A tragic story has just come to widespread public notice with a damning Report just published about a very sick infant (William Mead) who died overnight at home, despite his parents having repeatedly sought medical care for their poor little boy. One’s initial reaction is that being realistic, we all understand that doctors are only human so sometimes a very serious mistake gets made and a life is lost, don’t we?

However, in this sad case there wasn’t one slip-up, was there? No, there were well more than a dozen of them, that conspired to bring about the unnecessary end to this young lad’s life – and that is totally inacceptable, isn’t it?

The ultimate and final medical blunder that ended a life here, was made due to the inadequacies of the free NHS 111 (one-one-one) medical emergency telephone number service (it is intended for use when a caller suspects that the medical help needed is less urgent than a 999 call – the problem with that, is though that laymen callers are often not in the best position to make such a judgement, are they?). Indeed with this particular call, it provided the one last chance to save a one year old mite, but was sadly missed. Because of this, that service is unfairly bearing the brunt of media criticism. That is not to say that it is a blameless service, without serious deficiencies that need addressing, just that it is not solely culpable.

The 111 facility was introduced widespread in England only a couple of years ago by the Tories, to replace NHS Direct, NHS24, and GP out-of-hours services. It wasn’t to provide a better service though, was it? No, it was a widely criticised attempt to cut corners and save government money with a cut-price facility – at the expense of innocent lives moreover. It’s main problem, and ongoing issue, is that its lines are staffed by non-medical, inadequately trained, inexperienced, low paid people – that is hardly helpful when they are dealing with potentially dangerously ill individuals, is it? No, but their job is simply to ask questions of the caller from a structured pre-prepared list, and are totally incompetent to make personal judgements about the situation they are dealing with (unlike the previous services that were staffed by trained nurses and doctors, who didn’t use a script and could assess bad life threatening situations).

The 111 service suffered a disastrous launch following its precipitous introduction, with countless teething problems, and continues to attract serious criticism, as being able to neither recognise the need for urgent medical intervention when there are danger warning signs there, nor identify deadly illnesses that need to be escalated. At the outset doctors had warned that it could lower the standard of care that children receive There have been fatal mistake after mistake after mistake, mainly due to lack of medically trained staff, but with even many calls going unanswered in some areas – so it remains completely unsafe. Success it has been NOT.

In the specific case of young William, the worried parents were told by 111 that William’s condition was non-urgent (in reality he had a lung abscess) and that he didn’t require any emergency treatment, which really was what finally sealed his fate, didn’t it? A doctor called the Mum a few hours before William passed away, but never identified the seriousness of the situation (not helped by having zero access to the boy’s GP records- which leaves them a bit in the dark, doesn’t it?). The boy was suffering from septicaemia (sepsis), blood poisoning caused by bacteria and their toxins, brought about by a large invasion of bacteria into the blood stream, which overwhelms the white blood cells that fight-off infection.

It is a well known disastrous and sometimes deadly contamination that those of us who have had experience of hospital intensive care units will only know too well. Those who are really seriously ill from other causes are most at risk, and particularly children as they have a less well developed immune system. Basically, septicaemia travels round the body causing septic shock, multiple organ failure and hence death.

It can be difficult to identify, but there are some striking warning symptoms that should be picked-up by professionals even in young children, such as severe distress & crying, high temperature, shivering and temperature loss, pale & clammy skin (and sometimes pinprick bruises), and low blood pressure. Treatment is urgent and is by antibiotics, but this would normally by a targeted drug to attack the particular type of infection that has caused the outbreak in the first place.

In William’s case the septicaemia was caused by a well established and long running but undetected chest infection. In this day and age it is difficult to fathom out how that can come about, when his caring concerned parents repeatedly took their son to their GPs (as many as six visits, yet no alarm bells rang, for hecks sake?), one who even  missed tell tale signs like green phlegm in vomit (the classic sign of a chest infection as even a layman knows) or abnormal heart rate or high temperature , and didn’t prescribe a course of antibiotics (the safest thing to be done with a child of that age – but widely discouraged by the authorities)

It is said that the Report isn’t about blame – but why the hell not? Oh no, it is all about learning and awareness apparently – for goodness sake! As usual in these circumstances, all the culpable people crawl out of the woodwork promising “lessons will be learnt”. A few more lessons might be learned if ever the guilty were banged-up, or if someone was punished, or if a GP was struck-off, or if anybody whatsoever  lost their job, or even perhaps if a few individuals spent some time in the village stocks, eh? In William’s case we had the head guy responsible for this chaos, Jeremy Hunt, making a statement in Parliament to express his apologies to William’s parents – how can anyone say anything of comfort for their loss and a child’s unnecessary death? Others also trotted out similar messages including the Director of Nursing for South West England.

Just to add even further distress to William’s Mum & Dad, they have had to fight tooth and nail for a year against the authorities to get the truth out about their tot’s death – disgraceful. Initially it was decreed that William’s death was ‘natural causes’. It took a Coroner to overrule that decision, and now this full report to establish the real facts. With their long campaign, the parents have not been seeking retribution (as many of us would be), but to ensure such a thing never happens to another family. Unfortunately, their quest will probably be in vain – the system is too broken to be fixed, isn’t it?

[Many suspect that the woeful NHS 111 service is simply indicative of the truth that our UK Health Service is in a terminal state]