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It was the CQC's new chief inspector who led the review into children like Elizabeth Dixon. Out of all the bodies named in this episode it seems to be the only one that tried to do something even though it doesn't have the powers to investigate individual cases. Ted Baker isn't likely to change tack now he's in the top job.

The real question has to be how NHS England justifies its actions in 2014 given it was responsible for safety then. It poses the thought that because of this delay in investigating the case have opportunities to improve care been delayed or missed because of the decision to pull out in 2014?

Serious issues for Bill Kirkup to look at that transcend the tragic case of Elizabeth and apply to lots of other cases I suspect.