Baby death 'cover up' for nearly 20 years needs police investigation, inquiry says

Health authorities covered up failings that led to a baby’s death and should be investigated by the police, an inquiry has found after 19 years.

A string of errors were made by the care organisations which looked after Elizabeth Dixon between her birth and death in December 2001, just days shy of her first birthday.

Her parents spent nearly two decades campaigning to uncover how she died after several inquiries, including by police and by Parliament, faltered and an inquest failed to call key witnesses.

An independent inquiry was set up into the baby’s death in 2015 by Jeremy Hunt, then Health Secretary, headed by Dr Bill Kirkup, a former assistant chief medical officer for England.

On Thursday, he delivered the excoriating findings of his investigation, which said: "Elizabeth's profound disability and death could have been avoided had basic clinical principles been followed.”

It concluded 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, Dr Kirkup said, "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 has called for the Independent Office of Police Conduct to examine how Elizabeth’s case was handled.

On Thursday, her parents, Graeme and Anne Dixon, from Church Crookham, Hampshire, welcomed the findings, saying: “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.”

Elizabeth was born prematurely at Frimley Park Hospital in Surrey, where staff failed to diagnose the high blood pressure caused by a non-fatal form of the rare cancer neuroblastoma in her abdomen.

This led to her suffering permanent brain damage and requiring a tracheostomy tube.

After 10 months at Great Ormond Street Hospital, Elizabeth was discharged to Naomi House, a children's hospice near Winchester, where her mother 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 heartbeat and Elizabeth died.

Following her death, the Dixons became increasingly concerned that no post-mortem, investigation or inquest was held.

Hampshire Police subsequently said it could pursue manslaughter charges against Aburime and a Primecare manager, while an inquest was held without the main witnesses being called.

Dr Kirkup said: "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.”

Dr Timothy Ho, Medical Director at Frimley Health NHS Foundation Trust  said: “We welcome the publication of this report and would like once again to offer our sincere and heartfelt apologies to Elizabeth’s family.

"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.”

A spokesman for Great Ormond Street Hospital for Children said:  "We welcome the report from Dr Kirkup and we hope that it will bring Elizabeth Dixon’s family the answers they have sought. We know that this will be an emotional day for her family, and our thoughts are with them.

“As the report has just been published, we are now in the process of reviewing the findings and recommendations to understand what this means and identify the actions we need to take to learn from this case.

“It is clear that Elizabeth and her family have been let down at so many points during her life and following her death and we are very sorry for our role in this.”