Sam Morrish, a three-year-old boy, died from sepsis on 23 December 2010.
An investigation, undertaken by the Parliamentary and Health Service Ombudsmen (PSHO) in 2014, found that had Sam received appropriate care and treatment, he would have survived.
Yet, previous NHS investigations failed to uncover that his death was avoidable. So the family asked PSHO to undertake a second investigation to find out why the NHS was unable to give them the answers they deserved after the tragic death of their son.
The second PSHO investigation found that the local NHS investigation processes were not fit for purpose, they were not sufficiently independent, inquisitive, open or transparent, properly focused on learning, or able to span organisational and hierarchical barriers, and they excluded the family and junior staff in the process.
Had the investigations been proper at the start, it would not have been necessary for the family to pursue a complaint. Rather, they would, and should, have been provided with clear and honest answers at the outset for the failures in care and would have been spared the hugely difficult process that they have gone through in order to obtain the answers they deserved. As a result, service and investigation improvements were also delayed.