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Independents' Day

22 NHS 111 serious untoward incidents reported, including three deaths

Exclusive: At least 22 possible serious untoward incidents relating to NHS 111 have been reported since the soft launch of the service, including three incidents where a patient died, Pulse has learned.

Two deaths are being looked at in the East Midlands, and one in the West Midlands, while a further 19 possible incidents have been recorded by providers or commissioners since the service was ‘soft launched’. Providers or commissioners from 39 of the 43 areas in England that have launched the service provided data.

NHS England announced a review of the model used to roll out NHS 111 earlier this week and it will consider whether the current model needs revising. It would not comment ahead of its board meeting today on whether the patient deaths would form part of its review.

The possible SUIs include a 47-year old who died from a suspected overdose after relatives contacted NHS 111 requesting mental health assistance and ‘initial concern’ among staff over whether a call about severe abdominal pain in an 83-year-old patient who later died was ‘properly actioned’.

A spokesperson from Derbyshire Health United - which covers Derbyshire, Nottinghamshire and Northamptonshire - said it was investigating two deaths.

Lindsey Wallis, chief executive of Derbyshire Health United, told Pulse: ‘These cases that have been reported have been investigated and at this stage of the investigation it has been shown that the system and processes that were followed would have been exactly as expected.’

‘However, sadly the outcome was an unexpected death. DHU reports every death initially as a serious incident until the complete investigation where, following the investigation, there is a determination made as to whether or not it is stepped down from being a serious incident to an incident. As a company, we report at a very high level.’

NHS Direct - which covers eight NHS 111 areas that have soft launched - said it had recorded seven potentially serious incidents that had occurred in the ‘early period following the soft launch of the NHS 111 service’.

One of these incidents was the unexpected death of a patient after NHS 111 facilitated a referral to a GP out-of-hours service in the West Midlands.

A spokesperson said: ‘A number of health organisations were involved in the care of the patient in addition to 111. Unfortunately the patient sadly died unexpectedly so this is being looked into as a serious incident.’

South East Coast Ambulance Service, which runs NHS 111 in Kent, Surrey and Sussex, was among the other areas to report possible SUIs, with four in total. They related to an information governance breach, an IT system failure, a telephony system failure and a lack of appropriate advice given to a caller. A spokesperson said there was no indication that any patient came to harm as a result.

Pulse has reported a series of problems with the NHS 111 soft launch across the country, including out-of-hours groups having to take back the triaging of calls and up to 40% of calls being abandoned in some areas over the Easter weekend.

Dr Peter Holden, GPC negotiator, said: ‘We don’t know how serious these serious untoward incidents have been. More to the point, we don’t know how many calls have been abandoned.’

‘We are most concerned that we are where we are and we need to minimise harm for patients. But we didn’t need to be where we are.’

Commissioners and providers in Gloucestershire, Yorkshire and Humber and Bath, North East Somerset and Wiltshire refused to disclose how many suspected serious incidents there had been in their regions.


West Midlands (NHS Direct)

- NHS 111 facilitated a health professional referral to a GP out-of-hours service. A number of health organisations were involved in the care of the patient in addition to 111. Unfortunately the patient sadly died unexpectedly so this is being looked into as a serious incident.

East Midlands (Derbyshire Health United)

- Unexpected death of a 47-year-old. NHS 111 contacted by relatives due to mental health symptoms requesting mental health services contact. No direct telephone contact with patient possible. Home visit arranged and family present outside. No access to house and in darkness. Patient found deceased next day in the house with suspected overdose.

- Death of an 83-year-old. Friend called 111 stating the patient collapsed with severe abdominal pain. 999 ambulance called but initial concern by staff whether this had been properly actioned. The 111 service phoned and confirmed with 999 service ambulance was on route. Friend called back and CPR advice given. Patient pronounced dead on scene by paramedics. 



Readers' comments (12)

  • This comment has been removed by the moderator.

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  • Wow!! people die due to poor political decisions/planning but they continue as ministers.... sure Daily Mail would not taken it the same way if the GP's had anything to do with this

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  • Harry Longman

    Clearly very serious and I'm glad they are being taken seriously, but we need comparators - are there similar statistics say for previous OOH providers or NHSD?

    The other essential analysis is of patients overtreated through 111, for example sending an ambulance for trivial cases and therefore denying the service to more needy patients. Anecdotally many hospitals are reporting very busy A&E, but again we need good comparison data.

    The reason I'm afraid is not to do with poor implementation. It's much worse than that - the concept is utterly flawed, By throwing money at implementation, we will simply get "the wrong thing righter" which nothing like the right thing.

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  • This is only the tip of the iceberg...

    NHS Pr1m1t1ve fails at EVERY level, even the most basic ones:

    - "Expected death - Caller: Patient"
    - "4 week old baby - Caller: Patient"
    - Surgery "unknown", GP "unknown"... (if I can find the patient's surgery on the database, why can't the call takers find them!?!)

    The triaging and outcomes that I have to endure from some of our GP colleagues is, at times, totally inadequate.

    This isn't about Primary Care.

    This isn't about Secondary Care.

    This is about patient care.

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  • Now that CCGs are in the driving seat and has clinicians/GPs on board, it would be prudent such cases as & when reported be thoroughly investigated & reported and lessons learnt cascaded to all concerned.

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  • Just Your Average Joe

    The Government and DOH are solely to blame for the increased expectations, duplication of service provision, and privatisation of the NHS by the back door.

    So many patients are attending walk in centres, then when not getting the antibiotics they want attending A&E, who then send them to see the GP the next morning having given antibiotics just 12hrs earlier. What a waste of resources with each OOH attendance for a self limiting viral illness attracting a fee to the NHS. Patients need to relearn self care with them being turned away with non urgent conditions to see the GP in normal hours.

    Patients are no longer expecting to attend GP in working hours as they feel 24 hr care is possible for routine matters, and many using OOH as they don't want to take time off work, or take child out of school to be seen, then turn up as emergencies.

    OOH provision by private companies now running things is being downgraded to increase profits, so expensive staff are being replaced by nurses or in 111's case non medical triage. It takes so long to get contact to a GP, and if you wanted a Home visit, it often never happens as so few staff, much quicker to attend A&E with a 4hr guarantee of a doctor.

    Close all duplicated services which just provide multiple access points for minor problems, and fund a better OOH care - but for real emergencies, and push routine care back into the day.

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  • You need a drastic reduction in attendance anywhere for minor illness or you need to increase the number of daytime GPs.

    GPs cannot absorb anymore workload. We are full. If this is not addressed there will be a downward spiral whereby increased workload leads to premature retirement and emigration to protect from the insane workload.

    Workload is reminiscent of the exploitation of house officers in the 80's. Although at least we get some sleep now, unless the government force OOH back on us.

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  • I know of no other service to be submitted to such a rigorous and commissioner involved clinical governance process. Bearing in mind that any unexpected death following contact with 111 is considered as a SI and the fact that there are normally hundreds of unexpected deaths every day of the year one would be amazed if there weren't any SIs. It is a shame that there isn't an equal concentration on the no of cases of emergency referrals where there has been an undoubted success in saving life.
    NHS111 is a call triage service that does not discriminate between in and out of hours - for it to be successful there has to appropriate access to urgent care 24 hrs a day. GP commissioners will need to be assured that they have commissioned and funded adequate OOH services including access to community nursing and palliative care services.

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  • Anonymous 8:15

    Ha Ha !

    Do you think the CCGs have been adequately resourced for all this ?

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  • It is important to remember people die after contacts with any health provider in an unforeseen/ unpredictable manner. Given the known marked risk aversion and onward referral levels of 111 I would be surprised and concerned if analysis showed these where above the "twist of fate" we all risk every day. Note the qualification of "analysis" and ask me what I found surprising and concerning later.

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