Health Services Criticised Following Two Year Old’s Death
The mother of a Peterborough toddler who died four years ago from a twisted bowel has urged the NHS to make changes after an inquest heard that the 111 and Out Of Hours services missed chances to save her daughter’s life.
Myla Deviren, aged two, became unwell in the early hours of 27 August, 2015, with initial symptoms of abdominal pain and vomiting. Her parents became concerned when her breathing appeared fast and were directed to call the 111 service via an online NHS symptom checker.
Myla’s mother Natalie spoke to two 111 call handlers, one of whom was a clinically trained nurse. During the assessment, she listened to Myla’s breathing and identified it to be rapid, but upon her failure to act upon it, an ambulance was not triggered, an inquest was told.
Natalie’s call was then triaged to the NHS Out Of Hours service. She spoke with another nurse who also failed to act upon Myla’s rapid breathing and said she was suffering from gastroenteritis, the court heard.
Just a few hours later, Myla was unresponsive. She was taken by ambulance to hospital, but all attempts to resuscitate her failed and she passed away.
Myla’s family instructed specialist medical negligence lawyers at Irwin Mitchell’s Cambridge office to support them at the inquest last week.
During the inquest, it was heard that a joint investigation by Cambridge Community Services NHS Trust and Herts Urgent Care identified a series of failings by bother services relating to the management of Natalie’s call, and in particular that she should have been advised to take Myla to hospital.
An Internal Serious Incident Report also criticised the out-of-hours service for failing to reassess patient referrals from 111 for serious illnesses. It was stated that the NHS Pathways assessment “should have referred the child to hospital” and, because Myla was not seen, “the seriousness of her condition remained unrecognised.”
The inquest heard evidence that there was a lack of paediatric expertise within the services and the Coroner, Mrs Rosamund Rhodes-Kemp, intends to make a formal Prevention of Future Deaths reports to address this failing.
The Coroner also heard from representatives for both Cambridgeshire Community Services NHS Trust and Herts Urgent Care about the investigation that took place following Myla’s death and steps that have been taken to prevent the tragedy reoccurring.
However, despite action plans being made regarding the need for a face to face assessment for children under five, the medical director for Herts Urgent Care’s 111 service confirmed at the inquest that this had not yet been implemented.
NHS Digital confirmed that there had been changes made with regards to the questions put to patients in the Pathways assessments. The Coroner, however, noted that this was only half of the story, and the other half is interpreting the answers given to the questions.
The Coroner recorded a conclusion of natural causes contributed to by neglect due to the “gross failure” to trigger an ambulance. She highlighted the most significant moment in the history of the calls was when the clinical nurse for 111 listened to Myla’s breathing and did not call an ambulance. She concluded that “anyone with clinical training would have considered this pattern of breathing in a child as significant” and that ‘’there was sufficient information to mandate an ambulance being called”.
She also referred to the clear evidence of Mr Nitin Patwardhan, Consultant Paediatric Surgeon, called to give expert evidence, who said that if “a child got to hospital whilst still breathing and with a heart rate, that child could have been resuscitated and should have survived”.
The Coroner added that although there had been steps taken to improve the training of 111 and Out Of Hours staff, along with the reworking of the Pathways assessment, there are still concerns in terms of “knowledge and awareness of interpreting signs and symptoms of illness in sick children, and the handling of complex calls when the response should simply be to call an ambulance.”
A Prevention Of Future Deaths Report has now been issued, with action required by the NHS to ensure no other child goes through what Myla did.
The family hope that the steps taken by the Coroner will ensure the services are improved so that they are safe for the public to use.
Natalie said: “No parent should ever have to face what we are going through and knowing that this could have been prevented is heartbreaking for us.
“We trusted the advice from the 111 and out-of-hours service. It is awful being made to feel like you are just being a paranoid parent. It is deeply upsetting that your concerns can be dismissed and your instincts as a parent can be lost by this type of triage. I just wish that number never existed.
“Whilst we can only hope the Coroner’s concerns are addressed by the service, we are very disappointed the action plans identified in 2015 after the serious investigation had still not been implemented by NHS 111, despite there being several other Prevention of Future Death reports submitted around concerns with the 111 service. The way the pathways are being used by staff is a great concern particularly given that time is crucial when assessing young children.
‘’It is impossible to describe our devastation after losing our precious daughter Myla. The catastrophic effect on our entire family is simply indescribable; we love her with all our hearts and miss her every minute of every day. We can only pray this does not happen to anyone else and just hope the preventable tragedy that has struck our family is never repeated.”
Expert Opinion“This has been a hugely emotional time for the family, who have had to relive the devastating chain of events which ultimately led to their daughter’s death.
While nothing will sadly change what has happened, it is vital now that every effort is made to ensure the issues seen here are never repeated in the future.
Parents put a huge amount of trust in healthcare providers to look after their children and a case like this sadly only serves to undermine that.”
Sarah Wealleans - Senior Associate Solicitor