A BABY died after a nurse on her first shift for the 111 out-of-hours medical advice line failed to recognise he had a serious infection.
Amy Chapman was five minutes from the end of her night shift when Daniel Randle phoned about his poorly son, Sebastian, aged 11 weeks.
Mr Randle said Sebastian was "floppy", had a fever and a serious cough.
Ms Chapman advised him to keep the baby cool and look for any signs his condition was deteriorating.
Seven hours later, a worried Mr Randle and his wife Helen, from Oakwood, alarmed at Sebastian's condition, dialled 999 and the youngster was taken to the Royal Derby Hospital.
Doctors desperately fought to save him but he died at 7.40am.
A post-mortem examination found he had suffered blood poisoning which had caused his organs to fail.
In the inquest, the nurse admitted that, if she had realised the severity of the symptoms, she would have called in an out-of-hours GP to examine Sebastian.
Assistant coroner Louise Pinder said Ms Chapman had failed to recognise three "red flag" symptoms – temperature, the age of the patient and his limpness.
Miss Pinder said she "falsely reassured" the parents and did not tell them to call back.
She said: "Seb's condition significantly deteriorated during the night."
Miss Pinder said "a defect in the system utilised by the out of hours advice service" contributed to the failure to recognise Sebastian's symptoms.
But she said that although the baby's condition therefore went untreated following the out-of-hours call, "it would not, on a balance of probabilities, have altered the outcome".
Following the inquest, the head of Derbyshire Health United, which runs the 111 service in the county, said "clearly there was a failing in the quality of care that Sebastian received for which we deeply apologise".
Ms Chapman told the hearing she had been a nurse since 2006 and had been at Derby since 2012.
The night she handled the call from Mr Randall was her first as a fully-trained and independent caller. It arrived five minutes before her shift was due to finish. She received the call from a handler and was told Sebastian was a baby "with a cough".
Ms Chapman said: "There was quite a few calls before Daniel's. I had done two weeks with someone but this was my first shift on my own and I started at 6pm."
She said the call centre is in Derby where they work in pods of eight, with nurse advisers and shift managers.
Mr Randle finished the 111 call at 11.01pm. The following morning a call to the ambulance service was made at 6.18am.
Doctor Richard Bowker, from Derby Children's Hospital, which is part of the Royal Derby Hospital, said Sebastian arrived at the hospital at 7am on September 10, 2013.
He said: "At 7.01am he was not breathing, he was very pale and did have a pulse but it was very fast. His blood pressure was very low.
"At 7.06am his heart stopped beating for the first time.
"There is no doubt the chances of survival are significantly reduced during that time frame. But, the chances were quite low at 11pm before.
"Seb was not given the best chance of survival.
"This is not a common disease but it is devastating."
In her summing-up, Miss Pinder said: "The cough pattern was incorrectly chosen by the call adviser and the nurse adviser.
"The nurse had failed to notice three red flags, temperature, age and limpness.
"There was a failure to recognise the significance of these symptoms as a result of a defect in the system utilised by the out-of-hours advice service and a failure by the nurse adviser to recognise that the pathway disposition was incorrect."
Stephen Bateman, interim chief executive of Derbyshire Health United, said: "The tragic death of Sebastian has deeply affected us all. Our thoughts and deepest sympathies are with his family at this very difficult time.
"Derbyshire Health United is committed to the highest standards of patient care and clearly there was a failing in the quality of care that Sebastian received for which we deeply apologise.
"The health and safety of our patients continues to be our utmost priority and an exhaustive investigation and swift action was undertaken following Sebastian's death.
"We wish to assure all of our patients that the service is safe and every effort has been taken to ensure that this unfortunate event would never happen again."
In the 111 system, trained advisers who answer the phones offer basic health advice and direct the caller to the most appropriate service for their needs – A&E or GP out-of-hours services, for example.
A spokesperson from the Health and Social Care Information Centre said it is "deeply saddened by the tragic loss of this young life".
She said extensive safety checks of 111 guidance – known as NHS Pathways – are carried out.
"Immediate action was taken within four hours to provide all call handlers using NHS Pathways with an interim solution and a complete review of the system was also instigated."
