Prevention of Future Deaths report: Myla Deviren (24 September 2019)

Summary

Myla Deviren had congenital intestinal malrotation and developed a volvulus on 26 August 2015. Her mother checked the NHS Symptom finder on line and the advice was to take her to A&E but she called 111 for advice.

The Health Assistant who took the call did not appreciate the significance of key symptoms due to multiplicity of symptoms described at the outset. He passed the caller on a “ warm” transfer to the Clinical Adviser whose initial reaction on hearing that the symptoms included blue lips and breathlessness was to call an ambulance, ignored her instincts and took mum through a series of digital pathways re lesser symptoms. When directly asking about the breathlessness Myla's mum put the phone close to her daughter enabling the Clinical Adviser to hear the rapid breathing herself however they did not appreciate the significance of it and did not call an ambulance. She did however pass the call to the Out Of Hours Nurse who decided that this was a case of gastroenteritis early in the call and did not appreciate the description of a child with worsening signs.

Whilst the precise point at which Myla stopped breathing is not known it was sometime between when she was last seen alive approximately 06.00 and then found unresponsive at 08.00 on the 27 August 2015. She was then taken by ambulance to Peterborough City Hospital where, despite attempts at resuscitation, she did not recover a heartbeat and she died. Post mortem revealed small bowel infarction from untreated small intestinal volvulus. It is probable that with earlier transfer to hospital by ambulance and with appropriate treatment Myla would have survived. 

Content

Matters of Concerns:

Children-particularly small infants do not present like adults when they are very unwell. Nor can they articulate their symptoms in a way that lends itself to prescribed pathway questions and answers and they are not in front of the staff handling the calls who therefore rely on parents for information. Whilst since this event there have been steps to provide training of staff at 111 and Out of Hours services and NHS Digital have reworked the pathways to deal with multiplicity of symptoms there are still concerns re what further steps may be taken regrading cases involving children and infants.

Evidence given at the Inquest was that about 20% of calls to both services relate to sick children. There should therefore be robust systems in place to prevent sick children going without potentially lifesaving treatment. Steps should include:

1. Mandatory annual training for all staff on recognising and interpreting signs and symptoms for all staff taking calls needs to be put in place.
2. A suitably qualified paediatric specialist clinician should be available to discuss or review such cases at all times.
3. The default position and precautionary advice should be- if in doubt call an ambulance.