The government has apologised for a “20-year cover-up” over the death of 11-month-old Elizabeth Dixon, whose parents have fought an unrelenting battle for the truth.
A new report into the circumstances of Elizabeth’s December 2001 death from asphyxiation resulting from a blocked tracheostomy tube 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”.
The investigation identified failures of care by every organisation that looked after Elizabeth, starting from before she was born when an abnormal ultrasound scan was not acted on. The report’s author, Dr Bill Kirkup, said none of the failures were admitted at the time, nor properly investigated then or later.
“A cover-up began on the day that she died, propped up by denial and deception, which has proved extremely hard to dislodge over the years,” he wrote. “The fabrication became so embedded that it has taken a sustained effort, correlating documents from many sources and interviewing key participants, to demolish it.”
Immediately after her birth at Frimley Park hospital, Surrey, on 14 December 2000, Elizabeth’s blood pressure began to rise but was left untreated. This was despite the fact that aged four days old, Elizabeth’s parents, Anne and Graeme, noticed she had become floppy and unresponsive, the first signs of brain damage, consistent with untreated high blood pressure.
Elizabeth was transferred to Great Ormond Street children’s hospital when an abdominal tumour was detected two weeks after her birth where her high pressure was recognised but mismanaged, causing severe irreversible brain damage. When she was discharged, it was under the care of Nestor Primecare, a private nursing agency which, Kirkup wrote, “patently could not provide her with safe care”.
Joyce Aburime, the nurse caring for Elizabeth on the night of 3 December 2001, had no experience of tracheostomy care in a small child and was unqualified in children’s nursing, the report said. When Elizabeth’s tracheostomy tube became blocked, Aburime did nothing to clear or change it, instead carrying the baby upstairs and crying outside Anne and Graeme’s bedroom door, it found. Elizabeth died in the early hours of 4 December 2001.
The report states: “Elizabeth’s profound disability and death could have been avoided had basic clinical principles been followed.”
Kirkup said that while Aburime should have recognised her unsuitability, it was “fundamentally unjust that the only person held formally responsible [she was struck off the nursing register] has been the most junior involved”.
Dr Michael Tettenborn, Frimley Park hospital’s paediatric clinical director, was criticised in the report for recording Elizabeth’s death as from natural causes, for seeming to have “misled” the coroner as to the significance of the blocked tracheostomy tube and for not initiating a hospital inquiry into Elizabeth’s death.
Kirkup also criticised investigations by the health authority, Nestor Primecare, police, coroner and the Crown Prosecution Service.
He said Hampshire police should be referred to the Independent Office for Police Conduct because of its failure to realise some individuals were being dishonest and those who did not cooperate with his investigation should be investigated by their respective regulatory bodies.
The health minister Nadine Dorries said: “I offer my heartfelt condolences to Elizabeth’s family, to Anne and Graeme Dixon for their loss, compounded by the length of time – the passage of 20 years – before the facts of this case have been brought to light.”
Anne and Graeme Dixon thanked Kirkup for his investigation but questioned why the government statement did not come from the health secretary, Matt Hancock. They added: “No other families should have to witness such horrific events and lose cherished loved ones in this way, nor should they have to suffer the hell we’ve been through to learn the truth. Cover-ups must stop now.”
In 2014, a joint investigation by NHS England and the Care Quality Commission was launched only to be scuppered when NHS England pulled out. A proposed parliamentary and health service ombudsman probe was also abandoned.
The then health secretary Jeremy Hunt appointed Kirkup in 2017 to lead an independent inquiry.