Boy died of sepsis after call handler said condition wasn't life-threatening

Telegraph

02-07-2025

A three-year-old boy's condition was not deemed to be life-threatening by a 111 operator hours before he died of sepsis, an inquest heard.
Kayleigh Kenneford called 111 on the evening of July 7 2022, because her three-year-old son Theo Tuikubulau was unwell.
For the previous 36 hours, he had been gradually getting sicker and sicker with a high temperature, flu-like symptoms, breathing difficulties and was reluctant to drink or eat.
He had already been admitted and discharged from Plymouth's Derriford Hospital the previous day with a suspected upper respiratory infection.
Devon coroner's court has heard that 999 calls to the South West Ambulance Service Trust and to the 111 service use different pathways for grading emergencies.
The ambulance trust's Advanced Medical Priority Dispatch System (AMPDS) graded Theo's breathing difficulties as a category one on July 6, while the 111 service's NHS Pathway ranked similar symptoms as a category two the following day.
Ambulance took 90 minutes
This 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, had reviewed the 111 call and was asked what would have happened if it had been made to his employers.
'My belief is based on the trigger phrase that the patient was fighting for breath at the time, it would have triggered a [category one] through the AMPDS system,' he said.
Mr Knight said he was dealing with 'hypotheticals' as to how quickly a category one ambulance that night would have reached Theo.
'It is really hard to commit to a time,' he said.
'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.'
'Manage patient expectation'
Louise Wiltshire, assistant coroner for Devon, asked Mr Knight about the evidence of Ms Kenneford in which she said she was told by the 111 call handler an ambulance would not be long.
'What I can tell you is within the training with our own service, we would not ask or allow our colleagues to give people average or any sort of indication of ambulance response time,' he replied.
'What we say to patients is: 'An ambulance has been arranged for you. It will be with you as soon as possible. If your condition changes or worsens in any way, call us back immediately.'
'We try to manage patient expectation in that way and give them a very clear instruction to call us back, regardless of timescale.'
Mr Knight told the inquest that having reviewed documents relating to Theo's care that evening, the ambulance crew recognised he was seriously unwell and immediately took him to Derriford Hospital.
'I think the crew made all the appropriate and correct decisions in their decision to leave the scene and take Theo to hospital,' he said.
The hospital was also alerted in advance that the ambulance was coming and staff were waiting for him, Mr Knight said.
'I absolutely support all of the decision-making that was made at the time,' he added.
'Could have come in 30-33 minutes'
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.
'On balance, given the testimony I've already given to the coroner, I think that that's a reasonable assumption,' Mr Knight replied.
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.'