 Sam was very cheeky and mischievous and affectionate. He was just bursting with life and very inquisitive, very sensitive. In December of 2010. Three of us had flu, so Sue was holding us all together. On one night he started being sick. He was really thirsty, took him to the doctor who assessed him and said, yeah, he's just got flu. I left with a prescription just for some cough medicine and we went home. By then we had realised that he hadn't urinated for the whole day. We didn't really know what that meant, but we knew that the nurse had reacted as if that was a problem. I looked up on the internet and found something called Out of Hours Doctors and I phoned them. While we were waiting, Sam was sick again, but this time when he was sick it was all black stuff. He was in my arms when that happened and Sue was on the phone to the healthcare professionals at that moment. And they said take him to the local hospital. And then it was delay after delay. We haven't seen anybody at all and nobody's left the queue. When suddenly this minor injuries nurse walks past it's the first clinician I've seen and she takes one look at Sam and we're rushed off to this side room and all of a sudden he's got oxygen mask on. The doctor at the Out of Hours is calling ahead. The hospital is calling an ambulance. So we're taken off to the big hospital. And then everything that happened after that was so fast. All of a sudden his eyes rolled back and the alarms went off and he was whizzed off my lap onto the bed. All people turned up and we were put behind this curtain. And they tried to start his heart. His heart restarted and there's a sense of just relief and then it stopped again, but of course that second time it never restarted. And then they said we're really sorry but there's nothing more we can do. And it was 5 o'clock in the morning. It was only 12 hours since we'd left the GP surgery with cough medicine and Sam had died. I just remember telling him I loved him and I was sorry and not being able to understand or know what to do or how to help see or what we were going to tell Ben. So it's more than I can explain with words. The thing we had to do was get home and find Ben and tell him. It's almost Christmas and the Christmas tree's up in the living room. Kneeling by that very same Christmas tree in the living room we then have the time until the brother's not coming home. It was the areas where we were left with questions that eventually led to what turned out to be years of investigation. Lots of things had gone wrong with his care. The important information about Sam's deteriorating condition hadn't been passed on. When we arrived at the hospital they didn't give him the antibiotics for two and a half hours. I'd never heard of sepsis. I thought how can I not know as a parent that there is something out there that is so dangerous and have no idea what the signs and symptoms are. Of course it then took several years before anybody else was willing to accept that actually other things could have happened and his death was avoidable. Initially we brought this whole idea that what had happened to him was incredibly rare and nothing could have been done because that's what we were told. But actually sepsis isn't incredibly rare. You know 37,000 people a year dying of sepsis is not something that is incredibly rare. My thought process just came back to well why is the system like this? Why is the process like this? And how do we change that? Because I know some of those people wanted to do more but felt unable to or were prevented from doing more. There's too much blame in the system. There's too much of a tendency to shame people for the things they do and really what we need to do is to be able to nurture that goodwill and harness it and allow it to be innovative in order to solve problems and reduce risk and therefore ensure better outcomes for patients and also for staff. And so I think at the moment really all we have is a system which is pretty heavy on accountability and regulation very heavy handed regulation but is very haphazard as to whether any learning comes through at all. They're all good people. All the people that try to help Sam are all good people. They were trying to save him. I just want to know that the systems are better set up to support them so that they can give more care and hopefully more compassion. The problem with healthcare is where do you run? Where do you go if you're afraid of healthcare when you're ill? Or in our case when your child may be ill? The goal is a just culture. Within a just culture the first thing they'll do is say who's hurt? The second thing they'll ask is what do they need? How can we help them? And the third thing they'll do is identify who it is that can help them. And in a sense that's all I've ever expected from healthcare and I think it's all everybody should expect and I believe it's what everybody should get and could get. Although we may never get to perfectly just culture for everybody all of the time we could get there most of the time for most people and that would be a quantum leap forward. Transparency is courage. It's honesty. It's vulnerability. It's a word that's used all the time but only as a word. I want transparency about us as people whether we're patients or staff. Transparency about the harm that we're all experiencing.