A coroner has warned more children could die unless the NHS 111 service is reformed after call handlers missed several chances to save a young boy.
Sebastian Hibberd, six, died after staff failed to spot warning signs that part of his bowel had collapsed.
Senior coroner Ian Arrow has demanded the triage software used by staff is reviewed because it failed to generate the right questions to judge how seriously ill he was.
Mr Arrow has now sent a Prevention of Future Deaths report to NHS England and NHS Digital, saying: “In my opinion there is a risk that future deaths will occur unless action is taken.”
Sebastian had been throwing up green vomit, had cold hands and feet and was delirious when his concerned dad Russell called the 111 service on October 12, 2015.
Despite repeated calls, operators failed to pick up on the vital clues that Sebastian had the serious bowel condition until five hours later.
Sebastian had a cardiac arrest at his home in Plymouth, Devon, while waiting for treatment and was declared dead at Derriford Hospital.
His inquest, in February, gave a narrative conclusion for his death.
Mr Arrow said in his report: “It is more likely than not, had his condition been recognised and he had received treatment at 8.44am, his life might have been preserved.”
He has also called on the NHS to ensure a meeting with a doctor is arranged in the case of repeated calls regarding an ill child.
NHS England and NHS Digital have until mid August to respond.
Sebastian’s mum Nataliya and Russell said: “While nothing will bring our wonderful little boy back, this report is everything we have been asking for and we hope it will prevent any other family having to live through the nightmare that we have.”
