The death of a one-month-old baby may have been prevented if the NHS 111 algorithm had been more effective, according to a coroner.
Oscar Keenan, from Brill in Buckinghamshire, died in hospital after getting sepsis on 26 June 2024.
Judith Leach, assistant area coroner of Oxfordshire, said the 111 algorithm used by call handlers did not properly assess his altered breathing and sepsis.
The chief executive of the NHS South Central Ambulance Service (SCAS) apologised and said that following the call by Oscar's parents an ambulance should have been sent.
Problems 'widespread'
Ms Leach has published a prevention of future deaths report in which she raised concerns about the apparent failings of the present 111 algorithm in assessing ill newborns.
She said in particular it did not identify significant respiratory problems that required early clinical assessment.
"I have concerns that this is widespread and could occur in other areas," she said.
Oscar was born on 27 May with a naturally occurring e-coli infection for which he was treated with antibiotics.
After being discharged home the inquest heard the antibiotics should have restarted but this did not happen.
On 26 June, Oscar's condition deteriorated rapidly and a call was made to 111.
Ms Leach said the call handlers who use the algorithms are non-clinical and cannot identify a more urgent situation by asking the right questions.
A doctor was asked to call back who then told the parents to take Oscar to the nearest emergency department - John Radcliffe Hospital, Oxford.
Oscar died in hospital the same day.
'Missed opportunities'
In their response to the coroner, the chief executive of SCAS said it was disappointing the Trust was not invited to take part in the inquest.
They acknowledged that following an audit of the call "it was identified that there were missed opportunities" for a better outcome.
They said the trust was a user of the NHS Pathways system, and as a result it was not able to alter the algorithms contained within it, as only NHS England could do that.
However, in order to help call handlers assess breathing difficulties over the phone a bespoke package had now been developed.
In this, staff select a sound recording to play which demonstrates a type of breathing pattern and they then have to confirm which type of breathing they have heard.
The chief executive said they were satisfied these measures would mitigate against a similar situation to Oscar's from happening again.
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