FOUR seperate parts of NHS fail, NHS Complaints Process fails and Ombudsman fails.

NHS blunders led to Devon toddler’s death


A string of blunders by NHS workers led to the death of a three-year-old Devon boy, a review has found.

Sam Morrish died in December 2010 from a treatable condition because four health service organisations made mistakes, the Parliamentary Health Service Ombudsman (PHSO) said.

He died of severe sepsis after a “catalogue of errors”.

Sam’s parents also said they had “serious concerns about the competence and accountability” of the ombudsman.

Ombudsman Dame Julie Mellor said that had Sam received the appropriate care, he would still be alive today.

Cricketfield GP Surgery, NHS Direct, Devon Doctors Ltd and South Devon NHS Trust were all criticised.

Failures included inadequate assessment of the toddler, not recognising that he was vomiting blood and a three-hour delay before he received antibiotics at hospital.

His family said as well as losing their son, they feel they have been “failed” by the NHS complaints system.

In a statement released through the Patients Association, they also criticised the ombudsman.

“The astonishing length of time it has taken for PHSO to finalise this report has inescapably prolonged our distress.

“Although we are grateful that the PHSO has upheld our complaints… we are left with serious concerns about the competence, capability and accountability of the PHSO itself.”

Sam’s mother Susannah Morrish said: “The report looks the way it does because of our constant intervention.

“The fact there had to be two draft reports, both of which looked radically different to this final report, says something.

“Our involvement included providing information, pointing out omissions, correcting factual errors.

“Our thoughts were if we didn’t do this, who would?”

Sam’s father Scott Morrish said: “The thing that we’re still trying to push for is, we’re not clear who the ombudsman is accountable to, we’re not clear who really understands what happens behind the scenes there, and we’re not entirely sure that Parliament is actually able to look at anything more than what comes out in the report.”

Dame Julie said: “I accept that the family are right that the investigation method used in this case was not adequate to the complexity of the case.

“I really recognise that this contributed to the family’s distress and we have apologised for that and thanked the family for their feedback on the particular method we used in this case, because we are developing new investigation methods.”


Dame Julie said that Sam’s devastated family suffered “further injustice” because health officials failed to properly investigate the youngster’s death.

“But this case has to be looked at in the context of taking on over 4,000 cases to investigate every year, and receiving very few complaints about the quality of our decision making.

“When we do, we treat it like gold dust to help us improve our service.

“We’ve published this case so that the wider NHS learns from Sam’s death,” she added.

NHS England was ordered to pay £20,000 to the family.

Mr Morrish said: “The irony is we never wanted to lodge a formal complaint.

“We only did because we were advised to by the Patients Association in response to the NHS completely getting it wrong, not once, but twice.

“We didn’t want it to be about blame, we wanted it to result in good learning.”


Key recommendations

  • Cricketfield Surgery should train reception staff in directing patients through telephone triage system
  • NHS England should review out-of-hours guidelines and ensure other NHS organisations regularly test their own procedures
  • South Devon and Torbay Clinical Care Groups (CCGs), Northern, Eastern and Western Devon CCG and South Devon NHS Trust should provide bereavement services to families such as the Morrishes
  • Staff should be trained in bereavement services
  • South Devon and Torbay CCG and Northern, Eastern and Western Devon CCG should develop procedures for investigating serious incidents
  • Within three months, there should be people at the organisations trained to investigate serious incidents
  • The Morrishes should be paid £20,000
line break

Dr Graham Lockerbie, speaking on behalf of the local NHS, said: “Sam died when he should have survived.”

“We all accept the blame for that. Quite simply, we should have done better.

“When we investigated, we were still unable to provide adequate answers to Mr and Mrs Morrish about what had gone wrong, or to reassure them that things would change for the future. It is clear that this only compounded their grief.

“Again, on behalf of the local NHS, I apologise.”


I’m going to wager a guess that there are two reasons the Health Ombudsman receives very few complaints about it’s decisions:

One, because they often fail to bother investigating instances of poor care and two, because once you’ve gone through the effort involved in taking a legitimate complaint TO the Ombudsman, you are absolutely done with complaining and fail to see the point of getting back to them yet again.

And you start a blog instead!

DLA/PIP – you CAN ask for a claim form in writing!

I made a claim for Disability Living Allowance about three years ago and was not only turned down, but told at a tribunal that they didn’t believe I even have agoraphobia!

How ironic then that support workers employed to support me in the last few years seem to be of the opinion that I’m too crazy for their ‘ickle sensibilities! Yet, the DLA people think I have nothing wrong with me. Nice little cleft stick there.

I will include the DLA debacle in this site if I can ever revisit it long enough to so so. It was so harmful to me to be told that I was making up an illness that has ruined my entire life that my partner keeps begging me not to apply for PIP in case they do the same thing again. She’s that worried about the effect it had on me last time.

But, yes, I don’t see why the people on the tribunal and the GP who handed me to them on a plate shouldn’t be named and shamed here too. F**k them.

I’ve put off claiming for PIP because until today I was under the impression that you have to phone for them to send you a claim form. Nowhere on the official DWP site does it tell you that you can also write for a form, as far as I can see.

I am also terrified that the same thing will happen again but at least this time, when I go to them I will know beforehand that they might actually challenge the existence of my illness. Before I attended the tribunal I was told I had only to prove that I required extra help – not that I had a particular illness.

But you know, with the current focus by government on the weakest members of society – the poor (“benefits scroungers”) disabled (“perfectly able”) in order to justify not paying them – I should have known better. Now I shall be armed with as much written evidence as I can obtain from all the psychologists and shrinks who’ve seen me since I was 14.

Oh, that reminds me – when I was applying for ESA when the benefit rules changed last year, one of the questions was along these lines: “has anyone ever said you are hard to deal with” or something…and I said well, my last support worker dumped me like a hot shitty, brick because she suddenly found me SO hard to work with! They wanted to know the reason too, but to this day, I still haven’t got a clue. Let them ask her.

If you’re unable to use the phone to claim PIP

If you can’t use the phone, someone else can call the claim line on your behalf. However, you’ll need to be with the person making the call so that you can give the DWP permission to speak to that person.

If you’re unable to use the phone and you can’t get anyone to make the call with you, you can write to ask the DWP for a paper claim form PIP1 or ask for a paper claim by textphone on 0800 917 7777. The address to write to is:

Department for Work and Pensions

Personal Independence Payment New Claims

Post Handling Site B
WV99 1AH


OR! You can always get yourself a support worker to phone for you!      8bbd60b820f4a5ecc77e2b592834b28b




The Care Quality Commission is an absolute disaster

This is a disgrace. These people should be taken out and shot, in my humble opinion. The CQC needs to stop giving these people warnings that they’re coming to do inspections and start coming unannounced.


More than 30 recommendations have been made after a scandal-hit care home in West Sussex saw 19 unexplained deaths.

A serious case review found action to rectify problems was avoided at Orchid View. It also said “ineffectual action plans” were not acted on.

Five of the deaths at the now-closed home, which was run by Southern Cross in Copthorne, involved neglect.

The Care Quality Commission (CQC) has admitted a series of failings in how it handled incidents there.

An inquest last year found that all 19 people whose deaths were unexplained had received “suboptimal” care.

‘Catastrophic’ care standards

Residents were left soiled and unattended, and one night shift saw staff make 28 drug errors.

The five whose deaths involved neglect were Wilfred Gardner, 85, Margaret Tucker, 77, Enid Trodden, 86, John Holmes, 85, and Jean Halfpenny, 77.

Earlier, lawyers representing the families of those who died called for a complete overhaul of the care industry, and also a public inquiry to find out how standards dropped to “such a catastrophic level”.

But after the serious case review findings were published on Monday, independent chairman and report author Nick Georgiou said: “It is not possible to say that this report or any other will prevent all future safeguarding alerts.

“It will not do that, but acting on the recommendations will lessen the risk to other residents in other settings.”

 West Sussex councillor Peter Catchpole said the report would help prevent similar cases in the future

Following publication of the serious case review findings, the CQC also published its own report.

Andrea Sutcliffe, chief inspector of adult social care, said the primary responsibility for failings at Orchid View rested with care home staff and Southern Cross, but the CQC had looked at its own role and knew it did not fulfil its purpose of making sure the home provided safe, compassionate and high quality services.

“The way we worked when these serious incidents happened meant we did not respond to early warning signs, we were too easily reassured by the responses of Southern Cross and the people who worked there – and we did not take appropriate enforcement action quickly or strongly enough,” she said.

Ms Sutcliffe said work had been carried out to make the CQC more responsive to risks, to improve inspections, and appoint and train more inspectors. She said further improvements would be made.

‘Harrowing case’

The serious case review was commissioned by the West Sussex Adult Safeguarding Board.

Its 34 recommendations included that care operators must prove to the Care Quality Commission (CQC) they can recruit and keep trained and skilled staff.

The report also called for relatives always to be given a named point of contact in care homes and for concerns to be escalated outside the home if not dealt with promptly and properly.

Other recommendations included that care homes should hold open meetings with relatives and the local council.

And the report said there should be a threshold for informing the public about significant safeguarding issues to help people make informed choices about the homes they choose for their loved ones.

West Sussex councillor Peter Catchpole said: “What happened at Orchid View was harrowing.

“Nothing will help ease the pain of the families who were affected by these terrible events and who lost loved ones.”

But he added: “We do believe that acting on the recommendations contained in this report will go a long way towards preventing this happening again.”

The care home has since reopened under a new name and new management.

Support Work – You’re Doing It Wrong.

There is no better exercise for the heart than reaching down and lifting someone up.

These are some of the people and organisations whose failings this blog will highlight. They can run (away) and most of them have, but they cannot hide from their actions here.

I have ZERO sympathy for anyone who is paid to provide a service to vulnerable people, and who provides a poor service unchallenged because most of their clients can’t fight back. If no-one ever complains about poor service, nothing will ever change and people will continue to be short-changed by people and services who are failing in their duty.

These people totally failed in their duty of care to me and thought they could just walk away, forget all about it, blame me for it, learn nothing from it and pretend it never happened.Their behaviour bordered on the ridiculous. That almost guarantees that it will happen again to some other hapless person and that is fundamentally wrong.

Argyll and Bute Womens Aid, July 2012 – February 2013 Support Worker Liz and ABWA Manager Pamela MacDonald.

Dunoon Community Hospital, Accident and Emergency Department – December 2012 Dr Khan

Argyll & Bute Addictions Team, Late 2011 – September 2012 Community Psychiatric Nurse Geri Anduuru and Psychiatrist Dave Johnson

Inverclyde Royal Hospital, J North January 2012 RGN “Liz” and Female Nurse in Charge (Night Shift)

Maybe seeing their names in a public forum will force these people to clean up their act and actually provide the service they are being paid to.

The Nursing and Midwifery Council seems to be a bit of a joke.


Mid-Staffs scandal: Nursing and Midwifery Council criticised

The NMC is the regulator for the nursing profession

The Nursing and Midwifery Council is facing more criticism over its handling of disciplinary cases in a report by the Professional Standards Authority.

In particular, the report highlights failings over the handling of cases relating to the scandal-hit Mid-Staffordshire NHS Trust.

Investigations were poor, decision-making flawed and record-keeping lax, says the PSA.

The NMC is responsible for regulating 673,000 nurses and midwives in the UK.

It has previously been accused of failing to protect patients and has admitted “substantial failings” in the past – but says the latest report recognises the progress it has made.

The report by the PSA – the body that oversees health regulators – shows the Nursing and Midwifery Council is struggling to move on from its troubled past.

The NMC is letting down those patients who have received substandard care from these incompetent care professionals”

Katherine Murphy Patients Association

A huge backlog of cases and long delays led to accusations that it was failing at every level.

‘Ongoing weakness’

This latest report saw the PSA carry out an audit of 100 cases dealt with by the NMC’s disciplinary committee.

The report acknowledged that there had been some improvements under a new management team at the NMC, but outlines a number of areas where the organisation is still failing.

The report adds that there is an ongoing weakness in the NMC’s ability to identify for itself where improvements are needed.

The PSA said: “We were disappointed that the NMC’s internal review (in July 2013) of its handling of cases that involved registrants employed by Mid Staffordshire NHS Foundation Trust did not identify a number of serious issues that we picked up in our audit.”

The report also highlighted concerns over the use of voluntary removal, where a nurse or midwife facing a disciplinary hearing can apply to be removed from the register without a full public hearing.

“We identified concerns in all 21 of the cases we audited that were closed following the grant of applications for voluntary removal, and have urged the NMC’s Council to ensure that our concerns about the NMC’s procedures are addressed quickly.”

‘Letting down patients’

Chief executive and registrar of the NMC Jackie Smith said she was pleased the report highlighted the improvements made to the way the disciplinary process for nurses and midwives works.

“We know that there is still more we need to do,” she said.

“However, it recognises the progress we have made and confirms the commitment we made to improving performance.”

But Katherine Murphy, chief executive of the Patients Association, described the findings as “deeply worrying”.

“Delays in processing hearing cases and seeking interim orders would result in incompetent staff continuing to provide poor care to patients.

“The NMC is letting down those patients who have received substandard care from these incompetent care professionals who are free to continue to practice.

“It is disgraceful to see that lessons are still not being learnt from the Francis Inquiry and serious issues relating to registrants from the Mid Staffordshire trust have not been picked up.

“The Regulator needs to address these fundamental issues now and act urgently to protect the public.”

Campaigner Julie Bailey of Cure The NHS said it was time to accept that the NMC was “not fit for purpose”

“The public expect patients to be protected and this is another instance where the NMC have failed us.

RGN “Liz” and Nurse in Charge (Night Shift), J North, Inverclyde Royal Hospital, January 12th 2012

This incident highlights everything that is wrong with the NHS and indeed all areas of care. Of course there are wonderful people working in care and thank goodness for them but too many people see care as an easy way to earn a living, or a way to exercise some power over those less fortunate than themselves or the perfect way they can feel better about themselves whilst getting paid for it.

I had the misfortune of being transferred to J North ward in Inverclyde Royal Hospital on the night of January 11th 2012 after I took a massive overdose. Invercylde has always had a terrible reputation locally and many people just plain refuse to go there for treatment. Had I known I was going to be taken there I would have done anything to prevent it.

I was unconscious when I arrived and placed on a drip for around 36 hours. In addition to vomiting my guts up continually for the first 24 hours, I had had a severe allergic reaction and there was some concern that the drugs they were giving me may have caused it. The Doctors told the nursing staff to keep an eye on this and I eventually stopped being sick and started to recover.

The nursing staff were at best, coldly professional towards me from the outset – none of them was even remotely what could be described as warm or caring and some of the ancillary staff actually glared at me (I’m serious). No-one, and I mean NO-ONE, ever gave a “hello, good morning, how are you” or any other pleasantries to me at any time during my stay. I was not served lunch on the only day I was actually able to eat and to give you an idea of the kind of patient I was, I didn’t even bother pointing it out. I just sucked it up. I was, as I always am, polite to all the staff.

Then quite suddenly on my second night in the ward, I began to feel really ill and seemed to be having a violent reaction to something….I started throwing up again and, for the first and only time during my 3 day stay, I asked for help from the staff. I got out of bed and approached a women who was wearing this navy blue uniform indicating that she was either a Charge Nurse or a Ward Sister. Either way, she was the nurse in charge that night and also on the night I was admitted.

(The significance of the uniform colour will become evident later.)

According to this letter:

The navy blue uniform was developed to help patients and members of the public identify the nurse in charge. For this purpose, the navy blue uniform will be worn by Senior Charge Nurses. In addition, those employed as designated Team Leaders should wear the navy blue uniform where their role is similar to a Senior Charge Nurse and it is important they are visible to patients and the public.

The Nurse In Charge asked me what was wrong and I replied that I didn’t feel well, at which point she turned away from me and addressed a junior member of staff who was wearing the light blue tunic with the white piping and said “Veritas doesn’t feel well.” Meanwhile I was hanging onto a railing attached to the wall puking up into a cardboard hat. The other nurse, whom I was told by the senior nurse was called “Liz” said “Veritas is self-inflicted, C. is not. C. has diabetes.” and they both walked away into an ante room and left me standing in the corridor on very shaky legs puking my guts up. ( C. was a lovely young diabetic patient whom the staff were clearly very fond of and had known for years.)

At this point there was no-one else anywhere near me so, had I fallen to the ground and died on the spot from anaphylactic shock, my family would have never have known that I had done so as a result of sheer negligence.

I managed to make my way back to bed and after a couple of hours plucked up the courage to go back to the nurses station to ask the staff why they thought it was okay to refuse to help a patient in this way and was then subjected to a tirade of verbal abuse by “Liz” who looked all around her as if she couldn’t see me, and never looked at me and exclaimed “what is she saying? What is this thing saying?” and “Oh I’m not listening to this…I came here to have a cup of tea and a sit down for five minutes” etc……..The entire ward staff and some stragglers from another ward and a female doctor sat there and allowed this to happen – they said and did NOTHING to intervene. “Liz” was so abusive and dismissive that I got really upset and started crying, saying I didn’t deserve to be treated like this and eventually the nurse in charge led me away back to my room saying “now, you’re getting yourself into a state!” No I wasn’t! It was them who got me into that state!

When she was finally out of earshot of her creepy staring colleagues, the nurse in charge said “of course you’re entitled to the same treatment as everyone else, of course you shouldn’t be treated differently…” etc… and came back a while later with a sedative (I’m think a possible defence blaming me was already in the pipeline at this point)

The following day I resumed my silence, saying only please and thank you and so on and getting the same cold perfunctory treatment I had from the beginning.

In the afternoon I was told I was being discharged and had to make my own way home. It was freezing. I have agoraphobia, had no glasses, no watch, no phone, no money, no jacket and no decent clothes and I was expected to just go home on my own. My clothes were covered in 2 days of puke and I had managed to spill an entire jar of beetroot on my joggies before I did the suicide thang. (I think I was attempting suicide by juice.) I was crying I was so petrified to travel home on my own but they refused to arrange transport for me and they claim that there was nothing wrong with my clothes, that I was happy to go home alone and that I REFUSED a lift from a support worker (I didn’t even have a support worker back then). I would have accepted a lift home from Peter Sutcliffe in his lorry with a bag of hammers had he but offered. I had to get a bus, a ferry and another bus and then walk and it took me 2 and a half hours to get to my Mother’s house.

These are the clothes they sent me home in, on public transport:

T-shirt "closely inspected" by Charge Nurse and found to have "one small stain"!SAMSUNG DIGIMAX A503

Before I left I kept my promise that, in the absence of an apology, I would complain and got the necessary details from the Staff Nurse. Needless to say, the cold stares intensified and no-one would speak to me at this point other than to tell me I did indeed have to travel home alone.

As soon as I got home I made a start on writing a letter of complaint to the NHS about my treatment by the two nurses and although I mentioned the general attitude towards me of all the staff and the manner in which I was sent home, my complaint was only about their refusal to help me and the verbal tirade of abuse I got when I asked why·

I hoped that at least one of the nine staff members who had sat and done nothing while I was being verbally abused  would have a conscience and tell the truth about what happened . As it turns out not all of the staff on duty that night were even interviewed and the ones who were all lied.

To cut a long story short, I complained in writing to the relevant department who “investigated” and came to the conclusion that, not only did these incidents not happen to me, but the staff who did them to me weren’t even on duty on the night they didn’t happen..AND those staff who actually were on duty were caring and attentive beyond the call of duty! Apparently (yawn, this is such an oldie and it isn’t even a goodie), I jumped out of bed and charged out to the nurses station in an extremely upset state ranting and raving about what they were unable to say…..and all they did was calm me down

(to be contd…)