hospital drawer.
New, the oxygen tube cost less than $2. Used, it cost the hospital pennies.
Although British regulators strongly discouraged the practice, Broomfield Hospital, where Tony was treated, acknowledged then that it was reusing single-use devices against the recommendation of the devices' manufacturers. Hospital officials declined to comment for this article.
Since Tony's death, Britain has cracked down on the reuse of single-use medical instruments. But the practice has flourished in other parts of the globe, driven by cash-strapped hospitals' need to find savings. While France bans the reuse of single-use devices, it has taken hold in Germany. Hospitals in China are also reusing single-use devices with little oversight. And it is becoming increasingly common in the United States, where the practice originated, and is condoned by government regulators despite periodic reports of patient injuries.
"It's unbelievable that they're risking people's lives by reusing stuff," said George Clowes, Tony's father. In his son's case, he believes, "it was a cost-cutting exercise."
In May 2003, a coroner's jury ruled that Tony's death was partly the result of "system neglect," which included the hospital's "failure to follow guidelines concerning single-use medical devices."
As it turned out, a two-inch, right-angle oxygen tube -- called an elbow piece -- had been in the back of a drawer at the hospital, jumbled with other medical devices. That included a single-use intravenous kit. As devices jostled in the drawer, the clear cap of the intravenous kit had slipped inside the green elbow piece. After the nurse retrieved the elbow piece, it was attached to the breathing system, which was then connected to Tony.
Last month, the trust that runs the hospital pleaded guilty to failing to ensure Tony's health and safety; the penalty has not yet been decided.
It has been more than four years since the accident, but Tony's mother, Carol, now 43 years old, still cannot bring herself to collect Tony's cremated remains, though they sit not five minutes away at A.G. Butler Funeral Directors.
"I'm not ready to say this is just ashes," she said.
George, 48, struggles with his faith. Carol has come to believe that things happen for a reason. After all, shortly after Tony's accident, a British police officer was undergoing surgery when he had trouble breathing. Heightened awareness about Tony's case prompted doctors to check his oxygen tube. A similar blockage was found, and the man lived.
Tony would have liked the idea that he helped someone, Carol said. How else can she explain her child's death? She said, "There's no other reason."