Day 1: Friday, 1.15am
The parents of a three-year-old child contacted the NHS 111 service, concerned about her health.
The father reported his daughter had pain in her stomach, which had started during the evening after an episode of vomiting.
In addition, he reported she was not eating and was crying frequently between periods of sleep.
The child was asleep during the initial part of the call and the father was asked to wake her (to check she could be woken), following which she started to cry.
Following a series of questions, the father reported his daughter was complaining of pain in her chest area and stomach, but pointing everywhere on her body.
He explained that she was asking them to rub her chest region and that his wife reported hearing some sounds in her stomach.
The parents were offered an appointment with a GP at a treatment centre in a nearby hospital, which the father declined as he had no transport.
He agreed to try and give the paracetamol first to see whether this was effective at relieving his daughter’s pain.
The father called NHS 111 for a second time regarding his daughter’s stomach pain. He said she had vomited after having some food, following which she had not eaten and was complaining of stomach pain.
The father said he had called back as his daughter was still complaining of stomach pain despite having been given paracetamol.
She was taken to A&E after continuing to vomit and complain of a sore throat.
She was diagnosed with pustular tonsillitis (she had white spots on her left tonsil).
Local anaesthetic spray was given to ease the child’s sore throat and she drank 200mls of juice.
The family recollect that they had to ask for a straw, as their daughter was unable to drink fluids without one at this time, due to being unable to swallow properly.
The child was discharged home with local anaesthetic spray and antibiotics.
The child’s father attended hospital as his daughter had run out of antibiotics.
He was given an additional batch of the drugs and returned home to his daughter.
The parents booked an appointment to see a GP at their local medical practice due to ongoing concerns about their daughter.
She was still struggling to eat and had become ‘more quiet’ and less active.
But she was prescribed the remaining five days of antibiotics to complete the ten-day course and went home.
Day 10: Sunday, 9.44am
A 999 call was made as the child said to her parents that she was ‘unable to see’.
The father said his daughter was conscious but saying she could not see and was becoming distressed.
The incident was categorised as an emergency and summarised as: ‘unconscious, near fainting episode.’
An ambulance was dispatched with a double paramedic crew under emergency conditions, arriving at 9.55am.
Paramedic 1 was primarily responsible for the child’s care.
Paramedic 2 was observing Paramedic 1 as part of the routine appraisal process.
The Paramedics were met by the child’s father, who led them upstairs to the family’s flat.
As the Paramedics entered the flat, the child was lying awake on a mattress.
Her mother was sitting on the floor beside her. The paramedics asked the parents to take their daughter through to the lounge area so that they could assess her.
The child’s father picked her up and carried her through to the other room.
The Paramedics received no information relating to the primary care or hospital attendances other than the antibiotic prescription.
They therefore conducted an assessment and took a verbal history from the father.
The Paramedics described the child as being bright and alert.
They were satisfied that the results of their observations and examination fell within normal ranges.
They were assured that the previously prescribed medication was working as expected due to the absence of a high temperature.
Following assessment and discussion with the father, the child remained at home with her family.
Day 10: 6.15pm
A second 999 call was made for the child who was now in cardiac arrest, following a massive haemorrhage (bleed) from her mouth and nose.
The ambulance service arrived with multiple resources including an advanced paramedic.
Advanced life support was given at the scene and the child was taken to the local emergency department.
However, resuscitation was unsuccessful, and the child was pronounced deceased at 7.15pm.
Post-mortem examination identified a 23mm coin cell battery lodged in the child’s mid oesophagus.
This had resulted in erosion of the wall of the oesophagus and the formation of an oesophageal-arterial fistula (an abnormal connection between the oesophagus and an artery).