A TEENAGE boy died of sepsis after an NHS 111 call handler failed to escalate his six telltale symptoms to a medically trained clinician, an inquest heard.
Health advisor Sue Darnell told the inquest she thought she was giving Cyrus Perry, 17, “the right care at the time”.
Cyrus’s mum Hayley called NHS 111 after the teenager became very unwell at his home in Sturminster Marshall, Dorset, in June 2023.
She told the call handler Ms Darnell that her son had six different symptoms – he was grey and clammy, his skin felt hot, he was becoming confused and dizzy and his vision was going black when he stood up.
Mrs Perry also noted that her son had recently had surgery.
Both of these factors meant the call could have been referred straight to a clinician as a “complex call” – but Ms Darnell decided to continue the triage herself.
After consulting the NHS computer system’s algorithms, the health advisor told Mrs Perry to take her son to A&E within an hour.
But the mum said that because of Cyrus’s condition, she wasn’t able to get him downstairs on her own.
Ms Darnell said she would have a clinician call her back, putting Cyrus’s case in the priority clinical queue.
The inquest at Dorset Coroners’ Court in Bournemouth heard the call back should have been made within 20 minutes – instead it was eight hours later, just after 6am the following morning.
In that time, the 17-year-old died overnight in his bed of sepsis and group A strep, as shown in a post-mortem.
In a statement, Mrs Perry recalled the harrowing moment she went into her son’s bedroom while on the phone to the clinician to find him dead.
[bc_video account_id=”5067014667001″ application_id=”” aspect_ratio=”16:9″ autoplay=”” caption=”Teen died with cold symptoms hours after treatment at ‘ineffective’ hospital” embed=”in-page” experience_id=”” height=”100%” language_detection=”” max_height=”360px” max_width=”640px” min_width=”0px” mute=”” padding_top=”56%” picture_in_picture=”” player_id=”default” playlist_id=”” playsinline=”” sizing=”responsive” video_id=”6362985514112″ video_ids=”” width=”640px”]“I was shouting ‘why didn’t you send someone?’,” she said in a statement read out in court.
Ms Darnell told the inquest there were no clinicians available to immediately transfer the call to and she was confident putting it in the priority clinical queue would get Cyrus the quickest response.
She had worked as a 111 health advisor since 2017 and said her performance had never been questioned before.
Ms Darnell said: “Yes, it should have made it a complex case but because I was able to speak to Cyrus I was able to perform the triage.
“I felt I was doing the right care for him at the time.
“Once I put it in the queue I was under the impression it would be an urgent call back.”
She was asked why she did not carry out a ‘clinical hunt’ to check if a clinician was available immediately.
Ms Darnell responded: “On previous calls I knew I wasn’t able to get hold of anyone. I didn’t want to slow the care down for Cyrus. I felt that was the right thing at the time.
“We have clinicians who monitor the queue and call back priority patients. I was confident in the outcome of it going into the queue.
[quote credit=”Hayley Perry”]This will haunt me for the rest of my life, I put my faith and trust in the system[/quote]“A&E within the hour is a high outcome so it’s dealt with very quickly.”
The hearing heard all advisors are audited monthly on their calls and each one must achieve 86 per cent to be ‘compliant’.
However, Ms Darnell’s call with the Perry family was rated at just 59 per cent.
The auditor found Ms Darnell had not noted down all of Cyrus’s symptoms and had missed opportunities to seek clinical advice at the start and end of the call.
But if no one was available it would still have been sent to the clinical queue, with the same outcome.
‘Let down’
The court hasn’t yet been told what lead to such a delay in the call back.
But Christopher Bowden, from Dorset Healthcare, said on the night the most urgent patients who should have had a call back within 20 minutes, waited an average of three hours and six minutes.
Those on a lower priority two-hour call back list waited an average of two hours and 25 minutes.
The jury inquest also heard that health advisors like Ms Darnell have the authority to send an ambulance to callers if it isn’t recommended in the system’s outcome.
Cyrus’ mum has told the inquest her son’s death was preventable and she felt “let down” by the system.
He died sometime between 3am and 6.30am on June 8, 2023.
Mrs Perry said: “I have concerns about NHS 111, I feel the death was preventable. I feel let down by NHS 111, I clearly informed them Cyrus was too unwell to get to hospital.
“This will haunt me for the rest of my life, I put my faith and trust in the system.”
Cyrus had long-term health conditions – lupus, autism and arthritis – and had an operation to fit a grommet and remove his adenoids in April 2023.
He became unwell following the op and was given antibiotics, but was “more consistently ill” from May 29 onwards when the family got home from a holiday at Butlins Minehead.
By June 7, his health had gone further downhill.
The jury inquest in Bournemouth continues.