A heartbreaking inquest has concluded that a three-year-old boy, Theo Tuikubulau, died from sepsis after several missed opportunities for timely hospital intervention.
Theo was first admitted to Derriford Hospital in Plymouth on the afternoon of July 6, 2022, after showing signs of flu-like symptoms including a high fever, difficulty breathing, and refusal to eat or drink. Doctors initially diagnosed him with an upper respiratory tract infection and discharged him just hours later.
However, over the next day and a half, Theo’s condition rapidly deteriorated. His mother, Kayleigh Kenneford, believed it was part of the recovery process, having been told that symptoms could worsen before improving.
“I remembered that the doctor had said Theo might get worse before he got better, so I was thinking his body was just fighting off the infection,” she told the inquest. “But really, he was dying — and I didn’t realize.”
In the early hours following his discharge, Ms. Kenneford called the 72-hour open-access line listed in his hospital discharge letter but felt dismissed by the nurse on the other end. Alarmed by her son’s worsening state, she made a series of urgent calls to NHS 111.
Emergency services finally arrived at the family’s home just before 12:30 p.m. — over 90 minutes after her initial 111 call. Theo was transported to hospital and arrived shortly after 1 a.m. Despite emergency treatment, he went into cardiac arrest at 1:35 a.m. and died soon after.
A post-mortem examination revealed that Theo had died of sepsis caused by an aggressive Strep A infection.
The inquest jury determined that there were three key missed opportunities that could have altered the outcome:
The first call to the hospital’s 72-hour open-access line following discharge.
Discrepancies in emergency response categorization between NHS 111 and 999 services.
Delays in ambulance dispatch, resulting in a slower response time.
Crucially, the jury heard that before Theo’s initial hospital visit, the South West Ambulance Service Trust had categorized his symptoms as a Category 1 emergency — indicating an immediately life-threatening situation. However, during Ms. Kenneford’s later call to NHS 111, the case was downgraded to Category 2 by Herts Urgent Care, a different service provider. This categorization led to a slower ambulance dispatch.
Jon Knight, head of emergency operations for the South West Ambulance Service Trust, explained that had the call been routed through his service, it would have again been marked as Category 1, resulting in a quicker response. “It certainly would have been quicker than 90 minutes,” he said.
The inquest concluded that if the ambulance had arrived in line with national response targets, Theo might have reached the hospital by midnight — potentially giving doctors a critical window to save his life.
Theo’s tragic death highlights a growing concern about inconsistencies in emergency medical triage systems and communication between healthcare providers. The findings from the inquest have sparked renewed calls for greater coordination between 111 and 999 services and improved follow-up procedures for recently discharged pediatric patients.