A recent case has again highlighted concerns about the appropriateness of health advice given over the telephone. NHS24, the Scottish equivalent of NHS Direct, was criticised in October 2007 following a fatal accident inquiry into the death of Kyle Brown. The Edinburgh Sheriff concluded that the toddler’s death might have been avoided if appropriate advice had been given.

Kyle Brown’s mother telephoned the helpline in the early hours of the morning after noticing he was unwell and had developed a rash. She waited 40 minutes for an adviser to call her back. After his symptoms were described, Kyle was made a ‘priority 2 case’, and therefore it was not thought that he required an ambulance. A taxi was arranged to take him and his mother to the out-of-hours GP centre. Doctors here transferred him to the Royal Hospital for Sick Children but he died the following day.

The key finding were that:

		The call handling system only allowed symptoms to be considered individually rather than collectively (which would ensure decisions were based on a full picture and might allow a patient to be promoted to a more serious category).
		The nurse advisor who arranged the taxi had not had full training to recognise meningitis.
		Team leaders were needed to ensure calls were prioritised properly. The evidence suggested Kyle was accidentally given lower priority than intended.

The Sheriff did go on to find that even had Kyle been properly prioritised, and transferred to the right hospital by ambulance, he was unlikely to survive.

NHS24 made various improvements to their systems and practice after the incident.

We have noticed a growth of similar claims and anticipate that this will continue, given the increasing use of this type of service. If you provide or are responsible for similar telephone services, what standard of care is expected and what lessons can be learned from these cases?

Department of Health Guidance

The Department of Health issued guidance in 2004 on quality requirements in the delivery of out of hours’ services, which was updated in 2006. These are the key requirements for telephone advice:

1. There must be a system to identify all immediate life threatening conditions and such calls must be passed to the ambulance service within 3 minutes – we think it sensible to presume this means that even administrative staff who take initial calls have enough training to make this judgment call.

2. There must be a clinically safe and effective system for prioritising calls:

		For urgent calls, definitive clinical assessment must be started within 20 minutes of the first call being answered (i.e., an appropriately trained healthcare professional must call back within 20 minutes when a decision will be made whether to simply offer reassurance or advise a face-to-face consultation)
		For all other calls, the time limit is 60 minutes.
		If the system cannot distinguish between urgent and non-urgent calls, the blanket time-limit is 20 minutes.

3. At the end of an assessment, patients must understand clearly the outcome and where appropriate, the timescale and logistics for further action – a particular concern here is that any apparent language difficulties must have been overcome.

One particular newspaper’s report of the Kyle Brown inquiry listed other incidents which it claimed had shaken public confidence in NHS24. It is understandable that most patients would prefer to see a healthcare adviser face-to-face, whatever the time or place. The cost of the public’s ideal service would be great; telephone advice is a vital and cost-effective replacement at certain times. To minimise the risk of the public’s faith being ‘shaken’, the Government’s 2006 guidance should be reviewed and implemented at all times.