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Coroner blames 111 call handlers for teenager's brain damage death.


A Coroner has accused the NHS of duping the public by referring to unqualified call handlers as ‘health advisers’ after blaming them for the death of a teenager.

Teenager Hannah Royle’s father, Jeff, called the 111 hotline when she started vomiting and answered a list of questions. He was told a medic would call back within 12 hours.

The 16-year-old’s condition worsened and her mother, Anne, called again three hours later saying she was suffering severe stomach pain.

Instead of sending an ambulance, the adviser told Mrs Royle, 53, to take her daughter, who had a severe learning disability that left her unable to speak, to A&E herself.

But her daughter stopped breathing in the car and her mother desperately carried out mouth-to-mouth resuscitation as her father drove to East Surrey Hospital, Redhill.

Tests revealed Hannah Royle had suffered catastrophic brain damage. She had a twisted intestine and, while surgery was successful, she never woke up, dying just more than a week later.

West Sussex assistant Coroner, Dr Karen Henderson, wrote a Prevention of Future Deaths Report saying that, if the teenager had been taken to hospital after the first call, she would have survived.

She warned that renaming NHS 111 call handlers as ‘health advisers’ was ‘misleading as it implies professionalism which is untrue given their underlying skills.’

The assistant coroner said that this meant those calling 111 for help are ‘ill-informed’ with a ‘real risk they are being misled’ about its ‘role and capability’.

Hannah Royle of Horsham, West Sussex, is the latest of more than 20 deaths linked to the hotline since 2016 when it replaced the nurse-led NHS Direct.

Her parents, who are now taking legal action, have also warned that the problems afflicting NHS 111 would cost more lives and described it as ‘completely unfit for purpose.’

Dr Henderson said that Hannah Royle’s condition – gastric volvulus – could not have been diagnosed in a telephone call but her father’s ‘articulate’ call meant ‘it should have been recognised Hannah was acutely unwell and needed urgent care.’

The Coroner concluded Hannah died of natural causes contributed to by neglect.

A copy of the assistant Coroner’s future death’s report has been sent to NHS England Chief Executive, Amanda Pritchard.