Timeline of events
- January 1979 - Krista is born with a congenital heart condition (Fallots Tetralogy).
- In 1981 - Krista has an operation to successfully correct her heart condition (under her consultant Elliot Shinebourne at the Royal Brompton Hospital). Krista goes on to lead a normal life with her twin sister Kelly.
- 5 September 1995 - Krista complains of chest pain to GP & is referred back to the Brompton and seen by Dr Shinebourne on 13 September.
- 16 January 1996 - Krista is admitted to the Brompton for an exploratory catheterisation.
- 17 January 1996 - Krista is discharged and I (her mother), told nothing was found and no need for concern.
- On 5 December 1996 - Krista dies at home in bed.
- December 1996 - Coroner denies my request for an Inquest stating Krista died of natural causes.
- December 1996 - the Royal Brompton do not respond to my request for someone to call me to speak to me about Krista's death. My daughter had been under their care all her life.
- January 1997 - I make a complaint via the NHS Complaints Procedure and dissatisfied with the response from the hospital ask in March 1997 for the complaint to be referred to an Independent Panel Review (IPR).
- 22 June 1998 - The IPR issues its report making no finding of negligence or recommending any referral to the GMC.
- 1999 - I campaign for a wider Independent NHS Inquiry on behalf of some 40 families, after I hear on the radio that a whistleblower at the Brompton has raised issues of high baby death at the hospital. The Evans Inquiry was set up in September 1999 and reported back in April 2001. 120 recommendations were made to the Trust. The inquiry had no remit to look at negligence, but despite this, said specifically in my case that there was no negligence. They also said that they had found no evidence which warranted anyone being reported to the GMC. The Inquiry cost close to a million pounds.
Read the article here on Background to The Royal Brompton & Harefield Hospitals (NHS Trust) Independent Inquiries: The Evans Report, April 2001
You can view more about this and in greater detail by visiting the link: www.sin-medicalmistakes.org
- May 2001 - Shortly after the Evans Inquiry, I was told by a patients’ organisation that submitted evidence to the Inquiry about a doctor called Professor Jane Somerville employed at the hospital. I contacted her and she told me that she was asked by the chief executive of the hospital (Mark Taylor), shortly after Krista’s death to look at the case and she wrote to him stating that she thought there might be a case for negligence. This letter had never been given to me. I was only to find out in 2010 that Professor Somerville’s evidence had not been put to any of the 3 inquiries held by the Brompton into Krista’s care.
- November 2001 - I brought a civil action against the Brompton for damages for bereavement and personal injury. Professor Somerville came to court but ultimately we did not call her as she had repeatedly expressed a reluctance to give evidence in court against her employers. I found out in 2010 that the Brompton were obliged to put Professor Somerville’s evidence before the various inquiries into Krista’s care as part of dealing with my complaint. Had they done so I believe I would never have had to go into court. Mark Taylor despite failing to ensure Professor Somerville’s evidence was put to the inquiries into Krista’s care popped up many years later as a consultant to the Health Care Commission when looking at the failings at Mid-Staffs.
December 2001 - a legal ruling of negligence is made against the hospital. In his judgement, Judge Leveson accepted the unanimous conclusion of all the medical experts: that Krista should have been followed up and kept under active review. He also agreed that by the 16 January 1996, the Brompton should have told Krista, her GP and I that (i) Krista’s ventricular tachycardia was a cause of clinical concern; that (ii) she needed to avoid severe physical exertion and (iii) that she should re-attend [Grown-Up Congenital Heart Unit – GUCH] at the Brompton, if symptoms persisted or other symptoms appeared. Accordingly Judge Leveson 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 developing symptoms. He 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.
Despite the above however, I lost the legal case on causation, based on the argument by the hospital that despite their negligence, Krista would have died anyway. Costs were awarded against me of £120'000. These were only reduced by the NHSLA to £10'000 after publicity on the case.
- June 2004 - Mr Richard Lissack QC advised that the case had good grounds for appeal directly related to causation. I was unable to appeal in time because of the costs order being pursued against me.
- 25 June 2004 - a detailed application for funding was made to the Legal Service Commission (LSC).
- 23 December 2004 - the LSC makes its final decision to deny funding for an appeal. This was because I was apparently over the capital threshold because of my house, despite the fact that I was living on a grant as a PhD student.
- 21 March 2005 - an application is made to the European Courts for violation of the right to public funding to bring an appeal.
- 10 November 2005 - I was refused permission to submit the application without an explanation.
- November 2005 - the Parliamentary Ombudsman was approached about the denial of legal aid by the LSC.
- December 2005 - the Ombudsman's Office say they are unable to look at the LSC's decision simply because of the attempt to take legal action in Europe.
- December 2006 - I was contacted by a mother who saw me on the television who like me had lost her 17- year old son under Dr Shinebourne at the Brompton. I then returned to the Evans Inquiry documents I still had as I had begun to question how many patients had died under this doctor. From the documents I had of cases who went to the Evans Inquiry, I discovered the majority of complaints to the Evans Inquiry were about Dr Shinebourne, although the Inquiry had not told us this or named any doctor in its final report. This meant I now had in my possession about 18 cases including one discovered on the internet and a further discovery to make 19 cases. All of these families were making serious complaints against Dr Shinebourne relating to serious harm or to the death of their children, many involving a central theme like with Krista of failure to provide crucial information or treatment connected to their child’s heart condition. I then asked my solicitor to approach Professor Somerville again who wrote a further letter about Krista’s care and her belief it was negligent and stating she saw medical records when asked to look at the case in the hospital that were missing from Krista’s records when we went to court.
- December 2006 – I approached Trish Longdon at the Ombudsman’s office again with the evidence I had about the errors in my legal case and other cases and was told they could not look at my complaint because this had already been considered by a court.
- 24th July 2007 - I approached the GMC to investigate and they refused. Apparently the case was not even put properly into their system. A key reason cited was that the case had already been investigated by the Evans Inquiry. I later found out Ruth Evans had sat as a lay person on the GMC since the Inquiry. The police say (3 Sep 2007) it is the job of the GMC to look at any allegations of perverting the course of justice by the hospital by withholding evidence.
- Jan 9th 2008 - Sir Liam Donaldson former chief medical officer intervenes on my behalf and writes to the GMC saying there appears to be serious concerns about the way the case has been dealt with that need further investigation. This situation arose because I had by then become a WHO patient for patient safety (PFPS) champion. Because Sir Liam was connected to this work at the WHO I stood up and asked him at a conference what could be done for families like mine who had spent years trying to get justice because of medical harm and the way our complaints had been handled.
- Feb 11 2008 - the GMC refuse Sir Liam's request to investigate my case.
- June 2008 - Guardian publish article on case.
- 20th June 2008 - Brompton write offering to investigate if evidence exists that has not been reviewed by previous inquiries.
- Feb 2009 - meeting with Jackie Smith, GMC affiliate set up with the help of the Department of Health (DH). This opportunity arose because of my work as a PFPS champion including sitting on some key DH committees and because I had now completed a PhD in patient safety. The DH therefore felt that they could not ignore me. It was not because they wanted to help me.
- 24 April 2009 - Jackie Smith's response sheds no further light on reasons the GMC were not prepared to investigate the allegations surrounding Krista's death. The DH implied the case was thrown out before being put properly into their system and that this therefore could not be changed later.
- 6th January 2010 - I met with the DH, ICAS and my solicitor Deborah Nadel to discuss a way forward on the case. The DH made clear that the only thing they could do was to support me to go back down the route of asking the Brompton to look at my concerns more than ten years after I first went down this route. This was despite all they’re inquiries claiming there was no negligence/wrongdoing in Krista’s care.
- 5th March 2010 - Kingsley Napley write on my behalf to Bob Bell, chief executive at the Brompton. The letter stated that I would like to pursue the possibility of a new investigation offered by the Brompton in their letter of 20th June 2008 and noting my belief that ‘a range of evidence existed that had not been properly reviewed by previous inquiries’.
9th March 2010 – The above letter from Kingsley Napley went out at the same time as a letter (see abstract below), from Charles Dobson from the DH to the Brompton. This stated that I had brought my case to their attention as part of a programme of work they were carrying out which included the recommendation:
“The Department should consider what redress or support could be made available to patients who have raised a concern relating to patient safety and who are not satisfied that it is being investigated with an appropriate degree of independence.”
The letter from Charles Dobson to the Brompton stated the DH were keen see what wider lessons could be learnt from Krista’s case and noted that the DH was also copying the correspondence to Ruth Carnell at NHS London because of the SHA’s responsibility to ensure that adverse events were investigated with a proportionate degree of independence.
30th March 2010 – Bob Bell at the Brompton responded stating: they could not confirm that Prof Somerville’s letter of 25 March 1997 was definitely considered by the IPR and/or Evans Enquiry and/or seen by Mark Taylor, CE before he wrote to me on 22 May 1997. They completely ignored the points raised about the cluster of other cases that I now had about Dr Shinebourne. They asked us to provide further details and any other new evidence to enable them to determine the best approach to follow in any further investigation or to let them know how I wanted to proceed in terms of the ‘desire for a further independent investigation and/or inquiry’.
2/3 meetings were held at this time with Charles Dobson DH and Vicky Aldred from the SHA to put together what we considered to be new evidence for a new investigation and potential terms of reference for an Inquiry. The DH accepted that as there appeared to be evidence that the Brompton had withheld evidence from Prof Somerville and that previous investigations had not revealed issues about other cases, it was important that any new investigation set up by the Brompton was independent.
I said I was prepared to pay my solicitor to formally submit the evidence but would only do this if Charles Dobson gained an assurance from the Brompton that Prof Somerville’s evidence would be treated as new and therefore not rejected out of hand forcing me to incur the costs of compiling this evidence for nothing. This was a concern as the Brompton had implied that Prof Somerville’s evidence was not new as we had had a chance to call her at trial. We have argued however that the ToR for various Brompton inquiries show that a) they were required to put Prof Somerville’s evidence to them and they did not which should have meant I never went into court; b) that my barrister’s opinion after trial shows clear ground for appeal showing errors in the judgement which I could not appeal against because the NHSLA were threatening to enforce a costs order against me of £120’000.
It was agreed if the Brompton gave an assurance to investigate Prof Somerville’s evidence, I would compile it and any other evidence and it would go to the RBH and an SHA panel of independent people at the same time to see if the new evidence warranted a new investigation being set up. The idea in the light of this was for the RBH to agree a series of steps for a new investigation and to liaise with me over this by the anniversary of Krista’s death on Dec 5 2010. This was seen as straightforward by Charles Dobson but subsequently he and Vicky Aldred from the SHA met with the Brompton in a meeting that was attended by Capsticks, the Brompton’s lawyersers. My lawyer and I were not told about or invited to the meeting. In this meeting and without seeing any of the new evidence I had agreed with Charles Dobson was crucial to my case, Capsticks maintained that this new evidence would not have made any difference on causation anyway. Vicky Aldred and Charles Dobson fully went along with this and I was informed weeks later in a telephone call the day before Christmas.
- January 2011 - I challenged Charles Dobson over the fact that this meeting was held without me being present and represented and that that it had been unfairly dictated by the Brompton’s lawyers. Charles Dobson very reluctantly agreed to go back to Vicky Aldred about the SHA convening an independent panel (as previously discussed) to look at the evidence. When I spoke to Vicky Aldred it then transpired that she had already put what she considered to be key evidence, (excluding key material again from Prof Somerville and evidence relating to the errors made at trial contained in our appeal documents), to the SHA medical director who she said had made up his mind there was no need for further investigation. When I challenged the fairness of taking this decision without allowing me to compile the evidence she agreed to discuss this again with the medical director and my desire for an independent panel to look at any evidence submitted. This resulted in an email from Vicky Aldred dated March 10th 2011 which stated, ‘With regard to your request for a small panel to be convened to assess the evidence that you consider significant, I am afraid that the SHA consider that there is no justification for establishing such a panel.
11th March 2011 – The medical director of NHS London without giving me a chance to submit documents I considered appropriate for an independent investigation wrote to me stating:
‘Having familiarised myself with the details of Krista’s management, I have carefully considered this request and I have concluded that there is no justification for convening such a panel. I am satisfied that the information you have asked to be considered as new evidence is not sufficiently different from evidence already considered in previous investigations and therefore, would not lead anyone to a different conclusion’.
Had my request for an independent panel to review the evidence been granted the evidence that I would have submitted is set out below:
a) Professor Jane Somerville’s evidence set out in letters dated 25 March 1997 and 2007 and the document dated 13 September 2001 on procedures for emergency admission to RBH GUCH unit in 1995. This evidence has been withheld from all previous inquiries into Krista’s death and has never been independently reviewed. I was not allowed to submit it formally to the medical director of NHS London.
b) Appeal documents showing good grounds for appeal against the medical negligence court case showing errors were made in the judgement on causation. An appeal that could not take place in time because the NHSLA were pursuing me for costs.
c) Document ‘Krista Ocloo: Notes of a Meeting At The Royal Brompton Hospital, 15 December 2010’, written by Charles Dobson from the Department of Health. The note provides further evidence strengthening my case for appeal.Evidence of Wider Complaints/Concerns Against Dr Shinbourne
a) Document headed, Complaint made by Josephine Ocloo against Dr Elliot Shinebourne, Summary of information from other families. This shows a pattern of a number of other serious concerns/complaints being made against Dr Shinebourne relating to denial of appropriate information and treatment to families about their children’s heart condition.
b) Recent evidence in 2011 from a mother currently being treated under the RBH. This shows her son has had important evidence withheld from him by Dr Shinebourne about his heart conditionnover many years. The Brompton have responded to her concerns stating this situation with Shinebourne is not the first and won’t be the last and that they will not know about other possible cases concerning Shinebourne until they come into the adult clinic. This puts families at serious risk if they do not have important information about their children’s heart conditions given to them.
- 29th Jun 2012 - I submitted a request to the Ombudsman that they look at my new complaint to the Brompton in 2010.
- 28th Aug 2012 – the Ombudsman refused my request to look at this complaint, citing the fact I was outside the time limit of 1 year which I had to bring the complaint to thstrong after The Brompton and SHA refused to look at my concerns. They also cited the fact that I had had an opportunity for causation to be looked at in the court case.
- 28th Aug 2013 – after finding out by accident that I could ask for a review of this decision (I had never been told about this review procedure previously), I approached the Ombudsman again. Before I submitted the form I rang the office to check if it was worth my submitting the form and putting myself through the strongotional distress of the process. I did not want to do this if there was no chance my concerns would be properly considered. I was told on the phone that the primary reason for turning down the complaint the previous year was the time barrier and she encouraged me to submit the form again given that I also said there were mistakes in their previous letter to me turning down the case.
- 13 Sep 2013 - they replied turning me down again and stating that there were no reasons to review their decision, as the time limit still applied even though I was only 3 months over this and again citing the previous court case as a barrier to looking at my concerns.
- October 2013 – No avenue exists for me to get an independent investigation into my concerns.
- In 2015 I met with Dr Mike Durkin and Dr Andy Mitchell from NHS England (Andy Mitchell is the former medical director from NHS London who turned down my request for an independent investigation in 2010 in tandem with the Department of Health, closing down all attempts at that time to gain a new investigation). In this meeting I outlined the grounds for appeal for my court case and explained why there was indeed evidence of causation in my case and why it was wrong for Andy Mitchell to have turned my request down for an investigation in 2010.
- 2018 – It is 21 years since my daughter died. I have clear evidence that her death was due to negligence. I also have evidence of 20 other cases of families who have raised concerns about care provided to their children by Dr Shinebourne. Many of these cases seem to incorporate issues of the families not being given important information or treatment about their child’s heart condition like Krista. Many of these children subsequently died.