The tragic death of toddler William Meads as a result of sepsis in December 2014 was avoidable according to a root cause analysis report prepared by NHS England published today.
Sepsis, septicaemia or blood poisoning as it is variously known, is widely believed to be the second most common cause of death in the UK and is a complication arising from any number of clinical conditions.
William, who was only 12 months old at the time of his death, had developed a chest infection, a common illness, easily identifiable, responsive to treatment but with the capacity to have fatal results if left untreated.
The death of any child is a tragedy and should not go unnoticed but in William’s case it is the multiple missed opportunities to diagnose and treat his problem that are most striking and from which lessons must be learned. Unusually the root cause analysis report is clear and unequivocal in attributing William’s death to the failings in his care.
William’s parents took him to see a doctor on a number of occasions but each time were reassured that his condition was not serious. Over the course of the last three visits his symptoms were not recognised nor properly recorded, so that those GPs who saw him at the later appointments lacked a documented history. William’s parents were not given adequate advice as to what to do if his condition deteriorated over the weekend. The out of hours GP service did not have access to William’s medical records so as to be fully aware of how his condition had developed.
The failure of the NHS 111 service to refer William for further treatment has attracted the most attention. The report makes it clear that the medically untrained NHS 111 call handler correctly followed the protocol to which they work, using a series of predetermined questions to arrive at the advice given. The call handler’s lack of knowledge and experience meant that he was unable to identify indications that he was dealing with a very sick child who required immediate hospital treatment. Calls for changes to the system, including medically trained call handlers have been made. Some of those changes are already in place although how realistic it would be to achieve across the board medical training of all call handlers must be open to doubt.
To hear William’s mother describe how they were reassured by an out of hours GP call shortly before William died, confirming that they should let him sleep and ensure that he was well hydrated, is heart rending. That so many sectors of the primary care structure failed William and his family is unacceptable. For the NHS to acknowledge that had any one part of the system operated as it should, William’s life would probably have been saved, is shocking.
If you or your family have experienced medical treatment which has fallen short of your expectations and you would like to discuss your concerns, call or e-mail to speak to one of our experienced team.