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Francis adviser to lead inquiry into 'heart breaking' baby death

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An adviser to the Mid Staffordshire NHS Foundation Trust public inquiry will lead an investigation into the death and treatment of a baby girl whose case exposed a “regulatory gap” in the NHS.

Professor Peter Hutton, a senior consultant anaesthetist from the University Hospital Birmingham NHS Foundation Trust and a former chair of the Academy of Medical Royal Colleges and President of the Royal College of Anaesthetists, will conduct the inquiry into the death and treatment of baby Elizabeth Dixon.

“The Dixon family should have been given answers to the questions they have been asking many years ago”

Mike Durkin

She was born prematurely at Frimley Park Hospital in 2000 and was left with permanent brain damage after hospital staff failed to monitor or treat her high blood pressure. Less than a year later she died of suffocation when a newly qualified nurse failed to keep her breathing tube clear.

The cause of her brain damage only emerged in 2013 and her parents have a dossier of evidence suggesting their daughter’s poor care was covered up by senior clinicians in a number of organisations.

Health secretary Jeremy Hunt ordered an inquiry in September last year after Nursing Times’ sister title Health Service Journal highlighted the reluctance of national bodies, including NHS England and the health service ombudsman, to take on the case.

Mr Hunt said the case was “frankly heart breaking” and that the Dixons had been “passed around the system” for “far too long”.

It is likely to consider the care provided to Elizabeth by Frimley Park Hospital, Great Ormond Street Hospital and community services provider Prime Care, as well as subsequent investigations into her death.

Frimley Health NHS Foundation Trust

Francis inquiry adviser to lead review into baby death

Peter Hutton

Professor Hutton, who has carried out a number of inquiries into clinical care as well as a major report for the Home Office into forensic pathology and death certification last year, will meet with Elizabeth’s parents next month and begin work with them to develop the terms of reference for the inquiry.

Dr Mike Durkin, NHS national director for patient safety, said: “My priority has been to ensure that we could get somebody who would provide the high level of skill required to thoroughly examine what happened to Elizabeth Dixon and identify what needs to be put in place to prevent this from happening again.

“I am grateful that Professor Peter Hutton has agreed to lead this investigation. He brings with him considerable investigatory experience both in and outside of the NHS, including as part of the Mid Staffordshire public inquiry team,” said Dr Durkin.

He added: “The Dixon family should have been given answers to the questions they have been asking many years ago, and I know Professor Hutton shares my commitment to get those answers for them.”

“We hope that the investigation will be framed from the outset in ways which give us confidence”

Graeme and Anne Dixon

Dr Durkin said the investigation would be carried out independently of the new regulator NHS Improvement.

Elizabeth’s parents Graeme and Anne Dixon told HSJ: “We welcome the opportunity for an investigation and we look forward to meeting Professor Hutton next month. We hope that the investigation will be framed from the outset in ways which give us confidence and that mistakes, including wilful acts, will be addressed across health, care and justice systems.”

They added: “So much went wrong in the care of Elizabeth and failure to be open about this led to Elizabeth enduring unnecessary and extreme suffering during her life and a horrendous death, which could have and should have been prevented.”

Elizabeth Dixon

Elizabeth Dixon

Elizabeth Dixon

They said all they had wanted was safe care for their daughter and for “other children and families to be protected from what Elizabeth and our family experienced”.

In a statement, Frimley Health NHS Foundation Trust said:Over the past few years we have endeavoured to be open and transparent with Mr and Mrs Dixon about our involvement in the care and treatment provided by Frimley Park after Elizabeth was born, and we will continue to do so with the independent inquiry.”

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