Independent report

Learning from mistakes

An investigation report into how the NHS failed to properly investigate the death of a three-year old child



This report is about a family finally being given answers as to why the NHS failed to uncover that their son’s death was avoidable.

Sam Morrish, a three-year-old boy, died from sepsis on 23 December 2010. Our 2014 investigation 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 us 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.

We hope that this case acts as a wake-up call to drive through much-needed improvements in how the NHS investigates complaints about potential avoidable harm or death.

Published 20 July 2016