An ombudsman’s report has been strongly critical of hospital bosses and doctors, suggesting that they showed a consistent attitude of arrogance following the death of a three-year-old from sepsis.
Healthcare professionals involved in the case of Sam Morrish had gratuitously and rashly concluced that his passing was due to rare and unfortunate circumstances.
But the ombudsman investigating the case concluded that his death was avoidable.
The Parliamentary and Health Service Ombudsman (PHSO) urged for a “no-blame culture” to be developed within the NHS; a climate which would enable such incidents to be investigated more openly. allowing leaders and staff to feel confident to openly investigate complaints.
Morrish died in December 2010 from sepsis following a multitude of errors by GPs, hospital doctors and call handlers at NHS Direct.
The ombudsman report entitied “Learning From Mistakes” concludes those involved in the local NHS investigations were not sufficiently trained, aware of the relevant guidelines, nor sufficiently independent and objective.
“We have found that those involved were not always suitably independent and that the organisations failed to co-ordinate and cooperate sufficiently with one another. We have identified a failure to obtain appropriate information, a lack of timely statements being taken as part of any formal process and a lack of appropriate (and in some cases any) involvement and communication with both the family and the staff,” the report stated.
The report continues in strong language, describing what occurred at the Devon NHS institution as a fundamental failing.
“We believe a fundamental failure in this case was the organisations’ – in particular the trust – total unwillingness to accept that no view other than their own was the right one. Those involved appeared to accept almost immediately the view that Sam’s death was rare and unfortunate rather than being open to other possibilities and, in doing so, asking open questions as part of a proper investigation that involved staff and the family. This was coupled with a general failure to accept that the questions the family were asking might have been reasonable ones.”
The Morrish family welcomed and endorsed the report, and released a statement expressing their disappointment at the way that Sam’s case had been handled.
“When our son Sam died suddenly and unexpectedly we trusted that no stone would be left unturned in trying to understand what had happened and why. We were told that Sam had died of something rare, fast-acting, hard to spot and therefore very hard to treat. In the months that followed we were shown kindness but we were simultaneously excluded from investigations. As questions accumulated, they were increasingly left unanswered.”
The health secretary, Jeremy Hunt, commented on the case, and acknowledged the failings of the NHS in the passing of Morrish.
“The tragic death of Sam Morrish shows why it is so important we listen to patients and families – no other family should have to go through what they have, and we are determined to build the safest healthcare system in the world. The launch of the new healthcare safety investigation branch [HSIB] earlier this year marks an important step in improving the quality of local investigations and raising standards, which will allow staff to speak up and improve care for patients.”