Patient deaths linked to NHS 111 glitches
The deaths of 11 patients, including two children, have been linked to glitches in the system used by the NHS 111 and 999 services to assess the seriousness of their condition. Coroners have issued warnings about the “triaging” system. The “prevention of future death” reports were issued because of fears that the tragedies would be repeated. The 11 warnings by coroners highlight the pathway protocols used by the 111 service and most ambulance trusts.
THE deaths of 11 patients, including two young children, have been linked to glitches in the algorithms used by the NHS 111 and 999 services.
Coroners have issued warnings about the “triaging” system after a catalogue of safety concerns.
The “prevention of future death” reports were issued because of fears the tragedies would be repeated without swift action to improve the service.
The cases include Sebastian Hibberd, who died aged six when 111-call handlers failed to spot warning signs that his bowel had collapsed.
An inquest into Sebastian’s death heard his father, Russell, contacted NHS 111 after the child began throwing up green vomit, had cold hands and feet, stomach pain and was delirious.
Call handlers failed to recognise the boy’s condition as life-threatening in repeated calls. Sebastian suffered a cardiac arrest at his home in Plymouth while waiting for treatment and was declared dead after being taken to hospital in October 2015. Last month senior coroner Ian Arrow urged NHS officials to review the procedures, saying the child’s life might have been saved if call handlers had asked the right questions.
An investigation by Health Service Journal has identified 10 more reports by coroners, issued since 2015, warning of problems with the pathway protocols, used by the 111 service and most ambulance trusts.
Two-year-old Robert Hogg was taken to Stoke Mandeville Hospital in Buckinghamshire suffering from a temperature and cold, but was discharged. His mother rang 111 when he became lethargic and pale, but call handlers made him a further hospital appointment. The child became unresponsive and died in April 2014.
An investigation by South Central Ambulance service raised concern that the pathways algorithm was not detecting cases of very sick children, a coroner reported. In three other cases, concerns raised by coroners had previously been highlighted by health officials, yet not addressed, their reports suggest. Caragh Melling, 37 and Barbara Patterson, 67, both died after call handlers failed to recognise “agonal breathing”, which means urgent resuscitation is required.
Between 2010 and 2014, at least three different ambulance trusts had raised concerns with the national NHS Pathways team about the issue.
Susan Longden died aged 69 in 2018 after complications from a colonoscopy. Her husband David had called Weston General Hospital in Westonsuper-mare, Somerset, warning that she was in pain. He was told to give her a hot drink and paracetamol. As the day went on, Mrs Longdon began yelling out in agony. But after her husband called 111, call handlers only arranged for a doctor to call within two hours.
When she lost consciousness an ambulance was finally sent, with her husband left to perform CPR, She died after a second cardiac arrest.
The coroner criticised the failure to check whether Ms Longden had undergone recent medical procedures, or to take account of the fact that she had been too unwell to come to the phone.
NHS Digital said clinicians had overruled advice given by the software. But a spokesman said improvements to the questions, to ensure patients suffering severe abdominal pain were asked about recent procedures, were under consideration.
A spokesman said “We take any coroner’s report we receive very seriously and work with our partner organisations across the NHS to ensure that we respond appropriately and make the necessary changes to the system if required. We conduct regular reviews of NHS Pathways to ensure that it follows the latest clinical evidence”.