The grieving mother of a boy who died from sepsis during an eight-hour wait for a call back from the NHS has said she ‘will be haunted for the rest of my life’.
Cyrus Perry, 17, died in the early hours of 8 June 2023 after falling ill at his family home in Sturminster Marshall, Dorset, the previous day.
With the teenager struggling to eat, feeling sick and having a headache, temperatures and dizziness, his mother Hayley Perry called the NHS 111 service at 10.38pm on June 7, an inquest heard.
Mrs Perry was told by an advisor that a clinician would call back but due to a ‘system failure’ no call was made for eight hours.
When a clinician eventually made contact at 6.13am, Mrs Perry entered Cyrus’s bedroom and found him laying dead in a moment that will ‘haunt’ her for the rest of her life.
She said: ‘I do feel let down by NHS 111. I clearly said he was too unwell for me to take him to hospital, yet no medical care was provided.
‘This will haunt me for the rest of my life. I put my trust and faith in a system that so badly failed to help Cyrus.
‘The impact on my family has been huge. I cannot sleep at night thinking that one of my children might be ill in the night and die.
‘I would love Cyrus to still be here, he was great fun to be around and he is missed by everyone he let into his life.
‘We are struggling but have to try to put it behind us knowing things will be better for others in the future.’
A post-mortem examination revealed that Cyrus had died from sepsis and Group A strep.
The jury at his inquest returned a verdict that he died of natural causes but stated ‘multiple opportunities were missed’ that meant Cyrus was not given the opportunity of treatment that could have saved him.
During his mother’s conversation with a call handler on the night of June 7, she had been asked numerous questions and been advised to transport Cyrus to hospital within the hour.
When she explained he was too ill for her to get him there, they said someone from the clinical team would call back which should have been within 20 minutes.
Cyrus went to bed and his mum put the cover over him and placed a sick bucket next to the bed.
Mrs Perry did not see it until the following morning, but Cyrus had text her at 3.30am saying he was feeling worse.
Professor Richard Lyon, a consultant in emergency medicine, told the jury that the symptoms Cyrus’s mum described on the 111 call were consistent with sepsis – sickness, diarrhoea, dizziness, shortness of breath and increased heart rate.
Prof Lyon said the pathways outcome was appropriate, but Cyrus was ‘not afforded the opportunity of the medical treatment he required’.
Had an ambulance been sent he would have been given oxygen therapy and fluid resuscitation by paramedics and then intravenous antibiotics at hospital.
Prof Lyon continued, arguing a significant percentage of sepsis patients still die even with treatment and he could not say if Cyrus would have survived if the treatment had been given promptly, but it was possible.
He said the lack of early intervention was ‘significant’ in Cyrus’s death.
An inexperienced clinician who was on her fourth shift had looked at Cyrus’s case ‘very briefly,’ an inquest heard, after two hours but felt it was ‘too complex’ for her experience.
Gwen Payne had been advised to only call back cases appropriate for her experience level.
She did not notice how overdue the call was and did not notify her supervisor, Petra Brown, that it was too complicated for her.
Ms Brown’s job was to review the list of calls, with overdue call backs highlighted in red, but she didn’t access Cyrus’s case.
If a child or adult who has had any infection — even a mild cold — develops one or more of the following symptoms, call 999 immediately and say you think they have sepsis:
1. ABNORMALLY cold to touch.
2. BREATHING rapidly or struggling for breath.
3. VERY lethargic or difficult to rouse.
4. NO URINE (or wet nappy) for more than 12 hours.
5. SKIN mottled, blueish or extremely pale.
If sepsis is suspected by doctors, treatment with antibiotics must begin as soon as possible — ideally within one hour of diagnosis — even before blood tests have been carried out.
At this week’s hearing in Bournemouth, Ms Brown said there was not a robust system in place at the time.
NHS Dorset Healthcare carried out its own investigation after the death and found a number of shortcomings in the system.
Now, if someone gets an outcome of hospital within an hour and say they cannot get them there, they are directed to call 999 instead of waiting for a call back.
Staff have also undergone further training in complex calls, sepsis and identifying an ill child.
Dorset coroner Brendan Allen said he felt in light of this, he did not need to make a prevention of future deaths report.
Dawn Dawson, chief nursing officer for Dorset Healthcare, said: ‘Cyrus’s death at such a young age was an immense, tragic loss, and our heartfelt condolences go to his family and friends.
‘While our 111 service had the appropriate staffing levels and systems in place, we accept there were missed opportunities to respond as we should have done.
‘Following a thorough internal investigation, we have already made a number of changes to our 111 service processes. We have changed and strengthened arrangements for clinical call backs to ensure that calls are effectively prioritised by clinical need and urgency.
‘Where appropriate, we now direct people to immediately call 999 if they are too unwell to travel to an emergency department.
‘The service has also reviewed and strengthened training relating to complex calls and sepsis, and recruited to a number of new clinical roles to provide additional resilience.
‘A significant amount of work and learning has taken place to reduce risks for people needing urgent help, and we have the right safeguards in place to make sure we provide the best possible care and support for patients.’
Mrs Perry said: ‘I welcome the changes made and their work to raise awareness of the recognition of sepsis. It means a lot to the family if positive lessons can be learnt so no other family has to go through the tragic loss we have.’