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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.