• Devon Doctors and local NHS respond to Ombudsman report on the death of three-year-old from sepsis

    The NHS in south Devon accepts the findings of the Parliamentary and Health Service Ombudsman (PHSO) report into the death of three-year-old Sam Morrish, which is published today (Thursday) .

    Organisations recognise that they failed Sam at each stage of his contact with the health service, and in subsequent investigations, and have apologised to his family.

    As a result of the case, they are well-advanced on plans for the NHS’s first integrated care ‘pathway’ for children with suspected severe sepsis. This is designed to make sure the right questions are asked, advice given, tests carried out and treatment provided, whenever and however a child comes into contact with the NHS.

    Dr Graham Lockerbie, Medical Director for NHS England’s Area Team for Devon, Cornwall and Isles of Scilly, speaking on behalf of the local NHS, said:

    “Sam and his family have been let down by the NHS. It's clear that there were shortcomings at every stage of his contact with the health service and that, in the words of the Ombudsman, Sam died when he should have survived.

    “All of the organisations involved recognise that opportunities to alter the tragic outcome were missed. We all accept the blame for that. For this, we, the local NHS, apologise unreservedly to the Sam's family. 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. Again, on behalf of the local NHS, I apologise.

    “We all accept the criticisms within the Ombudsman report. We also accept its recommendations. These include the making of a joint payment to Sam's family.

    “Above all, we are determined to ensure that the lessons really have been learnt, and that systems are strengthened to support staff in the decisions they make and the care they provide.”

    The issue of sepsis is rising up the national agenda, not least because of the PHSO’s ‘Time to Act’ report last September, which urged action to combat the 37,000 sepsis deaths each year.  Dame Julie Mellor spoke further on the subject this week.

    Earlier this month, the All-party Parliamentary Group on sepsis also urged action in its annual review. MPs called for the development of collaborative care pathways, especially to span the “interface between pre-hospital and hospital care”.

    Graham Lockerbie said:“We recognise that the Ombudsman report will resonate outside our local organisations because the NHS, like other health systems around the world, struggles to identify sepsis early enough and then to provide the right treatment quickly enough.

    “This is why we have been pressing ahead locally with our work to help ensure that children with severe sepsis get the right treatment, whatever their point of contact with the NHS.

    “As a result, what we call a pathway of care – from initial information for parents right through to hospital - will be tested in Torbay and South Devon later this year. It will then be adapted and adopted across the South of England, and available for use elsewhere in the NHS.

    “We are all very clear that, if humanly possible, there should be no more cases like Sam’s.”

    Notes to Editors

    1. For any media enquiries please call the NHS England South press office on 020 7932 3911

    2. More about the sepsis work in south Devon is available at: http://www.england.nhs.uk/south/dcis-at/professionals/sepsis/

    3. The PHSO report, ‘Time to Act’, is available at: http://www.ombudsman.org.uk/about-us/news-centre/press-releases/2013/time-to-act,-says-ombudsman-in-report-which-reveals-failings-in-the-urgent-treatment-of-sepsis

    4. The annual review of the All-party Parliamentary Group on sepsis is available at: http://sepsisappg.com/wp-content/uploads/2014/06/APPGsepsis2014-final.pdf

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