THE FATHER of a Newton Abbot toddler who died from sepsis has called for change in the culture of the NHS to enable staff to talk more honestly when mistakes are made.
Three-year-old Sam Morrish died from the treatable blood poisoning condition 36 hours after falling ill just before Christmas in 2010.
Despite clear signs of developing illness, GPs at Cricketfield Surgery in Newton Abbot, the Devon Doctors on call service, NHS 111 and Torbay Hospital all failed to treat him until too late.
A report published by the Parliamentary and Health Service Ombudsman showed the way in which the NHS failed to uncover that his death was avoidable and reveals how those involved in the local NHS investigations were not sufficiently trained, aware of the relevant guidelines or sufficiently independent of the facts complained about.
Sam's father Scott Morrish told a parliamentary select committee on Tuesday that the initial investigation was marred because staff were frightened to speak freely for fear of reprisals.
He has called for a system similar to the aviation industry where staff can talk honestly about how mistakes were made so lessons can be learned, and that the culture change must come from the top.
Mr Morrish, a member of the Healthcare Safety Investigation Branch Expert Advisory Group, said: “There is too much blame in the system and a tendency to shame staff for what they do.
"There needs to be a move to nurturing and compassion to staff so that they can in turn deliver that to patients. They need to know that if they have made a mistake that they can speak freely."
The inquiry held in Westminster on Tuesday has been set up to examine the failures into the initial investigation into the case, and Mr Morrish told the committee that so far, the pace of change has been too slow.
He showed the inquiry an information leaflet made in Sam's name to help parents and healthcare staff identify sepsis.
But despite promises, the leaflet has not been rolled out across the UK and could undergo a further two years of evaluation before any further progress is made - eight years since Sam's death.
He told the committee: “We have been told for five years that lessons have been learned but those lessons are only just beginning. The actions that need to follow have barely started. It should not take this long and I don't know why people have so much tolerance of it taking this long."
The government is obliged to respond to the committee findings.
Mr Morrish was a witness to the inquiry alongside Steve Shorrock, European Safety Culture, Programme Leader, Prof. Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission, Keith Conradi, Head of the new Healthcare Safety Investigation Branch and Helen Buckingham, Executive Director of Corporate Affairs, Care Quality Commission.
Julie Mellor, the Parliamentary Health Ombudsman who completed the two reports into the case said after the hearing that still too many NHS investigations into avoidable deaths are inadequate.
She said: “Sadly the experience of the Morrish family is not unique. We see too many local NHS investigations into avoidable deaths that are not fit for purpose.
'We have recommended that people at the top of the NHS consider how they can create an environment in which leaders and staff in every NHS organisation feel confident and have the competence to find out why something went wrong and to learn from it."
The ombudsman's report in 2014 revealed that a catalogue of errors led to Sam's death. He was failed by all the NHS medics who saw him 36 hours before he died of severe blood poisoning. Despite clear signs of developing illness, GPs at Cricketfield Surgery in Newton Abbot, the Devon Doctors on call service, NHS 111 and Torbay Hospital all failed to treat him until too late.
Sam's parents were directed to a local treatment centre by an unqualified out-of-hours call handler, when he should have been gone immediately to A&E. When he was eventually rushed to Torbay Hospital, it took three hours for staff to give him antibiotics, by which point a bacterial infection had already taken hold. He died of septic shock the following day, two days before Christmas on December 23, 2010.