Learning from mistakes

Chapter 2


  1. Mr and Mrs Morrish complained to us in April 2012 about the care provided to their son, Sam, by the Cricketfield Medical Centre, Devon Doctors, NHS Direct and South Devon NHS Foundation Trust. They complained that the inadequate care and treatment provided to Sam had led to his death. They also complained about how the organisations involved had handled their subsequent complaints. We investigated their complaint and upheld it. We concluded that Sam's death had been avoidable. We published our report of our investigation in June 2014, recommending an apology from all of the organisations and the payment of a financial remedy. We also made wider recommendations intended to address the failures we had identified.

    '… The result of the Ombudsman's enquiry is contained in a report issued by them and that report goes some way to answering the questions and concerns I had but I still have issues that need to be addressed.
    I am not complaining specifically about what did or didn't happen to Sam because that has happened and been covered. It's all about how the NHS was able to draw the wrong conclusion and reassure itself that Sam couldn't be saved, despite the fact they were being asked questions which should have helped them actually think a bit harder.'

  2. Mr and Mrs Morrish welcomed our findings but felt that our investigation had not gone far enough. They told us that they were still left asking why the failings had occurred in Sam's treatment, and why the subsequent investigations conducted locally had failed to conclude that Sam's death was avoidable. They said they believed a key feature in any complaint investigation should be consulting with patients and their families, and that organisations involved must listen to, and act upon, any concerns raised. They told us they felt the primary aim of any such enquiry should be to find out what had happened, and how and why failures had occurred so that lessons can be learned and changes made. Mr Morrish wrote:
  3. We agreed to carry out a second investigation to explore further Mr and Mrs Morrish's complaint that the investigations into Sam's death by the organisations involved were inadequate. As part of that investigation we have considered the importance of investigations into serious incidents being undertaken fairly, effectively, compassionately and inclusively in the best interests of patients, families, staff and identifying wider learning. We also agreed to consider what we as an organisation could learn from our handling of Mr and Mrs Morrish's earlier complaint.

What happened to Sam

  1. Sam (aged three) became unwell during a flu epidemic in December 2010. He had been ill for about a week when a GP at the Surgery saw him on 21 December. The GP sent him home with a prescription for antibiotics to take just in case he developed an infection.
  2. On 22 December, Sam's condition continued to cause concern and Mrs Morrish returned to the GP who assessed him and sent him home with some cough syrup. Sam's condition continued to deteriorate and he vomited later that evening. Mrs Morrish contacted NHS Direct and a Nurse Advisor assessed Sam's condition over the phone. She referred Sam to Devon Doctors, an out-of-hours GP service.
  3. A GP from Devon Doctors subsequently called the Morrish family home but there was no answer. Mrs Morrish called them a couple of hours later. The call handler contacted Newton Abbot Treatment Centre and spoke to a member of staff (who was not clinically trained). Following discussion with the staff member, the call handler told Mrs Morrish to take Sam to see an out-of-hours GP at Newton Abbot Treatment Centre.
  4. When Mrs Morrish arrived at the Treatment Centre she was asked to wait. Around 20 minutes later a minor injury unit nurse walked past Sam and Mrs Morrish alerted her to his condition. The nurse took Sam into a resuscitation room for treatment where he was seen by a doctor who immediately arranged for him to be transferred by ambulance to Torbay Hospital, part of the Trust.
  5. A Paediatric Registrar at the Trust saw Sam and prescribed him antibiotics and fluid for pneumonia. The antibiotics were not administered for two to three hours. Due to the severity of his condition, Sam was admitted to the paediatric high dependency unit but he deteriorated further and died early in the morning of 23 December.
  6. Following Sam's death, Mr and Mrs Morrish met with GPs from the Surgery and the Paediatric Consultant at the Trust to find out why Sam died. The Primary Care Trust (PCT) began a root cause analysis5 into the circumstances around Sam's death. Mr and Mrs Morrish were unhappy with the findings of the root cause analysis and the PCT commissioned an independent investigation into their complaints. It is accepted that this second investigation did not meet all of the intended objectives, and as such it did not address all of the family's concerns. Fundamentally, it failed to give a definitive answer as to whether earlier treatment would have saved Sam's life.
  7. A third investigation was offered to the family but, understandably, they lacked confidence in the NHS complaints process. In April 2012 the family asked us to investigate the matter. We accepted the complaint for investigation in August 2012.
  8. Our first investigation report, published in 2014, found service failure in almost every aspect of the care provided for Sam. We found that, had Sam received appropriate treatment, he would have lived. We also found maladministration in the way the organisations had dealt with the family's subsequent complaints and requests for information.
  9. We also found maladministration in relation to every organisation involved, in their attempts to investigate the concern raised by Sam's family. Amongst other things, we identified failures in communication, poor explanations and a failure to understand the heart of Mr and Mrs Morrish's complaints.

The purpose of our second investigation

  1. In this investigation we have looked further into how the organisations conducted their investigations following Sam's death to find out why they failed to identify the failures we found in the treatment Sam received and, most importantly, why they were unable to identify that Sam's death was avoidable.
  2. In this report we will highlight where the systems have failed, and where possible, identify how and why they failed. Specifically:
    • how organisations implemented, executed and governed their investigative procedures;
    • the gaps in those procedures and the consequences of those gaps;
    • communication between different health organisations and the co-ordination of cases that involve more than one organisation;
    • communication between those organisations and the family;
    • how failings early on in the investigative process, and assumptions made on the part of those investigating, affect conclusions made by subsequent reviews and investigations; and
    • how the whole investigation process can be improved from start to finish for all organisations concerned in this case.
  3. As part of this second investigation we also undertook to identify our own learning following our first investigation, to look at how we could have handled the family's complaint differently, and what we could do in the future to improve our service.

Our statutory role and how we consider complaints

  1. We make final decisions on complaints that have not been resolved by the NHS in England and UK government departments and some UK public organisations. We do this independently and impartially.
  2. We are not part of government, the NHS in England or a regulator. We are neither a consumer champion nor arbitrator.
  3. We look into complaints where an individual believes there has been injustice or hardship because an organisation has not acted properly or fairly, or has provided a poor service and not put things right. We normally expect people to complain to the organisation first so it has a chance to put things right. If an individual believes there is still a dispute about the complaint after an organisation has responded, they can ask us to look into the complaint.
  4. We are the final stage for complaints about the NHS in England and some public services delivered by the UK Government.
  5. We are accountable to Parliament and our work is scrutinised by the Public Administration and Constitutional Affairs Committee.
  6. When considering a complaint we begin by comparing what happened with what should have happened. We consider the general principles of good administration that we think all organisations should follow. We also consider the relevant law and policies that the organisation should have followed at the time.
  7. If the organisation's actions, or lack of them, were not in line with what they should have been doing, we decide whether that was serious enough to be maladministration or service failure. If we find that service failure or maladministration has resulted in an injustice, we will uphold the complaint. However, if we do not find that the injustice claimed has arisen from the service failure or maladministration we identified, we will only partly uphold the complaint. Alternatively, if we do not find service failure or maladministration then we will not uphold the complaint.
  8. If we find an injustice that has not been put right, we will recommend action. Our recommendations might include asking the organisation to apologise, or to pay for any financial loss, inconvenience or worry caused. We might also recommend that the organisation takes action to stop the same mistakes happening again.

The scope of the complaint we investigated

  1. Mr and Mrs Morrish complain that despite internal investigations at the Surgery, Devon Doctors, NHS Direct, the Trust and the PCT, those organisations were able to draw the wrong conclusion and reassure themselves that Sam could not have been saved.
  2. Mr and Mrs Morrish complain that the NHS independent investigation review processes are not fit for purpose, believing that they are not sufficiently independent, inquisitive, open or transparent, properly focused on learning, or able to span organisational and hierarchical barriers, and that they exclude patients, their families, and junior staff in the process. They point out specifically that clinicians who were either involved in providing or overseeing Sam's treatment had influence over [1] early investigations and [2] reaching the conclusion that Sam's death was unavoidable.
  3. Mr and Mrs Morrish complain that in the absence of 'understanding' and 'learning' about 'how' and 'why' Sam's death was deemed unavoidable, investigations and complaint systems will continue to fail, exposing patients and staff to avoidable risk.
  4. Mr and Mrs Morrish also complain that the Child Death Review process itself (and therefore the Child Death Overview Process / Panel) is fundamentally flawed and of unknown effectiveness. They believe it was mishandled in their case, citing the fact that a consultant responsible for Sam's care at South Devon Healthcare NHS Foundation Trust was allowed to chair the local Child Death Review meeting. They complain that the Child Death Review process accepted the NHS's conclusions that Sam's death was unavoidable whilst simultaneously excluding the family and ignoring or dismissing their concerns. They suggest it lacks impartiality, checks and balances, and meaningful or effective accountability, is not open or transparent in its approach or its findings, and that as a result it cannot reliably fulfil its purpose, which is to help reduce avoidable child deaths.
  5. As a result of the way that the various organisations dealt with Mr and Mrs Morrish's complaint, they felt that whilst grieving and isolated they had to persistently challenge all relevant organisations, departments, processes and systems for a number of years, concerned by the apparent lack of ability or willingness to investigate, understand, or learn from Sam's unexpected death, in the hope of reducing additional avoidable deaths.

How we conducted this investigation

  1. Our investigation has been carried out by a team with dedicated roles and responsibilities. The team consisted of a senior investigator and two other members of staff who carried out specific functions. One a dedicated single point of contact for the family (the family liaison), who also conducted enquiries, and the second, an investigator who reviewed the material gathered as part of our original investigation and conducted interviews with staff at the organisations involved in the case.
  2. We interviewed a number of the health care professionals who were involved in Sam's care and treatment. We wanted to find out about the processes the organisations involved had in place for dealing with cases such as this, whether those organisations followed those processes and, if they had followed them, whether the processes were adequate. We sought to understand what information they had gathered after Sam's death up until the point the family referred the matter to us. We considered the standard of the investigations that had been undertaken locally alongside the policies and processes that were in place at the time. We also considered the standard of the local investigation in line with the NHS Complaints Regulations 2009, the NHS Constitution, and the Ombudsman's Principles of Good Complaint Handling, and these documents can be found in full at Annex B.
  3. We recorded the interviews we conducted and they have been transcribed as part of the evidence on which we are basing our findings and recommendations. We also considered again the significant amount of information we gathered during our first investigation. Most importantly, we worked with Sam's family to make sure that we had fully understood their concerns, their perspective and what they wanted to achieve.

5 A root cause analysis is a method of problem solving used for identifying why faults or problems happened.