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Coroner demands NHS 111 changes after six-year-old Sebastian Hibberd’s death | UK News



More children in England could die unless the NHS takes action after call handlers missed several opportunities to save the life of a six-year-old boy, a corner has warned.

Sebastian Hibberd died after staff failed to spot warning signs that part of his bowel had collapsed.

He then suffered a cardiac arrest at home while waiting for medical treatment.

A Prevention of Future Deaths Report has now demanded NHS England and NHS Digital carry out a review of their procedures.

It says call handlers were not being “adequately assisted” by the algorithm used to assess patients over the phone.

Senior coroner Ian Arrow said in the report: “In my opinion there is a risk that future deaths will occur unless action is taken.

“Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child.”

An inquest into Sebastian’s death in February heard his father, Russell, contacted NHS 111 on the morning of 12 October, 2015, after he began throwing up green vomit.

Sebastian Hibberd died after staff failed to spot warning signs that part of his bowel had collapsed
Call handlers failed to spot warning signs that part of his bowel had collapsed

The child also had cold hands and feet, stomach pain and was confused and delirious, all signs of a child suffering from intussusception. Intussusception is where part of the intestine “telescopes” inside another part, causing an obstruction.

Call handlers failed to recognise his condition as life-threatening in repeated calls until his father again contacted them five hours later.

The little boy had a cardiac arrest at his home in Plymouth while waiting for treatment but was declared dead after being taken to Derriford Hospital.

Mr Arrow said in his report: “In particular, it is more likely than not, had his condition been recognised and he had received treatment at 8.44am, his life might have been preserved.

“By the time the seriousness of his condition was recognised at 13.54 it was less likely that his life could be preserved.”

There were inadequate NHS Pathways questions for children over five about two of the symptoms for intussusception and a seriously ill child – cold hands and feet and green vomit, Mr Arrow said.

The coroner also concluded the Pathways questions do not allow a meaningful assessment of how much pain a child is in.

He called for a review into support for 111 handlers, who are not clinically trained, when dealing with unusual cases.

Mr Arrow also asked NHS England to review the need for a fail-safe mechanism to ensure a face-to-face meeting with a doctor is arranged following repeated calls concerning the condition of a child.

Mid August has been set as the deadline for NHS England and NHS Digital to respond.

In a statement, parents Nataliya and Russell Hibberd said: “While nothing will bring our wonderful little boy back, this Prevention of Future Deaths Report is everything we have been asking for and we hope it will prevent any other family having to live through the nightmare that we have.

“For three long years we have been fighting for change, reading NHS reports and documents in pursuit of the truth, and we are extremely grateful to the coroner for agreeing to our request for an inquest and listening to our concerns.”

The family’s legal representative, Dawn Treloar, said: “It is imperative that changes are made to avoid further tragedies occurring.

“Preventing this happening to anyone else has been my clients’ motivation during the long inquiry and I hope this report gives them solace and allows them to start rebuilding their lives.”

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