Kirkup: ‘Significant reluctance’ in health system to review ‘historic’ cases

Bill Kirkup also said there was a “lack of clarity” over what families should do when their concerns have not been treated with openness and transparency, and said a national commissioner should be appointed to hear appeals and order investigations.

Dr Kirkup’s report has alleged a “cover up” from the day Elizabeth Dixon, who was left permanently brain damaged after several mistakes were made, died in 2001. The report said “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”.

The report also said it found Elizabeth’s death could have been avoided and that it had seen “clear evidence that some individuals have been persistently dishonest,” in the investigations that followed, including formal statements to police and regulatory bodies.

There was also a “clear failing” in the subsequent police investigation as it was closed without considering the events after Elizabeth’s death, missing the opportunity to identify the “persistently dishonest” individuals, the report found. The review called for the investigation to be referred to the Independent Office of Police Conduct.

Jeremy Hunt intervened to order the review in 2015, when the health secretary, after multiple stories in HSJ,  highlighted the case and the battle by her family to get an investigation. 

Dr Kirkup, speaking to HSJ following the publication of the report, said he is aware of other people who are in a similar position to the Dixon family. 

He said: “I’m concerned that it’s possible that sometimes there’s a reaction to something that happened a long time ago that says ‘there’s can’t be anything new to be learned about this’. 

“I don’t think that’s true – I think it’s impossible to see without looking. [When] those cases that do get looked at [it] very often turns out there are still behaviours and attitudes now that haven’t been put right.”

In 2014, NHSE chief executive Simon Stevens ruled out his organisation taking part in an investigation into Elizabeth’s deaths, scuppering the potential inquiry. It led to a review by the Care Quality Commission which concluded there was a “gap” in the regulatory system in investigating historic complaints.

Dr Kirkup said he understood NHSE’s decisions at that point, but that NHSE did not nominate an “alternative mechanism” for the Dixon family to pursue their case.

He said: “There’s a lack of clarity. I don’t think anybody understands what to do if the answers have not been forthcoming.

“I think there should be a standing mechanism with a commissioner of independent investigation who would be there to appeal to, who could then set up the right sort of independent investigation.

“There’s a problem with a regulatory gap. I would support moves to put something in place that meant that there was someone to appeal to.

“There’s a very complex landscape that people can appeal to when they feel they are not getting the answers properly and honestly. Part of the problem is it’s so complex – it’s not always evident which is the best place to approach to get the answers they are looking for.”

Elizabeth was born prematurely at Frimley Park Hospital in 2000 but was left with permanent brain damage when staff failed to monitor or treat her high blood pressure over 15 days. In December 2001, she suffocated and died when a newly qualified nurse, Joyce Aburime, working for Nestor Primecare, failed to keep her breathing tube clear.

No post mortem or inquest was held at the time after what the report called a “sham” of an investigation by the coroner’s office. The report said that “it seems” the doctor responsible for Elizabeth’s care – Michael Tettenborn – “misled” the Surrey Coroner’s officer Sue Masters about the significance of the blocked tracheostomy tube and a morphine medication error. Dr Tettenborn has consistently maintained since that he notified Ms Masters of very serious concerns, the report added.

The report said Dr Tettenborn did not trigger a serious untoward incident investigation – which it called “an extraordinary failure of clinical governance” – and that he drove to the Dixon’s home with Elizabeth’s body which “ended the possibility of Elizabeth’s parents saying something at Frimley Park Hospital that would have challenged Dr Tettenborn’s account of an expected death”.

Anne and Graeme Dixon, the parents of Elizabeth, said in a statement they have been “failed by every agency possible” over the past 19 years.

They said: “It is inconceivable to us that not one of these earlier agencies knew, or suspected, the truth. The evidence was there. We have been treated appallingly.

“Over the years, we have unearthed a significant amount of evidence about the circumstances which led to Lizzie’s painful and needless death, some of this was not used by the inquiry. While we are pleased to see the recommendations put forward and that some of the blatant lies, deception and cover-ups of mistakes and incompetence have been called out, we are disappointed that certain aspects of Lizzie’s care and the cover-up have not been addressed.”

Minister for patient safety Nadine Dorries said she was “truly sorry” for the time taken for the facts to be brought to light.

She said: “This report describes a shocking series of mistakes associated with the care received by Elizabeth and the response to her death.

“It is unacceptable for patients ever to be exposed to unsafe or poor care, and the health system must carefully consider the report’s recommendations. We will do everything in our power to ensure such events cannot happen again.”

Timothy Ho, medical director at Frimley Health FT offered “sincere apologies” to Elizabeth’s family. He added: “Our care for neonatal infants, our support for bereaved parents and how we investigate concerns have changed beyond recognition over the past 19 years, but we will carefully consider the report and its recommendations with a commitment to taking any action that is needed.”

Hampshire constabulary assistant chief constable Ben Snuggs said the force conducted an investigation into the death of Elizabeth in April 2005. A woman from Coventry was arrested but it was decided with the Crown Prosecution Service no charges would be brought.

In 2010 the Independent Police Complaints Commission considered an appeal against this decision and did not uphold the appeal.

Mr Snuggs said: “Now that the report has been published and shared with us, we will read its findings carefully in order to determine whether there is any future role for Hampshire Constabulary.”