NHS 111 staff need more training and the algorithms need to be adapted to better notice sepsis, health minister Jeremy Hunt concluded in light of a one year olds tragic death in Cornwall.
William Mead, from Penryn, Cornwall, died on 14 December 2014, and his death was put down to natural causes. However, a coroners inquest in June 2015 found that he had treatable blood poisoning (septicaemia) caused by a chest infection.
His mother, Melissa Mead, spoke to medics at least nine times in the 11 weeks leading up to William’s death, and on the day before his death, she called 111 for advice and also spoke to an out-of-hours GP.
“The issues raised in this case have significant implications for the rest of the NHS, which we are determined to learn from. We let [William’s mother], William and her family down in the worst possible way,” Hunt said in the House of Commons yesterday afternoon.
He added that the changes to 111 should be “treated as a national and not a local issue”.
Hunt said that call-handlers were “trained not to deviate from their script, but the report says they need to be trained to appreciate when there is a need to probe further, how to recognise a complex call and when to call in clinical advice earlier.
“It also highlights limited sensitivity in the algorithms used by call handlers in the signs relating to sepsis,” he stated.
NHS 111 call handlers are not medically trained, and the report said William might have lived if they had realised the seriousness of his condition.
Identified problems in the case report
· The Call Advisor should have considered this a complex call and sought clinical support due to the complex symptom history and recent medical history. Moreover they did not probe enough around some of the answers given.
· The NHS Pathways tool is not sensitive enough to red flags relating to sepsis. In particular, subtle changes seen in a deteriorating paediatric patient are not easily identified through the structured questioning within the pathways.
· William was not showing all of the classic red flags for sepsis.
· William’s mother was given “vague” and “non-specific” safety netting advice, so that she could recognise any deterioration of symptoms.
· GPs did not look at the whole picture of attendances and their frequency. “This is commonly known as a ‘pattern of recognition’, which raises a clinician’s ‘index of suspicion’” the report read.
· There is no system for various clinicians in the urgent care system to see the primary care records of a patient. The OOH doctor could not see the detail and nature of the attendances of William in primary care since October.
National recommendations in the case report
· That NHS England South (South West) escalates to national bodies the issues relating to the pressure on primary care in relation to: antibiotic prescribing; referrals to secondary care; and workload.
· That NHS England South escalates the issues regarding the sensitivity of NHS 111 Pathways.
· That NHS England South escalates the issues regarding the need for more defined standards regarding how 111 services and local OOH services interact in regard to dispositions.
· That NHS England South escalates the importance of progressing the information/record-sharing agenda for all NHS bodies.
· That NHS England Medical Director Office and the UK Sepsis Trust work actively together, with the input of experts and parents in the SW, on the development of national guidance to parents and GPs regarding childhood sepsis, using the SW as the initial pilot site.