NHS 111 OPERATOR THOUGHT TODDLER’S BLUE LIPS WERE NO CAUSE FOR ALARM
An NHS 111 operator did not think a three-year-old who was “turning blue” and “fighting for breath” was in a life-threatening situation, a coroner has said.
Theo Tuikubulau died in July 2022 from sepsis after multiple failings by Derriford Hospital in Plymouth, and the wider NHS system, an inquest, held last year, into his death heard.
It took 90 minutes for Theo to be taken to hospital after his mother called 111 because of a “two-tier response” in how NHS 111 and 999 assess lips turning blue.
Louise Wiltshire, assistant coroner for Devon, Plymouth and Torbay, issued a prevention of future death notice to NHS England after the three-year-old died because ambulance times varied depending on which line was called.
NHS England said in its response that the NHS Pathways system, used by NHS 111 services and “more than half of England’s 999 telephony services”, did not recognise lips turning blue as a life-threatening emergency.
It said after a review it was “clear that there is variation between the two triage systems with regards to respiratory distress in children under five, specifically in relation to the management of declared cyanosis (where the patient’s skin or lips have turned blue or grey)”.
The letter added: “If a caller volunteers ‘cyanosis’, they will be recognised as having ineffective breathing through the MPDS (the Medical Priority Dispatch System used by the 999 provider in Devon) triage. However, the presence of cyanosis is not interrogated within NHS Pathways (used by the 111 provider in Devon) and as such this symptom/sign is not a specific trigger for generating a category 1 disposition for ineffective breathing within NHS Pathways, instead resulting in the generation of a Respiratory Distress disposition that is mapped to a category two response.”
Theo had initially been taken to hospital by ambulance after his mother called 999 and the South West Ambulance Service (SWAS) deemed the case a category 1 emergency, the highest priority for life-threatening cases.
The toddler, however, was discharged hours later with a suspected respiratory infection.
Kayleigh Kenneford, his mother, told the inquest the doctor had said Theo would get worse before he got better.
When this happened and he continued to deteriorate, she turned to NHS 111 for help after being “fobbed off” by the hospital helpline.
But the “NHS Pathways system” used to allocate an ambulance by the 111 service differed from the 999 system used in Devon, and so a less-urgent category 2 ambulance was sent.
‘Two-tiered system’
Jon Knight, head of emergency operations at the SWAS, told the inquest that if his team answered the call it would have been graded as a category 1.
Ms Wiltshire said the difference “appears to create a two-tiered system of assessment and ambulance categorisation in the Devon area [and potentially nationally]”.
“It appears that similar breathing complaints requiring urgent medical attention will result in a different ambulance disposition depending on whether the call is triaged via MPDS (used by the 999 provider in Devon) or NHS Pathways (used by the 111 provider in Devon),” she wrote.
Ms Whiltshire added that during various calls to 999 and 111, Ms Kenneford had described breathing complications and expressed that Theo’s lips had turned “a little blue”, and that he was “gasping”, and fighting for every breath.
Ms Wiltshire said she had written to both organisations responsible for the two different assessment systems after the inquest to establish why there was a difference.
An independent case review from the International Academies of Emergency Dispatch (IAED) confirmed that the category 1 response via the 999 call had been correctly assigned, she said.
‘This is a tragic case’
Ms Wiltshire said the NHS had advised her it would try to ensure “the triage and categorisation of ineffective breathing and respiratory distress is consistent across the two triage systems and remains clinically appropriate”. But she concluded that “as this has not yet occurred and the two-tiered triage system continues to exist, so does my duty to make a report to prevent future deaths in this matter”.
A spokesman for NHS England said: “This is a tragic case and we offer our deepest sympathies to Theo’s family for their unimaginable loss.
“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.”
2026-02-14T18:25:42Z