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Daily Mirror
03-07-2025
- Health
- Daily Mirror
Three-year-old toddler dies after heartbreaking 'missed opportunities'
Theo Tuikubulau, 3, was deteriorating rapidly at home with flu-like symptoms, a high temperature, and breathing difficulties - but critical opportunities to get him urgent treatment were repeatedly missed A three-year-old boy tragically died from sepsis after a series of "missed opportunities" denied him prompt hospital care that could have saved his life, an inquest has found. Theo Tuikubulau was deteriorating rapidly at home with flu-like symptoms, a high temperature, and breathing difficulties - but critical opportunities to get him urgent treatment were repeatedly missed. An inquest jury concluded there were three key "missed opportunities" that contributed to his death: failures on the 72-hour open access line, inconsistencies between 111 and 999 triaging, and delays in ambulance allocation. "From this, Theo died from an invasive Group Strep A infection contributed by missed opportunities to render earlier care and treatment," they said. Theo had first been admiteed to Derriford Hospital in Plymouth on July 6, 2022, but was discharged just hours later with a suspected upper respiratory infection. Over the following days, his mother, Kayleigh Kennerford, grew increasingly concerned as his condition worsened - but she believed this was part of his recovery. "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," she told the inquest. "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." Ms Kenneford called the 72-hour, open access line listed in a discharge letter but said she felt "fobbed off" by a nurse. An hour later at 11pm, she called 111 and after a further three calls, an ambulance arrived at their home near Plymouth shortly before 12.30am. Theo reached the hospital just after 1am - some 90 minutes after Ms Kenneford first called 111. He received emergency treatment but suffered the cardiac arrest at 1.35am and died a short time later. His cause of death was from sepsis, caused by an "invasive" Strep A infection. Before Theo was first admitted to hospital, call handlers from the South West Ambulance Service Trust graded his case as category one - meaning it was life threatening. But when Ms Kenneford called 111, her son's case was rated at category two by service operator Herts Urgent Care, which led to the ambulance taking longer to respond. The inquest heard the two services used different pathways for grading emergencies. Jon Knight, head of emergency operations at the South West Ambulance Service Trust, said that if the call was handled by his team, it would have been considered 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. Professor Damian Roland, a paediatric consultant in emergency medicine, said Theo's original discharge from the hospital in the early hours of July 7 was not "unreasonable," but following Ms Kenneford's call with a nurse, he should have been reviewed. Prof Roland said he could say when the sepsis had developed but once an "inflammatory cascade" begins it "can be difficult, sometimes impossible to stop". He said: "I am very clear about the fact that the night before (July 6), we were not in a cascade situation." The inquest heard it was difficult to know what the outcome would have been if Theo had been re-admitted to the hospital after his mother spoke with the nurse on the phone or following the 111 call. "I can't say on the balance of probability that intervention by 11pm would have made a critical difference," he said. Assistant coroner Louise Wiltshire asked: "Is it likely on balance of probabilities that Theo would have died when he did if appropriate care and treatment was administered at 11pm?" Prof Roland replied: "I think had he arrived earlier, I think it is possible that he would not have suffered the cardiac arrest at that point." He was asked about what could have happened had Theo arrived at the hospital by midnight if the 111 call had been graded as a category one emergency. "I think some earlier treatment would have especially delayed the collapse," Prof Roland said. At the end of the inquest, Ms Wiltshire said she had concerns about the 111 and 999 systems for grading calls which "appear to create a two-tier system particularly if both are used in the same geographical area". She said she would be requesting further information before determining whether to issue a Preventing Future Deaths report.
Daily Mail
01-07-2025
- Health
- Daily Mail
Mother made four ambulance calls and had 90-minute wait before son died in hospital from sepsis, inquest hears
A mother concerned about her sick young son made four calls for an emergency ambulance and had to wait for 90 minutes for it to arrive before he then died in hospital from sepsis, an inquest has heard. Kayleigh Kenneford dialled 111 on the evening of July 7, 2022, because her three-year-old son, Theo Tuikubulau, had been getting continually sicker over the space of around 36 hours. Poorly Theo had been suffering with a high temperature and flu-like symptoms and was reluctant to eat or drink after spending the previous day in Derriford Hospital, Plymouth, with a suspected upper respiratory infection, before being discharged. Devon Coroner's Court heard the 111 operator, who worked for Herts Urgent Care, graded Ms Kenneford's call as a category two - urgent but not life threatening - meaning an ambulance should respond by an average of 18 minutes. But it took a further three calls over the space of an hour-and-a-half by the distressed mother for the ambulance to arrive at her home. Theo returned to the hospital shortly after midnight on July 8 where he died a few hours later from sepsis, caused by an 'invasive' Strep A infection. Louise Wiltshire, assistant coroner for Devon, questioned Dr Hannah Graham, the clinical director of Herts Urgent Care, about the length of time it took for the ambulance to reach the three-year-old. She said: 'I think in this case, it took another 90 minutes and then three more calls, two of which were diverted incorrectly before the ambulance arrived. 'I'm wondering if there is any additional safety netting that could be done in that situation to prevent someone just waiting, thinking it's coming.' Dr Graham replied: 'We work across quite a broad footprint of the country. Certainly, the East of England Ambulance Service will send us alerts now if they are under pressure, so that we know that response times will be slower. 'I think having that sense of response times and pressures on the service is really helpful, and certainly something that we are now getting from the East of England so that we know that response time.' Dr Graham said she was unaware of Herts Urgent Care being provided with this information from other ambulance trusts. The inquest heard that callers would be advised of what level their call was being graded and an idea of how long the ambulance would be. 'If it was an emergency ambulance, we'd give a sense that it's going to be an emergency response,' Dr Graham continued. 'I don't think they get specific time in minutes.' She said a request would be made to the local ambulance trust for an ambulance but they would not know how busy that service was, adding: 'What we do is we would always say if things are worsening, if you've got further concerns, then call 999. 'You can't always just upgrade because response times are longer. 'If every category three becomes category two or every category two becomes category one, then what's the value of people having a cardiac arrest in that moment? 'How do we differentiate? It's really difficult with the resource that we have.' The coroner queried why Theo's case had been graded at two different levels 24 hours apart by the South West Ambulance Service and Herts Urgent Care. Ms Wiltshire said: 'I'm sure you can understand my concern that there seemed to be two different algorithms, two different systems in place within the UK that would lead to a different category, different ambulance disposition - one a category one and one a category two. 'Now in a situation where you don't have shortage of ambulances that might not make a huge amount of difference, but it possibly did in this case. 'Are you able to assist me with why there is a difference in the assessment?' Dr Graham replied that the grading system they used was provided by NHS England. 'NHS Pathways is an NHS England product, and individual providers don't have any jurisdiction over that product,' she said. The inquest before a jury at County Hall in Exeter continues.
