In his investigation report, Dr Bill Kirkup describes the life and death in 2001 of 11-month old Elizabeth Dixon as a “catalyst for change”. The report identifies multi-agency system failures in Elizabeth’s short life and the investigation of the circumstances of her death. Twelve recommendations are made, which span NHS and private healthcare, regulators, Royal Colleges, police and the justice system itself.  In this insight, we summarise a number of themes emerging from the recommendations.

Safety and learning

The report identifies the need for:

  • Clear communication between clinicians, particularly at handover.
  • Training in clinical error (including reactions and responses to it) and investigation to be part of the core curriculum for clinicians.
  • Removing blame from discussions around clinical error, which should be “openly disclosed, investigated and learned from”.

Lack of communication or misunderstanding between clinical teams is a common feature of clinical negligence claims. It is often compounded by inadequate medical records. A comprehensive handover is essential to the continuity of care and a full clinical record of key information is vital to good patient care. Healthcare providers should ensure that the duty of candour is embedded in their organisations. When errors occur, openness, transparency and learning should be the focus rather than the attribution of blame. Staff should receive regular training on the duty and the investigation of serious incidents.


The report recommends that:

  • When the NHS commissions services from the private sector, clinical governance requirements are made explicit.
  • Complaints should be integrated into the NHS clinical governance structure.
  • There should be clear signposting to help families navigate the multiplicity of organisations available to deal with complaints when things go wrong.

The need for cross-sector governance arrangements was identified in the Paterson Inquiry Report as crucial to prevent future harm. The Parliamentary and Health Service Ombudsman (PHSO) review in July 2020, entitled ‘Making Complaints Count’, means that changes are likely to be made to local health service complaints systems. In an interview with the Health Service Journal (HSJ), Dr Kirkup explained that he envisaged a Commissioner of Independent Investigation to hear appeals from families and with the power to set up the right sort of investigation.

Delivery of care

Elizabeth’s post-natal problems included hypertension. Subsequently, deficiencies were identified in her post-discharge care planning. The report notes that hypertension is often under-recognised in infants and inconsistent management can lead to significant complications. The report recommends:

  • A single set of charts showing the acceptable range at different ages / gestations, together with a single protocol to reduce blood pressure safely. A single early warning scoring system should be devised to alert clinicians to a deterioration.
  • Community care for patients with complex conditions, or conditions requiring complex care, must be properly planned. Mental or physical disability must not be used to justify / excuse different standards of care.

Dr Kirkup makes it clear that the profile of hypertension in infants needs to be raised. Pending implementation of the recommendations, healthcare providers should review their protocols in this area. Proper discharge planning is integral to safe and effective community care. Commissioners and providers need to ensure that patients with mental or physical disability are treated in an equal and non-discriminatory manner.

Additional recommendations

These are made around regulatory issues, scrutiny of death and the selection of medico-legal experts. They include mechanisms to:

  • Hold individuals to account for the information they provide to the investigation or their failure to co-operate;
  • Trigger investigation of wider systemic failures;
  • Ensure that medical examiners are properly independent; and
  • Review the system for generating clinical expert witnesses (in this context in connection with a police investigation).

What to take away

The events surrounding the tragedy of Elizabeth Dixon predate the Francis Inquiry Report (2013) which led to the statutory duty of candour. However, the report echoes concerns around transparency and openness, governance and learning identified in the Paterson Inquiry Report and the Independent Medicines and Medical Devices Safety Review earlier this year. There is still work to be done to embed the duty of candour in the health service and to learn from clinical error. Although the report’s remit is historic, it highlights the need to seize every opportunity for learning and that this should not be restricted to current incidents, complaints and claims.

How Capsticks can help

Capsticks is a national leader in representing both NHS and private healthcare providers as well as medical malpractice insurers. Our dedicated team is renowned for advising on the defence and resolution of clinical negligence claims, inquests, management of complaints and serious incident investigations/inquires, and providing an innovative outsourcing service for claims and inquests handling.

If you have any queries on the topics discussed in this insight, or the impact on your organisation, please contact Philip Hatherall.