Today we have published the report into the events surrounding the death of Elizabeth Dixon – a baby who sadly died in December 2001 from asphyxiation resulting from a blocked tracheostomy tube and while under the care of a private nursing agency.
I offer my heart-felt condolences to Elizabeth’s family, to Anne and Graeme Dixon for their loss, compounded by the length of time – the passage of twenty years – before the facts of this case have been brought to light.
The investigation led by Dr Bill Kirkup was tasked with reviewing the care given to Elizabeth Dixon between her birth on 14 December 2000 and her death on 4 December 2001 - and the response of the health system to a catalogue of errors and serious failings in that care.
This report describes a harrowing and shocking series of mistakes associated with the care received by Elizabeth and a response to her death that was completely inadequate and at times inhumane. Elizabeth and her family were let down by a failure to diagnose or respond to her underlying condition, to put in place the care she required, to acknowledge the circumstances of her death or provide her parents with an honest account of these failings.
The investigation sheds light on what the report describes as a ‘twenty year cover up’. It alleges that some individuals have been persistently dishonest in accounting for their actions or inaction.
Underlying all of this was the acceptance of a flawed prognosis that influenced the future course of events. It created a situation in which “facts were wilfully ignored, and alternatives fabricated”. Shocking too is the implication in the report’s recommendations that the presence of her physical and mental health needs may have been used to justify or excuse the inadequate care she had received.
On behalf of Government and the health system I would like to say I am truly sorry for the devastating impact this must have had upon the Dixon family.
Individuals made mistakes and acted unprofessionally, but the system allowed it. The report makes clear that “clinical error, openly disclosed, investigated and
learned from, should not result in blame or censure; equally, conscious choices to cover up or to be dishonest should not be tolerated”.
It is also unacceptable for patients ever to be exposed to unsafe or poor care, and I remain fully committed to ensuring we provide the highest standards of quality and safe services to all patients.
I am grateful to my Right Honourable Friend the member for South West Surrey for commissioning this investigation in June 2017 when he was Secretary of State for Health and bringing these events into the open. I would also like to thank Dr Bill Kirkup and his team for the diligence and hard work that has informed their report.
Particularly, I would like to pay tribute to Anne and Graeme Dixon who have fought so hard for answers. I hope this report is the beginning of a process that will bring some closure for the family. They should not have had to wait for so long.
This report shines a light on a culture of denial and cover up 20 years ago that left a family with little choice but report their concerns to the police. Families should not have to fight a closed system for answers and I will not hesitate to expose this sort of behaviour whenever it appears today.
Indeed, Elizabeth’s legacy should be that other families will always be told the truth.
Relevant organisations will need to consider and reflect carefully on the report’s recommendations. There is no room for complacency. The continual appearance of shocking reports about patient safety – historic or more recent – implies there is much for the NHS to focus on. My Department will therefore have oversight of their responses and report back to the House. There needs to be learning and implementation, but above all I want to be assured that we are doing all we can to make sure such events cannot happen again.
No other family should ever again have to go through the heartache and frustration experienced by the Dixon’s and I apologise again for the failings set out in this report.
Copies of the report have been laid before the House.
This statement has also been made in the House of Lords