Changes promised after Surrey teenager's meningitis death when no ambulance was sent
Ambulance bosses and NHS England set out new rules after 17-year-old Oliver Shelley died
Ambulance chiefs have promised a series of changes after a Surrey teenager died from meningitis when no ambulance was sent to his home.
Oliver Charles Major Shelley was 17 when he died at East Surrey Hospital in Redhill on 22nd July 2024, around seven and a half hours after his parents rushed him there themselves.
His family had called 999 earlier that day, telling the call handler they were worried he had meningitis and describing a non-blanching rash, vomiting and a reduced level of consciousness.
No ambulance was dispatched, and a promised call back did not happen until much later, so his parents took the decision to drive him to hospital themselves.
An inquest concluded in February that Oliver died as a result of complications of overwhelming meningococcal septicaemia.
What the coroner was worried about
Following the inquest, Surrey Assistant Coroner Dr Karen Henderson wrote a Prevention of Future Deaths report raising two main concerns.
The first was a lack of a dedicated sepsis pathway to help call handlers using the NHS Pathways system during 111 and 999 calls.
The report said the call handler began triaging Oliver using the system but was unable to prioritise any of his symptoms, and sought support to ask whether there was a meningitis pathway.
The second concern was around the job title "Emergency Medical Advisor", which the coroner said could mislead the public because those staff generally have no medical or nursing qualifications.
The changes being promised
NHS England's South East Regional Team has been working with South East Coast Ambulance Service, which ran a full investigation into Oliver's death.
The Trust said it had identified learning around how it responds when patients have multiple or unclear symptoms, situations where it can be harder to recognise how serious someone's condition is.
A number of improvements have now been put in place.
Staff have been given clearer rules on escalation, and are now told that when a patient has multiple or unclear symptoms they must involve a clinician earlier rather than trying to manage the call alone.
The Trust said it had removed any ambiguity around seeking clinical support, with staff actively encouraged to get clinical advice promptly.
New technology, called the Intelligent Clinical Queue, has been brought in to help identify higher-risk patients and prioritise them for clinical review.
Training and support have also been strengthened to help staff recognise when concerns should be escalated, and to build a culture where raising concerns is encouraged.
In its investigation, the ambulance service acknowledged the call handler's management of the 999 call was not compliant and has offered ongoing training.
The NHS England response
In its official response, NHS England's National Medical Director expressed deep condolences to Oliver's family and said the concerns had been listened to and reflected upon.
NHS England said that rather than one single sepsis algorithm, a sepsis screen is embedded across a wide range of symptom-based pathways.
It said that had the call handler selected any of Oliver's declared symptoms as the main problem, the system would have led to questions about a non-blanching rash and resulted in a Category 2 ambulance being dispatched.
On the job title concern, NHS England said the term "Health Advisor" is set by the NHS 111 service specification, while 999 services can choose their own titles locally, such as "Emergency Medical Advisor".
It added that whatever the title, staff using the system work within a structured clinical support system with access to clinical supervision available at all times.
NHS England said all such reports are now discussed by a Regulation 28 Working Group so learning can be shared across the NHS nationally and regionally.