The Parliamentary and Health Service Ombudsman recently released its report into the death of Samuel Morrish. The report finds strong evidence of NHS failures:
"We have found that each of these organisations have failed in some way... Had Sam received appropriate care and treatment, he would have survived, and that a lack of appropriate and timely bereavement support compounded the distress caused... We have also found failures in the way that the NHS investigated the events that took place."
The parents of Samuel Morrish, a three-year-old, took him to a local GP, worried about his "flu-like symptoms", and were given antibiotics in case an infection developed. The next day, a second GP gave him cough syrup and sent him home. As his condition worsened, Sam's mother phoned NHS Direct's "111" service, and was referred to Devon Doctors. However, the call centre failed to notice the severity of Sam's case, and Mrs Morrish was told to take him to a GP. That GP immediately arranged for him to be admitted to Torbay Hospital.
While the doctors at Torbay realised that he had pneumonia, and suspected Sepsis, they prescribed antibiotics that were not administered for three hours, after which time they were too late to have any effect. Sam died of Sepsis, an avoidable condition, due to the failures of the NHS organisations that were charged with his care.
Following Sam's death, there was insufficient bereavement support. The local surgery did not contact the family, while there was confusion between the surgery and the NHS Trust at Torbay Hospital as to who was to assist the family.
The NHS Complaints Procedure
When NHS care results in the death of a patient, clarity, openness and timely responses to communications are essential. The experience of the Morrish family is characteristic of the NHS complaints system, which fails to uphold these values.
The Surgery itself conducted a "root cause analysis" of Sam's death, but the meetings held simply consisted of the relevant GPs denying that Sam had seemed seriously ill when they saw him. They failed to respond to the family's specific questions, giving inadequate responses. Having discovered Sam's death three months later, NHS Direct conducted its own review. They did not, however, contact them or attend the root cause analysis meeting, nor did they release their recordings to the PCT. The report found that "the actions of NHS Direct fell so far below the applicable standards that they amount to maladministration."
The PCT's report failed to give evidence-based responses to the concerns of the family, and the second report's improvements still failed to reach this point. The Morrish family was left without any confidence in the NHS.
The report credits the Morrish family for its contributions of information and responses to draft reports. This underestimates their role. They pushed at every stage to ensure that the PHSO understood their complaints and had the evidence it needed to reach a conclusion. To date, we have found that in Averil's case the NHS Trusts involved work from a premise of denial.
Over a year after Averil's death, responses to our inquiries become slower and slower. Many of our most important questions remain unanswered, and some have been dodged on technicalities. While Norwich and Norfolk University Hospitals Foundation Trust have promised an independent review, neither Cambridgeshire and Peterborough Foundation Trust nor the North Norfolk Clinical Commissioning Group have been able to make the same promise. Instead, they have attempted to duck questions wherever possible, and, in so doing, are preventing us seeking the clear explanation we need.