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  • Prevention of Future Deaths report – Hannah Royle (4 October 2021)

    Mark Hughes
    • UK
    • Reports and articles
    • Pre-existing
    • Public domain
    • No
    • Karen Henderson
    • 04/10/21
    • Patients and public, Health and care staff, Patient safety leads


    Hannah Royle was a sixteen-year-old girl on the autism spectrum. Her parents had contacted the NHS 111 service on 20 June 2020 after she became unwell with vomiting and diarrhoea, but they were not advised to go to hospital. Three hours later as her conditioned worsened they phoned again, and the call handler, who took advice from a clinical adviser, opted not to call an ambulance and instead told her parents to make their own way to hospital. She died following a cardiac arrest as she was driven to hospital by her parents.

    In her findings the Coroner states that the NHS 111 service failed to provide the appropriate triage for Hannah on the information provided to them by her parents. This resulted in a cardio-respiratory arrest arising from an avoidable delay in being adequately resuscitated either by prompt attendance of the emergency services or through earlier admission into hospital.


    In her report the Coroner notes the following matters of concern:

    1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case.
    2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm.
    3. The skill and expertise of the ‘clinical advisor’ was wholly inadequate for her position as she had no contemporaneous or relevant experience in working in an emergency department as a nurse. She was also insufficiently robust in her assessment and understanding of Hannah’s condition when the call handler contacted her for advice.
    4. Members of the public who contact the 111 are ill-informed with a real risk they are being misled over the role and capability of the 111 service. There is little clarity or understanding by the public that it is based on following and completing an algorithm by individuals who have no need for any qualification in health care and who will only receive a short training programme after they are employed. Hannah’s parents indicated that if they knew this, they would have opted to ring 999 and the outcome would have been different.
    5. The 111 service is not a ‘diagnostic’ service yet the ‘call handlers’ have been renamed ‘health advisors’. This is misleading to the public as it implies professionalism which is untrue given their underlying skills and unsubstantiated given it is their role to complete an algorithm.
    6. The NHS pathway for ‘Abdominal Pain’ is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint.

    This report was sent to NHS England and NHS Improvement, Health Education England, NHS Digital and South East Coast Ambulance Service.

    Prevention of Future Deaths report – Hannah Royle (4 October 2021) https://www.judiciary.uk/publications/hannah-royle-prevention-of-future-deaths-report/
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