Mum of Peterborough toddler calls for changes to 111 system after chances were missed to save daughter’s life

Myla Deviren, aged two, became unwell in the early hours of 27 August, 2015, with initial symptoms of abdominal pain and vomiting. Her parents became concerned when her breathing appeared fast and were directed to call the 111 service via an online NHS symptom checker.

Myla’s mother Natalie spoke to two 111 call handlers, one of whom was a clinically trained nurse. During the assessment, she listened to Myla’s breathing and identified it to be rapid, but upon her failure to act upon it, an ambulance was not triggered, an inquest was told.

Natalie’s call was then triaged to the NHS Out Of Hours service. She spoke with another nurse who also failed to act upon Myla’s rapid breathing and said she was suffering from gastroenteritis, the court heard.

Just a few hours later, Myla was unresponsive. She was taken by ambulance to hospital, but all attempts to resuscitate her failed and she passed away.

Natalie said: “No parent should ever have to face what we are going through and knowing that this could have been prevented is heartbreaking for us.

“We trusted the advice from the 111 and out-of-hours service. It is awful being made to feel like you are just being a paranoid parent. It is deeply upsetting that your concerns can be dismissed and your instincts as a parent can be lost by this type of triage. I just wish that number never existed.

“Whilst we can only hope the Coroner’s concerns are addressed by the service, we are very disappointed the action plans identified in 2015 after the serious investigation had still not been implemented by NHS 111, despite there being several other Prevention of Future Death reports submitted around concerns with the 111 service. The way the pathways are being used by staff is a great concern particularly given that time is crucial when assessing young children.

“It is impossible to describe our devastation after losing our precious daughter Myla. The catastrophic effect on our entire family is simply indescribable; we love her with all our hearts and miss her every minute of every day. We can only pray this does not happen to anyone else and just hope the preventable tragedy that has struck our family is never repeated.”

During the inquest, it was heard that a joint investigation by Cambridge Community Services NHS Trust and Herts Urgent Care identified a series of failings by bother services relating to the management of Natalie’s call, and in particular that she should have been advised to take Myla to hospital.

An Internal Serious Incident Report also criticised the out-of-hours service for failing to reassess patient referrals from 111 for serious illnesses. It was stated that the NHS Pathways assessment “should have referred the child to hospital” and, because Myla was not seen, “the seriousness of her condition remained unrecognised.”

The inquest heard evidence that there was a lack of paediatric expertise within the services and the Coroner, Mrs Rosamund Rhodes-Kemp, intends to make a formal Prevention of Future Deaths reports to address this failing.

The Coroner recorded a conclusion of natural causes contributed to by neglect due to the “gross failure” to trigger an ambulance. She highlighted the most significant moment in the history of the calls was when the clinical nurse for 111 listened to Myla’s breathing and did not call an ambulance. She concluded that “anyone with clinical training would have considered this pattern of breathing in a child as significant” and that “there was sufficient information to mandate an ambulance being called”.

Myla’s family instructed specialist medical negligence lawyers at Irwin Mitchell’s Cambridge office to support them at the inquest last week.

Sarah Wealleans, the expert medical negligence lawyer at Irwin Mitchell who is acting for the family, said: “This has been a hugely emotional the for the family, who have had to relive the devastating chain of events which ultimately led to their daughter’s death.

“While nothing will sadly change what has happened, it is vital now that every effort is made to ensure the issues seen here are never repeated in the future.

“Parents put a huge amount of trust in healthcare providers to look after their children and a case like this sadly only serves to undermine that.”