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A further blog considering the investigation into the death of 3 year old Sam Morrish in December 2010 in light of the recent report of another tragic and avoidable child death from sepsis.
In June 2014 the Parliamentary and Health Service Ombudsman (PHSO) published their report: “An avoidable death of a three-year-old child from sepsis”. This report was instigated following a complaint raised by the parents of Sam Morrish, who died in December 2010 following a short illness. The report looked at both the care Sam received, the way in which his parents’ complaint was handled and the lack of bereavement support for them. There were a number of different NHS care providers and agencies involved in Sam’s care resulting in a complex investigation and very detailed report.
The report of the Ombudsman makes for very sad reading indeed, the factors leading to Sam’s death were entirely avoidable had he received the correct standard of care and if the different NHS bodies involved took a more inter-linked holistic approach when looking at the bigger picture of a developing serious illness. In particular the Ombudsman lamented the lack of focus on symptoms of sepsis with early referral for emergency care, this is despite their report on sepsis, “Time to Act”. The loss of their child has been unbearable for this family, their pain only compounded by the poor NHS complaints investigation, necessitating a protracted investigation by the Ombudsman.
The basic facts of this case are that Sam presented as an ill child during a flu epidemic in the South West in December 2010. He was first seen by his GP on 21st December who prescribed antibiotics, despite this the next day his mother was concerned about his worsening condition. Sam was seen by a second GP in the afternoon of 22nd December who gave cough syrup and sent him home. He probably had early signs of pneumonia at this time, however his chest was recorded as “clear” when in all probability it was not. Later that evening his mother was again concerned and contacted NHS Direct, she spoke to a nurse who did not advise taking Sam to A&E but arranged for a GP to call, after which time Sam was taken to see a GP at an out of hours treatment centre. Once seen he was immediately referred to A&E, arriving at Torbay hospital at 10.30pm. He wasn’t given antibiotics until 1.30am and had inadequate fluid support. Despite treatment Sam tragically died as a result of pneumonia and sepsis in the early hours of 23rd December.
Summary of key findings and recommendations regarding the care:
There are a number of findings and recommendations in the PHSO’s report, this a brief summary of the critical findings relating to the care provided.
The facts here speak for themselves in showing how badly Sam and his parents were let down by the NHS system. It is hard to take in how this young child was failed by every medical centre or service provider involved in his care, it was a whole cascade of errors.
Mrs Morrish was fully entitled to rely on the medical advice given and indeed was following government campaigns not to rush to A&E departments, but this mantra cannot apply in all cases and we must accept that parents alarm calls are extremely serious and should be listened to. Sepsis is the second largest cause of death in the UK, it’s appalling that basic vital signs in an ill child were not recorded and ongoing deterioration with significant symptoms were not acted upon.
The failure to quickly and properly investigate this death has led to gaps in the investigative process in terms of fact finding; injustice for Sam and his parents was used to describe this. Indeed it in turn leads to an inability to make full conclusions and recommendations. Have lessons been learnt? Unfortunately the answer to that is only maybe, for there is no point learning of errors if you don’t make every effort to prevent them occurring again and it seems from this week’s reports of a further child death from sepsis that there is still a long way to go.