A three-year-old boy died from a treatable condition following “repeated failures” by GPs, out-of-hours services and hospital staff, a damning report has found.
Sam Morrish, of Newton Abbott, Devon, died from severe sepsis poisoning in December 2010. GPs had failed to spot the severity of his condition, and when his parents later called NHS Direct, the nurse adviser failed to record the fact that he was no vomiting blood – a signal his condition required urgent attention, the Parliamentary and Health Service Ombudsman’s report said.
His case was referred to an out-of-hours service, Devon Doctors Ltd, which advised that he should be taken to a Treatment Centre. However, the report said there was no evidence that the urgency of Sam’s condition had not been passed on, and Sam’s mother had to “flag down” a nurse at the centre to get urgent treatment.
He was taken by ambulance to A&E at Torbay Hospital, part of the South Devon Healthcare NHS Foundation Trust, where he was prescribed with antibiotics. However, it took nearly three hours for these to be administered and he died the next morning, only two days after first seeing a GP.
“This service failure led the family to suffer the most significant of injustices,” the report said. “Were it not for the errors in the care and treatment provided to Sam, he would have survived his illness.”
The Ombudsman’s report also criticised the local Primary Care Trust for failing to fully investigate Sam’s death, and the Ombudsman service itself has been condemned by Sam’s family for taking too long to investigate the case.Reuse content