An NHS 111 operator did not think a three-year-old who was ‘turning blue’ and ‘fighting for breath’ was in a life-threatening situation before he died from sepsis, a coroner has said.

Theo Tuikubulau died in July 2022 after multiple failings by Derriford Hospital, Plymouth and the wider NHS system, an inquest into his death heard last year.

He had been gradually getting sicker with a high temperature, flu-like symptoms, breathing difficulties and was struggling to eat or drink in the lead up to his tragic death. 

Due to a ‘two-tier response’ in how NHS 111 and 999 assess lips turning blue, it took 90 minutes for Theo to be taken to hospital after his mother called 111 just before 11pm on July 7 2022.

After young Theo’s death, Louise Wiltshire, assistant coroner for the County of Devon, Plymouth and Torbay, issued a prevention of further death notice to NHS England because ambulance times varied depending on which line was called. 

In the UK, 999 is used for life-threatening or immediate emergencies, while 111 is for urgent, non-life threatening medical advice, or when you are unsure where to go.

NHS England said in its response that the NHS Pathways system, used by the NHS 111 services and ‘more than half of England’s 999 telephony services’, did not recognise ‘lips turning blue’ as a life-threatening emergency.

MPDS is a rapid triage tool for 999 emergency calls, whereas NHS Pathways is a clinical assessment system used for both 999 and 111 services. 

After a review, NHS England said it was ‘clear that there is variation between the two triage systems with regards to respiratory distress in children under five, specifically in relation to the management of declared cyanosis (where the patient’s skin or lips have turned blue or grey)’.

Just a day earlier, Theo had been taken to hospital by ambulance after his mother, Kayleigh Kenneford, called 999 and the South West Ambulance Service (SWAS) deemed the case a category one emergency – the highest priority for life-threatening cases.

However, hours later, the toddler was discharged from Derriford Hospital in Plymouth with a suspected respiratory infection.

Ms Kenneford told an inquest that the doctor had said Theo would get worse before he got better.

When Theo got worse and was starting to deteriorate, she turned to NHS 111 for help after being ‘fobbed off’ by the hospital helpline.

The 111 service she called operated on a different system than the 999 service in Devon, meaning a less urgent category two ambulance was sent.

Jon Knight, head of emergency operations at the SWAS, told the inquest that if his team answered the call, it would have been graded as a category one.

Ms Wiltshire said the difference ‘appears to create a two-tiered system of assessment and ambulance categorisation in the Devon area (and potentially nationally)’.

She wrote: ‘It appears that similar breathing complaints requiring urgent medical attention will result in a different ambulance disposition depending on whether the call is triaged by MDPS (used by the 999 provider in Devon) or NHS Pathways (used by the 111 provider in Devon).’

Ms Wiltshire said she had written to both organisations responsible for the two different assessment systems after the inquest to establish why there was a difference.

An NHS spokesperson said: ‘999 and 111 services use clinical triage systems to identify life-threatening symptoms such as breathing difficulties at speed so patients receive the right response as quickly as possible, and calls are escalated immediately if new information comes to light.

‘We continually work with providers to ensure the response across both systems remains consistent for patients, and we will respond to the findings in due course.’