We reported on the outcome of the investigations into the tragic death of Devon toddler Sam Morrish from sepsis in 2010. In her first report published 2 years ago, the Parliamentary and Health Services Ombudsman criticised the failings in care provided by The Cricketfield GP Surgery, NHS Direct, Devon Doctors Ltd, and South Devon NHS Trust and found that Sam would have survived had he received appropriate care.
Subsequent reports in to the death of baby Charlie Jermyn and William Meads, who was only 12 months old at the time of his death, have highlighted similar unacceptable failings by other health professionals at other trusts. The cases highlighted the need for all medical professionals and indeed, parents, to be aware of the signs of sepsis. The Sepsis Trust provide useful guidance on recognising the symptoms and have done sterling work to raise profile and awareness of the condition, culminating in the issue of recent NICE guidelines promoting sepsis as a possible diagnosis in many scenarios where it might previously have been overlooked.
The latest report from the Ombudsman is not however an investigation into the poor standard of treatment received by Sam Morrish but a review of the response of the organisations involved in his care when asked to explain their conduct.
For those of us working in the field of clinical negligence the findings of the report will come as no surprise. “It is not about the money” is a genuine and often heard assertion by clients who seek the assistance of solicitors only because they have been met with a wall of silence, or a blanket denial of any failing from Trusts, GPs or other medical practitioners when questions are raised about care, or rather lack of care in a particular case. The openness required in law by the duty of candour is often absent. In the words of the mother of William Meads “the shutters come down”. The failure to deal with concerns and complaints openly and honestly is not an accusation levelled at the NHS only by Claimant’s solicitors, who might be seen to have an political agenda but reflects the findings of the Ombudsman in her recent report, identifying 40% of NHS investigations as inadequate.
In Sam’s case the Trust were unwilling to accept any view other than their own and excluded family and junior staff from, what by all accounts appears to have been a self serving process, lacking in independence. It is no surprise that in such cases the failings of care are overlooked and the conduct of clinicians is exonerated without any rigorous analysis of the facts.
The concerns are twofold, how can the NHS learn from it’s mistakes if it refuses to accept that a mistake may have been made and, for the parents of Sam, Charlie, William and many others, how can the NHS let them down for a second time by failing to take their concerns seriously, having already failed to look after their children.
A drive to cut NHS compensation costs must begin with addressing the errors, overcoming a self serving culture and taking a basic human interest in those who are left damaged and distressed by poor treatment.
If you or your family have experienced medical treatment which has caused you concern contact our specialist clinical negligence team on 0800 316 8892.