NHS too slow to learn from Sam's death

The father of a South Devon toddler who died from sepsis has called for compassion to fix the NHS that failed his family.

Little Sam Morrish from Newton Abbot was just three-years old when he died in 2010 after a series of failures by call handlers and care staff that treated him.

A later report into the case also uncovered serious flaws into the investigation into his death.

Sam’s father Scott Morrish told a parliamentary select committee on Tuesday that the initial investigation was marred because staff were frightened to speak freely for fear of reprisals.

He is calling for a system similar to the aviation industry where staff can talk honestly about how mistakes were made so lessons can be learned.

And that culture change must come from the top, he said.

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Investigations in the NHS need to change, Mr Morrish said

Mr Morrish, a member of the Healthcare Safety Investigation Branch Expert Advisory Group, said: “There is too much blame in the system and a tendency to shame staff for what they do.

“There needs to be a move to nurturing and compassion to staff so that they can in turn deliver that to patients. They need to know that if they have made a mistake that they can speak freely.”

The inquiry held in Westminster on Tuesday has been set up to examine the failures into the initial investigation into the case.

It follows from a report by the Parliamentary Health Service Ombudsman ‘Learning from Mistakes’, published in July to find how the NHS failed to properly investigate Sam’s death.

Key findings in the report revealed a defensive culture in the NHS where fear of blame inhibits open investigations, learning, and improvement; a lack of competence and sufficient independence in the conduct of NHS investigations into potentially avoidable harm and death; poor co-ordination and co-operation between NHS organisations involved in investigations, and failure to collectively identify and act on lessons and insufficient involvement of families and staff in NHS investigations.

Mr Morrish told the committee that so far, the pace of change has been too slow.

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A number of healthcare staff missed Sam’s symptoms

He showed the inquiry an information leaflet made in Sam’s name to help parents and healthcare staff identify sepsis.

But despite promises, the leaflet has not been rolled out across the UK and could undergo a further two years of evaluation before any further progress is made – eight years since Sam’s death.

He told the committee: “We have been told for five years that lessons have been learned but those lessons are only just beginning. The actions that need to follow have barely started. It should not take this long and I don’t know why people have so much tolerance of it taking this long.”

He said that he and his wife were seen as a problem by the NHS from the night Sam died. We need to support staff and families and not be pitting them against each other,” he said.

The government is obliged to respond to the committee findings. Mr Morrish was a witness to the inquiry alongside Steve Shorrock, European Safety Culture, Programme Leader, Prof. Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission, Keith Conradi, Head of the new Healthcare Safety Investigation Branch and Helen Buckingham, Executive Director of Corporate Affairs, Care Quality Commission.

Julie Mellor, the Parliamentary Health Ombudsman who completed the two reports into the case said after the hearing that still too many NHS investigations into avoidable deaths are inadequate.

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40% of NHS inquiries were found to be inadequate

She said: “Sadly the experience of the Morrish family is not unique. We see too many local NHS investigations into avoidable deaths that are not fit for purpose.

‘We have recommended that people at the top of the NHS consider how they can create an environment in which leaders and staff in every NHS organisation feel confident and have the competence to find out why something went wrong and to learn from it.”

Between 1 January and 30 September 2016 , the Ombudsman investigated 625 complaints about potential avoidable deaths, of which 279 were fully or partly upheld.

The findings in the Ombudsman’s Learning from Mistakes report echo a recent review into the Quality of NHS investigations which found 40 per cent of investigations were not adequate at finding what had happened, published in December 2015.

The ombudsman’s report in 2014 revealed that a catalogue of errors led to Sam’s death. He was failed by all the NHS medics who saw him 36 hours before he died of severe blood poisoning. Despite clear signs of developing illness, GPs at Cricketfield Surgery in Newton Abbot, the Devon Doctors on call service, NHS 111 and Torbay Hospital all failed to treat him until too late.

Sam’s parents were directed to a local treatment centre by an unqualified out-of-hours call handler, when he should have been gone immediately to A&E. When he was eventually rushed to Torbay Hospital, it took three hours for staff to give him antibiotics, by which point a bacterial infection had already taken hold. He died of septic shock the following day, two days before Christmas on December 23, 2010.

The UK Sepsis Trust is soon to launch a major campaign to raise awareness of sepsis and help parents to spot the signs and symptoms of this devastating condition in children under 5. It is being launched with the Department of Health and Public Health England.

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