The avoidable death of a baby girl was covered up by NHS staff and organisations over 20 years, a major inquiry has found - with facts “wilfully ignored, and alternatives fabricated” to deny her parents the truth.
In a damning report published today, Dr Bill Kirkup, who led the investigation, said the death of baby Elizabeth Dixon in December 2001 could have been avoided and concluded: “There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later” adding: “A cover up began on the day that she died.”
Baby Elizabeth was left brain damaged after doctors and nurses at Frimley Park Hospital, in Surrey failed to treat her dangerously high blood pressure for 15 days after she was born prematurely in December 2000.
She was left severely brain damaged as a result and needing ongoing round the clock care. Almost a year later she suffocated during the night when an agency nurse, Joyce Aburime, who did not have experience of looking after babies with a tracheostomy tube to help them breathe, failed to keep the tube clear.
Her parents rushed her to hospital but in a highly unusual act they were were later driven home with Elizabeth’s body by the doctor responsible for Elizabeth’s care, Dr Michael Tettnenbaum. No post mortem or inquest was held at the time.
A planned investigation collapsed in 2014 after NHS England chief executive Simon Stevens pulled NHS England out of taking part in the inquiry. The health onbudsman then refused to investigate the case sparking critcism of a regulatory gap for ‘historic cases’. The then health secretary Jeremy Hunt commissioned the inquiry saying Elizabeth’s parents had been “passed around the system for too long”.
Dr Kirkup’s report found evidence that “some individuals have been persistently dishonest, both by omission and by commission, and that this extended to formal statements to police and regulatory bodies.”
Baby Elizabeth Dixon died in December 2001
The investigation’s report makes 12 recommendations, including eight about how safety incidents are managed and reviewed and it calls for a referral to the Independent Office for Police Conduct over a poor police investigation.
Dr Kirkup, chair of the investigation, said: “Our findings raise very significant concerns over the conduct and veracity of individuals, some of whom have occupied senior positions, which would have emerged if police had examined the events after Elizabeth’s death, but they closed their investigation without doing so. This should now be the subject of a statutory referral to the Independent Office of Police Conduct.”
He added: “Elizabeth was one child, but the failures that affected her care at every stage are not unique. Had she lived, she would be almost twenty years old, but the same attitudes and behaviours as were evident then may still be found in places today.
“As a result of the concealment of key facts about her death from the outset, her parents have been left for far too long without a complete, true account of what happened. This was a needless and cruel burden for a mother and father already grieving the loss of their child.
“That a cover up so rapidly and simply instigated could be so influential and persistent has significant implications for all of us, and for how public services react when things go wrong.”
He added: “Clinical error, openly disclosed, investigated and learned from, should not result in blame or censure; equally, conscious choices to cover up or to be dishonest should not be tolerated.
“A full response will require some deep-seated changes in organisational and professional culture as well as better recognition of clinical problems and response to safety incidents.”
More to follow…