• Professor Peter Hutton will lead inquiry into care and treatment of Elizabeth Dixon
  • National patient safety director says her parents deserve answers
  • Health secretary Jeremy Hunt intervened after PHSO and NHS England declined to investigate

An adviser to the Mid Staffs public inquiry will lead an investigation into the death and treatment of a baby girl whose case exposed a “regulatory gap” in the NHS, HSJ can reveal.

Professor Peter Hutton will conduct the inquiry into the death and treatment of baby Elizabeth Dixon.

He is a senior consultant anaesthetist at University Hospital Birmingham Foundation Trust, and former chair of the Academy of Medical Royal Colleges and president of the Royal College of Anaesthetists. He was also part of the Francis inquiry team.

Elizabeth was born prematurely at Frimley Park Hospital in 2000 and was left with permanent brain damage after hospital staff failed to monitor or treat her high blood pressure. Less than a year later she died of suffocation when a newly qualified nurse failed to keep her breathing tube clear.

The cause of her brain damage only emerged in 2013 and her parents have a dossier of evidence suggesting their daughter’s poor care was covered up by senior clinicians in a number of organisations.

Health secretary Jeremy Hunt ordered an inquiry in September after HSJ highlighted the reluctance of NHS England and the Parliamentary and Health Service Ombudsman to take on the case.

Mr Hunt said the case was “frankly heart breaking” and that the Dixons had been “passed around the system [for] far too long”.

The review is likely to consider the care provided to Elizabeth at Frimley Park Hospital, Great Ormond Street Hospital and community services provider Prime Care, plus subsequent investigations into her death.

Professor Hutton, who has carried out a number of inquiries into clinical care as well as a major report for the Home Office into forensic pathology and death certification, will meet with Elizabeth’s parents next month and begin work with them to develop the terms of reference for the inquiry.

Elizabeth Dixon

Elizabeth Dixon

The review is likely to consider the care of Elizabeth by a number of providers

Dr Mike Durkin, NHS national director for patient safety, said: “My priority has been to ensure that we could get somebody who would provide the high level of skill required to thoroughly examine what happened to Elizabeth Dixon and identify what needs to be put in place to prevent this from happening again.

“I am grateful that Professor Peter Hutton has agreed to lead this investigation. He brings with him considerable investigatory experience both in and outside of the NHS, including as part of the Mid Staffordshire public inquiry team.”

He added: “The Dixon family should have been given answers to the questions they have been asking many years ago, and I know Professor Hutton shares my commitment to get those answers for them.”

Dr Durkin said the investigation would be carried out independently of NHS Improvement.

Elizabeth’s parents Graeme and Anne Dixon said: “We welcome the opportunity for an investigation and we look forward to meeting Professor Hutton next month.

“We hope that the investigation will be framed from the outset in ways which give us confidence and that mistakes, including wilful acts, will be addressed across health, care and justice systems.

“So much went wrong in the care of Elizabeth and failure to be open about this led to Elizabeth enduring unnecessary and extreme suffering during her life and a horrendous death, which could have and should have been prevented.”

They said that all they had wanted was safe care for their daughter and for “other children and families to be protected from what Elizabeth and our family experienced”.

Frimley Health Foundation Trust said in a statement:Over the past few years we have endeavoured to be open and transparent with Mr and Mrs Dixon about our involvement in the care and treatment provided by Frimley Park after Elizabeth was born and we will continue to do so with the independent inquiry.”