Prevention of Future Deaths: Sebastian Hibberd (23 August 2019)

Summary

Sebastian Hibberd, 6 years old, became ill on Saturday 10 October having developed intussusception of the bowel. He deteriorated over the weekend. His father sought medical advice on the Monday from NHS 111 and from his GP's surgery. Sebastian's condition went unrecognised as being life threatening. There were several missed opportunities for him to receive life saving treatment. Sebastian suffered a cardiac arrest and transferred to Derriford Hospital where he sadly died in the Emergency Department shortly after his arrival on the 12 October.

Content

Coroner's concerns

Without changes in the NHS Pathway the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular:

1. at the time of the conclusion of the inquest, there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five
2. at the time of the conclusion of the inquest, the question regarding green vomit, asked in respect to children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian's case
3. there is no indication that NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified advisers to refer unusual cases to clinically qualified staff
4. at the time of the conclusion of the inquest, NHS Pathways' questions did not allow meaningful assessment of pain in a child; that is to say questions about severity of pain and the ability of a child to communicate such pain should be reviewed at national governance level.