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NHS 111 updated protocols after it was blamed for death of six-year-old boy

Updates have been made to NHS 111 after the service ‘missed opportunities’ to save the life of a six-year-old boy.

A coroner called on NHS Digital and NHS England to change NHS 111 ‘systems and protocols’ after multiple calls to the service did not detect the seriousness of the patient’s condition.

NHS 111 updated its threshold for recommending emergency treatment and has introduced new training for call handlers to better recognise complex cases.

It follows the death of Sebastian Hibberd in October 2015 after an intussusception of his bowel, which the call handlers initally missed. 

NHS 111 was first called at 8:45am when his father explained his son’s symptoms. But the condition was not considered life threatening until another call to NHS 111 at 1:54pm, which meant it was ‘less likely’ for his life to be preserved, according to the coroner.

In a prevention of future deaths report, a coroner urged NHS England and NHS Digital to review their systems to prevent further instances like this.

Coroner Ian Arrow said: ‘On the balance of probability therefore there were several missed opportunities for him to receive lifesaving treatment.

‘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.’

He added: ‘There is no indication NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified call advisors to refer unusual cases to clinically qualified colleagues.

‘At the time of the conclusion of the inquest NHS Pathways questions did not allow meaningful assessment of pain in a child; that is to say questions about severity of pain and ability of a child to communicate such pain should be reviewed at national governance level.’

In response to the case, NHS Digital facilitated a discussion between NHS 111 and 999, which resulted in the creation of six posters to remind staff of what constitutes a complex call, and the development of a training session introduced at the end of June.

NHS Digital said it also undertook several reviews of questions and criteria asked by call handlers, including lowering the threshold for recommending emergency treatment from green vomit and severe pain to green vomit and moderate pain.

NHS Digital said in its letter to the coroner: ‘The changes are intended to support call handlers by providing additional opportunities to identify potentially critically unwell children.

‘The data we have examined has not given any indication that the pathways are deficient nor that children presenting with green vomit are not being identified using the current question sets.

‘We are simply expanding the range of scenarios in which green vomit may be interrogated as a precautionary measure to avoid any potential human error and further develop an evidence base for telephone triage.’

After the inquest earlier this year, parents of Sebastian, Russell and Nataliya Hibberd, said: ‘It is crucial that NHS investigations should lead to comprehensive changes to prevent similar tragedies. Whilst some changes have been brought in since we lost Sebastian, we believe these haven’t gone far enough to protect children.

‘NHS call handlers repeatedly failed to spot the signs of intussusception and this needs to be addressed with more clinical support.

‘NHS Pathways should recognise that green vomit and cold hands and feet are signs of serious illness, warranting urgent medical attention.’

It follows similar calls to update NHS 111 wording after the death of a young adult who had four telephone triage assessments by NHS 111.