NHS staff missed opportunities to save six year old

An inquest into the death of a six-year-old boy has left a senior coroner considering the need for further action to prevent further avoidable deaths.

Sebastian Hibberd died 20 minutes after arriving at Derriford Hospital, run by University Hospitals Plymouth NHS Trust, after his family made repeated phone calls to both their local GP and the NHS 111 service.

Sebastian’s parents had notified NHS 111 that he was delirious, had cold hands and feet and had been bringing up green vomit. Dr Dorothy Kufeji, a paediatric surgeon, identified three symptoms that were communicated to NHS 111 as being “three particular red flags” that serve as a sign that a child is very unwell.

Mr Hibberd, Sebastian’s father, rang the NHS 111 service five times, and each time was told to speak to a GP, until he told the call handler his son’s vomit had turned green. At this point, an ambulance was despatched. At the same time, Mr Hibberd had done as requested and contacted the GP but was waiting for a call back from a doctor, having only been able to get through to reception.

Sebastian died of intussusception, which, according to Great Ormand Street Hospital, is the main cause of bowel obstruction in young children.

The senior coroner, Mr Arrow, found there were “several missed opportunities” that could have seen Sebastian receive the treatment he needed. Mr Arrow is considering making a prevention of future deaths report.

What is Intussusception?

Intussusception is a bowel obstruction where the bowel “telescopes” in on itself causing the walls of the bowel to press in on one another. It is not known what causes this condition, but may be linked to having an infection prior to the condition. Treatment of intussusception requires hospitalisation and will usually involve an air enema or in more serious cases, surgery may be required.

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