Missed chances to prevent boy's sepsis death

Kayleigh Kenneford said her son Theo was a "happy, loving and affectionate little boy"

Missed opportunities to provide earlier care contributed to the death of a three-year-old boy, an inquest jury has concluded.

Theo Tuikubulau died from a Strep A infection which led to sepsis, the jury at County Hall in Exeter concluded.

Kayleigh Kenneford called 111 on the evening of 7 July 2022 because her son was unwell, but the inquest heard the call was graded as category two so an ambulance was not requested straight away. After three further calls an ambulance was despatched and reached Theo's home in Torpoint, Cornwall, 90 minutes after the initial call. He died in the early hours of the next day.

The jury heard Theo would not have had a cardiac arrest and would not have died if he had arrived at hospital sooner.

Ms Kenneford told the inquest Theo was a "happy, loving and affectionate little boy" who was obsessed with buses and fire engines and loved being at nursery.

The jury concluded there were "missed opportunities" in Theo's early care

The 10-person jury returned a narrative conclusion and highlighted three "missed opportunities" when his mother called the 72-hour open access line, the differences in 111 and 999 categorisations, and the allocation of ambulances following the emergency call as being contributory factors.

Before Ms Kenneford made the 111 call on 7 July, Theo had already been admitted and discharged from Plymouth's Derriford Hospital the previous day with a suspected upper respiratory infection, the inquest heard.

For the previous 36 hours before the call, Theo had been gradually getting sicker with a high temperature, flu-like symptoms, breathing difficulties and was reluctant to drink or eat, the hearing was told.

It heard the ambulance trust's Advanced Medical Priority Dispatch System graded Theo's breathing difficulties as a category one on 6 July, while the following day the 111 service's NHS Pathway ranked similar symptoms as a category two.

Quickly deteriorated

At 21:47 BST on July 7, Ms Kenneford rang a 72-hour hotline to the child assessment unit at the hospital where Theo had been earlier and spoke to a nurse who suggested she give Theo some sugary drinks.

An hour later at 23:00, she called 111 and after a further three calls an ambulance arrived at their home near Plymouth shortly before 00:30.

Theo was taken back to Derriford Hospital where he suffered a cardiac arrest at 01:35. He died a short time later as his parents held his hands.

Consultant paediatrician Dr Andy Robinson told the inquest jury Theo did not have sepsis when he assessed him two days prior to his death.

Early identification challenging

The inquest heard he would have got to hospital earlier had a 111 operator graded his call as life-threatening.

Darryn Allcorn, chief nurse and director of integrated professions at University Hospitals Plymouth NHS Trust, said after the inquest the "early identification of sepsis in children be challenging, even for very experienced healthcare staff".

"Whilst NICE [National Institute for Health and Care Excellence] guidance and all relevant procedures were followed including Theo being examined carefully, he was diagnosed with a viral infection and thought well enough to return home," he said.

"He deteriorated quickly afterwards.

"Our staff are committed to always considering sepsis as a possible diagnosis in any child who presents as unwell with a fever.

"We continue to give our heartfelt condolences to Theo's family and will continue to offer them our support."

Amendment 10 July 2025: We have changed this article to make it clearer the ambulance delays were caused by the grading of the call.