NHS England

YAS 5. Mrs H complains when her husband called 111 on 11 September 2022, the YAS call handler failed to recognise the urgency of his condition and advised Mr H to call an out-of-hours GP-led service.

6. Much later that day, Mr H was advised by the GP to call for an ambulance. Mrs H says by the time her husband arrived in A&E, he had a perforated bowel and sepsis. Mr H sadly died in hospital on 14 September. Mrs H says the 111 service should have advised her husband to attend A&E urgently, and if this correct advice had been given at that earlier time, her husband may not have died.

7. To resolve her complaint, Mrs H seeks service improvements and a financial remedy.

NHSE 8. Mrs H complains the NHS Pathways triage system used for all NHS 111 calls is flawed, as it fails to recognise the possibility of sepsis for a caller who reports recent surgery and chemotherapy.

9. She says NHSE advises her the NHS Pathways triage system was followed when her husband called, and yet he subsequently died from a serious post-operative problem and sepsis, which the triage system failed to identify.

10. Mrs H seeks a full review of the adequacy of the NHS Pathways triage system and amendments made to its application nationwide, to ensure this failing is rectified in future.

11. Mr H called the 111 service on 11 September 2022. He informed the call handler he had been discharged from hospital a couple of weeks previously, after having a stoma reversal ileostomy (bowel) surgery.

12. Mr H explained his stomach was distended, with a feeling of compaction and abdominal pain from the pressure. He said he had stopped passing bowel movements and having tried measures such as drinking prune juice, he remained unable to pass motions.

13. The call handler completed an assessment, asking various questions of Mr H during the call. At the end of the assessment, the call handler advised Mr H to speak with a local service within the hour. The call handler found a GP Access Hub locally, giving Mr H the contact telephone number, asking him to call within the hour to explain 111 had advised him to call.

14. The call handler gave Mr H some care advice, including to sit upright, to take any nebulisers or oxygen he had, to take paracetamol for any pain but not anti-inflammatories until he had spoken with the healthcare professional. The call hander said if Mr H had any new symptoms, his condition got worse or changed or if he had any concerns, to call back.

15. Mrs H tell us her husband called the number given and waited some time for a call back. She says the GP who eventually called from the Access Hub immediately recognised the urgency of her husband’s condition and told him to call for an ambulance. Mrs H says the ambulance arrived 40 minutes later and took him to hospital, where Mr H was found to have a perforated bowel and sepsis.

16. Very sadly, Mr H died in hospital on 14 September. Remaining unhappy with the responses received to her complaint, Mrs H brought her concerns for our consideration.

111 call 20. Having listened to the recording of the 111 call we do not find anything to indicate any failing in its handling. We are satisfied the call was conducted in line with NHS Pathways, as is appropriate. NHS Pathways is a triage tool used nationally, by every 111 provider. It is a computer-based system used by non-clinical call handlers, who are presented with a series of questions.

21. Depending upon the answer given by the caller and entered by the call handler, the computer will then prompt the next question. How these questions are answered by the caller will determine what code is produced, with this code determining the appropriate clinical response and the specific level of care in the relevant timeframe.

22. We recognise Mrs H’s concern that the call handler failed to recognise the urgency of her husband’s condition. We hope to assure Mrs H we find the call handler managed the call as they should, in line with NHS Pathways. Alongside the audio recording, we have seen good evidence from YAS showing the real time information provided to and prompted by NHS Pathways, including the answers given by Mr H and entered by the call handler. This shows the call was handled well and the answers given by Mr H were accurately entered by the call handler.

23. We know Mrs H is concerned with the call handler’s advice, for Mr H to call an out-of-hours GP-led service. Our adviser confirms the advice given aligned with the outcome concluded by NHS Pathways. This was the appropriate outcome to the answers Mr H gave, under the NHS Pathways system.

NHS Pathways 24. Mrs H complain the NHS Pathways system is flawed as it fails to recognise the possibility of sepsis for a caller who reports recent surgery and chemotherapy. We can confirm that Mr H informed the call handler he had surgery recently, however chemotherapy was not mentioned at any time during the call.

25. Our adviser explains it is challenging for any telephone triage system to recognise sepsis. NICE guidance explains that when identifying sepsis, clinical judgement is a critical component as it often requires face-to-face assessment.

26. That said, having listened to the call, from the questions asked and the answers given, the appropriate risk factors for sepsis were queried. Our adviser confirms there was nothing to suggest Mr H had any apparent red flag indicators for sepsis in response to those appropriate, probing questions. This was in line with NICE guidance on recognising sepsis, which, in terms of in primary (GP-led) care, says:

‘16. NICE recommends that people with suspected sepsis are assessed for risk factors and then clinically using a structured set of observations (temperature, heart rate, respiratory rate, level of consciousness, oxygen saturation) to stratify risk of severe illness or death…’

27. Temperature was assessed during the call, with Mr H reporting his skin temperature was normal. For level of consciousness, Mr H was clearly alert, oriented and not confused. For respiratory rate, although Mr H said he was breathless he was able to speak fluently, in full sentences and in a measured manner. At no time did he have to stop, nor did he present with any audible suggestion that he was gasping for breath or had any rapid breathing.

28. For oxygen saturation and respiratory rate, our adviser says this is not information reasonably gained via telephone triage – we reiterate the above NICE guidance is for application in primary care settings. We do not consider it a flaw in the system that this was not questioned via telephone triage. Notably, Mr H did not report any dizziness, palpitations or any similar symptoms to suggest these factors were any cause for concern.

29. We are assured the risk factors for sepsis that would reasonably be expected to form part of the NHS Pathways triage process were covered during Mr H’s 111 call. We hope to assure Mrs H none of the responses given by her husband suggested any red flag nor apparent concern for sepsis.

30. We therefore find no indication of any failing or flaw in the NHS Pathways system with regards to it considering the possibility Mr H had sepsis. We do, however, acknowledge the NHS Pathways system does not enable exploration of recent surgery as a risk factor in this manner. We highlight the same NICE guidance we refer to above, also makes clear this gap:

‘(Note recent surgery is a risk factor [for suspected sepsis] but as discussed this isn’t picked up by NHS Pathways for abdominal pains.)’

31. We take this opportunity to clarify this was not a shortcoming of the call handler. Mr H said his main concern was abdominal distension pain, he reported recent surgery, the advice he was given at hospital before discharge, and reported a loss of bowel movement. The call handler asked the relevant, probing questions when prompted, in response to this information.

32. It remains there is clear acknowledgement in NICE guidance that NHS Pathways does not currently explore recent surgery as a possible risk factor for suspected sepsis. Whilst we cannot apply paramedics’ guidance to telephone triage, our adviser highlights that paramedics’ guidance says:

‘A precise diagnosis of the cause of abdominal pain is often not possible without access to tests and investigations in hospital or via primary care.’

33. We do not find NHS Pathways is flawed in the manner alleged, as we have explained the various risk factors for sepsis that did form part of the triage process in Mr H’s case. We do find a gap, in that NHS Pathways does not explore further the possibility of recent surgery, yet we cannot say exploration of this alone would have changed the outcome. We heard Mr H advising the call handler about his recent surgery alongside his main concerns, meaning this information still formed part of the assessment, and for all those sepsis risk factors that were explored, there was nothing reported by Mr H to suggest any emergent clinical concern. He was given appropriate safety netting advice and appropriately signposted to a primary care provider in a short, prompt timeframe, in line with reasonable expectations as well as the paramedics’ guidance above.

34. Our adviser concludes this is not a clear flaw in considering sepsis under the NHS Pathways system, yet we do consider it a gap. Mrs H is rightly concerned about this. She told us she seeks a review of the adequacy of the system and national change in this regard. We do not consider this such a significant flaw to require amendment, yet we do recognise the importance of highlighting this gap in suspected sepsis exploration, alongside it already having been identified in NICE guidance. We do think some action should be taken.

35. NHS Pathways is developed and audited by doctors and specialists in their field of healthcare. As NHSE explained in response to Mrs H’s complaint, the National Clinical Assurance Group (NCAG) undertakes regular reviews, where clinical leads discuss subjects such as this. NHSE agreed with our proposal, that it take Mr H’s case to the NCAG, for it to be considered by those clinical leads and healthcare specialists to consider what learning could be taken or changes made in its onward continual improvement programme.

36. We consider this aligns with Mrs H’s sought outcomes, and we think it enough to resolve the matter. We will therefore take no further action. We understand how important this complaint is to Mrs H, and we thank her for bringing her concerns to our attention.

1. Mrs H complains about the events on 11 September 2022 when her husband called 111.

2. We have considered the evidence carefully and we do not see any indication of failings in the way the 111 call was handled by YAS.

3. We have seen a gap in the NHS Pathways system used by 111 call handlers, as it currently does not explore recent surgery as a risk factor for suspected sepsis. We do not consider this a significant flaw for the reasons we explain in more detail below, yet it remains a gap. We shared this information with NHSE. It has agreed to send Mrs H a letter, to confirm it will take Mr H’s case to the National Clinical Assurance Group. Their consideration will enable learning to be taken from this event, to aid continuous review of the system with the possibility of this leading to wider change.

4. We consider this achieves a satisfactory outcome for Mrs H and as such consider the matter remedied. We recognise how important this complaint is to her, and we take this opportunity to further extend our condolences, on the loss of her beloved husband.