The Parliamentary Health Service Ombudsman has refused to investigate the death of a baby at the centre of claims of a ‘regulatory gap’ between national bodies preventing them looking into historic complaints.

  • PHSO will not investigate the care and death of baby Elizabeth Dixon, after NHS England pulled out of joint inquiry with CQC
  • Family say complaints process “feels designed to frustrate and exhaust you”
  • PHSO: “Regretfully, there are times when we are unable to investigate a complaint”

The parents of baby Elizabeth Dixon, who died in 2001, told HSJ their experience of the PHSO process had been a nine month “nightmare”, with the ombudsman eventually accepting it was incapable of investigating all aspects of the case.

Anne and Graeme Dixon said: “If the ombudsman won’t investigate the death of our daughter, the [Care Quality Commission] doesn’t have the powers and NHS England has refused, the question has to be who will?”

Elizabeth, who was born prematurely at Frimley Park Hospital in 2000, was left with permanent brain damage after hospital staff failed to monitor or treat her high blood pressure over 15 days. She suffocated to death almost a year later when a newly qualified nurse failed to keep her breathing tube clear. The cause of her brain damage was only confirmed in 2013.

Over the past decade, her parents have amassed a dossier of evidence which they say proves their daughter suffered poor care and that the circumstances were covered up by senior clinicians and officials in a number of organisations.

The PHSO’s refusal to investigate the case follows the decision last year by NHS England to pull out of a joint independent inquiry with the CQC. This prompted CQC chief executive David Behan to say NHS England’s stance had revealed “a gap in the system” which prevented the investigation of historic complaints.

Dame Julie Mellor

Dame Julie Mellor said last year that the PHSO would act to close the gap

In October 2014 the ombudsman Dame Julie Mellor said the PHSO would act to close the gap and would consider serious historic cases, despite its usual 12 month time limit. However, it has rejected the Dixons’ complaint.

Mr and Ms Dixon told HSJ their experience with the PHSO had exacerbated their grief. They added: “Torture is an accurate description of what we have been through.

“The whole process feels designed to frustrate and exhaust you. It is totally stressful and you have to constantly check what they say and point out their mistakes. It’s a nightmare and a farce and now nine months on we have got nowhere.”

They outlined a number of complaints with the way the PHSO had handled their case, including:

  • The PHSO telling the family it would pass on information related to criminal activity, but in a follow-up letter it confirmed this was wrong and it was barred by law from passing on information, unless it poses a risk to the health and safety of patients.
  • In its initial scope for a proposed investigation, the PHSO failed to include the NHS trust, health authority and key clinical staff from the investigation and also refused the family’s suggestion that the PHSO use a former police investigator as it had done in other cases. It then abandoned the proposed investigation.
  • Mr and Ms Dixon arranged to have their documents photocopied at the PHSO’s request, but after arranging this were told that instead the PHSO would go directly to the organisations involved. When it finally decided not to investigate the case, the PHSO then claimed the family were unwilling to share documents despite the parents sharing their information and meeting on several occasions with PHSO staff.
  • The PHSO repeatedly sent the family password protected documents which they could not open until a separate email containing the password was sent.

In letter to the family last month, Mick Martin, PHSO managing director and deputy ombudsman, said: “We must be able to investigate on our terms and in keeping with the particular circumstances of the case.

“We simply cannot investigate some of the issues you maintain are fundamental to our investigation. We do not consider an investigation by us would provide you with what you need and we are conscious that the longer we continue with this conversation the greater the impact on you and your family. I am sorry but we think we need to draw a line under our consideration of your complaint.”

A PHSO spokeswoman said it would not comment on individual cases, but added: “We have investigated several historic complaints about serious health cases, but regretfully there are times when we are unable to investigate a complaint because, for example, it’s about an organisation that’s not within our jurisdiction or we are unable to agree with the complainant what we can investigate.”

She would not say exactly how many historical cases had been investigated.