Michael Lane: could face disciplinary charge

It said the health authority "acted within its powers and did all that it should have done to monitor the state of preparedness of the Towngate Dental Practice to undertake dental general anaesthesia".

Karla was brought to the surgery by her mother Tracey Marsh for a general anaesthetic because she was afraid of needles.

The practice was the only one within the health authority that gave general anaesthetics following the introduction of new guidelines from the GDC in November 1998.

As the child was coming out of the anaesthetic she began to choke and collapsed.

Karla was taken to Chorley and South Ribble District General Hospital but was pronounced dead.

Surgery inspection

The inquiry, chaired by Christine Jackson, began investigations into the role of the health authority and the two men following the collapse of the trial at Preston Crown Court in February.

An inspection of the surgery had been carried out by Dr Nigel Entwistle, the dental practice adviser for the health authority, five months before Karla's death.

He was shown around the surgery by Dr Vanner and found a number of problems including the fact that adrenaline for emergency use was not available on the premises and the resuscitation equipment was set up for an adult rather than a child.

Dr Entwistle was assured that these would be sorted out.

Follow-up letter

He sent a follow-up letter and decided a second visit was necessary but before he could arrange it Karla died.

The inquiry concluded the health authority and Dr Entwistle had done all they could to monitor the practice.

Ms Jackson said such a tragedy would never happen again in south Lancashire following the introduction of new national guidance and regulations.

She said: "I am pleased that the health authority has accepted our report in full."

I need to take into consideration whether disciplinary action would hold up the processes of the General Medical Council

David Edmundson, health authority chief executive

Chief Executive of the health authority, David Edmundson, said he would be considering whether or not to take disciplinary action against Mr Lane, who still practices as a dentist. Dr Vanner was now retired.

He said the dentist had already been referred to their governing professional body.

Mr Edmundson said: "I need to take into consideration whether disciplinary action would hold up the processes of the General Medical Council."

Pathologist's 'mistake'

The manslaughter trial at Preston Crown Court collapsed after a Home Office pathologist conceded that he had made a "mistake" by ruling out a heart defect which may, in fact, have killed Karla.

The judge directed a jury to find the two men not guilty.

Mr Lane was fined �3,000 for breaching health and safety regulations.