the root cause analysis report was sent to the Surgery, NHS Direct, Devon Doctors Ltd and the Trust for comment. The report noted ‘care and service delivery
problems’, identified contributory factors,
root causes and lessons learnt, and made recommendations. This was a draft report, which was not sent to Mr and Mrs Morrish. There was little detail about NHS Direct’s involvement in Sam’s care.
106. At the beginning of June, the PCT emailed the NHS organisations to confirm that, following Mr Morrish’s request, a meeting had been arranged for 28 June to discuss Mr and Mrs Morrish’s outstanding concerns.
107. On 9 June the Trust emailed the PCT asking for amendments to be made to the root cause analysis report, including the reasons why nurses had not given Sam antibiotics in A&E. The PCT’s draft root cause analysis report indicated that Sam was not given antibiotics ‘most probably
due to education and training’. The Trust
said that this was not the case, and that he was probably not given antibiotics:
‘due to time constraints as Sam was only in A&E for 2.5 hours before being
transferred to the [high dependency
unit]. During that time he was reviewed by [various doctors]. All medical and nursing staff working in the clinical area are fully competent in the
administration of antibiotics, however the adult nurses are less familiar with the administration of such drugs to children.’
108. The PCT agreed to omit the reference to education and training from a revised report. The root cause analysis report that was sent to Mr and Mrs Morrish on 14 June, and the final version of the report, stated that there was a delay in Sam receiving antibiotics because of ‘the lack of [a] paediatric nurse overnight in A&E, combined with the reluctance of A&E staff to calculate doses for children and
administer them’. The Trust subsequently
told us that this statement is incorrect, and that Sam was not given the antibiotics sooner because transferring him to the high dependency unit took priority (the paediatric consultant told us staff got their priorities wrong and that staff had not
109. On 12 June Mr Morrish emailed the PCT with questions about the meeting scheduled for 28 June. In addition to who would be present, Mr Morrish asked whether the root cause analysis process itself would be discussed, and whether NHS Direct would go into more detail about its involvement. The PCT explained that representatives from the relevant NHS organisations would be present, and clarified that the meeting would be about ‘the [root cause analysis] of what
happened to Sam’ and why there were
so many delays in progressing the root cause analysis itself. The PCT said that information not available to the root cause analysis meeting in April would be discussed, along with any actions that had been or would be taken, to form an
‘overarching action plan’ that it would
monitor. The PCT told Mr Morrish that one of its representatives would chair the meeting.
110. A couple of days later, Mr Morrish emailed the PCT asking for a copy of the Trust’s internal investigation report into his son’s death, and copies of the various organisations’ complaints policies. The PCT sent the policies to Mr Morrish and a list of who would be attending the meeting on 28 June. The PCT told us that it could not tell Mr Morrish whether the paediatric consultant would attend the meeting because the Trust had not confirmed whether he would be there.
111. As referenced above, Mr and Mrs Morrish first received a copy of the root cause analysis report on 14 June. This differed from the initial draft report. In particular, version five stated that the evidence reviewed now included ‘voice recordings from NHS Direct and Devon Doctors Ltd’. The report recommended that in the future, in organisations where voice recordings are routinely made, they
should be reviewed at the root cause analysis meeting. Despite the root cause analysis report stating that the voice recordings from NHS Direct had been reviewed, information about the calls was not included in the report because NHS Direct had not completed its investigation. Instead, the PCT stated that the voice recordings were one of the ‘areas [that required] clarification [with NHS Direct]’. The root cause analysis report contained additional information about Devon Doctors Ltd’s voice recordings. It identified that a telephone call Mrs Morrish made to the organisation at 8.52pm was not properly documented on their computer system, and that Mr and Mrs Morrish were not told that the decision to send Sam to the Treatment Centre was made after discussions between staff who were not medically trained. Version five of the root cause analysis report included additional recommendations. These included that staff at the Surgery should: check the nappies of children who have symptoms of fever; have a greater awareness of streptoccocal A infections; improve its computer record keeping in order that patients’ past medical histories can be more easily identified; and give patients the opportunity to see the same GP. The report also commented that the Surgery should have had direct contact with Mr and Mrs Morrish sooner. Version five of the root cause analysis report recognised that where there are complex ‘multi agency’ investigations in the future, the chair of the root cause analysis process should take a lead in explaining the process to the family and co-ordinating responses. The root cause analysis report stated that ‘there is a lack of availability of paediatric nurses working in A&E to give complex medications, such as
antibiotics, to children’. There were no
recommendations to address the failure
to give Sam antibiotics. Mr Morrish told us that the root cause analysis report ‘did everything linguistically possible to avoid apportioning blame to anyone for anything’. He said that it ‘missed the point’. 112. Mr Morrish contacted Devon Doctors Ltd
on 15 June after he had received the root cause analysis report. He said that he felt the report had relied on his wife’s narrative of events (provided before the root cause analysis meeting in April) as a finite list of questions to be answered. He said that each organisation should have scrutinised its own involvement, spoken to the family, and given information about its findings to the root cause analysis process. The chief executive of Devon Doctors Ltd responded the same day explaining that while he accepted that they ‘had a role within the [root cause analysis] we did not think
that our role was central to the [root
cause analysis]’. Any inadequacy in their investigation was because they trusted the root cause analysis process. The chief executive said that ‘there were criticisms that could rightly be made of aspects of our service … however I remain of the view that those criticisms did not affect the
sad outcome for your son’.
113. Mr Morrish responded to the chief executive’s email, and his previous comment that he was unsure that in the circumstances Devon Doctors Ltd could have responded any differently. Mr Morrish felt that the root cause analysis process was so flawed that Devon Doctors Ltd should not have waited to be told what went wrong and how to put it right: any issues should have been identified during their own investigation. He said that both the root cause analysis and Devon Doctors Ltd had failed to ask the basic question of why they were told to take their son to the Treatment Centre rather than A&E.
Mr Morrish said that Devon Doctors Ltd investigation had failed to identify the lack of verbal assessment of Sam’s condition by the call handler; the call handler’s failure to tell his wife that they had not spoken to a clinician about Sam’s condition; the failure to pass on critical information to relevant staff at the Treatment Centre; or the excessive waiting time at the Treatment Centre. He said that he had no confidence that Devon Doctors Ltd had understood the issues or corrected them.
114. Over the next couple of days, Mr Morrish sent a list of questions to Devon
Doctors Ltd and the Trust so that these organisations were briefed on his outstanding concerns before the meeting. 115. In correspondence with the chief executive
of NHS Direct, Mr Morrish said that the report did not accurately portray what had happened. The chief executive confirmed that the NHS Direct nurse adviser made an inappropriate referral to Devon Doctors Ltd, and that the NHS Direct nurse adviser failed to accurately assess Sam. He said that a more urgent referral ‘should’ have been made. He accepted that it was wrong for previous reports to have suggested that it ‘may’ have been appropriate to refer Sam urgently. The chief executive told Mr Morrish that whilst the algorithm used by the NHS Direct nurse adviser included a question about how sleepy a child was, staff did not have to repeat these questions verbatim. However, he said that in Sam’s case, this issue should have been probed further. While a positive response to this question would not, on its own, have been ‘sufficiently alarming’ to prompt an urgent referral, he said it should still have been explored further. The chief executive confirmed that if the NHS Direct nurse adviser had recorded ‘yes’ to the questions about whether Sam
had vomited coffee ground-like material, the advice would have been to take him to A&E. Mr Morrish has told us that he had to repeatedly ask the chief executive to attend the meeting planned for 28 June, and it took a great deal of persistence from him before the chief executive agreed to do so.
116. Mr Morrish asked the PCT to obtain a
‘truly’ independent chair for the meeting
who would answer all his questions. Mr Morrish explained that the root cause analysis process had failed to address pivotal questions, missed relevant information and had established a false picture of what had happened. He said that this was a ‘disgrace’, that the investigations conducted by the individual organisations were ‘clearly inept’, and the PCT should have spotted this. He said that the organisations involved had still not established why a GP failed to check Sam’s nappy; whether the out-of-hours doctors tried to call them back; why they were told to take Sam to theTreatment Centre; why they were told to wait in a queue; and why they had to ask for help from a passing nurse. He said that the answers to these questions were in the voice recordings, but no one had listened to them until months after Sam’s death. Mr Morrish was unhappy that no one had spoken to the family to find out their view of what happened, and was unhappy that the process had taken so long. He said that the organisations should gather all the evidence relating to his son’s death, and what had happened to the process afterwards. Only then would
‘the NHS’ be able to see the differences
between the picture portrayed by the root cause analysis, and what actually happened.
117. Mr Morrish spoke to the PCT on 15 June, again questioning the appropriateness of a member of its staff chairing the forthcoming root cause analysis meeting. The PCT asked him to write down his thoughts about who might chair the meeting instead. The following day, Mr Morrish emailed the PCT explaining that:
‘the [PCT’s root cause analysis] process itself is now the focus of so many questions, not just from me, but also from some of the organisations that have fed into it, that on top of everything else, it (the root cause analysis process) also needs to be critically analysed and held to account (if it has indeed been mishandled), which I suggest at least partially undermines its ability to do its job. ‘ …
‘Whilst I am clear about certain things – I am unclear about how to proceed from here – but I am not content to either leave things as they are (in a mess), or to simply cross my fingers and hope that [the PCT] gets it right next time, either for us – or for anyone else. Left to their own devices – I don’t believe they will.’
118. Mr Morrish told us that the PCT was adamant that it was best placed to chair the root cause analysis meeting. He said that ‘it took a lot of debate/argument from me to explain the inappropriateness
behind the decision [for the PCT to
chair the meeting] given their abysmal
performance up until that time’.
119. The PCT acknowledged Mr Morrish’s email, and following his concerns about who
would chair the meeting, confirmed that the meeting would be chaired by the chief executive from another trust (the Chair). The PCT told Mr Morrish that the Chair would provide the objectivity the family required, and that a wider independent investigation should achieve the outcomes he sought. Mr Morrish has questioned how ‘independent’ the Chair was. He says that because leaders from both the PCT and the other trusts sit on each other’s committees, he does not feel that the Chair was as independent as he appeared. He said ‘the decision [to change the chair of the meeting] was not voluntary. It was
definitely made under pressure from me’
and he is ‘absolutely convinced that whilst the PCT wanted to give the impression of an independent investigation - it was not in fact as independent as it appeared to
be to us at the time’. One of the successor
organisations to the PCT (Northern, Eastern and Western Clinical Commissioning
Group) told us that when the PCT suggested to Mr Morrish that it would chair the root cause analysis meeting,
‘Mr Morrish was understandably very
concerned about this and made clear his view that someone independent should chair the meeting’. It added that it:
‘agreed to find an independent chair and having secured the chief executive of another organisation he then
met Mr Morrish.64 Mr Morrish then
agreed to go ahead with the meeting. If Mr Morrish had not agreed to this person chairing, the PCT would have continued to find an appropriate and suitable independent chair.’
120. On 20 June Mr Morrish emailed the PCT to raise questions about the validity of the root cause analysis report. In particular, he
64 It should be noted that the meeting the PCT is referring to took place immediately before the meeting was due to start on 28 June.
said that the report had little information about the involvement of NHS Direct, and had no information relating to the voice recordings. Later that day, Mr Morrish emailed the same list of questions to the chief executive of NHS Direct.
121. On 23 June the PCT confirmed that the paediatric consultant who treated Sam in hospital would not be attending the meeting. The next day, the Chair wrote to all the organisations due to attend the meeting on 28 June. He said that there were a number of unanswered questions and the meeting was an opportunity to review what had happened. The Chair said he would look at how the root cause analysis process could be improved because Mr and Mrs Morrish did not believe that they had been given all the facts, or that lessons had been learnt. 122. Before the meeting, NHS Direct emailed
the PCT with updates to the root cause analysis report. On 24 June the PCT sent the final version of the first root cause analysis investigation report to Mr and Mrs Morrish and the organisations involved in Sam’s care (Annex E). This report
contained more details of NHS Direct’s involvement, including an analysis of the voice recordings, and details relating to the NHS organisations’ internal investigations and learning points. The report also stated that ‘there had been no intentional delays and no unexplained moments that would
have constituted a delay’.
123. Mr Morrish emailed the chief executive of NHS Direct with further concerns about the root cause analysis report, in particular that there was little detail about NHS Direct’s involvement. The chief executive explained to Mr Morrish that the first root cause analysis report contained little information about his organisation’s involvement because the
other organisations had had over three months to review their involvement. The chief executive said that once NHS Direct had completed its review, the information was emailed to the PCT and that he was disappointed the PCT only included its report as an addendum.
124. Before the meeting, Devon Doctors Ltd completed their internal investigation into the care provided for Sam. This found that a doctor had tried to call Mr and Mrs Morrish when information about Sam was passed to them by NHS Direct. Devon Doctors Ltd identified a number of issues relating to the call hander. They found that the call handler had not logged information properly on to the system (including escalating Sam’s condition from routine to urgent) and the advice given to Mrs Morrish to attend the Treatment Centre was not based on clinical advice. Whilst this report was primarily for the board of directors at Devon Doctors Ltd to review, the report stated that ‘a root cause analysis is being undertaken by the PCT due to the multi-disciplinary nature of the patient pathway and this report will feed into this process’. The investigation report highlighted various failings in their service and concluded that:
‘the decision [to send Sam] to [Newton
Abbot Treatment Centre] did give the quickest access to a GP. It did not
necessarily delay [Sam] being seen in
A&E or contribute to [Sam’s] sad death. This does not mean that there are no failings or learning for Devon Doctors Ltd namely:
• Vomiting black liquid/coffee grounds being shown as an urgent rather than emergency priority;
• Human error by the call operators in the documentation of their actions;
• Lack of clarity in communication between the call operator and the receptionist to the family;
• Failure of the Governance team to locate the first contact to the control centre [by Mrs Morrish]; • Failure to make direct contact with
the family, assuming that feedback and liaison was being dealt with via the [root cause analysis] process.’
125. Devon Doctors Ltd set out a number of