Failures of the 111 Helpline

Lord Prior of Brampton Excerpts

Tuesday 26th January 2016 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, with the leave of the House, I shall repeat as a Statement the Answer to an Urgent Question given in another place by my right honourable friend the Secretary of State for Health on NHS England’s report into the death of William Mead and the failures of the 111 helpline. The Statement is as follows.

“Mr Speaker, this tragic case concerns the death of a one year-old boy, William Mead, on 14 December 2014 in Cornwall. While any health system will inevitably suffer tragedies from time to time, the issues raised in this case have significant implications for the rest of the NHS which I am determined we should learn from.

First, though, I would like to offer my sincere condolences to the family of William Mead. I have met William’s mother Melissa, who spoke incredibly movingly about the loss of her son. Quite simply we let her, her family and William down in the worst possible way through serious failings in the NHS care offered, and I would like to apologise to them on behalf of the Government and the NHS for what happened. I would also like to thank them for their support and co-operation in the investigation that has now been completed. Today, NHS England published the results of that investigation—a root-cause analysis of what happened. The recommendations are far-reaching, with national implications.

The report concludes that there were four areas of missed opportunity by the local health services where a different course of action should have been taken. These include primary care and general practice appointments by William’s family, out-of-hours calls with their GP and the NHS 111 service. Although the report concluded that these did not constitute direct serious failings by the individuals involved, had different action been taken at these points, William would probably have survived.

Across these different parts of the NHS, a major failing was that in the last six to eight weeks of William’s life the underlying pathology, including pneumonia and a chest infection, was not recognised and treated. The report cites potential factors such as a lack of understanding of sepsis, particularly in children, and pressure on GPs to reduce antibiotic prescribing and acute hospital referrals. Although this was not raised by the GPs involved, the report also refers to the potential pressure of workload.

There were specific recommendations in relation to NHS 111 which should be treated as a national, not a local, issue. Call advisers are trained not to deviate from their script, but the report says that they need to be trained to appreciate when there is a need to probe further, how to recognise a complex call and when to call in clinical advice earlier. It also cites limited sensitivity in the algorithms used by call handlers to red-flag signs relating to sepsis. The Government and NHS England accept these recommendations, which will be implemented as soon as possible.

New commissioning standards issued in October 2015 require commissioners to create more functionally integrated 111 and GP out-of-hours services, and Sir Bruce Keogh’s ongoing urgent and emergency care review will simplify the way the public interacts with the NHS for urgent care needs.

Most of all, we must recognise that our understanding of sepsis across the NHS is totally inadequate. This condition claims around 35,000 lives every year, including around 1,000 children.

I would like to acknowledge and thank my honourable friend the Member for Truro and Falmouth, who, as well as being the constituency MP to the Mead family, has worked tirelessly to raise awareness of sepsis and has worked closely with the UK Sepsis Trust to reduce the number of avoidable deaths from sepsis.

In January last year I announced a package of measures to help improve diagnosis of sepsis in both hospitals and GP surgeries, and significant efforts are being made to improve awareness of the condition among both doctors and the public. But the tragic death of William Mead reminds us there is much more work to be done”.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the noble Lord for repeating that. I start by paying tribute to Melissa Mead and her husband Paul, who have fought to know the truth about their son’s death and who are now campaigning to raise awareness about the care of sepsis and how we can improve it.

Clearly, the key is to learn lessons and take action in the immediate future. Ministers were warned about poor sepsis care back in September 2013 when an ombudsman report highlighted shortcomings in initial assessment and delay in emergency treatment that led to missed opportunities to save lives. Can the Minister say what action has been taken by the Government? Will he urgently meet the UK Sepsis Trust to discuss what needs to happen to raise awareness among GPs, the NHS and the public?

The Minister outlined the failures in the 111 response. He will know that the replacement of NHS Direct, which was predominantly a nurse-led service, with NHS 111 means that the service now relies mainly on call handlers who receive as little as six weeks’ training and where turnover among staff can be very rapid. Is he going to review the training that call handlers receive and will he consider increasing the number of clinically trained staff available to respond to calls?

The Minister will be aware that there are two other inquiries into NHS 111 failures at the moment: in the east Midlands and on the south-east coast. Can the public have confidence that the 111 service is fit to diagnose patients with life-threatening conditions?

[Lord Prior of Brampton]

My Lords, I echo the tribute that the noble Lord paid to the Mead family and their recognition that we can only learn from these terrible tragedies. The fact that they are prepared to make available the report to other parts of the NHS will help in that learning process. I, or one of the other Ministers concerned, will certainly undertake to meet the UK Sepsis Trust.

The noble Lord raised the issue of the 111 service. It is worth making the point that, in this case, the call handler took the call and referred it to a GP who was part of the out-of-hours service. The GP then spoke directly to William’s mother and decided on what the right course of action was. However, I take on board exactly what the noble Lord said about training and the mix between clinicians and non-clinicians in 111 call centres. It will become a better service when the out-of-hours service and the 111 service are integrated.

One point that came out of the report was that had there been an electronic patient record indicating the evidence of the time that William had spent with GPs in the preceding six weeks, the GP who took the call might possibly have come to a different decision. This was a tragic case of all the holes in the Swiss cheese lining up to cause this awful tragedy. Therefore, I take on board what the noble Lord said about 111 and will pursue that with NHS England.

[Baroness Walmsley (LD)]

My Lords, I share the concerns of the noble Lord, Lord Hunt, about 111, but does this not go much wider? On the issue of medical and public education about sepsis, what are Public Health England and Health Education England going to do about this? We cannot rely on the BBC1 programme “Trust Me, I’m a Doctor”, which this week has certainly increased my understanding of the symptoms of sepsis. But that needs to be spread to the wider public. I recommend that people go on iPlayer and watch that programme if they want to know about this. Does this not also indicate that this very conscientious and determined mother was not listened to? She knew her child was behaving abnormally and all the people who talked to her—from GPs through to everyone else—just did not listen.

[Lord Prior of Brampton]

My Lords, the facts of this case demonstrate that a lot of things went wrong. That is the real tragedy of it. Had one of those things not gone wrong, the tragedy may not have happened. The noble Baroness referred in particular to medical education but it is wider than that. As I said, a whole stream of things went wrong and we must learn from that.

[Baroness Masham of Ilton (CB)]

My Lords, does the Minister agree that confusing messages are coming out? One is that antibiotics are being given too liberally. The other is that they are desperately needed for serious chest infections—and this boy had pneumonia, which was missed. Cases of meningitis are also missed. Such illnesses really need antibiotics. Does he agree?

[Lord Prior of Brampton]

My Lords, in a sense there are mixed messages—but there is a common-sense message here as well. We do not want to overuse antibiotics but, on the other hand, clearly where there is a serious infection, antibiotics are absolutely necessary. At one level it is a mixed message but there is a common-sense way through the two.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, the noble Lord has pointed out—as those of us who have read about this case are aware—that the patient was a very young child. One thing that I find troubling about this whole history is that that fact appears not significantly to have influenced the way in which his case was handled. Is it not the case that there should be a default position in respect of very young children exhibiting symptoms where the precautionary principle should apply, whether in respect of prescribing antibiotics, referring to hospital or any other kind of presumption of the possibility of acute illness?

[Lord Prior of Brampton]

My Lords, one would expect the doctors concerned to make that presumption in the case of a very young child. But the noble Baroness makes a valid point and I am sure that NHS England will take it on board.

[Baroness Meacher (CB)]

My Lords, does the Minister agree that this tragic case occurred in an environment of incredible pressure on GPs and others within the NHS, with a growing blame culture and huge numbers of patients—they have to see 60 to 70 in a day very often? We all have to accept that things will go wrong if we leave GPs, in particular, working under those sorts of personal pressures and so on. We know that 30% or so will leave the profession in the coming years. Will the Minister meet with me to discuss what he might do to alleviate some of those problems? That could be very helpful.

[Lord Prior of Brampton]

My Lords, unquestionably there are huge workload pressures on GPs. There is no doubt about that. I do not think they were a primary cause of this particular tragedy, but I will be happy to meet with the noble Baroness to discuss that.