According to media reports the NHS internal inquiry found there were 16 mistakes and at least 4 missed chances to save baby William Mead’s life, including failures by several GPS to recognise William’s symptoms as sepsis and an NHS 111 operator who apparently advised his mother not to worry.
Sadly, William died in September 2014 within 12 hours of the call to the helpline.
It’s a sad fact that serious conditions are misdiagnosed or diagnosed too late when the warning signs and symptoms were available and such mistakes could have been prevented, but what is particularly shocking about William’s story is that it is reported that the Trust’s internal inquiry concluded that even if the NHS 111 operator had properly applied the helpline service guidelines to William’s case, it was likely that the seriousness of William’s condition would still have been missed.
The tick-box system itself has been described by commentators as too crude a tool to pick up the red-flag warnings of serious illness. Speaking in Parliament Mr Jeremy Hunt accepted that inquiry recommendations for 111 call advisers to probe beyond their script need to be implemented.
I imagine a vast majority of the public will be surprised that NHS 111 operators do not have any specific medical training, and that concerns have been voiced about the ability of such a service to ever recognise the signs of a serious and subtle illness like sepsis.
It is reported that a spokesperson for NHS England in the South West has said that the local NHS 111 service in question has been given extra staff training to recognise when cases may need referring on.
However, it strikes me as actually a complicated and demanding task to recognise when you are out of your depth and that something is more complex than you understand.
Without medical training and education, how can we expect 111 operators to realise when something is beyond their scope, and when a seemingly innocuous sign such as a child’s whine or high pitched cries is actually a red flag for a life threatening medical condition?
Similar concerns could be raised for other NHS first points of contact such as nurse staffed Minor Injuries Units.
Earlier this week failings were identified at the inquest into the death of 21-year-old Fallan Kurek, who was seen at a Minor Injuries Unit in Tamworth days before she died exhibiting signs and symptoms of deep vein thrombosis and a possible pulmonary embolism which were missed by the nurse who attended her.
No doctors were available at the unit to recognise her symptoms as potentially life threatening.
NHS 111 is of course a ‘non-emergency’ helpline but this does place responsibility at the feet of the patient to assess whether their condition is serious or not and which service to use.
This should never be the case- we rely on medical staff to be in an informed position to be able to refer us on for the appropriate investigations or treatment.
I imagine one the consequences of William’s death will be that many members of the public will be reluctant to access the 111 service.
Presumably medically untrained staff manage these helplines in an effort to save NHS money. If corners are cuts and costs saved by employing non-medically trained staff to make potentially life or death decisions then the inevitable consequence is that more members of the public will self-present at A&E and the pressure on emergency services will only intensify.