The parents of baby Elizabeth Dixon who have spent nearly 20 years fighting a “cover-up” over their daughter’s treatment and death have welcomed an independent inquiry’s calls for a police investigation to be launched.
Anne and Graeme Dixon said they have been “failed by every agency” as they try to find out the truth surrounding the death of their daughter 10 days before her first birthday in December 2001.
They have faced multiple inquiries – including by police and by Parliament – being pulled as well as an inquest which failed to call important witnesses.
Now, chairman of the inquiry Dr Bill Kirkup, a former assistant chief medical officer for England, has made 12 recommendations including eight on how safety incidents are managed and reviewed.
And he has called for Elizabeth’s case to be referred to the Independent Office of Police Conduct.
The Dixons, from Church Crookham, Hampshire, said: “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.
“We cling to the hope Dr Kirkup’s report will do enough to ensure that lessons are genuinely learnt and that these are put into practice and that there is an honest and robust commitment, set out in law, that there is no longer a place for deception or dishonesty by the professionals and organisations we all place our trust in.”
The investigation found that “Elizabeth’s profound disability and death could have been avoided had basic clinical principles been followed”.
It concludes that “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”.
Instead, the investigation found that “a cover-up began on the day that she died”.
The investigation also found clear 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”.
Dr Kirkup said: “Elizabeth was one child, but the failures that affected her care at every stage are not unique. Had she lived, she would be almost 20 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.
“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.”
Health Minister Nadine Dorries, who is responsible for patient safety, apologised to the Dixon family and said her department would oversee the implementation of the report’s recommendations.
“This report describes a harrowing and shocking series of mistakes associated with the care received by Elizabeth and a response to her death that was completely inadequate and at times inhumane,” she said.
“No other family should ever again have to go through the heartache and frustration experienced by the Dixons and I apologise again for the failings set out in this report.”
Elizabeth was born prematurely on December 14 2000 at Frimley Park Hospital in Surrey, and when she was two weeks old she was diagnosed with a non-fatal form of the rare cancer neuroblastoma in her abdomen.
Staff at the hospital failed to diagnose or provide treatment for high blood pressure caused by the condition, which led to her suffering permanent brain damage, leaving her profoundly neurologically disabled and having a tracheostomy tube inserted.
After 10 months at Great Ormond Street Hospital, Elizabeth was discharged to Naomi House, a children’s hospice near Winchester, where Mrs Dixon had to insist that nurses were given training on tracheostomy care.
On December 4 2001, when Elizabeth was in the care of Primecare agency nurse Joyce Aburime, she became seriously ill and Mrs Dixon found that the tracheostomy tube had become blocked.
She was taken by ambulance to Frimley Park Hospital but paramedics found no heart beat and Elizabeth died.
Following her death, the Dixons became increasingly concerned that no post-mortem examination, investigation or inquest was held and they eventually went to Hampshire Police in 2005 for help.
However, the force was unable to bring manslaughter charges against Aburime and a Primecare manager after the Crown Prosecution Service said there was no realistic prospect of conviction.
An inquest was held in 2008 but without main witnesses being called and, following pressure by the Dixons, a joint investigation by NHS England and the Care Quality Commission (CQC) was held only for NHS England to pull out.
Another probe was also to be launched by the Parliamentary and Health Service Ombudsman (PHSO), only for this to be abandoned as well.
Then, in September 2015, Jeremy Hunt, the then health secretary, ordered an independent inquiry and appointed Dr Kirkup in February 2017.