Krista Ocloo, my daughter was born in 1979 with a congenital cardiac abnormality which was successfully repaired at the Royal Brompton Hospital shortly before her second birthday. Krista went on to lead a completely happy and normal life with her twin sister Kelly, until she started to complain of chest pain in 1995. Under the care of her consultant Elliot Shinebourne this led to an admission to the Brompton for an exploratory catheterisation in January 1996. I was subsequently told that nothing had been found and that Krista was perfectly all right and would be sent another appointment in due course. Despite a reminder call from Krista in June 1996, an appointment was not scheduled by the Brompton until a year after Krista's catheterisation in January 1996. The family were not informed of this. On 5th December 1996, I found Krista dead at home in bed. The post-mortem revealed death from acute heart failure.
I have fought a long battle to get an independent investigation and open and honest answers from the Brompton, but they have consistently failed to provide me with the truth concerning my daughter’s death and about similar allegations to my own concerning other families. In my search for answers, I was denied an Inquest into Krista's death and therefore felt forced to go through both stages of the NHS Complaints’ Procedure and a wider NHS Inquiry (The Evans Inquiry), in my quest for answers and justice. All of these inquiries lacked independence and conspicuously failed to tell me the truth claiming no negligence was involved in my daughter's death.
In 2001, as a result of the failure of the Brompton inquiries to tell me the truth about Krista’s death, I decided to bring a civil action against the hospital. A legal ruling of negligence was made against the hospital. The Judge, Leveson J, accepted the unanimous conclusion of all the medical experts: Krista should have been followed up and kept under active review.
He agreed that, by 16 January 1996, the Brompton should have told Krista, her GP and I that her heart condition
(i) ventricular tachycardia was a cause of clinical concern; that
(ii) Krista needed to avoid severe physical exertion and
(iii) that she should re-attend [the Grown Up Congenital Heart Unit – GUCH at the Brompton, if symptoms persisted or other symptoms appeared.
Leveson J found that the failure by the Brompton to organise suitable further appointments was negligent. The Judge also found that the Brompton’s negligence caused the loss of the opportunity both to test whether there was any symptomatic deterioration in Krista’s condition, and to provide key information to Krista and I about any further developing symptoms.
In addition, the Judge held that the reassurance given to Krista after the cardiac catheterisation could well have meant that she did not appreciate the importance of reporting continued symptoms.
Notwithstanding these findings on negligence, I lost the case on causation. In order to win a medical negligence case, a claimant has to prove not only negligence, but that the negligence is directly causative of the harm incurred. In my case the Brompton argued that despite their negligence, Krista would have died anyway. My claim against the Brompton was therefore dismissed and I was ordered to pay costs to the Brompton of £120,000. I believed I had good grounds for appeal but could not bring an appeal in time, because had I done so it is likely that the National Health Service Litigation Authority (the body that fights claims on behalf of the NHS), would have moved to enforce the costs order against me which would have bankrupted me.
In March 2002 however, as a result of publicity on the case, the Brompton agreed to accept £10,000 in full and final settlement of the costs order. I believe this was a recognition of the legitimacy of my case. I subsequently sought further legal advice and was advised by leading counsel Richard Lissack QC that there were good grounds for challenging the legal finding in my case on appeal. I therefore applied to the Legal Services Commission for funding to lodge an appeal. They turned down my application despite the fact I was a student living on a small grant, leaving me with no means of funding further access to the courts. Unlike with criminal cases no other means exist to rectify this Miscarriage of Justice.
New Evidence Since the Court Case:
Evidence backing up my claim that my daughter died due to a failure of her consultant Elliot Shinebourne at the Brompton has the support of internationally renowned cardiologist, Professor Jane Somerville, formerly one of the Brompton’s top doctors who is now retired. The views of Professor Somerville were first sought by the chief executive Mark Taylor about Krista’s condition and treatment as a result of my complaint to the hospital starting in 1997. However, I only found out in 2010 that Professor Somerville’s evidence was withheld by the Brompton from all three inquiries held into Krista’s death despite complaint procedures obliging them to submit all information relating to my complaint.
Mark Taylor subsequently acted as a consultant into the Healthcare Commission’s Report into Mid-Staffs in 2009. Professor Somerville maintains that Krista’s death was avoidable and that Krista had a serious heart disorder not something minor as suggested by Dr Shinebourne. I first made contact with Professor Somerville in 2001 after all the inquiries into Krista’s death had been completed by the Brompton. Whilst we had a chance to call Professor Somerville in court, we did not do so because she was reluctant to testify against her employer where she had forged her whole career.
Wider Concerns about Dr Shinebourne from other families:
In addition to the evidence above, it has also come to light that many other families have raised serious concerns about Dr Shinebourne’s care and treatment of their children. The Brompton have never publicly admitted this.
On 5 March 2010 Deborah Nadel my solicitor from Kingsley Napley wrote to the hospital about wider complaints concerning Dr Shinebourne. The letter stated:
"…..Ms Ocloo has brought to our attention that a significant number of complaints that went to the Evans Inquiry [a previous Brompton Inquiry funded by the Department of Health] were about Dr Shinebourne. We do not believe that the Evans inquiry identified this position or brought it to the attention of the families going to the inquiry. A number of these complaints, (which we have in our possession), appear to contain serious allegations, similar to those being made by Ms Ocloo about the apparent denial of information and treatment to children under Dr Shinebourne's care, and which may have led to their deaths.
With regards to the Evans Inquiry, Ms Ocloo has since been told by a member of the investigating panel, that she was unaware of this cluster of complaints against Dr Shinebourne at the time the Inquiry was taking place. Despite the existence of this cluster and the seriousness of these complaints against Dr Shinebourne, the Inquiry did not reveal this situation and found no reason to refer any individual doctor to the GMC. Ms Ocloo has concerns that the cluster of complaints against Dr Shinebourne reveals a pattern of wrongdoing and poor care that has not been properly investigated. We believe this issue needs to be looked at afresh by a new inquiry.”
These allegations were given new momentum when the mother of a current Brompton patient contacted me in 2011. She contacted me with evidence about her son’s treatment that corroborates my long-standing claim that Dr Shinebourne appears to have withheld important clinical information and/or treatment from a number of young patients and their families. She told me in response to raising these concerns with the Brompton, a member of staff at the hospital told her that they had long been aware of these issues with Dr Shinebourne and that ‘she is not the first person to be affected and won’t be the last’. This staff member maintained that many families have not been given important information about their children’s heart condition by Dr Shinebourne, and would not find out about this information until they are eventually transferred from the paediatric into the hospital’s adult clinic, which could be in many years’ time.
This delay in contacting families to review whether they have received the appropriate information and treatment about their children’s heart condition, is considered to have potentially serious implications for these children, which like the case of Krista and other families identified, could severely compromise their treatment or even lead to their deaths. This situation will be made worse if the Paediatric Unit is closed at the Brompton, as a way of streamlining paediatric congenital cardiac surgery services (PCCS) around the country.This may mean that families will not find out about important cardiac information that they have not been given until it has had serious or even fatal consequences, as in the case of my daughter Krista.
Given that significant and relevant evidence from Professor Somerville exists that has been withheld from the three inquiries into Krista death. Given that there is also evidence about other families adversely affected by Dr Shinebourne’s care that has never been properly investigated, I believe this justifies the setting up of a new and completely independent inquiry to look at my concerns.
Response to this issue from Robert Francis QC :
‘If the material you refer to was available at the time and should have been given to the various inquiries, but was not, then it could raise a question mark over the validity of those processes. I would respectfully suggest that is a concern which you may wish to raise with the Ombudsman’. 9th July 2013
Failure of Regulatory Bodies to Act:
Yet, I have been unable to get any of the official regulatory bodies in health to investigate this matter. This evidence was brought to the attention of the Department of Health and NHS London in 2010. Despite initially appearing to support an independent investigation, after a private meeting with the Brompton and their lawyers, from which I was excluded, they decided not to let me put the new evidence I had to an independent inquiry after the Brompton claimed it was of no relevance.
The Ombudsman has repeatedly turned down my request to look at the new evidence into my case citing the fact that I have previously taken legal action so they cannot look at my complaint. They have completely ignored the evidence with respect to the other families.
After returning to the Ombudsman recently to ask them to review their decision not to look at my complaint, about the withholding of evidence by the Brompton from inquiries into Krista’s death, they turned me down again. They cited the fact that the complaint was submitted outside of the one year deadline that I had to make the complaint. Yet despite the fact that I was exhausted after years of fighting to get answers and I was only three months outside of the time limit and despite the fact that the Ombudsman had the discretion to set the time limit outside, they chose not to do so.
Since Krista died the system has completely and utterly failed to provide me with a way to independently establish the facts concerning my daughter's death and any culpability. This has caused my family and I absolute heartbreak and misery for almost 21 years. Not only am I still waiting for justice, but absolutely no-one has been held to account for their actions as a result of my daughter's death.