Advising with empathy and experience

Tragic death of boy, 6, "let down by NHS".

The death of a six year old boy was "totally avoidable" but he was “let down by the NHS”, an inquest was told.

The hearing into the death of six-year-old Sebastian Hibberd from Plymouth found there were numerous missed opportunities for him to have received life-saving treatment.

Sebastian died on Monday October 12, 2015 after falling ill on the morning of October 10. His classmates had been suffering upset stomachs and his parents initially thought he had a 24-hour bug and treated it accordingly.

He appeared to have improved by the Sunday but later that night he deteriorated and his vomiting got worse. By the Monday morning it was clear to his father, Russell,  that Sebastian was "really uncomfortable" and crying when being sick, wriggling around his bed and his hands and feet felt cold.

Mr Hibberd called his GP at Glenside Medical Centre at 8am but was met by an automated response saying the surgery was closed. At 8.15am Mr Hibberd called the NHS 111 Helpline, reporting his son's abdominal pain and vomiting. He was given advice to call his GP, but was unable to get through.

At 8.44am he could still not get through to the surgery so called 111 again. He reported his son's green vomit and having been sick for 48 hours, but was again advised to call his GP.

At 8.58am he got through to the senior receptionist at the surgery who offered an appointment at 11.35am, but, as Mr Hibberd considered it difficult to get Sebastian to the surgery in his current state, this was declined.

The surgery offered a call back from the duty doctor which he agreed to, after passing on details about his son, saying he was still vomiting, delirious and suffering abdominal pain.

After receiving no callback, Sebastian's father called the surgery between 1.15pm and 1.30pm and was again met with a automated message saying it was closed for lunch.

At 1.30pm Mr Hibberd called NHS 111 and reported his son's arms and legs were cold and that he had last vomited an hour previously. He was advised to call his GP within two hours.

At 1.54pm Mr Hibberd again called NHS 111 reporting the same symptoms of vomiting, deliriousness and abdominal pain and an emergency ambulance was despatched. However, Mr Hibberd told the inquest that his son's condition worsened and he went into cardiac arrest while having a fit.

Mr Hibberd called 999 and then started CPR on Sebastian. The ambulance was upgraded to an immediate response. Paramedics worked on Sebastian before he was taken to Derriford Hospital but he was confirmed dead in the emergency department.

Mr Hibberd told the inquest that he was never transferred to a clinician when he called NHS 111 Helpline. He said: "A complex call should have been transferred to a clinician. If that was done, an ambulance would have been dispatched in 30 minutes."

The inquest was told by the duty doctor at Glenside Medical Centre, Dr Daniel Fay, that he did not pick up details suggesting any urgency.

Senior coroner, Ian Arrow, said the medical cause of death was ischemic/necrotic bowel and intussusception, a condition in which one segment of intestine "telescopes" inside of another, causing an intestinal blockage.

The inquest also heard from a number of witnesses and experts including Dr Andrew Leech, a GP and Dorothy Kufeji, an experience paediatric surgeon.

Mr Arrow said a common element of their evidence was that a child suffering from intussusception will compensate its bodily regulation until the child suffers an irretrievable collapse.

The proper method of treatment would have been to stabilise the patient by rehydration and antibiotics followed by an air enema or surgery.

He said Sebastian's condition "was not identified and he did not have sufficient timely transfer to a hospital to enable either course of care to be adopted."

He noted how Dr Kufeji identified "three particular red flags" which would indicate that a child was seriously unwell: green vomit, cold hands and feet and confusion and restlessness.

Mr Arrow said that on the balance of probabilities all the red flags had been passed onto NHS 111 but the information had not been passed onto a medical clinician and it "did not provoke the activation of urgent assistance until a point at which the possibility of receiving life-saving treatment was rapidly diminishing.

"At the point Sebastian suffered a cardiac arrest the possibility of a resuscitation was extremely remote.”

Mr Arrow said that expert witness, Dr Andrew Leach, recommended that arrangements should be put in hand that "should an individual seek advice on three occasions in relation to an individual patient with an ongoing complaint, the concern should be reviewed by an appropriate clinician at the third time of contact.”

He also noted how Dr Dorothy Kufeji had explained that at her hospital trust a second telephone call from a concerned parent of an unwell child "escalated the attention given to the query.”

Recording narrative verdict he said: "On the balance of probability there were several missed opportunities for Sebastian to receive life-saving treatment. In particular it is more likely than not that, 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 1.54pm it was less likely that this could happen."

 

 

 

 

 

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