My daughter Krista died as a result of a failure to treat her heart condition while under the care of Dr Shinebourne at the Brompton Hospital.  I have fought for years to uncover the truth about her death. In 2010 I found crucial information from a renowned cardiologist (previously employed at the Brompton) that was withheld by the Brompton into all 3 inquiries into Krista’s death.

A Recent Review by the Department of Health and Social Care in December 2018 found:

Some Key Findings Included:

  • All Brompton Inquiries into Krista's death had procedural irregularities raising issues of procedural unfairness.
  • Evidence from Professor Somerville was not put by the Brompton to any of their Inquiries and has never been reviewed by any inquiry into Krista's death. Professor Somerville's evidence stated in letters of March 1997, September 2001, May 2007 make clear that Krista's death was negligent.
  • Evidence of further cases were provided to the review against Elliot Shinebourne. The review noted Josephine Ocloo believes these case need to be further investigated to understand any wider issues about negligence or discrimination which may help shed further light on the actions of Elliot Shinebourne in relation to Krista's care. 
  • Josephine Ocloo brought a civil action against the Royal Brompton which led to a ruling of negligence but failed on the issue of causation. The review states we note her concerns relating to the outcome of the Court's proceedings, that the Court's decision on the issue of causation was wrong on advice from her Counsel (set out in grounds for appeal). Richard Lissack QC notes in appeal documents: "Although he [the Judge] was in a unique position of having heard all of the evidence, I believe it arguable that the Judge erred in his finding and that the weight of the evidence in fact suggested intervention on the 4 or 5 December 1996 would have prevented Krista's death".
  • Funding to appeal was denied. The review notes this had the practical effect of financially inhibiting Josephine Ocloo from appealing the Court decison, which she believes was unfair. We have also previously noted that the costs awarded against Josephine Ocloo by the Judge were also significant, even when reduced, and that this also financially inhibited Josephine Ocloo from appealing the Court case.

Despite the damning conclusions of the review which went to Conservative Health Ministers, Matt Hancock and Jacqueline Doyle-Price, they have apparently decided according to the DHSC that despite 'some shortcoming' in inquiries into Krista's death, the review did not warrant setting up any further ndependent investigation.  

After the Mid-Staffordshire Inquiry I wrote to Robert Francis QC about Krista's case.

Response 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’. 

Despite this context, there has been a failure by all of the regulatory bodies (the GMC, the Ombudsman the Care Quality Commission, the Department of Health and Social Care), to take action about this situation and to provide an independent investigation into my daughter’s death and to look at the allegations coming from other families to establish whether there has been any criminal behaviour or intent. All these bodies cite timescales or their organisational remit as excuses for not acting. I was told that Dr Shinebourne had retired from the Brompton in 2008. He is not registered to practice clinically by the GMC. However he still sits on ethics committees at the Brompton and has in his own words acted as a medical expert in over 400 cases, even being used by the NHS Litigation Authority (now NHS Resolution), to fight cases on behalf of the NHS.

Supportive Comments

‘I am a solicitor in Kingsley Napley’s clinical negligence department. I have acted for Josephine Ocloo for many years in her campaign for justice from the Royal Brompton NHS Foundation Trust for the death of her 17 year old daughter, Krista. She has made many attempts to get the issues raised by her case independently investigated but has failed to achieve the accountability that she seeks. Her case potentially raises wider and ongoing concerns about the care at the Brompton and has links with the issues being considered by the Mid-Staffs Inquiry and is also topical in the light of the judicial review by the Brompton to try and save its paediatric care unit. I feel strongly that an injustice has been done with records lost and critical views from the Brompton’s own consultant not considered by the reviews that have taken place. Ms Ocloo has potentially uncovered a wider pattern of wrong doing on the part of the Brompton but without funding it is impossible from the legal perspective to take this any further.

Deborah Nadel
Senior Associate
Kingsley Napley LLP

I fully support Ms Ocloo's fight to have the circumstances surrounding her daughter's death properly and independently investigated." Ms Ocloo's case is especially pertinent given that Parliament is currently debating the NHS Redress Bill. This is supposed to give patients and relatives speedier access to justice and compensation when things go wrong. However, despite the fine aims, there are flaws in the Bill that as they currently stand, will not deliver the type of independent investigation of adverse incidents that most are agreed are crucial to guaranteeing fairness and credibility and helping to bring to an end acrimonious litigation that at the end of the day benefits no-one."

Sarah Teather MP

AvMA supports Josephine’s quest for justice
Krista’s case is a poignant example of so much that is wrong with the systems for investigating and responding to medical errors and the barriers to accessing justice. Her mother’s determination to ensure that lessons are learnt for the benefit of others also typifies the feelings of thousands of families who have lost loved ones as a result of avoidable errors".

Peter Walsh, Chief Executive, Action against Medical Accidents (AvMA)

January 2008 – Sir Liam Donaldson (former chief medical officer), takes the unusual step of writing to the GMC suggesting they open an investigation into Krista’s death. He pointed out that he was aware it would not normally open one after five years “unless it was felt to be in the public interest”, but he wrote ‘I feel that the accusations are very serious, and thus you may wish to consider them despite the lapse of time since they occurred’. This request was refused by the GMC.

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