Mr Morrish, 41, said: “Following Sam’s death we started off believing what people told us. But over the past few years we had our faith completely undermined. We needed proper answers and we want the health service to learn the lessons of our own tragedy to make sure it never happens again to other families.”
Sam died in December 2010, just 36 hours after falling ill at his family’s home, in Newton Abbott, Devon.
Suspecting he had flu and a chest infection his mother took him to his local GP, who said Sam did not have an infection.
Sam Morrish (Scott Morrish)
By the next morning the little boy’s condition had worsened and Mrs Morrish rang the GP surgery, saying his condition had deteriorated and that he was “constantly thirsty”.
At the surgery the doctor asked if Sam had been passing urine. Mrs Morrish, 38, said that he was too ill to get up and go to the lavatory and she had therefore kept him in a nappy. Crucially, the GP failed to ask whether there was any urine in the nappy. In fact it was dry, a clear signal that Sam’s kidneys were failing.
Sam was sent home with a prescription for cough medicine, but that evening he vomited what appeared to be blood.
Anxious over this disturbing turn for the worse his parents rang NHS Direct.
On being told that Sam’s nappy was dry, and that he had not passed urine all day, the nurse appeared concerned and said she would get someone to call back.
But the mishandling of Sam’s case was now compounded by a series of further mistakes.
The nurse recorded wrongly on the computer system Mrs Morrish’s information about the boy’s condition. Furthermore the call was recorded as routine rather than as the emergency it clearly was.
Increasingly anxious Mrs Morrish contacted the out-of-hours GP service, Devon Doctors, later that evening. Instead of recommending she take Sam to her nearest hospital’s Accident and Emergency department, she was instead told to go to the local treatment centre in Newton Abbott.
When Mrs Morrish questioned whether the treatment centre was the right place for him she was wrongly assured it was. Months later Mr and Mrs Morrish discovered that this incorrect advice was based on a conversation between the unqualified call handler and a driver.
Things got even worse at the treatment centre. Instead of seeing a doctor straight away the family were placed in a queue behind three other patients.
Growing increasingly frightened Mrs Morrish asked a passing nurse to help. On taking one look at the child, by now seriously ill, the nurse raised the alarm and Sam was rushed by ambulance the five miles to Torbay Hospital, run by South Devon Healthcare NHS Foundation Trust in Torquay.
Here Mr and Mrs Morrish thought he would finally get the treatment he needed, but, astonishingly, he was not given the antibiotics he needed until three hours after they had been prescribed.
By this point an invasive bacterial infection had taken hold in Sam’s bloodstream, entering the boy’s system as a result of his severely weakened state.
He died from septic shock on December 23.
Stunned by their loss, Mr and Mrs Morrish were determined to discover whether Sam could have been saved and establish what lessons needed to be learnt to prevent future tragedies.
However, they say there where failed by the very bodies established to help NHS patients let down by the system.
According to the Patients Association, two investigations into Sam’s death, commissioned by Devon NHS, “failed to find answers and hold those involved to account”.
The first report merely concluded that there had been “no intentional delays” in the treatment of the child. The second investigation, although a “big step forward”, did did not examine whether Sam could have lived if he had received the right care.
A third investigation was abandoned after Mr and Mrs Morrish said they had lost all confidence in the process.
Mr Morrish said: “Even after internal, multi-agency, and a regional independent investigation, there were still fundamental issues that were not being acknowledged or understood, and that there were still obvious unanswered questions.”
In March 2012 Mr and Mrs Morrish complained to the Ombudsman, the highest authority on NHS complaints, which agreed to investigate. However the couple where shocked that the officials repeatedly failed to understand the information they were given about the events leading up to and following Sam’s death, forcing them to relive “the life-shattering death” of their child.
Furthermore the Ombudsman’s investigation turned out to be largely a paper based exercise – with no face-to-face meetings held with any of the healthcare staff involved – and which the family felt failed to examine the incident properly.
As a result the Ombudsman produced several inaccurate draft reports which had to be corrected by Mr and Mrs Morrish which led to long delays in the investigation.
The experience has shaken the family’s faith in the NHS and the bodies which are supposed to protect patients.
“The reason we started asking questions after Sam’s death was that we wanted to regain trust in the system,” said Mr Morrish. “I wanted to know that my two other children would be safe if something happened to them. Unfortunately it became harder and harder to believe that would be the case.”
Mr Morrish added: “We have had plenty of expressions of regret over what happened to Sam, but they don’t go anywhere. Our experience of the NHS complaints procedure and the Parliamentary and Health Service Ombudsman is that, when challenged, it is a closed and unaccountable system that seems to protect assets and reputations, not people like my son, the patients.”
What compels Mr and Mrs Morrish to keep going in the face of bureaucratic obduracy is the memory of their child, and their desire to improve the service on which they and their two other boys, now aged nine and two, still rely.
“Sam was absolutely full of life. He was a force of nature, with an infectious sense of fun,” said Mr Morrish. “If nobody listens and if the system is not changed then children like Sam will keep dying.
Devon Doctors said: “We are committed to doing everything possible to ensure such an occurrence cannot happen again.”
A spokesman for the Health Service Ombudsman said: “We recognise that we took too long to investigate this case and we are sorry for the family’s experience of our service. Their feedback has helped us improve our investigation methods and we look forward to briefing the complainant on other changes we are making.”
3-12 months-old"s death crushed our faith in NHS
