NHS services failed in their investigation of a three-year-old’s death from sepsis, a critical report has found.
Sam Morrish died in December 2010 from sepsis following a "catalogue of errors" by GPs, hospital doctors and call handlers at NHS Direct, now replaced by the 111 service.
The three-year-old from Devon died 36 hours after his parents sought help from a GP for suspected flu and a chest infection. Later in the evening, there was blood in Sam’s vomit. Their call to NHS Direct was not categorised as an emergency and the information was incorrectly recorded.
Mrs Morrish was advised by an out-of-hours GP service that a local treatment centre in Newton Abbot was their best option. It was later learned that this information was based on a conversation between an unqualified call handler and a driver. Sam was placed in a queue at the treatment centre until an ambulance was called.
At Torbay Hospital, Sam’s prescribed antibiotics took three hours to be administered, by which time a bacterial infection had entered his weakened immune system, causing a septic shock hours later.
Following his tragic death, Sam’s parents requested an investigation into the events leading to Sam’s death from septic shock to prevent future tragedies.
The first investigation found that four health service groups had made errors. A second review by the Parliamentary and Health Service Ombudsman (PHSO) examined how the NHS investigated Sam’s death.
The report said: "We think that a fundamental failure in this case was the organisations' - in particular the Trust's - unwillingness to accept that any view other than their own initial view might not be the right one.
"Those involved appeared to accept almost immediately the view that Sam's death was rare and unfortunate rather than being open to other possibilities".
Sam’s father, Scott Morrish, told the BBC: "The NHS should have given us the answers we needed soon after he died, to enable improvements to be made," adding that Sam’s death was “avoidable”.
A PHSO spokesman said: “We recognise that we took too long to investigate this case.”