Overview

• The inquest jury at County Hall in Exeter returned a narrative conclusion pinpointing three missed opportunities in Theo’s emergency care and is considering formal prevention recommendations.
• Evidence showed that NHS 111’s Pathway tool graded Theo’s breathing difficulties as a category two call on July 7, 2022, leading to a 90-minute ambulance wait.
• South West Ambulance Service Trust witnesses said the Advanced Medical Priority Dispatch System used for 999 calls would have classified Theo as category one, enabling a response in 30 to 33 minutes.
• Professor Damian Roland testified that an earlier hospital readmission could have delayed Theo’s cardiac arrest and possibly altered his outcome.
• The ongoing hearing is probing gaps between NHS 111 and 999 triage protocols and shortcomings in post-discharge monitoring that may have contributed to the fatal delay.