“as follows”

The coroner’s concerns

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as follows. — 41. Itis apparent that there is a failure in the process of the transfer information regarding a patient's original disposition by the NHS 111 Service to the ambulance service and the treating clinicians on the ground. In Oliver's case a non-cliniclan NHS Pathway Advisor using the NHS Pathway algorithms identified a ‘severe illness and a rash suggestive of septicaemia’ following a 5-minute phone call with his mother. As identified at inquest meningococcal septicaemia was Oliver's actual cause of death and the NHS 111 Service identified this as a possible risk at 13.00, some 5 hours 45 minutes before it was diagnosed by a medical clinician. In response to their algorithms the NHS 111 Service implemented a disposition of an ‘emergency ambulance response for septicaemia’ and an automatic referral was made to the 999 service. This disposition and a ‘severe illness and a rash suggestive of septicaemia’ were included in the information transferred to the East of England Ambulance Service. However, it was then identified that the current East of England Ambulance Service system does not provide the ambulance crew (and therefore in this case subsequently the GP's) with that information. The message made available to the crew simply read ‘headache/abdo-pain/fever- no access issues, patient not alone 38.8’. Both the ambulance crew and GP’s stated in their evidence that had they known the original disposition from the NHS 111 Service had been suggestive of septicaemia it would have informed their decision-making processes and may have changed their clinical management of Oliver. 2. It was heard in evidence that since this incident the East of England Ambulance Service have introduced a system whereby if a medical professional calls requesting an ambulance and one is not available (due to pressure on the service exceeding capacity) they will inform the medical professional if the anticipated response time is outside the key performance times for the category of call. It was identified, that in a septicaemia case similar to Oliver's (or indeed any case where time is of the essence to transport a patient to hospital to commence life saving treatment) the correct category for the ambulance response would be Category 2. As such, any medical professional who calls for an ambulance will only be told there will be a delay if it is anticipated that delay would be longer than 40 minutes (40 minutes being the Category 2 aimed response time in 9 out of 10 cases). Therefore, under the current system, a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less. Evidence was heard, that in a patient with meningococcal septicaemia the bacterial loading in their system will have almost doubled in that 39 minute time period and the patient’s condition would have rapidiy deteriorated. As such, under the current system of a medical professional being told of the delay if it is only 40 minutes or more {in a Category 2 case), that attending medical professional will be unable to make an informed judgement as to whether waiting for an ambulance or using another form of transport is the right course of action for the patient they are treating. 3. It was apparent from the evidence given by both the ambulance crew and treating doctors that there was some lack of clarity over the current National Institute for Health Care Excellence guidance on the treatment of sepsis and the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee. This lack of clarity centred around the heart rate which should trigger a medical treatment response in a sick six-year-old child. Evidence heard stated that a heart rate of 120 beats per minute was given in some guidance as being at the top end of the normal range for a six-year-old child. The health professionals involved in Oliver's case said they had relied on this guidance. However, in other guidance a heart rate of 120 beats per minute in a six-year-old child is considered to be a high-risk criteria in cases of suspected sepsis requiring an urgent response. The health professionals involved in Oliver's case said they were either unaware of this guidance, or they were aware of it but placed their reliance on the ‘normal range’ guidance above. Therefore, it is apparent that the significance of Oliver's heart rate of 120 beats per minute was not identified as being a symptom of his meningococcal septicaemia by the health professionals responsible for his treatment, likely to be due to the nature of the conflicting guidance as detailed above.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2019-0198

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0