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'Repeated mistakes' led to child's avoidable death from sepsis

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A string of blunders by NHS workers led to the death of a three-year-old boy, a review has found.

Sam Morrish died from a treatable condition because four separate health service organisations made repeated mistakes in his care, the Parliamentary and Health Service Ombudsman (PHSO) said in a report today.

Sam died of severe sepsis in December 2010 following a “catalogue of errors” by the Cricketfield GP Surgery, by NHS Direct, by the out-of-hours service Devon Doctors Ltd and by the South Devon Healthcare Foundation Trust.

“Sadly, this case reinforces that the NHS needs to do much more to prevent avoidable deaths from sepsis”

Julie Mellor

Failures included inadequate assessment of the toddler, not recognising signs of blood in vomit and a three-hour delay before he received antibiotics at hospital.

Ombudsman Dame Julie Mellor said that had Sam received the appropriate care, he would still be alive today.

She added that Sam’s devastated family suffered “further injustice” because health officials failed to properly investigate the youngster’s death.

Dame Julie said: “We’ve published this case so that the wider NHS learns from Sam’s death and action is taken to help prevent lives being lost from repeated mistakes.

“Sadly, this case reinforces that the NHS needs to do much more to prevent avoidable deaths from sepsis.”

Last year the ombudsman published a report called Time to Act, which revealed that not enough was being done to save the lives of sepsis patients across the NHS.

However, Sam’s parents, Scott and Susanna Morrish, said that, as well as losing their son, they feel they have been “failed” by the NHS complaints system.

In a statement released through the Patients Association, they said: “The astonishing length of time it has taken for PHSO to finalise this report has inescapably prolonged our distress, as we have repeatedly had to revisit and relive the hardest day of our lives.

They added: “We pursued our complaints because we wanted to reduce the likelihood of the mistakes that were made in Sam’s care, and the subsequent investigations, from being repeated.

“This was not only for the individual organisations that made those errors − but for the NHS as a whole,” they said. “We never have been interested in blame. We have only ever been interested in learning and understanding, in the hope of change wherever necessary.

“Clearly we feel the complaints systems failed us, but it is important to note that we also believe it failed NHS staff too.”

“It’s clear that there were shortcomings at every stage of his contact with the health service”

Graham Lockerbie

Dr Graham Lockerbie, medical director of NHS England’s local area team for Devon, Cornwall and the Isles of Scilly, said lessons would be learnt.

He added: “Sam and his family have been let down by the NHS. It’s clear that there were shortcomings at every stage of his contact with the health service and that, in the words of the Ombudsman, Sam died when he should have survived.

“All of the organisations involved recognise that opportunities to alter the tragic outcome were missed. We all accept the blame for that. For this, we, the local NHS, apologise unreservedly to Sam’s family. Quite simply, we should have done better.”

According to the UK Sepsis Trust, the condition claims 37,000 lives in Britain every year.


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Readers' comments (1)

  • michael stone

    I think this is only the tip of a big iceberg - Sam's parents pursued this with a level of determination and effectiveness which most bereaved people simply cannot manage.

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