Coroner calls for NHS 111 changes after girl’s death

No ambulance sent to two-year-old who died soon afterwards

A coroner has called for changes to the NHS nonemergency 111 and out-ofhours services following the death of a two-year-old girl with a twisted bowel.

Myla Deviren, from Peterborough, became unwell in the early hours of August 27, 2015.

Her mother, Natalie, called the NHS 111 service for advice but, despite Myla’s symptoms including blue lips and breathlessness, an ambulance was not called, a prevention of future deaths report said.

Two 111 call handlers and an out-of-hours nurse “did not appreciate the significance” of the symptoms, with the latter believing she had gastroenteritis, the report said.

Myla was found unresponsive hours later and died the same day. An inquest concluded in July the little girl died of natural causes contributed to by neglect due to the “gross failure” to call an ambulance, said Irwin Mitchell solicitors which represented the family.

Rosamund RhodesKemp, assistant coroner for Cambridgeshire and Peterborough, issued a report to prevent future deaths which was published last week. She wrote: “It is probable that, with earlier transfer to hospital by ambulance and with appropriate treatment (Myla) would have survived.”

She raised concerns about “prescribed pathway questions and answers” that were in place at the time and said there should be “robust systems in place to prevent sick children going without potentially lifesaving treatment”.

She said mandatory annual training on how to recognise and interpret symptoms needs to be in place for all staff taking calls. The report has gone to NHS 111 and Herts Urgent Care Limited, which runs the 111 service in Cambridgeshire and Peterborough.

Herts Urgent Care Limited said it “accepts the conclusions reached by the coroner at the inquest following Myla’s tragic death and would like to reiterate our heartfelt condolences to Myla’s family”.

A spokesperson said changes have since been made to its service, including mandatory training for staff directly relating to illnesses in children, access to GPs for all staff, and more clinical advisers who have paediatric nursing experience.

Myla Deviren