- Bill Kirkup confirms terms of reference for new investigation into death of baby Elizabeth Dixon
- Inquiry will include inaction by national bodies and regulators in response to concerns by parents
- Jeremy Hunt criticised NHS for family being “passed around the system”
A new inquiry by Bill Kirkup into the death of a baby girl 16 years ago will examine the role of NHS regulators and national bodies whose inaction led to a “regulatory gap”, HSJ can reveal.
Health secretary Jeremy Hunt asked Dr Kirkup, who led the investigation into poor care at Morecambe Bay, to examine the case of baby Elizabeth Dixon, who died in 2001 after being left permanently brain damaged after several mistakes were made.
Dr Kirkup, a former member of the Hillsborough Independent Panel, said he had agreed to the terms of reference for the inquiry, which are wide enough to look at not just the care of Elizabeth and her mother but also the wider failure of the NHS to investigate – including a decision by NHS England in 2014 to pull out of a joint investigation with the Care Quality Commission.
Dr Kirkup told HSJ: “I have undertaken to Mr and Mrs Dixon that we will pursue the evidence wherever it takes us.
“It’s clear that they have had significant concerns and that those concerns haven’t been addressed for more than 15 years. That is going to take an awful toll on anybody. It’s very important that we now make sure we make every effort to look at all aspects of what happened; it’s no good doing part of the job and leaving some of the questions unaddressed.
“I have deliberately set the terms of reference wide enough to be able to look at all of that.”
He confirmed the inquiry would include looking at the “regulatory gap” Elizabeth’s case exposed when HSJ highlighted it in 2014 (see timeline).
He said: “It’s all part of the response to what happened. It is clear this isn’t an isolated example. It is bad enough that there is one case but it’s clear there are others too. It causes untold harm to people when we fail to get this right and the longer it goes on the worse it gets for them.”
Elizabeth, who was born prematurely at Frimley Park Hospital in 2000, was left with permanent brain damage after staff failed to monitor or treat her high blood pressure over 15 days. She suffocated and died almost a year later when a newly qualified nurse failed to keep her breathing tube clear. The cause of her brain damage was confirmed in 2013.
A thematic review last year by the CQC, inspired by Elizabeth’s case, found “significant risk” to hundreds of babies and children in a similar situation still.
Dr Kirkup said his investigation would begin this month and involve an expert panel of two paediatricians, an obstetrician, a paediatric nurse and a community services specialist.
Dr Kirkup added: “Whenever I have been involved in investigations they have always shown there were lessons to be learned, however long ago the incident took place. You can only assume that is not the case if you are sure there has been a proper thorough investigation at the time. I am absolutely not convinced there was in this case.
“We are going to be objective and we are going to look at what the evidence says; but from what I know about it, I think there will be lessons not only about the care at the time but the handling of concerns and the desire for information afterwards.”
He urged organisations and individuals to cooperate. “It is incumbent on all of us that have anything to do with patient care to cooperate when something needs to be looked at so we can learn and improve. It is not only a professional duty but an ethical one to do that,” he said.
Mr and Mrs Dixon said: “We thank Jeremy Hunt for offering this investigation and Dr Kirkup for agreeing to lead it and we appreciate the assurances we have received from both of them.
“No one cared at all about what we were going through or how their behaviour would wreck our lives or squander the chance of safeguarding another child or adult. We now have an opportunity to change this for other patients and other families.
“When harm happens under the NHS, no family should endure a cover up that forces them to relive their child’s death for more than 15 years while the family seek the truth for themselves.”
The couple said child death overview processes needed to be overhauled and they hoped Dr Kirkup’s inquiry would add weight to the proposal for independent medical examiners.
A final report with recommendations is expected to be published next year.
Timeline – A family ‘passed around the system for too long’
- 2013 – Independent report confirms Elizabeth’s brain damage was due to failures by staff at Frimley Park Hospital.
- August 2014 – NHS England chief executive Simon Stevens pulls the organisation out of a planned joint investigation with the CQC. NHS England later said it was “not and has never been an investigatory body”.
- September 2014 – CQC chief executive David Behan said Elizabeth’s case exposed a “regulatory gap”, which prevented the investigation of historic patient complaints.
- August 2015 – Parliamentary and Health Service Ombudsman refuses to investigate the case after what Elizabeth’s parents described as a nine month “nightmare”.
- September 2015 – Health secretary Jeremy Hunt intervenes to order independent inquiry saying Elizabeth’s parents had been “passed around the system” for “far too long.”
- 2016 – CQC thematic review warns of “significant risk” to hundreds of babies and children in a similar situation to Elizabeth.
- 2017 – Bill Kirkup appointed to lead independent inquiry.