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NHS 111 'not sensitive enough' to pick up potentially fatal conditions

NHS 111 call handlers are unable to identify potentially fatal cases of sepsis because the system is not sensitive enough to pick up red flags, according to a report into the tragic death of a 12-month-old toddler in 2014.

NHS England’s report into the death of William Mead from septicaemia after a long-lasting chest infection found a series of factors were to blame, including pressure on GPs to reduce antibiotic prescribing and A&E admissions, and GP workload pressures.

It concludes that NHS Pathways, the system used by NHS 111 operators, was not sensitive enough to identify sepsis red flags such as a sudden drop in temperature.

Additionally, the report suggests that if a medically trained person had handled the call from William’s mother, they would have recognised his cries of distress in the background as something warranting further medical attention.

GP leaders said that this case proves that inexperienced call handlers should not be triaging calls, and there needs to be greater clinician input.

The helpline was introduced in 2013, using NHS Pathways to guide the non-medically trained call handlers through a series of questions to determine the patient’s condition.

It has been heavy criticised by GPs, with LMC leaders last year calling for it to be scrapped.

Pulse has previously reported that three-quarters of NHS 111 referrals to A&E are unnecessary and three-quarters of NHS 111 referrals to general practice are inappropriate further showing the flaws in the system.

However, the report concludes that there are also risks of missing potentially life-threatening cases.

It said: ‘The NHS Pathways tool used nationally by all NHS111 service providers has limited sensitivity to red flags relating to sepsis. Patients that experience minor symptoms might therefore not be identified when using this triage tool.

‘In particular, subtle changes seen in a deteriorating paediatric patient are not easily identified through the structured questioning within the pathways.’

The report also criticises pressure on GPs to reduce antibiotics prescription or refer to A&E, as William had previously presented at the practice with a chest infection.

It says: ‘it is clear from this investigation and from ongoing conversations with GPs that they are under constant pressure to reduce antibiotic prescribing and referrals to acute hospital A&Es… It is the panel’s view that GPs feel this pressure acutely and it might well have had an impact on their decision-making and practice in this case.’

Former GPC negotiator Dr Peter Holden told Pulse that this was a very sad case ’but of course this is what happens when you try and mechanise a triage system that requires judgement’.

He added: ‘Triage requires the most experienced person to do it successfully therefore it is no surprise that a lay person running a computer program that cannot exercise judgement will fail. We have been saying this for four years.’


Readers' comments (31)

  • It is incorrect to measure this against the triage by the medical team.

    There simply isn't a clinical resuroce (GP numbers) required to provide the service.

    111 triage should be measured against interactions with the reception team in the surgeies and compared accordingly.

    111 Pathways should be improved and redesigned without panic around individual cases, however unfortunate. At the end of the day, GPs make mistakes too, even in face to face consultations. There was a similar case, but with a GP in the middle in East London not too long ago.

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  • Vinci Ho

    (1) Sepsis in the two extremes of the age spectrum( under 2 and above 75) are the most challenging .
    (2) Big brother approach to cut antibiotics prescribing is contradictory and will give you more cases of sepsis.
    (3) Near patient testing of CRP can be helpful but need genuine investment in GP practices . But the test is not always practical especially in young children.

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  • Bob Hodges

    Not only is NHS 111 insufficiently 'sensitive' in serious cases, it is also entirely non 'specific' as evidenced by the massive (and completely unwarranted increases in 999 responses issued.

    It other words, they are sending out ambulances to people with trivial illnesses, and still missing the serious illness.

    There is no 'clever' London solution to this problem. The only answer is more organ grinders (GPs) working BOTH during the week and out of hours.

    It won't be cheap, but then again we do spend a smaller proportion of our GDP on healthcare than comparable countries, and we spend less than 7% of that now on primary care.


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  • To be fair this was a very complex case and my understanding is that this poor child had been seen by various clinicians over an extended period of time.
    That said, if the report has found a weakness in NHS pathways then it must be corrected if that is indeed possible. It is hard to tell if the report is suggesting that no algorithm would have worked or whether this is fixable. If not then in essence they are suggesting we should scrap the system - at least for this patient demographic.

    What also needs attention is the question as to whether the service works at all and if it provides value for money. Around £25 for a 7 minute call, usually to a non-clinician does not seem like good value to me, especially as such a large proportion of patients do not actually follow the advice.
    I do not have the exact figures which show the percentage who ignore the advice given but I have seen them and they are quite shocking. It would be good if Pulse could ask NHSE for this information.

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  • Bob Hodges

    "Around £25 for a 7 minute call, usually to a non-clinician does not seem like good value to me"

    Our CCG is paying for additional capacity on Saturday mornings no less, with fully qualified GPs. £30 for 10 minutes. That's cheaper than 111, and a damn site more than GPs get out of hours even. In fact, if GPs were paid at that rate all week, there would be a surplus of GPs and a highly efficient competitive environment looking for creative ways to take work out of hospitals (which are even more expensive than 111).

    It would appear that you DON'T get what you pay for after all.

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  • Bob, I agree it is relatively poor value
    compared to GP services but that is because GP's are prepared to work for peanuts. There are also significant overheads to running this sort of service.
    It is no wonder that the NHS wants to leave ownership of general practice in GP's hands. Costs would spiral if the NHS owned it.

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  • A limitation and danger of telephone triaging, or perhaps use of algorithms? In any case
    why would any parent have taken this advice from 111, rather than take an obviously very ill child to hospital directly?

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  • A very tragic case highlighting the risks of triage in this age group. This is mainly a failure of NHS 111 but unfortunately the headlines on newspapers and the bbc have GPs highlighted first as responsible. The key here is that triage/ telephone consultations should not be used in acute illness in this age group. Yes, it's fine for a nappy rash, a bit of thrush etc but these children under 2 need to be seen if you don't want this to happen again. This needs experienced manpower in the form of GPs or paediatric trained nurses both of which the NHS currently cannot afford. There also needs to be more awareness of sepsis and recognition of the Ill child among healthcare professionals. But I don't think algorithms are the answer. Some IT clinical systems pop up a tool which is next to useless and over calculates risk. If such tools were mandated as may become likely as a response to this tragedy then secondary care will be overwhelmed.This would be counterproductive. What's needed is experienced staff seeing patient's and making a judgement. It's also worth noting that that judgement is a snapshot at that particular time and parents also need educating in recognition of sepsis as sepsis can develop very rapidly in an otherwise well looking child eg meningococcal septicaemia. Teaching better parental judgement and use of healthcare cannot be understated. Despite all this there will be still be some cases of sepsis which present in an otherwise well child fulminantly. It's sad to say that the real blame for this tragedy lies with the last and current government who have failed to listen to the profession on the use of a layperson lead triage service.

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  • Apoligies as this is not really related to this but I would like to call 111 to complain about the conservative MP who slandered all junior doctors by saying they did not want to work in Wales because of the poor schools.... Increadible what the government is doing...

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  • Bob Hodges

    "the conservative MP who slandered all junior doctors by saying they did not want to work in Wales because of the poor schools"

    Saying that would be diagnostic of being 'a bit of a twat'.

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