The avoidable dying of a child woman was lined up by NHS workers and organisations over 20 years, a serious inquiry has discovered – with information “wilfully ignored, and alternate options fabricated” to disclaim her mother and father the reality.
In a damning report revealed right this moment, Dr Invoice Kirkup, who led the investigation, mentioned the dying of child Elizabeth Dixon in December 2001 when her respiratory tube was blocked might have been averted, concluding: “There have been failures of care by each organisation that taken care of her, none of which was admitted on the time, nor correctly investigated then or later” including: “A canopy up started on the day that she died.”
It added that after her dying, Elizabeth’s “mother and father had been met with indifference, rejection and outright deception as a substitute of openness and honesty”.
Child Elizabeth was left mind broken after medical doctors and nurses at Frimley Park Hospital, in Surrey didn’t deal with her dangerously hypertension for 15 days after she was born eight weeks preamature in December 2000. Her blood stress was attributable to a tumour in her adrenal glands, a neuroblastoma.
She was left severely mind broken consequently and needing ongoing around the clock care. Virtually a yr later she suffocated in the course of the evening when an company nurse, Joyce Aburime, who didn’t have expertise of taking care of infants with a tracheostomy tube to assist them breathe, didn’t maintain the tube clear.
Her mother and father rushed her to hospital however in a extremely uncommon act they had been had been later pushed house with Elizabeth’s physique by the physician accountable for Elizabeth’s care, Dr Michael Tettenborn. No put up mortem or inquest was held on the time.
A deliberate investigation collapsed in 2014 after NHS England chief government Simon Stevens personally pulled NHS England out of collaborating within the inquiry. The well being service Ombudsman then refused to research the case sparking critcism of a regulatory hole for ‘historic circumstances’. The then well being secretary Jeremy Hunt commissioned the inquiry saying Elizabeth’s mother and father had been “handed across the system for too lengthy”.
Dr Kirkup’s report discovered proof that “some people have been persistently dishonest, each by omission and by fee, and that this prolonged to formal statements to police and regulatory our bodies.”
The investigation’s report makes 12 suggestions, together with eight about how security incidents are managed and reviewed and it requires a referral to the Impartial Workplace for Police Conduct over a poor police investigation by Hampshire police.
Dr Invoice Kirkup, chair of the investigation, mentioned: “Our findings elevate very important considerations over the conduct and veracity of people, a few of whom have occupied senior positions, which might have emerged if police had examined the occasions after Elizabeth’s dying, however they closed their investigation with out doing so. This could now be the topic of a statutory referral to the Impartial Workplace of Police Conduct.”
He added: “Elizabeth was one little one, however the failures that affected her care at each stage will not be distinctive. Had she lived, she could be virtually twenty years outdated, however the identical attitudes and behaviours as had been evident then should still be present in locations right this moment.
“Because of the concealment of key information about her dying from the outset, her mother and father have been left for a lot too lengthy with out a full, true account of what occurred. This was a unnecessary and merciless burden for a mom and father already grieving the lack of their little one.
“ cowl up so quickly and easily instigated could possibly be so influential and chronic has important implications for all of us, and for a way public providers react when issues go flawed.”
He added: “Medical error, overtly disclosed, investigated and discovered from, shouldn’t lead to blame or censure; equally, aware selections to cowl up or to be dishonest shouldn’t be tolerated.A full response would require some deep-seated modifications in organisational and professional tradition in addition to higher recognition of medical issues and response to security incidents.”
Talking to The Impartial right this moment, Elizabeth’s mother and father thanked Dr Kirkup for his work and referred to as for a brand new physique to research NHS cowl ups.
Elizabeth’s mom Anne Dixon mentioned: “There must be an organisation with the powers to do a full investigation. All the prevailing organisations have completely different roles and remits and even Dr Kirkup’s inquiry wasn’t capable of compel NHS workers or non-NHS organisations to cooperate.”
She added: “This isn’t only a tradition 20 years in the past, it is a tradition we’ve got skilled all through all of the investigations and it’s a tradition that different households expertise right this moment.”
When Elizabeth was born, medical doctors gave an instruction in her medical notes for blood stress to be checked each 4 hours, however the instruction was ignored, and it wasn’t measured once more till the fourth day. Once more it was discovered to be excessive however was not handled. Measured 10 days later it was dangerously excessive once more.
Her mother and father observed Elizabeth turned “floppy” days after being born – the primary indicators of extreme mind injury.
She was taken to Nice Ormond Road Hospital the place her blood stress was “decreased precipitately” inflicting additional mind injury, the report discovered. This mirrors failings in care recognized by consultants within the case of Jasmine Hughes, who died in 2011. Nice Ormond Road have been accused of masking up what occurred to Jasmine earlier this month after proof went lacking and key info was not shared with a coroner nor included in her medical notes.
Months later as Elizabeth was able to be discharged, the NHS mentioned it couldn’t present the extent of care she would wish at house however a personal firm was commissioned with out correct scrutiny of its means take care of Elizabeth below a contract the inquiry mentioned was “fully insufficient”.
On the evening she died Paul Collins, a senior supervisor for the corporate, allotted Joyce Aburime to take care of Lizzie regardless of figuring out she had no expertise of tracheostomy care in a small little one, and was not certified in kids’s nursing.
Through the evening Elizabeth’s respiratory tube turned blocked. The inquiry mentioned: “The almost definitely clarification is that [Aburime] had fallen asleep after an extended journey and maybe a previous shift in Coventry. Whether or not or not that is what occurred, her lack of motion represents a transparent failure of nursing care.”
When she was rushed to hospital Dr Michael Tettenborn, who was accountable for Elizabeth’s neighborhood care, was referred to as and he informed medical doctors her dying was anticipated and her dying was pure causes.
Dr Kirkup’s report mentioned: “This notice was flawed in virtually each important respect” including it appeared designed to minimize what might have occurred. He additionally directed a junior physician to fill out a dying certificates incorrectly.
Dr Tettenborn then drove the Dixon’s house with Elizabeth’s physique, accompaniedby Ms Aburime in what the report mentioned was an “ uncommon and irregular” motion. It added thst this additionally “ended the opportunity of Elizabeth’s mother and father saying one thing at Frimley Park Hospital that may have challenged Dr Tettenborn’s account of an anticipated dying…When theyarrived on the home Dr Tettenborn merely let all the passengers out on the drive, Mrs Dixon carrying Elizabeth, and left them there.”
The report mentioned the coroner’s workplace carried out a “sham” of an investigation that denied the household a put up mortem after Dr Tettenborn misled the coroner’s officer about what occurred to Elizabeth.
A police investigation and CPS determination to not prosecute was “severely flawed” the report discovered with an absence of unbiased recommendation and proof and “pervasive” view that Elizabeth was terminally ailing and her dying the results of a tragic one-off accident as a substitute of care failings.
In an announcement to the Home of Commons affected person security minister Nadine Dorries mentioned: “This report describes a harrowing and stunning collection of errors related to the care obtained by Elizabeth and a response to her dying that was fully insufficient and at instances inhumane.
“Elizabeth and her household had been let down by a failure to diagnose or reply to her underlying situation, to place in place the care she required, to acknowledge the circumstances of her dying or present her mother and father with an trustworthy account of those failings.”
She added: “On behalf of presidency and the well being system I want to say I’m really sorry for the devastating influence this should have had upon the Dixon household.
“I hope this report is the start of a course of that may deliver some closure for the household. They need to not have needed to wait for thus lengthy.
“Elizabeth’s legacy needs to be that different households will at all times be informed the reality.”
She mentioned the NHS and nationwide our bodies ought to “mirror rigorously” on the report including: “There isn’t a room for complacency. The continuous look of stunning stories about affected person security – historic or newer – implies there may be a lot for the NHS to deal with. My division will due to this fact have oversight of their responses and report again to the home. There must be studying and implementation, however above all I need to be assured that we’re doing all we will to ensure such occasions can’t occur once more.
“No different household ought to ever once more need to undergo the heartache and frustration skilled by the Dixon’s.”
Professor Stephen Powis, NHS England medical director, mentioned: “Whereas NHS England isn’t and has by no means been an investigatory physique so was not in a position itself to conduct a assessment into this tragic case from almost twenty years in the past, we absolutely supported an unbiased investigation all through in order that the household might get the information they deserve, which should now be acted on.”
Dr Timothy Ho, medical director at Frimley Well being NHS Basis Belief, mentioned: “We welcome the publication of this report and would really like as soon as once more to supply our honest and heartfelt apologies to Elizabeth’s household.
“Our take care of neonatal infants, our help for bereaved mother and father and the way we examine considerations have modified past recognition over the previous 19 years, however we are going to rigorously contemplate the report and its suggestions with a dedication to taking any motion that’s wanted.”
A spokesperson for Nice Ormond Road Hospital mentioned it was working to “establish the actions we have to take to be taught from this case”.
“It’s clear that Elizabeth and her household have been let down at so many factors throughout her life and following her dying and we’re very sorry for our position on this,” the spokesperson added.