Learning from mistakes in the NHS: a special report by the Parliamentary and Health Service Ombudsman (PHSO) into how the NHS failed to investigate properly the death of a three-year-old child.

By John Tingle

In the UK where health is concerned money is a particularly poor compensator for the loss of a limb, faculty or even a family member. In my experience patients who have suffered adverse health incidents, negligence, more often than not, are not primarily motivated by obtaining monetary compensation. They seek in the main an explanation of what occurred and why, an apology and an assurance that what happened will not happen to anybody else; that lessons have been learned.

The NHS (National Health Service) for decades has been unable to provide a satisfactory complaints and patient adverse incident investigation service which provides these outcomes generally. More often than not patients have to resort to complaining or beginning litigation in order to find out what happened and why and the process that they have to embark on can alienate them even more as they soon hit major and seemingly unsurmountable obstacles. The NHS maintains a defensive and blame ridden culture when errors happen as the terrible events of Mid Staffordshire revealed.

The report

The  PHSO has just published a special report into how the NHS failed to properly investigate the death of a three-year-old child.The report focuses on one case but the failures identified are common throughout the NHS and need urgent remedy. The parent’s experiences are fully catalogued in the report and the PHSO makes some important recommendations for change.

Sam Morrish, a three-year-old boy, died from sepsis on 23 December 2010. The parents were eventually given answers as to why the NHS failed to uncover that their son’s death was in fact avoidable. The report goes into some detail about the various levels of investigation and how various organizations failed the parents. The PHSO found that in relation to the investigations undertaken after Sam’s death that the NHS investigation review procedures was not fit for purpose. They were found not to be sufficiently independent, inquisitive, open or transparent. They were not properly focused on learning and not able to span organizational and hierarchical barriers. They excluded patients, their families and junior staff in the process. The care of Sam was also investigated and failings identified. Failures in communication and poor decision making were identified:

Once the antibiotics had been prescribed, the administration of those drugs should have been immediate. Furthermore, as soon as it was realized that the antibiotics had not been given, they should have been. Instead the decision was made to delay their administration until Sam had been transferred to the high dependency unit. Not only was this decision flawed, there was clearly a breakdown in communication that led to further unnecessary and avoidable delay.” (p.36).

This report draws all the NHS investigative failings neatly together in one place within a very sad context and as such it is a very powerful learning and educational tool. The parents journey in the report is a sad and long one but through their determination and perseverance they obtained answers. The report should be read by all those concerned with patient safety and care quality.