A TODDLER died of a twisted bowel after NHS 111 staff failed to spot the signs – despite her lips turning blue.
Myla Deviren, from Peterborough, Cambs, became unwell in the early hours of August 2015.
Her mum, Natalie, called the NHS non-emergency number for advice and told them the two-year-old had blue lips and was breathless.
She spoke two 111 call handlers and an out-of-hours nurse but none "appreciated" her symptoms and didn't call an ambulance, she said.
Myla was found unresponsive hours later and died at Peterborough City Hospital the same day.
An inquest concluded in July that the little girl died of natural causes contributed to by neglect due to the "gross failure" to call an ambulance, said Irwin Mitchell solicitors which represented the family.
Rosamund Rhodes-Kemp, assistant coroner for Cambridgeshire and Peterborough, issued a report to prevent future deaths, which was published online this week.
She wrote in the report: "It is probable that, with earlier transfer to hospital by ambulance and with appropriate treatment, (Myla) would have survived."
Ms Rhodes-Kemp said Myla became unwell in the early hours of August 27, 2015, and Natalie called 111.
With earlier transfer to hospital by ambulance and with appropriate treatment, (Myla) would have survived
During the call, the health assistant "did not appreciate the significance of key symptoms", she said.
The call was then passed to an out-of-hours nurse who "decided that this was a case of gastroenteritis early in the call and did not appreciate the description of a child with worsening signs".
Myla was later found unresponsive and despite being taken to hospital by ambulance was pronounced dead later that day.
Ms Rhodes-Kemp raised concerns about "prescribed pathway questions and answers" that were in place at the time and said that a qualified paediatric specialist clinician should be "available to discuss or review" cases at all times.
She said there should be "robust systems in place to prevent sick children going without potentially life-saving treatment".
Ms Rhodes-Kemp said that mandatory annual training on how to recognise and interpret symptoms needs to be put in place for all staff taking calls.
"The default position and precautionary advice should be – if in doubt, call an ambulance," she added.
What are the symptoms of a twisted bowel in kids?
A twisted bowel, or volvulus, is when the intestine gets twisted which can cause a blockage and cut off the blood flow.
In children, it can be the result of a birth defect, known as intestinal malrotation.
It's when the baby's intestinal tract doesn't form as it shouldn't during pregnancy.
Most children have symptoms within the first year of life, but some can go their whole lives without any and are never diagnoased.
Symptoms can happen a bit differently in each child. They can include:
- Vomiting green digestive fluid (bile)
- Drawing up the legs
- Stomach pain
- Swollen belly
- Rectal bleeding
- Failure to thrive
- Fast heart rate
- Fast breathing
- Bloody stools
Source: University of Rochester Medical Center
The report is being sent to NHS 111 and Herts Urgent Care Limited, which runs the 111 service in Cambridgeshire and Peterborough.
A spokesperson for Cambridgeshire and Peterborough Clinical Commissioning Group said: "The CCG would like to express our sincere condolences to Myla's family.
"We continue to work closely alongside our providers of the NHS 111 service to ensure all recommendations and learnings from the coroner's report have been implemented and are monitored on an ongoing basis."
In a statement, Herts Urgent Care Limited said it accepts the coroner's conclusions and "would like to take this opportunity to reiterate on our heartfelt condolences to Myla's family".
It said that it has made a number of changes to its service since Myla's death including mandatory training for staff within the service "directly relating to illnesses in children".
"Herts Urgent Care remains committed to the ongoing improvement of its services through continued monitoring of its procedures and learning from all incidents," it said.
"We will provide a full response to the coroner's prevention of future deaths report within the statutory deadline."
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