NHS England has pulled out of an investigation into the treatment and death of a baby girl, left brain damaged after nurses and doctors failed to monitor or treat her high blood pressure.
The parents of baby Elizabeth Dixon, who was born at Frimley Park Hospital in 2000, had been promised a joint investigation by NHS England and the Care Quality Commission into her poor treatment and death as a result of nursing negligence, following a 13 year battle for answers.
“NHS England is not and never has been an investigatory body”
They were due to meet with NHS England’s director of patient safety Dr Mike Durkin and officials from the Care Quality Commission earlier this month to hear the detailed plans for the investigation, but NHS England pulled the plug just days before.
Dr Malcolm Coulthard, a consultant paediatric nephrologist, who reviewed Elizabeth’s treatment in 2013, found she was left with severe brain damage after staff at Frimley Park Hospital failed to treat her “dramatically high” blood pressure over a period of 15 days.
Instead she was treated for a non-existent infection before being transferred to Great Ormond Street Hospital. Notes from her time in hospital also went missing and were later destroyed. The hospital apologised last year for the poor care of Elizabeth.
Dr Coulthard concluded it was “overwhelmingly likely” the high blood pressure cased her brain damage and “led ultimately to her early death.”
Elizabeth suffocated and died 10 days before her first birthday when a newly qualified agency nurse, who had no experience of caring for children with brain damage, failed to keep her breathing tube clear.
The agency nurse, Joyce Aburime, was later struck off by the Nursing and Midwifery Council for failures related to Elizabeth’s care.
Her parents Graeme and Anne Dixon have fought to get answers from the NHS after the poor care was confirmed in 2013.
They said the latest decision has left them “devastated”, adding: “NHS England have prevented the investigation from going ahead and the CQC do not have the powers to investigate Elizabeth’s individual case.
Mr and Mrs Dixon said they wanted an independent inquiry “so that the whole truth is out there, not just for Elizabeth but for other children like her and their families”.
An e-mail sent from the watchdog to the family in June promised the family an “independent and rigorous investigation into Elizabeth’s tragic path from birth to death” with an “investigation panel” set up “in partnership with NHS England.”
Instead, the CQC will now carry out a “thematic review”, which will identify wider lessons for the NHS from Elizabeth’s case.
The CQC told Nursing Times it had been “discussing carrying out a joint piece of work with NHS England, but this has not been possible”.
While it would no longer investigate the “issues raised by the sad death of Elizabeth”, it would use her case as the starting point for “an examination of failures from which wider system learning and improvement can be drawn.”
A spokesperson for NHS England said: “NHS England is not and never has been an investigatory body”.
“We strongly support the independent CQC investigation to ensure the facts and lessons are learned from this tragic case,” he added.
“Patients and relatives also have the right to request the independent Health Ombudsman to investigate individual cases of concern,” he said. “We…sincerely apologise for any misunderstandings that have arisen.”
The Parliamentary Health Service Ombudsman said it was aware of Elizabeth’s case but that it could only investigate cases within 12 months of the “events complained about”.