The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found.
Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing".
The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest".
Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home.
Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided".
He said: "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."
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Source: BBC News, 26 November 2020
Patient Safety Learning's statement on the Dixon Inquiry report