Exclusive: Hunt orders investigation of 'regulatory gap' baby death case

Jeremy Hunt told HSJ he had intervened in the “frankly heart breaking” case of Elizabeth Dixon after her family’s concerns had been “passed around the system” for “far too long”.

He said NHS England patient safety director Mike Durkin would commission an independent investigation of the case in his new role in charge of patient safety at NHS Improvement – the regulator to be formed by merging Monitor and the NHS Trust Development Authority.

Elizabeth was born prematurely at Frimley Park Hospital in 2000. She was left with permanent brain damage after hospital staff failed to monitor or treat her high blood pressure, and in 2001 she died of suffocation 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 family’s hopes for a joint investigation by NHS England and the Care Quality Commission were dashed last year when NHS England pulled out at a late stage, prompting CQC chief executive David Behan to warn of a “gap in the system” preventing investigation of historic complaints.

Parliamentary and Health Service Ombudsman Dame Julie Mellor later pledged to close this gap by considering serious historic cases, in spite the watchdog’s usual 12 month time limit. However, the watchdog also eventually refused to probe Elizabeth’s case, after a lengthy preliminary process the family described as “torture”.

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Speaking to HSJ yesterday, Mr Hunt said: “It’s an incredibly distressing case. When you look at the details of what’s happening, it’s frankly heart breaking. It does need an investigation and I think for various unintended reasons, the case was passed around the system and it’s happened for far too long.

“But I have spoken to Mike Durkin about the case, and he has said that he will make sure there is an independent investigation, which he will commission as part of his new role heading up the safety function at NHS Improvement. 

“I can’t say what the outcome of that investigation is, but I hope that will give some comfort to the Dixon family that we are taking this very seriously, and we do want to get to the bottom of what happened.”

Elizabeth’s parents Graeme and Anne Dixon said they were “relieved” that Anne’s antenatal care, the care of Elizabeth and her subsequent death were going to be investigated.

They added: “We await the details of the investigation but we hope it will explore thoroughly both health [and] care and justice matters, as had been offered last year. Our hope is that it will help us achieve a second inquest into the death of our daughter.

“We are grateful to the secretary of state for intervening after the PHSO decided it couldn’t take the case forward, and hope that this intervention will help lead to safer care for other expectant mothers and children, especially those with learning difficulties, and the advancement of dedicated teams of nurses and carers for adults and children needing breathing support in the community, thereby reducing the risks which may and have come so tragically for our daughter and others, with ad hoc agency care and excessive working hours.

“We should like to thank HSJ for highlighting our daughter’s case and all the people who have supported us along the way.”