Theo Tuikubulau, 3, was deteriorating rapidly at home with flu-like symptoms, a high temperature, and breathing difficulties – but critical opportunities to get him urgent treatment were repeatedly missed
A three-year-old boy tragically died from sepsis after a series of “missed opportunities” denied him prompt hospital care that could have saved his life, an inquest has found.
Theo Tuikubulau was deteriorating rapidly at home with flu-like symptoms, a high temperature, and breathing difficulties – but critical opportunities to get him urgent treatment were repeatedly missed. An inquest jury concluded there were three key “missed opportunities” that contributed to his death: failures on the 72-hour open access line, inconsistencies between 111 and 999 triaging, and delays in ambulance allocation. “From this, Theo died from an invasive Group Strep A infection contributed by missed opportunities to render earlier care and treatment,” they said.
Theo had first been admiteed to Derriford Hospital in Plymouth on July 6, 2022, but was discharged just hours later with a suspected upper respiratory infection. Over the following days, his mother, Kayleigh Kennerford, grew increasingly concerned as his condition worsened – but she believed this was part of his recovery.
“I remembered that the doctor had said that Theo might get worse before he got better, so I was thinking that it was his body fighting the infection,” she told the inquest. “I was watching my son deteriorate and just thinking that this was how things were supposed to happen, that he would get worse before he got better, but really, he was dying.”
Ms Kenneford called the 72-hour, open access line listed in a discharge letter but said she felt “fobbed off” by a nurse. An hour later at 11pm, she called 111 and after a further three calls, an ambulance arrived at their home near Plymouth shortly before 12.30am. Theo reached the hospital just after 1am – some 90 minutes after Ms Kenneford first called 111. He received emergency treatment but suffered the cardiac arrest at 1.35am and died a short time later. His cause of death was from sepsis, caused by an “invasive” Strep A infection.
Before Theo was first admitted to hospital, call handlers from the South West Ambulance Service Trust graded his case as category one – meaning it was life threatening. But when Ms Kenneford called 111, her son’s case was rated at category two by service operator Herts Urgent Care, which led to the ambulance taking longer to respond.
The inquest heard the two services used different pathways for grading emergencies. Jon Knight, head of emergency operations at the South West Ambulance Service Trust, said that if the call was handled by his team, it would have been considered a category one. Asked about a likely response time, he replied: “It certainly would have been quicker than 90 minutes, would be my belief.” The inquest heard that, had the ambulance reached Theo within the national target, he could have been in hospital by midnight.
Professor Damian Roland, a paediatric consultant in emergency medicine, said Theo’s original discharge from the hospital in the early hours of July 7 was not “unreasonable,” but following Ms Kenneford’s call with a nurse, he should have been reviewed.
Prof Roland said he could say when the sepsis had developed but once an “inflammatory cascade” begins it “can be difficult, sometimes impossible to stop”. He said: “I am very clear about the fact that the night before (July 6), we were not in a cascade situation.”
The inquest heard it was difficult to know what the outcome would have been if Theo had been re-admitted to the hospital after his mother spoke with the nurse on the phone or following the 111 call. “I can’t say on the balance of probability that intervention by 11pm would have made a critical difference,” he said.
Assistant coroner Louise Wiltshire asked: “Is it likely on balance of probabilities that Theo would have died when he did if appropriate care and treatment was administered at 11pm?” Prof Roland replied: “I think had he arrived earlier, I think it is possible that he would not have suffered the cardiac arrest at that point.”
He was asked about what could have happened had Theo arrived at the hospital by midnight if the 111 call had been graded as a category one emergency. “I think some earlier treatment would have especially delayed the collapse,” Prof Roland said. At the end of the inquest, Ms Wiltshire said she had concerns about the 111 and 999 systems for grading calls which “appear to create a two-tier system particularly if both are used in the same geographical area”.
She said she would be requesting further information before determining whether to issue a Preventing Future Deaths report.