A 111 call handler referred the parents of a premature baby to an out-of-hours GP rather than dispatch an emergency ambulance to their home due to “external pressures”, an inquest heard.
Two-month-old Ben Condon died at Bristol Children’s Hospital in April 2015 after developing a respiratory illness.
An inquest originally recorded his death as being caused by acute respiratory distress syndrome (ARDS), human metapneumovirus (hMPV) and prematurity.
High Court judges quashed the conclusion and ordered a fresh inquest after new evidence emerged about Ben’s treatment at the hospital.
The University Hospitals Bristol and Weston NHS Foundation Trust admitted their failure to give Ben timely antibiotics contributed to his death.
A new inquest, which began on Monday, heard Ben was born at 29 weeks at Southmead Hospital in Bristol on February 17 2015 and spent weeks in the paediatric intensive care unit.
Avon Coroner’s Court heard he went home on April 7 with his parents to Weston Super Mare, North Somerset but soon developed a cold and runny nose.
When he became pale and cold and was not feeding properly, his worried father Allyn, a former Olympic sprinter, rang the non-emergency 111 service at around 6pm on April 10.
After Mr Condon answered a series of questions, the call handler referred Ben for an out-of-hours telephone call-back appointment with a GP within two hours rather than send an ambulance.
The court heard that by 7.45pm when Mr Condon and his wife Jenny had not received the call from the GP, they took their son to the Weston General Hospital.
Reading from a written statement, Assistant Coroner Robert Sowersby said Care UK, which runs the 111 service, apologised to the Condon family and the advisor was taken off calls for nearly three weeks and received further training.
“Care UK admitted it was at fault for having not sent an ambulance after the call,” Mr Sowersby said.
“It said that changes in the recordings of telephone calls needed to be made and apologised for their failings.
“Care UK identified in the root cause analysis that the health advisor failed to actively listen and failed to accept the responses provided and there was a failure to select the appropriate pathway responses.”
Mr Sowersby said the incident report found the call handler had incorrectly recorded answers to questions to whether Ben was conscious and alert, and whether he was pale, limp and unresponsive.
“A correct response to just one of these questions would have led to the dispatch of an emergency ambulance,” Mr Sowersby said.
“Cognitive bias was a contributory factor in the response measure in that the health advisor was mindful of the external pressures regarding ambulances being called out and moved towards, rather than away from a GP outcome.”
At the beginning of the inquest, Mr Sowersby had said evidence would focus on the care Ben received after being transferred to Bristol from Weston in the early hours of April 11 until he died six days later.
He had been diagnosed with hMPV – like the common cold in adults – and later found to have ARDS. The boy also tested positive for pseudomonas, a bacterial infection.
Ben’s condition worsened and he was prescribed antibiotics at 11am but these were not administered until 8pm. By then he had suffered a cardiac arrest. He died shortly after 9pm after suffering a second cardiac arrest.
Mr Sowersby said he would be hearing evidence of “whether there were any culpable human failings during the course of that care”.
He said the evidence would also consider the management of Ben’s temperature and ventilation, his blood tests and tests for infection, the administration of antibiotics and the response to his deterioration on April 17.
“The extent to which internal hospital guidelines and protocols were adhered to and the extent to which any relevant national and professional guidelines were adhered to,” Mr Sowersby said.
The inquest continues.
