A coroner has warned NHS England and NHS Digital that more children could die unless they take action following the death of a six-year-old boy.

Sebastian Hibberd died after a catalogue of errors in which ‘numerous opportunities’ to save him were missed, an inquest previously heard.

Now Senior Coroner Ian Arrow has written a report demanding NHS England and NHS Digital carry out a review of their procedures to prevent further avoidable tragedies.

When Sebastian fell ill in October 2015 his family made repeated calls to NHS 111 and his GP for help, but the GP failed to return the call at all and the call handlers failed to spot the warning signs for intussusception – when one part of the bowel telescopes into the next.

Calls to the NHS 111 helpline reported he had been throwing up green vomit, had cold hands and feet, had tummy pain and was confused and delirious – all signs of a child having the condition.

Sebastian suffered a cardiac arrest at home whilst waiting for medical treatment and died around 20 minutes after he arrived at Derriford Hospital in Plymouth on October 12, 2015.

In the Prevention of Future Deaths Report Mr Arrow said:

“During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken.

“Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child.”

He said that in particular there were inadequate Pathways questions for children over five about two of the symptoms for intussusception and a seriously ill child – cold hands and feet and green vomit. In addition he said that the Pathways questions do not allow a meaningful assessment of how much pain a child is in and there is a need to review the support for 111 handlers, who are not clinically trained, when dealing with unusual cases.

The Senior Coroner asked that NHS England review the need for a failsafe mechanism to ensure that when there are repeated calls over a child, an assessment is made about if there should be a face-to-face meeting with a doctor.

The coroner concluded: “In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action by reviewing the present systems and protocols in place to assist in particular parents seeking assistance for ill children.”

NHS England and NHS Digital now has until mid August to respond.

Sebastian’s mother and father Nataliya and Russell, from Plymouth, Devon, said they were pleased with the coroner’s recommendations.

In a statement they said:

“While nothing will bring our wonderful little boy back, this Prevention of Future Deaths Report is everything we have been asking for and we hope it will prevent any other family having to live through the nightmare that we have. For three long years we have been fighting for change, reading NHS reports and documents in pursuit of the truth, and we are extremely grateful to the coroner for agreeing to our request for an inquest and listening to our concerns.

“We would like to thank our legal team of Dawn Treloar and James Robottom as we would not have been able to have done this without them. We remain heartbroken that our little boy’s life has been taken from him, but we hope this report will prevent the tragic death of a precious son and brother.”

James Robottom was instructed by Dawn Treloar of Hodge Jones & Allen for the family.

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