02-07-2025
Dying toddler waited 90 minutes for ambulance after call deemed 'not critical'
An inquest at Devon Coroner's Court heard that a paramedic crew could have reached three-year-old Theo Tuikubalau 'within 30 minutes' if his mum's 111 call was graded differently
A critically ill toddler spent 90 of his remaining minutes before dying of sepsis waiting for an ambulance that could have come sooner if an emergency call was upgraded, an inquest has heard.
Theo Tuikubalau, three, was suffering from a high temperature, flu-like symptoms, breathing issues, and a loss of appetite when his mum, Kayleigh Kenneford, called 111 on the evening of July 7, 2022. The tot, who had already been admitted and discharged from Plymouth's Derriford Hospital with a suspected upper respiratory infection the day prior, was becoming increasingly unwell. But when Ms Kenneford placed the call to the service, the 111 differently appraised a critical symptom.
Jurors participating in an inquest at Devon Coroner's Court heard that the South West Ambulance Service Trust's Advanced Medical Priority Dispatch System (AMPDS) graded Theo's breathing difficulties as a category one - indicating "life-threatening illnesses or injuries" - on July 6.
But the 111 service's NHS Pathway - which uses a different method for grading emergencies from 999 calls - ranked similar symptoms as a category two the following day. The alternate appraisal meant crews took 90 minutes to reach Theo after Ms Kenneford first phoned for an ambulance shortly before 11pm on July 7.
Theo was taken back to Derriford – arriving shortly after 1am – where he died a few hours later from sepsis, caused by an 'invasive' Strep A infection. Jon Knight, head of emergency operations at the South West Ambulance Service Trust, reviewed the 111 call and was asked what would have happened if it had been made to his employers.
He said the childs' breathing difficulties would have triggered a category one through SWAST system. He said: "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."
Mr Knight said he was dealing with 'hypotheticals' as to how quickly a category one ambulance that night would have reached Theo, but added it would have "certainly" arrived fewer than 90 minutes earlier. He said: "It is really hard to commit to a time. 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.'
Mr Knight told the inquest that ambulance crews "made all the appropriate and correct decisions", however, with staff ready and waiting for the ambulance's arrival. Having reviewed documents relating to Theo's care that evening, he said the ambulance crew recognised he was seriously unwell and immediately took him to Derriford Hospital.
He said: 'I think the crew made all the appropriate and correct decisions in their decision to leave the scene and take Theo to hospital." He added: "I absolutely support all of the decision-making that was made at the time."
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. He said: "On balance, given the testimony I've already given to the coroner, I think that that's a reasonable assumption."
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.
