A three-year-old boy exhibiting blue lips and struggling to breathe received a non-urgent response from NHS 111, contributing to his death from sepsis, an inquest reveals.
Theo’s Rapid Decline
Theo Tuikubulau succumbed to sepsis in July 2022 following multiple shortcomings at Derriford Hospital in Plymouth and across the NHS framework. In the days leading up to his passing, Theo displayed escalating symptoms including high fever, flu-like illness, labored breathing, and difficulty eating or drinking.
Just one day prior to the fatal call, his mother, Kayleigh Kenneford, dialed 999. South Western Ambulance Service (SWAS) classified the emergency as category one—the highest priority—prompting swift hospital transport. Doctors diagnosed a suspected respiratory infection and discharged him, with one physician noting that Theo’s condition might worsen before improving.
Critical Call to NHS 111
As Theo’s health deteriorated further, showing cyanosis (blue lips) and fighting for breath, Ms. Kenneford contacted NHS 111 around 11 p.m. on July 7, 2022, after receiving inadequate guidance from the hospital helpline. The operator assessed the situation as category two, resulting in a 90-minute ambulance delay before Theo reached the hospital.
The head of emergency operations at SWAS testified that their team, using a different triage protocol, would have rated it category one.
Triage System Disparities Exposed
Louise Wiltshire, assistant coroner for Devon, Plymouth, and Torbay, highlighted a ‘two-tier response’ between NHS 111 and 999 services. She issued a prevention of future deaths report to NHS England, citing inconsistencies in handling cyanosis in young children.
The NHS Pathways system, employed by NHS 111 and many 999 services, does not flag ‘lips turning blue’ as immediately life-threatening. In contrast, the MPDS tool for 999 calls prompts faster action. The coroner noted: ‘Similar breathing complaints requiring urgent medical attention will result in a different ambulance disposition depending on whether the call is triaged by MDPS or NHS Pathways.’
Post-inquest review by NHS England confirmed variations in managing respiratory distress and cyanosis in children under five.
NHS Response
An NHS spokesperson stated: ‘999 and 111 services use clinical triage systems to identify life-threatening symptoms such as breathing difficulties at speed so patients receive the right response as quickly as possible, and calls are escalated immediately if new information comes to light. We continually work with providers to ensure the response across both systems remains consistent for patients, and we will respond to the findings in due course.’
