A five-year-old boy died from meningitis after confusion between ambulance operators and the NHS 111 service caused delays to his treatment, a coroner said.
Yusuf Abdismad’s mother, Sofia Mohammed, called 999 only to be told by a London ambulance service dispatcher, following an assessment, she should instead ring the non-emergency number, 111. By the time an ambulance arrived, Yusuf was in cardiac arrest.
Mary Hassell, a senior coroner at St Pancras coroner’s court in London, warned there was “a risk that future deaths will occur unless action is taken” and said that the emergency services had failed to recognise the key signs of meningitis.
During the call to 111, Yusuf’s mother said at one point that her son was not breathing. But rather than calling for paramedics to attend him immediately, the call handler continued asking questions, Hassell said.
London ambulance service’s emergency medical dispatcher (EMD) was also criticised for asking Yusuf’s mother a series of confusing questions. In trying to establish whether or not the boy was conscious, the call handler first asked: “Is Yusuf awake?”
When Mohammed replied “no”, they asked: “Is he conscious?” Mohammed panicked and incorrectly said he was when she had not tried to wake him. The coroner said this was “a confusing way of approaching this very important question”. Hassell wrote: “If the answer to the question, ‘is he awake?’ is ‘no’, then the most obvious follow up to that would appear to be: ‘Can you wake him?’”
The call handler also failed to recognise the significance of a description of the boy’s pupils no longer being visible, and that a description of scratches could have referred to a rash. The coroner said it was concerning that meningitis had not been considered a possibility, and issued an “action to prevent future deaths” report in May. Yusuf died on 2 January from meningococcal septicaemia.
The case, which was first reported by the Evening Standard, only came to light after the London ambulance service (LAS) board discussed plans for a capital-wide meningitis awareness campaign, to be launched in September.
An LAS spokesman said: “We would like to say sorry once again to the family of Yusuf Abdismad. We accept the findings of the coroner’s court, and have provided a comprehensive response. We have also completed our own internal investigation into the circumstances of Yusuf’s death. The findings of this investigation have been presented to [the family].
“In response to this tragic event, we are launching an internal awareness campaign for our staff to help further heighten awareness of the symptoms strongly associated with meningitis. This will commence in September to coincide with the start of the academic year – the time when meningitis can peak due to people, particularly children and younger people, being in closer proximity to one another, following the summer break.”
A spokeswoman for London Central and West Unscheduled Care Collaborative (LCW), a GP-led organisation that operates the 111 service in six west London boroughs, told the Evening Standard: “LCW accepts the findings of the coroner in relation to this tragic case and would like to take this further opportunity to extend its condolences to Yusuf’s family.
“While we note the coroner found that Yusuf died from natural causes and that by the time a 999 call was made, it was probably too late to alter the outcome in this case, as a responsible healthcare provider and one of the providers involved LCW is keen to take every opportunity to identify learning from events wherever they occur in order to improve systems and practice.
“We are therefore carefully considering all of the coroner’s comments arising from the inquest and the subsequent prevention of future death report and will be responding in full in due course.”
