NHS 111 call handlers ‘missed numerous opportunities’ to save boy, 6, with blocked bowel, coroner says
MORE children will die if the NHS fails to take action after the death of a six-year-old boy, a coroner has warned.
Sebastian Hibberd, died holding his dad’s hand as NHS 111 call handlers missed a number of “red flags”, an inquest heard.
His desperate dad Russell, was unable to get hold of a doctor for six hours, before his son died on Monday, October 12, 2015.
He repeatedly called NHS 111 but call handlers failed to recognise Sebastian’s condition was life-threatening.
‘More children will die’
The helpline uses the NHS Pathways algorithm to “assess, triage and direct the public to urgent and emergency care services”.
But senior coroner Ian Arrow today warned more children will die if changes are not made to the system.
He has demanded NHS England and NHS Digital carry out a review of their procedures, saying call handlers are not “adequately assisted” by the algorithm.
Mr Arrow said: “In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action by reviewing the present systems and protocols in place to assist in particular parents seeking assistance for ill children.
“Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child.”
The NHS Digital website states the NHS Pathways and Directory means “up to 15 per cent of 999 calls are now closed without ambulance being sent – before the introduction of NHS Pathways this was just 1 per cent”.
Missed opportunities
Sebastian died of a cardiac arrest at home in Plymouth. He was later declared dead at Derriford Hospital, after paramedics rushed him to hospital.
At first his dad and mum Nat, dismissed his symptoms as a tummy bug.
But when the sickness and diarrhoea had not eased up by 8am two days later, Russell called the medical helpline NHS 111.
He made repeated calls, telling call handlers Sebastian had been throwing up green vomit, had cold hands and feet, tummy pain and was confused and delirious.
The 40-year-old said: “I went upstairs and Sebastian was fitting.
“I checked whether he was breathing and he wasn’t so I dialled 999.
“I was performing CPR while we were waiting for the ambulance to arrive.
“The ambulance crew did their best but unfortunately he died.”
NHS 111 call handlers ‘missed killer signs’
In February, an inquest into the death found the cause of death was necrotic bowel and intussusception – where one segment of intestine telescopes inside another causing an internal blockage.
Paediatric surgeon Dr Dorothy Kufeji said Russell’s description of Sebastian as delirious, with cold hands and feet and throwing up green vomit were “three particular red flags” that shouldn’t have been ignored.
Coroner Ian Arrow said there had been “several missed opportunities for him to receive life-saving treatment.”
He added that, had his condition been recognised at the time that the surgery should have been open – 8.44am – “his life might have been preserved.”
NHS England and NHS Digital now has until mid August to respond to Mr Arrow’s report.
Sebastian’s mother and father Nataliya and Russell, from Plymouth, Devon, said they were pleased with the coroner’s recommendations.
In a statement they said: “While nothing will bring our wonderful little boy back, this Prevention of Future Deaths Report is everything we have been asking for and we hope it will prevent any other family having to live through the nightmare that we have. For three long years we have been fighting for change, reading NHS reports and documents in pursuit of the truth, and we are extremely grateful to the coroner for agreeing to our request for an inquest and listening to our concerns.
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“We would like to thank our legal team of Dawn Treloar and James Robottom as we would not have been able to have done this without them. We remain heartbroken that our little boy’s life has been taken from him, but we hope this report will prevent the tragic death of a precious son and brother.”
Dawn Treloar, Partner at Hodge Jones & Allen, who represent the family, said: “The inquest into Sebastian’s death highlighted the complexity of the urgent care system and the considerable difficulties those trying to access urgent care face.
“The failures in that system, as well as the failings if individuals that Sebastian’s father faced, resulted in his death.
“It is imperative that changes are made to avoid further tragedies occurring.
“Preventing this happening to anyone else has been my clients’ motivation during the long inquiry and I hope this report gives them solace and allows them to start rebuilding their lives.”
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