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Six-year-old died after NHS ‘missed numerous opportunities’ to save him, finds inquest

NHS staff “missed opportunities” to save the life of a six-year-old boy in Plymouth who died after medical staff failed to recognise major red flags that he was seriously unwell.

An inquest heard how the family of Sebastian Hibberd made repeated calls to NHS 111 and his GP, but call handlers failed to spot warning signs of intussusception, a process where one part of the bowel’s telescopes into the next.

Plymouth’s Coroner Court heard that he died 20 minutes after he arrived at Derriford Hospital on 12 October 2015, and senior coroner Ian Arrow said there were “several missed opportunities” for Sebastian to receive life-saving treatment.

Sebastian Hibberd was suffering from cold hands and feet, was confused and delirious, and had been throwing up green vomit – “three particular red flags” indicating a child was seriously unwell according to paediatric surgeon Dorothy Kufeji.

Parents Russel and Nataliya spoke with three different call handlers who didn’t recognise the seriousness of Sebastian’s condition and were unable to speak to a doctor at their GP surgery before his father phoned 999 - Sebastian suffered a cardiac arrest at home waiting for treatment.

Arrow concluded: “It is more likely than not, had his condition been recognised and he had received treatment at 8.44, his life might have been preserved.”

He said that Sebastian’s condition had not been identified and was transferred to a hospital too late to enable the necessary treatment to be provided “despite red flag information being conveyed to the 111 service.”

The GP surgery, South Western Ambulance Service Trust (SWAST), NHS Pathways, NHS England South West and NHS England all carried out investigations following his death and SWAST apologised “unreservedly” for the “tragic circumstances surrounding Sebastian’s death.”

The parents said in a statement: “What is most tragic and inexplicable in all of this is that Sebastian’s passing was totally avoidable. To have found out the catalogue of errors that led to his death has deeply shocked and angered us.

“It is crucial that NHS investigations should lead to comprehensive changes to prevent similar tragedies.”

Coroner Arrow said he was considering producing a prevention of future deaths report and stated that the investigations and reviews carried out all shared the finding that the contact system in place was too complex.

Representing the family, clinical negligence lawyer Dawn Treloar said the inquest had found “multiple failures by individuals and organisations” and “the safety of the urgent care system has been called into question.”


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