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| Version 0 | Version 1 |
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| NHS blunders led to Devon toddler's death | NHS blunders led to Devon toddler's death |
| (about 7 hours later) | |
| A string of blunders by NHS workers led to the death of a three-year-old Devon boy, a review has found. | A string of blunders by NHS workers led to the death of a three-year-old Devon boy, a review has found. |
| Sam Morrish died from a treatable condition because four health service organisations made mistakes, the Parliamentary Health Service Ombudsman (PHSO) said. | Sam Morrish died from a treatable condition because four health service organisations made mistakes, the Parliamentary Health Service Ombudsman (PHSO) said. |
| Sam died of severe sepsis in December 2010 following a "catalogue of errors". | Sam died of severe sepsis in December 2010 following a "catalogue of errors". |
| Ombudsman Dame Julie Mellor said that had Sam received the appropriate care, he would still be alive today. | 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. | 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. | 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. |
| Facts about sepsis | |
| Devastated family | Devastated family |
| His family said as well as losing their son, they feel they have been "failed" by the NHS complaints system. | His family said as well as losing their son, they feel they have been "failed" by the NHS complaints system. |
| In a statement released through the Patients Association, they also criticised the ombudsman. | In a statement released through the Patients Association, they also criticised the ombudsman. |
| "The astonishing length of time it has taken for PHSO to finalise this report has inescapably prolonged our distress. | "The astonishing length of time it has taken for PHSO to finalise this report has inescapably prolonged our distress. |
| "Although we are grateful that the PHSO has upheld our complaints... we are left with serious concerns about the competence, capability and accountability of the PHSO itself." | "Although we are grateful that the PHSO has upheld our complaints... we are left with serious concerns about the competence, capability and accountability of the PHSO itself." |
| Dame Julie said that Sam's devastated family suffered "further injustice" because health officials failed to properly investigate the youngster's death. | Dame Julie said that Sam's devastated family suffered "further injustice" because health officials failed to properly investigate the youngster's death. |
| "We've published this case so that the wider NHS learns from Sam's death," she said. | "We've published this case so that the wider NHS learns from Sam's death," she said. |
| NHS England was ordered to pay £20,000 to the family. | NHS England was ordered to pay £20,000 to the family. |
| Sam's father Scott Morrish said: "The irony is we never wanted to lodge a formal complaint. | |
| "We only did because we were advised to by the Patients Association in response to the NHS completely getting it wrong, not once, but twice. | |
| "We didn't want it to be about blame, we wanted it to result in good learning." | |
| Key recommendations | |
| Dr Graham Lockerbie, speaking on behalf of the local NHS, said: "Sam died when he should have survived." | Dr Graham Lockerbie, speaking on behalf of the local NHS, said: "Sam died when he should have survived." |
| "We all accept the blame for that. Quite simply, we should have done better. | "We all accept the blame for that. Quite simply, we should have done better. |
| "When we investigated, we were still unable to provide adequate answers to Mr and Mrs Morrish about what had gone wrong, or to reassure them that things would change for the future. It is clear that this only compounded their grief. | "When we investigated, we were still unable to provide adequate answers to Mr and Mrs Morrish about what had gone wrong, or to reassure them that things would change for the future. It is clear that this only compounded their grief. |
| "Again, on behalf of the local NHS, I apologise." | "Again, on behalf of the local NHS, I apologise." |