Boy, three, who died of sepsis would have got to hospital earlier if 111 operator graded calls life-threatening, inquest hears

Daily Mail​

02-07-2025

A three-year-old boy who tragically died from sepsis might have been rushed to hospital earlier if a 111 operator had treated his call as a life-or-death emergency, an inquest heard.
Mother Kayleigh Kenneford dialled 111 on the evening of July 7, 2022, desperate for help as her son, Theo Tuikubulau, felt seriously unwell.
For 36 hours, little Theo had been steadily worsening, battling a high fever, flu-like symptoms, struggling to breathe, and refusing food and drink.
Just a day earlier, Theo had already been admitted and discharged from Plymouth's Derriford Hospital with what doctors suspected was an upper respiratory infection.
But confusion over emergency call grading systems sealed Theo's fate.
At Devon Coroner's Court, it emerged that 999 calls and 111 calls use separate triage systems, and while Theo's breathing difficulties were classified as the highest emergency level, category one, by the 999-linked medical priority system on July 6, the 111 service ranked the same symptoms a less urgent category two the next day.
That meant paramedics took a full 90 minutes to reach Theo after his mother first called for an ambulance just before 11pm on July 7.
Theo was rushed back to Derriford Hospital, arriving just after 1am, but tragically died hours later from sepsis caused by a deadly 'invasive' Strep A infection.P
Jon Knight, head of emergency operations at the South West Ambulance Service Trust, had reviewed the 111 call and was asked what would have happened if it had been made to his employers.
'My belief is based on the trigger phrase that the patient was fighting for breath at the time, it would have triggered a cat one through the AMPDS system,' he said.
Mr Knight said he was dealing with 'hypotheticals' as to how quickly a category one ambulance that night would have reached Theo.
'It is really hard to commit to a time,' he said.
'It certainly would have been quicker than 90 minutes, would be my belief.
'I think with the right set of circumstances - if you didn't have an ambulance available in the area and you were bringing one from Derriford Hospital - you are probably looking at 30 minutes.'
Louise Wiltshire, assistant coroner for Devon, asked Mr Knight about the evidence of Ms Kenneford in which she said she was told by the 111 call handler an ambulance would not be long.
'What I can tell you is within the training with our own service, we would not ask or allow our colleagues to give people average or any sort of indication of ambulance response time,' he replied.
'What we say to patients is: 'An ambulance has been arranged for you. It will be with you as soon as possible. If your condition changes or worsens in any way, call us back immediately.'
'We try to manage patient expectation in that way and give them a very clear instruction to call us back, regardless of timescale.'
Mr Knight told the inquest that having reviewed documents relating to Theo's care that evening, the ambulance crew recognised he was seriously unwell and immediately took him to Derriford Hospital.
'I think the crew made all the appropriate and correct decisions in their decision to leave the scene and take Theo to hospital,' he said.
The hospital was also alerted in advance that the ambulance was coming and staff were waiting for him, Mr Knight said.
'I absolutely support all of the decision-making that was made at the time,' he added.
Andrew Morse, representing Theo's family, suggested if the call on July 7 had been assessed as a category one then he could have potentially arrived at the hospital by 11.45pm.
'On balance, given the testimony I've already given to the coroner, I think that that's a reasonable assumption,' Mr Knight replied.
The inquest heard there was a paramedic crew who could have reached Theo within 33 minutes had his call been graded as category one.
Megan Barker, Mr Knight's deputy, said: 'At best guess, if we compared that to the resource that did go approximately an hour and a bit later, it would have taken them around 30 to 33 minutes to get to Theo.
'We can guess that they would have spent a similar amount of time with Theo, so likely have had a hospital arrival time of about 30 minutes later.
'That puts us around maybe 12.10am.'
The inquest before a jury at County Hall in Exeter continues.