A coroner has called for changes to the NHS non-emergency 111 and out-of-hours services following the death of a two-year-old girl with a twisted bowel.
Myla Deviren, from Peterborough, became unwell in the early hours of August 27 2015.
Her mother, Natalie, called the NHS 111 service for advice but, despite Myla’s symptoms including blue lips and breathlessness, an ambulance was not called, a prevention of future deaths report said.
Two 111 call handlers and an out-of-hours nurse “did not appreciate the significance” of the symptoms, with the latter believing she had gastroenteritis, the report said.
Myla was found unresponsive hours later and died 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.”
She 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.
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.”