Patient Safety Learning's statement on the Dixon Inquiry report


  • 26th November 2020

Patient Safety Learning welcomes the publication of today’s report by Dr Bill Kirkup investigating the death of Elizabeth Dixon and setting out a series of recommendations in respect of the failures in the care she received from the NHS.

Elizabeth Dixon was a child with special health needs. She had been born prematurely at Frimley Park Hospital on 14 December 2000. Following treatment and care at Great Ormond Street Hospital and a children’s hospice she was nursed at home under a care package. As a result of a failure to clear a tracheostomy tube she asphyxiated and was pronounced dead at Frimley Park hospital on 4 December 2001.

The report noted that:

“Elizabeth’s profound disability and death could have been avoided had basic clinical principles been followed. There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later. Instead, 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. The fabrication became so embedded that it has taken a sustained effort, correlating documents from many sources and interviewing key participants, to demolish it.”[1]

Helen Hughes, Chief Executive of Patient Safety Learning, said:

“This is a truly harrowing case and our thoughts are with Anne and Graeme Dixon at this incredibly difficult time. They have spent years campaigning to ensure that the truth around their daughter’s death was uncovered, that there is honesty, that lessons are learned and that other deaths are prevented. The report has revealed many failures and sets out a number of recommendations. We will be reviewing the report in detail and commenting further. We will do all we can to ensure that lessons are learned and action is taken”

[1] Dr Bill Kirkup CBE, The Life and Death of Elizabeth Dixon: A Catalyst for Change, November 2020.

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