Learning from mistakes


I am laying this report before Parliament under section 14(4)(b) of the Health Service Commissioners Act 1993.

This report is about a family finally being given answers as to why the NHS failed to uncover that their son's death was avoidable.

Sam Morrish, a three-year-old boy, died from sepsis on 23 December 2010.

Our 2014 investigation found that had Sam received appropriate care and treatment, he would have survived.

Yet, previous NHS investigations failed to uncover that his death was avoidable. So the family asked us to undertake a second investigation to find out why the NHS was unable to give them the answers they deserved after the tragic death of their son.

Our second investigation found that the local NHS investigation processes were not fit for purpose, they were not sufficiently independent, inquisitive, open or transparent, properly focused on learning, or able to span organisational and hierarchical barriers, and they excluded the family and junior staff in the process.

Had the investigations been proper at the start, it would not have been necessary for the family to pursue a complaint. Rather, they would, and should, have been provided with clear and honest answers at the outset for the failures in care and would have been spared the hugely difficult process that they have gone through in order to obtain the answers they deserved. As a result, service and investigation improvements were also delayed.

We hope that this case acts as a wake-up call to drive through much-needed improvements in how the NHS investigates complaints about potential avoidable harm or death. Our report highlights two key areas for focus.

Firstly, the NHS needs to build a culture that gives staff and organisations the confidence to find out if and why something went wrong and learn from it.

Secondly, complaints about avoidable harm and death need to be investigated thoroughly, transparently and fairly by the NHS, to make service improvements possible. Sadly the experience of this family is not unique. Time and time again we find that the NHS' investigations are not consistent, reliable, or good enough.

I would like to thank the family for pursuing the complaint, which has important lessons for both the NHS and for our own organisation.

Dame Julie Mellor DBE
Chair and Ombudsman

Parliamentary and Health Service Ombudsman
July 2016