NHS Failures Killed Three-Year-Old Boy - Report

A boy died from a treatable condition because four separate NHS organisations made repeated mistakes in his treatment, an investigation concludes.

The family of Sam Morrish suffered a further injustice because the Primary Care Trust (PCT), NHS Devon, Plymouth and Torbay Cluster, failed to fully investigate the three-year-old's death. Sam died from severe sepsis poisoning in December 2010.

An investigation by the Parliamentary and Health Service Ombudsman, published today, upheld all of the family's complaints. These were about the care and treatment provided to their son and the way in which the NHS investigated the circumstances surrounding Sam's death.

The report by the ombudsman service unveiled a catalogue of errors by the Cricketfield GP Surgery, by NHS Direct, by the out of hours service Devon Doctors Ltd and by the South Devon Healthcare NHS Foundation Trust in their care of Sam.

The errors included a failure to assess the little boy fully, recognise he was vomiting blood and there was also a three-hour delay in the boy receiving antibiotics at the hospital.

If he had received appropriate care and treatment Sam would have survived, the report says.

The ombudsman service has recommended that NHS England review questions asked by NHS 111 call handlers to ensure emergency cases are not missed and for NHS England to make a payment of £20,000 to the family in recognition of the missed opportunities to save the little boy's life. All of the report's recommendations have been accepted.

(CVS/CD)