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NHS 24 blamed for treatment delay NHS 24 blamed for treatment delay
(10 minutes later)
An NHS 24 system for dealing with calls was to blame for the delay in emergency treatment given to a toddler who died from meningitis, a sheriff has ruled.An NHS 24 system for dealing with calls was to blame for the delay in emergency treatment given to a toddler who died from meningitis, a sheriff has ruled.
Sheriff Andrew Lothian said the procedure used by call handlers in place at the time of Kyle Brown's death was insufficient to spot the condition.Sheriff Andrew Lothian said the procedure used by call handlers in place at the time of Kyle Brown's death was insufficient to spot the condition.
The judge also ruled there was a chance he might have survived had he been taken to hospital by ambulance sooner. The sheriff also ruled there was a chance he might have lived had he been taken to hospital by ambulance sooner.
It follows a fatal accident inquiry at Edinburgh Sheriff Court last month. His findings followed a fatal accident inquiry at Edinburgh Sheriff Court.
Kyle died from meningococcal septicaemia on 2 April last year.Kyle died from meningococcal septicaemia on 2 April last year.
I have to determine that Kyle's death might have been avoided had emergency treatment by means of a 999 ambulance call to take him to the Royal Hospital for Sick Children been made Sheriff Andrew Lothian
His mother, Lisa Thomson, had called NHS 24 the day before after finding her son unwell and covered in a "bruise-like" rash.His mother, Lisa Thomson, had called NHS 24 the day before after finding her son unwell and covered in a "bruise-like" rash.
She waited 40 minutes for a call back from a nurse adviser who then sent her to the primary care centre at Edinburgh Royal Infirmary by taxi.She waited 40 minutes for a call back from a nurse adviser who then sent her to the primary care centre at Edinburgh Royal Infirmary by taxi.
Kyle was later transferred to the Royal Hospital for Sick Children in Edinburgh but died the following day in his father's arms.Kyle was later transferred to the Royal Hospital for Sick Children in Edinburgh but died the following day in his father's arms.
Medical experts had told the court that even if Kyle had lived, he would have lost at least one limb and suffered brain damage.Medical experts had told the court that even if Kyle had lived, he would have lost at least one limb and suffered brain damage.
In his determination, Sheriff Lothian said that while he could not rule out the possibility of Kyle surviving, it seemed "improbable" that he would have, given how ill he was when his mother first called NHS 24.
However, three members of NHS 24 staff failed to recognise the need for an emergency ambulance.
"I have to determine that Kyle's death might have been avoided had emergency treatment by means of a 999 ambulance call to take him to the Royal Hospital for Sick Children been made," said the sheriff.
Team leaders
He criticised the procedure used by NHS 24 call-handlers at the time because it only allowed them to consider symptoms individually rather than collectively, and that "rash" was not a specific enough term on its own to signify on meningitis.
Sheriff Lothian said the nurse adviser who sent for a taxi rather than an ambulance when she called Ms Thomson back had not been properly trained in recognising meningitis and meningococcal septicaemia.
The sheriff also called for NHS 24 to adapt the system to allow team leaders to check that they have not made errors in prioritising calls and to recognise a rash of bruises as possible meningitis.
NHS 24 brought in sweeping changes to its call procedures days after Kyle's death.
"I am satisfied that NHS 24 and its management has treated the matter of Kyle's death with the utmost seriousness and has behaved responsibly in endeavouring to put matters right," added Sheriff Lothian.