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| Version 2 | Version 3 |
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| NHS 24 blamed for treatment delay | NHS 24 blamed for treatment delay |
| (about 6 hours 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 sheriff also ruled there was a chance he might have lived 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. |
| NHS 24 officials said it had since made improvements to the service. | |
| The findings followed a fatal accident inquiry at Edinburgh Sheriff Court. | The 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 | 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 previous day after Kyle became unwell and was covered in a "bruise-like" rash. | His mother, Lisa Thomson, had called NHS 24 the previous day after Kyle became unwell and was 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 the arms of his father, Stuart Brown. | Kyle was later transferred to the Royal Hospital for Sick Children in Edinburgh but died the following day in the arms of his father, Stuart Brown. |
| Medical experts had told the court that even if Kyle had lived, he would have suffered brain damage and lost at least one limb. | Medical experts had told the court that even if Kyle had lived, he would have suffered brain damage and lost at least one limb. |
| 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. | 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 staff at NHS 24 failed to recognise the need for an emergency ambulance. | However, three staff at NHS 24 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. | "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. |
| Kyle's mother, Lisa Thomson, found her son with a "bruise-like" rash | Kyle's mother, Lisa Thomson, found her son with a "bruise-like" rash |
| 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 meningitis. | 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 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. | 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 errors have not been made in prioritising calls and to recognise a rash as possible meningitis. | The sheriff also called for NHS 24 to adapt the system to allow team leaders to check that errors have not been made in prioritising calls and to recognise a rash as possible meningitis. |
| NHS 24 brought in sweeping changes to its call procedures days after Kyle's death. | 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. | "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. |
| Progress rapidly | |
| Eileen Burns, NHS 24 nurse director, said: "This is a particularly tragic situation and nothing can make up for the death of a child and our hearts go out to Kyle's family. | Eileen Burns, NHS 24 nurse director, said: "This is a particularly tragic situation and nothing can make up for the death of a child and our hearts go out to Kyle's family. |
| "Since Kyle's death we have made many improvements to the service, including, a review of induction, a review of the routing tool, revised training for all levels of staff; and have worked very closely with the Meningitis Foundation and the Meningitis Trust. | "Since Kyle's death we have made many improvements to the service, including, a review of induction, a review of the routing tool, revised training for all levels of staff; and have worked very closely with the Meningitis Foundation and the Meningitis Trust. |
| "At NHS 24 patient care is paramount to us and if there are further actions that we need to take we will of course take these." | "At NHS 24 patient care is paramount to us and if there are further actions that we need to take we will of course take these." |
| A Meningitis Research Foundation spokeswoman said: "This case shows that when dealing with meningitis and septicaemia, you have to act fast. | |
| "Meningitis and septicaemia are devastating diseases which can kill in hours. | |
| "Although we have successful vaccines, not all types of meningitis are preventable, for example Men B. | |
| "It is therefore important to be aware of the symptoms as they can progress very rapidly." |