A three-year-old boy has tragically died from sepsis after there were 'missed opportunities' for earlier hospital care, an inquest jury has concluded.
Theo Tuikubulau was admitted to Derriford Hospital in Plymouth on the afternoon of July 6, 2022 after he began experiencing flu-like symptoms.
The little boy was suffering from a high fever, and difficulty breathing, as well as a reluctance to eat or drink.
However, he was soon released from care after just a few hours, with the diagnosis being what was thought to be an upper respiratory tract infection, the inquest heard, as per the BBC.
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But for the next 36 hours, Theo’s mother Kayleigh Kenneford grew increasingly worried as his condition worsened.
She initially thought it was simply part of the healing process and was under the impression that her son had to ‘get worse before he got better’.
“I remembered that the doctor had said that Theo might get worse before he got better, so I was thinking that it was his body fighting the infection,” Ms Kenneford told the inquest.
She heartbreakingly added: “I was watching my son deteriorate and just thinking that this was how things were supposed to happen, that he would get worse before he got better, but really, he was dying.”
The mother then called the 72-hour, open access line which was listed in her son’s discharge letter but said she felt ‘fobbed off’ by a nurse.
Just one hour later she proceeded to call 111 and after a further three calls, the emergency services arrived at their home just before 12.30pm.
Theo reached the hospital just after 1am, which was around 90 minutes after Ms Kenneford first called 111.
The three-year-old received emergency treatment but suffered a cardiac arrest at 1.35am and died a short time later.
Theo’s cause of death was declared as sepsis, which was caused by an ‘invasive’ Strep A infection.
In the inquest, the 10-person jury concluded that there were three ‘missed opportunities’ - the first time his mother called the 72-hour open access line, then the differences in 111 and 999 categorisations, and finally the allocation of ambulances following the emergency call, all as being contributory factors.
Before Theo’s first admission, call handlers from the South West Ambulance Service Trust had graded his case as category one – meaning it was life threatening.
However, when Ms Kenneford called 111, the little boy’s case was rated at category two by service operator Herts Urgent Care, which then led to the ambulance taking longer to respond.
The inquest heard that the two services used different pathways for grading emergencies and Jon Knight, head of emergency operations at the South West Ambulance Service Trust, said that had the call been answered by his team it would have been graded as a category one.
Asked about a likely response time, he replied: “It certainly would have been quicker than 90 minutes, would be my belief.”
The inquest heard that, had the ambulance reached Theo within the national target, he could have been in hospital by midnight.
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Madison Burgess