Last month, the Parliamentary and Health Service Ombudsman (PHSO) published a report relating to the tragic death of 3 year old Sam Morrish. Sam died in 2010 from sepsis. In 2014, the PHSO published a report that found Sam would have survived had he received appropriate care and treatment. However, whilst the 2014 report confirmed that Sam’s death was avoidable, it didn’t provide a satisfactory explanation as why it was that the local NHS failed to uncover what happened and therefore couldn’t ensure that necessary learning took place. At the request of Sam’s parents, the PHSO undertook a new investigation to look at why.
The report found that the local investigation process was not fit for purpose, was not sufficiency independent, inquisitive, open or transparent and that the people carrying out the investigation were not sufficiently trained. It’s a hard hitting, compelling document that builds on the now strong evidence base that tells us there is an urgent need for change in the way the NHS responds and learns from mistakes. Sam’s father, Scott Morrish said: