Advising with empathy and experience

Failings in sepsis investigation.

NHS workers failed to properly investigate how NHS errors led to a boy’s death from sepsis, a report has found.

The review is the second by the Parliamentary and Health Service Ombudsman (PHSO) into the death of three-year-old Sam Morrish from Devon.

The first review found four health service groups made errors. The second examined how they investigated the child’s death.

Sam Morrish died in December 2010 from a treatable condition because four health service organisations made mistakes, the initial Parliamentary Health Service Ombudsman (PHSO) said.

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

Cricketfield GP Surgery, NHS Direct, Devon Doctors Ltd and South Devon NHS Trust were all criticised.

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

The first report in 2014 focussed on complaints made by Sam's parents about the care he received from the four organisations.

The most recent review looked at criticisms about how their son's death was investigated by the organisations and the Primary Care Trust.

The report said: "A fundamental failure in this case was the organisations' - in particular the Trust's - unwillingness to accept that any view other than their own might not be the right one.

"Those involved appeared to accept almost immediately that Sam's death was rare and unfortunate rather than being open to other possibilities.”

The review also established that the investigation processes were "not sufficiently independent" and "excluded the family and junior staff in the process.”

An NHS England spokesman said it was encouraging people to raise concerns about services to prevent further mistakes.

He added: "What happened to Sam Morrish highlights the tragic consequences when things go wrong."

NHS England added that it wanted staff to acknowledge when mistakes were made.

Sam's father, Scott Morrish, said the youngster's death was "avoidable.”

He said: "The NHS should have given us the answers we needed soon after he died, to enable improvements to be made."

The PHSO said the report echoed its recent findings that 40% of NHS investigations were inadequate and has called for a national accredited training programme for staff.

- Sepsis happens when the body’s immune system goes into overdrive. It is a more common reason for hospital admission than heart attack and has a higher mortality.

- The most common causes of severe sepsis are pneumonia, bowel perforation, urinary infection and severe skin infections               

- The most common signs of sepsis are a high fever, violent shivering, fainting, cold and pale hands, rapid breathing, confusion or delirium

There are 200,000 estimated cases of sepsis in the UK each year and 37,000 people are estimated to die. From the time sepsis first takes hold, healthcare workers have just hours to deliver the right care. A total of 12,000 cases each year are thought to be avoidable.

                  

 

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