NHS England has published a highly critical report of the NHS 111 service following an investigation into the death in December 2014 of 12-month old William Read from septicaemia after a severe chest infection. The report concludes that a number of opportunities to diagnose and treat William were tragically missed. 

William’s death was originally put down to natural causes, but an inquest last year concluded that his fatal blood poisoning could have been avoided if NHS 111 had been equipped to recognise the seriousness of his condition. Public concern has previously been voiced that NHS 111 call handlers are not medically trained. They follow computerised flow charts, asking prescribed questions and inputting the caller’s responses before giving the advice generated by the computer. 

This investigation concludes that the NHS 111 systems were too crude to recognise the seriousness of William’s condition and the evident signs of sepsis. Had a doctor been involved, William’s “cries as a child in distress” would have led to urgent medical attention. 

The investigation is also critical of the care William received from his GP. Over several months, despite repeat attendances, his chest infection was not properly diagnosed and treated. Relevant information was left out of his medical notes. Pressures of GP workload and an emphasis on not over-prescribing antibiotics have been blamed. 

Commenting on the report, Andrew Clayton of Penningtons Manches’ clinical negligence team, says: “This case highlights a number of systemic issues in NHS care. Fundamental changes in the training and equipping of NHS 111 are needed for the public to trust it to offer sound medical advice. 

“The GP care William received raises significant concerns over lack of awareness of the signs and symptoms of sepsis and when it is appropriate and necessary to prescribe antibiotics. 

“We hear frequent complaints that primary care services, including NHS 111, ‘out of hours’ services and GP practices have given wrong advice. Often this resolves only if and when patients take it on themselves to seek a second opinion elsewhere, but inevitably leads to delay in diagnosis and treatment. 

“William’s tragic story highlights the potentially fatal consequences. A far greater awareness of the signs and symptoms of sepsis is needed. More widely, this case is a stark call for an urgent review of the mechanisms by which NHS 111 advises patients.