At the end of last month the Government published its report into the events surrounding the tragic 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.
Commissioned by Jeremy Hunt when he was Secretary of State for Health, the investigation led by Dr Bill Kirkup, was tasked with reviewing the care given to Elizabeth 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. Sadly, in spite of the historic events, the failures identified in Dr Kirkup's subsequent report have a relevance for all involved in current healthcare and investigations when things go wrong. The report's subtitle indicates that it should be 'A Catalyst for Change' – an endorsement that every reader will share.
The failures and the cover ups
This report pulls no punches in its description of the harrowing and shocking series of mistakes associated with the care received by Elizabeth a her mother, including;
- Antenatal review – tumour missed on ultrasound scanning
- Delivery – emergency caesarean mismanaged at Frimley Park
- Neonatal care- untreated high blood pressure caused brain damage at Frimley Park, that damage being increased following transfer to Great Ormond Street Hospital
- Hospice and community care mistakes – failures by Nestor Primecare and their staff leading to death.
Dr Kirkup is clear that Elizabeth's disabilities and death were avoidable and as the above list identifies, every organisation that she received care from failed her.
The concerns do not, however, stop there. Following Elizabeth's death we have investigation failures by the Coroner, Frimley Park, Nestor Primecare, the local Health Authority, Nursing and Midwifery Council and the Police, which were completely inadequate and which perhaps explains why it has taken 19 years to get to this point.
The relevance of the recommendations
When a historic case is reviewed investigators can conclude that some of the failures 'couldn't happen now' – the past being a foreign country. No such reassurance is or can be given in this report. Whilst there has been progress with openness via the duty of candour and recognition that patients have a voice that should be listened to since 2001, the findings of denial and deception in this case are traced back to clinicians failing to admit fundamental errors at the outset. This goes to the heart of how unintended harm is recognised (or not) in healthcare.
Of the 12 recommendations made by Dr Kirkup, training for clinicians in how to deal with errors when they occur and how error should not automatically equal blame are key, as is his call for a 'stop button' for criminal and regulatory investigations as soon as a systemic failure is recognised.
The report references that clinical mistakes are the third leading cause of death in western healthcare systems – a theme that DWF will be exploring further at our international Harm in Healthcare conference taking place on 8th and 9th February 2021 .