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Sepsis Death: NHS 111 System Failed Toddler
16 Feb
Summary
- A three-year-old died from sepsis after NHS 111 missed critical signs.
- Different assessment systems for 111 and 999 caused delayed ambulance response.
- An inquest revealed multiple systemic failings contributed to the child's death.
A three-year-old boy's death from sepsis has exposed critical failings within the NHS, particularly concerning its 111 and 999 services. Theo Tuikubulau died in July 2022 after a series of systemic errors led to a delayed response when his mother sought help.
Theo had been increasingly unwell with flu-like symptoms, a high temperature, and breathing difficulties. When his mother called NHS 111 just before 11pm on July 7, 2022, the operator did not classify his condition as life-threatening, despite his lips turning blue and struggling to breathe. This led to a 90-minute delay in getting him to Derriford Hospital.
An inquest revealed that the NHS Pathways system, used by NHS 111, did not recognize 'lips turning blue' as a critical emergency, unlike the MPDS system used for 999 calls. This discrepancy created a 'two-tier system' for emergency assessments, with similar breathing complaints receiving different ambulance responses depending on the service called.
Assistant coroner Louise Wiltshire issued a notice to NHS England, highlighting the urgent need to address these variations to prevent future deaths. While Theo had been deemed a category one emergency by 999 the previous day, his NHS 111 call resulted in a less urgent category two response, underscoring the flawed system.
