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NHS regulators face scrutiny in new Kirkup inquiry over baby death

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A new inquiry by Dr Bill Kirkup into the death of a baby girl 16 years ago will examine the role of NHS regulators and national bodies, it has been reported.

Health secretary Jeremy Hunt asked Dr Kirkup, who led the investigation into poor care at University Hospitals of Morecambe Bay NHS Foundation Trust, to examine the case of baby Elizabeth Dixon, who died in 2001 after being left permanently brain damaged after several mistakes were made.

“It is bad enough that there is one case but it’s clear there are others too”

Bill Kirkup

Dr Kirkup said he had agreed to the terms of reference for the inquiry, which are wide enough to look at not just the care of Elizabeth and her mother, but also a wider failure to investigate – such as a decision by NHS England to pull out of a joint investigation with the Care Quality Commission in 2014.

“I have undertaken to Mr and Mrs Dixon that we will pursue the evidence wherever it takes us,” Dr Kirkup told Health Service Journal. “It’s clear that they have had significant concerns and that those concerns haven’t been addressed for more than 15 years.

“It’s very important that we now make sure we make every effort to look at all aspects of what happened; it’s no good doing part of the job and leaving some of the questions unaddressed,” he said. “I have deliberately set the terms of reference wide enough to be able to look at all of that.”

He has reportedly confirmed that the inquiry would include looking at the “regulatory gap” that Elizabeth’s case exposed when it was first highlighted it in 2014.

He said: “It’s all part of the response to what happened. It is clear this isn’t an isolated example. It is bad enough that there is one case but it’s clear there are others too. It causes untold harm to people when we fail to get this right and the longer it goes on the worse it gets for them.”

Elizabeth, who was born prematurely at Frimley Park Hospital in 2000, was left with permanent brain damage after staff failed to monitor or treat her high blood pressure over 15 days.

She suffocated and died almost a year later when a newly-qualified nurse failed to keep her breathing tube clear. The cause of her brain damage was confirmed in 2013.

Bill Kirkup

Copy of Bill Kirkup

Bill Kirkup

A thematic review last year by the CQC, inspired by Elizabeth’s case, found “significant risk” to hundreds of babies and children in a similar situation still.

Dr Kirkup told Health Service Journal his investigation would begin this month and involve an expert panel of two paediatricians, an obstetrician, a paediatric nurse and a community services specialist.

He added: “Whenever I have been involved in investigations, they have always shown there were lessons to be learned, however long ago the incident took place.

“We are going to be objective and we are going to look at what the evidence says; but from what I know about it, I think there will be lessons not only about the care at the time but the handling of concerns and the desire for information afterwards,” he said.

He urged organisations and individuals to cooperate. “It is incumbent on all of us that have anything to do with patient care to cooperate when something needs to be looked at so we can learn and improve. It is not only a professional duty but an ethical one to do that,” he said.

Elizabeth Dixon

Elizabeth Dixon

Elizabeth Dixon

Mr and Mrs Dixon said: “We thank Jeremy Hunt for offering this investigation and Dr Kirkup for agreeing to lead it and we appreciate the assurances we have received from both of them.

“No one cared at all about what we were going through or how their behaviour would wreck our lives or squander the chance of safeguarding another child or adult. We now have an opportunity to change this for other patients and other families,” told Health Service Journal.

“When harm happens under the NHS, no family should endure a cover up that forces them to relive their child’s death for more than 15 years while the family seek the truth for themselves,” they said.

The couple said child death overview processes needed to be overhauled and they hoped Dr Kirkup’s inquiry would add weight to the proposal for independent medical examiners.

A final report with recommendations is expected to be published next year.

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