Dying toddler waited 90 minutes for ambulance after call deemed 'not critical'
A critically ill toddler spent 90 of his remaining minutes before dying of sepsis waiting for an ambulance that could have come sooner if an emergency call was upgraded, an inquest has heard.
Theo Tuikubalau, three, was suffering from a high temperature, flu-like symptoms, breathing issues, and a loss of appetite when his mum, Kayleigh Kenneford, called 111 on the evening of July 7, 2022. The tot, who had already been admitted and discharged from Plymouth's Derriford Hospital with a suspected upper respiratory infection the day prior, was becoming increasingly unwell. But when Ms Kenneford placed the call to the service, the 111 differently appraised a critical symptom.
Jurors participating in an inquest at Devon Coroner's Court heard that the South West Ambulance Service Trust's Advanced Medical Priority Dispatch System (AMPDS) graded Theo's breathing difficulties as a category one - indicating "life-threatening illnesses or injuries" - on July 6.
But the 111 service's NHS Pathway - which uses a different method for grading emergencies from 999 calls - ranked similar symptoms as a category two the following day. The alternate appraisal meant crews took 90 minutes to reach Theo after Ms Kenneford first phoned for an ambulance shortly before 11pm on July 7.
Theo was taken back to Derriford – arriving shortly after 1am – where he died a few hours later from sepsis, caused by an 'invasive' Strep A infection. Jon Knight, head of emergency operations at the South West Ambulance Service Trust, reviewed the 111 call and was asked what would have happened if it had been made to his employers.
He said the childs' breathing difficulties would have triggered a category one through SWAST system. He said: "My belief is based on the trigger phrase that the patient was fighting for breath at the time, it would have triggered a cat one through the AMPDS system."
Mr Knight said he was dealing with 'hypotheticals' as to how quickly a category one ambulance that night would have reached Theo, but added it would have "certainly" arrived fewer than 90 minutes earlier. He said: "It is really hard to commit to a time. It certainly would have been quicker than 90 minutes, would be my belief.
'I think with the right set of circumstances – if you didn't have an ambulance available in the area and you were bringing one from Derriford Hospital – you are probably looking at 30 minutes.'
Mr Knight told the inquest that ambulance crews "made all the appropriate and correct decisions", however, with staff ready and waiting for the ambulance's arrival. Having reviewed documents relating to Theo's care that evening, he said the ambulance crew recognised he was seriously unwell and immediately took him to Derriford Hospital.
He said: 'I think the crew made all the appropriate and correct decisions in their decision to leave the scene and take Theo to hospital." He added: "I absolutely support all of the decision-making that was made at the time."
Andrew Morse, representing Theo's family, suggested if the call on July 7 had been assessed as a category one then he could have potentially arrived at the hospital by 11.45pm. He said: "On balance, given the testimony I've already given to the coroner, I think that that's a reasonable assumption."
The inquest heard there was a paramedic crew who could have reached Theo within 33 minutes had his call been graded as category one.
Megan Barker, Mr Knight's deputy, said: 'At best guess, if we compared that to the resource that did go approximately an hour and a bit later, it would have taken them around 30 to 33 minutes to get to Theo. We can guess that they would have spent a similar amount of time with Theo, so likely have had a hospital arrival time of about 30 minutes later.
'That puts us around maybe 12.10am.' The inquest before a jury at County Hall in Exeter continues.
Hashtags
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
STV News
8 hours ago
- STV News
'We trusted them with our boy - we'll never forget how he suffered'
The mother of a boy left with lifelong injuries after a series of morphine underdoses at Scotland's largest children's hospital warns there will be another incident unless urgent changes are made. Ellie McAdam's son Theo was one of seven children given a tenth of the pain relief they should have had after undergoing the surgery at the Royal Hospital for Children in Glasgow last summer. The underdoses affected seven operations over six days within a single theatre between June 13 and 24 last year but were not discovered until nearly a month later, on July 6. A review by NHS Greater Glasgow and Clyde (NHSGCC) following the incidents found that overworked and fatigued staff at the Royal Hospital for Children in Glasgow missed vital checks. But Theo's mother, Ellie McAdam, from Peterhead, fears another child could be harmed unless action follows. 'I have no doubt that there will be a next one. I have no doubt it will – unless serious changes are made. 'Every birthday for Theo is so much more than a birthday because we're just glad he's still here.' STV News Theo was four weeks old when he needed the first of two open-heart surgeries. After undergoing his second open heart surgery, a critical mistake meant he received just a tenth of the morphine he needed – 1.5mg instead of 20mg. Ellie said her son ripped all his lines out in pain and collapsed his own lung. 'That's not repairing itself at all. We don't know the impact it'll have – it's seeing how it affects him long-term. 'He was genuinely traumatised. He was a completely different boy. 'Because he was so little, he got over it – which is amazing, but we'll never forget it. I can speak on behalf of many other families; they won't either. 'It's had a lasting impact. We're still dealing with the aftermath. It has caused a lot of pain and suffering.' An investigation has now been undertaken, which revealed a catalogue of failures. STV News The review found that 10mg of morphine had been ordered by theatre staff, but that the strength delivered was only 1mg. Staff assumed the order was correct, and the wrong amount was then used. A new stock system was also blamed, with the review citing the font size and colour made it difficult to read the amount of milligrams. A review found the seven children, including Charlotte, were administered 1mg/ml of morphine – when they should've received 10mg/ml. The report also found that the underdose went unnoticed for nearly a month due to staff going on 'assumption' rather than doing two-person checks as the procedure requires. It concluded that human and systematic factors played a significant role. The Significant Adverse Event Review (SAER) by NHSGGC also found that staff were overworked and overtired during shifts. The review recommendations included additional staff training and an improved stock management system to ensure 'any incident of this nature is prevented from happening again'. NHS Greater Glasgow and Clyde have again apologised to the families impacted and say they've begun the process of implementing the recommendations. STV News But Theo's mother, Ellie, said the review does little to address the reality of what happened. 'The review felt like a half-hearted acknowledgement of them not following their own policies. It doesn't really take any accountability for what happened. It diminishes the lived experience of the families who went through it. 'It seems almost dismissive of the human error. They called it 'local rationale' for the staff making these assumptions – you can fluff it up with a name all you want, but it's complacency. 'The tone is 'these things happen', but that's not good enough. These people are handing their babies, their whole world, to you. 'The review found that staff were tired and overworked – then hire more staff, stop paying your big bosses £200,000 and put more boots on the ground. 'If it's leading to these kinds of things, you need to do better. Take a look at yourselves and think, 'this isn't working, we need to change it.'' Ellie McAdam She added: 'I'm not on a witch hunt for someone's job, but several people didn't do theirs. You've not done the checks you're meant to do. I'd be held accountable if I didn't do my job, so what's going to change?' It's now been more than a year since Theo's surgery, and he is continuing to recover. But its been very hard on Ellie. She believed her son was in the safest place – and and says she still feels the lasting emotional impact of the ordeal. 'There's anxiety knowing they've done this, and even though they're saying 'maybe it's our fault,' what can you do? 'To then have to put him back in that situation, you think 'are they going to do their checks, all the points that need to be done to ensure he's safe?' I don't know. But we have no choice either way. 'I know what's happened and that we are going back. I can't imagine how we will cope when that time does come.' NHSGCC apologised and said families have been invited to meet with members of the review team to discuss their concerns. 'We know the care these patients received fell below the standard expected, and we are sorry,' a spokesperson for the health board said. 'Both human and systems factors played a role in this incident, and we are committed to ensuring that lessons are learned from this extensive review, which was carried out with the involvement of pharmacy, nursing, and medical staff, as well as an individual panel member providing expert opinion.' The health board said it began implementing the report's five recommendations as soon as the error was identified. 'It includes recommendations around staff training, the physical environment and stock management system, which are designed to ensure any incident of this nature is prevented from happening again,' the board said. Get all the latest news from around the country Follow STV News Scan the QR code on your mobile device for all the latest news from around the country
The Independent
16-07-2025
- The Independent
TV star with brain tumour joins squats challenge to raise funds to find cure
A TV star living with a highly-aggressive brain tumour is doing 88 squats a day while undergoing chemotherapy in a fitness challenge to help fund research into brain tumours. Antiques Roadshow star Theo Burrell, of East Lothian, was diagnosed with a glioblastoma in June 2022, a highly-aggressive form of brain tumour with a life expectancy of 12-18 months. Burrell, 38, is halfway through the 88 Squats A Day In July challenge, which she has taken on despite currently having treatment. Funds raised will go towards Brain Tumour Research, a charity dedicated to curing the disease. Despite an initial small target of £500, the TV star has so far raised more than £7,500 and still has two weeks left of the challenge. Burrell, who is a patron of the charity, said: 'I've been doing my squats and I'm actually enjoying it. I may do around 20 and then take a break and have a cup of tea, but I get them done. 'My son Jonah has been asking me what I'm doing so he's been joining in, doing two or three here and there and then he's done. 'I think I'll keep it up after the challenge has ended because it's supposed to be one of the best exercises you can do, particularly for the back.' This week marks Glioblastoma Awareness Week, which aims to shine a light on the disease and how it is the most commonly diagnosed high-grade brain tumour in adults. Glioblastoma is incurable and there has been no advance in treatments for two decades. Around 3,200 people are diagnosed with it a year in the UK, of which around 160 will live for five years or more. Burrell, whose son is four, said: 'I'm nearly 40 and I've seen just how devastating this has been for my parents. They never stop worrying about it, ever. 'This disease is stealing young people away from their families. I've seen lots of people lose their life to glioblastoma who are parents of young children, it's just so devastating for everyone involved. 'The idea that you will never see your children grow up. There are lots of things I've come to terms with on this journey, but I will never ever be okay with the fact that I'm going to miss out on a lot of Jonah's life. 'That will always make me feel completely grief stricken and I imagine it's the same for any other parent who finds themselves in this situation. No time will ever be long enough really.' Since her diagnosis, Burrell has undergone life-extending surgery, followed by radiotherapy and chemotherapy. A scan in December 2024 showed some regrowth of the tumour but her latest scan in June showed there were no active cancer cells left. 'It means that some of those cells have been killed off, while others have been put to sleep and are dormant,' she said. 'But as we know with glioblastoma, they always wake up at some point and the tumour will start to grow again – but it's as good a situation as I could have hoped for given the nature of the disease.' Burrell played a pivotal role in the launch of the Scottish Brain Tumour Research Centre of Excellence in January. The centre, a unique partnership between Brain Tumour Research and Beatson Cancer Charity, is the first of its kind in Scotland and focuses specifically on glioblastoma. She said: ' People need to know how damaging glioblastoma is and how desperate people like I am to increase the treatment options. 'What Brain Tumour Research and Beatson are doing at the Scottish centre is giving so many people in the community hope, and I think they will produce something really spectacular. 'But all of these things take time. How many lives are we going to lose before then?' Dan Knowles, chief executive of Brain Tumour Research, said: 'During Glioblastoma Awareness Week, we are shining a spotlight on this most devastating of brain tumours. 'We are incredibly fortunate to have such a passionate patron in Theo, who works tirelessly for the brain tumour community. 'The statistics around glioblastoma are shocking, and it is only through increased government funding into critical research that we will get closer to a cure.'
Scottish Sun
09-07-2025
- Scottish Sun
Mum died at home an HOUR after medic said she looked ‘normal' – but missed key warning sign on her lips
After her death, it emerged Charlotte had group A streptococcus, a common but potentially deadly bacterial infection VITAL SIGNS Mum died at home an HOUR after medic said she looked 'normal' – but missed key warning sign on her lips Click to share on X/Twitter (Opens in new window) Click to share on Facebook (Opens in new window) CHARLOTTE Alderson died of an infection at home hours after medics missed a key warning sign on her lips, an inquest heard. The mum-of-three from Suffolk had been vomiting and complained of excruciating headaches before she died on December 21, 2022. Sign up for Scottish Sun newsletter Sign up 2 Charlotte Alderson was not taken to hospital and died hours later, an inquest is told **TAKEN WITHOUT PERM** Credit: Family Handout An emergency medical technician (EMT) who attended the scene spoke to a GP on the phone about the 34-year-old's condition. Both decided Charlotte, a swimming instructor, did not need hospital treatment. After her death, it emerged Charlotte had group A streptococcus (Strep A), a common but potentially deadly bacterial infection. Her husband, Stuart Alderson, told Suffolk Coroner's Court that he had noticed a blue tinge on her lips, a classic warning sign of sepsis, a life-threatening infection. He said he called NHS 111 after Charlotte had been vomiting and suffering diarrhoea all night, and that she lacked energy, which was 'really unusual' for her. An ambulance was sent out, and Stuart said that the staff told him there was a 14-hour wait at the hospital and that Charlotte would "just get a blood test". "To my mind, I thought, 'Well if you think she's OK, we're happy to accept that decision not to go,'' the husband said, according to BBC reports. The inquest heard that Charlotte first fell ill on 15 December 2022 with cold symptoms and an earache. She saw her GP, who diagnosed an outer ear infection and prescribed a topical spray. Medical staff used a clinical scoring system called Centor, which suggested no antibiotics were needed. The signs and symptoms of sepsis to look out for, according to The UK Sepsis Trust The coroner later said another system, Feverpain, might have recommended antibiotics and potentially changed the outcome. EMT Morgan Burt said she did not see the blue tinge on Charlotte's lips, but if she had, it would have been treated as a 'high priority' case. A recording of a phone call between EMT Burt and on call GP, Dr Emma Ayers, was played in court. Dr Ayers said she thought Charlotte might have a viral infection and advised plenty of fluids and a Covid test. But she added: 'When I said it could be viral infection, that was only half of the sentence. I was thinking this could be bacterial and she could be septic.' Dr Ayers said she was not informed about the blue lips during the call and that had she known, she would have sent Charlotte straight to hospital as an emergency. 2 She also said that if she could change her advice, she would have invited Charlotte for an appointment that afternoon. Ambulance staff found Charlotte's temperature and heart rate slightly elevated but other signs 'generally within normal range.' With no immediate hospitalisation needed, the ambulance left at around 1pm. Charlotte's condition got worse that afternoon. Her husband went out to buy pain relief, but when he came back, he found her collapsed, unconscious but still breathing. He called 999 again at around 2pm, during which time Charlotte stopped breathing. Paramedics arrived just before 2:30pm and despite resuscitation efforts, she sadly passed away. A post-mortem confirmed the cause of death as multi-organ failure due to septic shock from the rapid spread of the bacterial infection. Sepsis spotting Suffolk Coroner Darren Stewart raised 'several matters of concern' about Charlotte's death. He warned the NHS's Feverpain and Centor scoring systems for infections can give conflicting results, and said using Feverpain might have led to antibiotics being prescribed earlier, possibly saving her. 'There is a need to review these scoring systems to provide guidance on a single system clinicians can rely on,' he said. He called for faster sepsis tests like CRP, finger prick, and lateral flow, stressing: 'The risks of sepsis and rapid deterioration are well known. We need urgent tools to help spot and treat it early.' The coroner also slammed the 111 call system for delays when ambulances must be booked manually, not automatically. The inquest is ongoing.
