Blue lips and black skin: Did a standard 111 question help cause Olufemi Akinnola’s death from Covid-19?

Curled up in the foetal position in the passenger seat of his ex-girlfriend’s car, weeping uncontrollably, Lobby Akinnola didn’t want the journey to ever end, but he also wanted to get there – now. What was waiting for him at the end of the two-hour drive from Lobby’s London flatshare to his family home in Leamington Spa was unimaginably harrowing: his beloved dad, Olufemi Akinnola, lying dead on the living room floor. Lobby’s mum, Atinuke, had found him that morning, 26 April. The family had thought he was recovering from Covid-19, but they had been wrong. The paramedics had come, but there was nothing they could do, and now the family was waiting with Femi for Lobby to arrive from London, before they called the funeral home. Lobby was scared to go, but he had to be there. He needed to say goodbye to his dad.

***

When Covid-19 began to spread across the world, Olufemi (known to all as Femi) and Atinuke (AKA Tinu) talked about it. Tinu, 60, who is a pharmacist, was alarmed by the government’s failure to close our international border, after the World Health Organization declared Covid-19 a pandemic on 12 March. “I said: ‘Can you believe it?’” Tinu remembers. “Flights are still going as normal!’” They prayed together for the people affected.

It was a loving partnership. “We had just come through 31 years of marriage,” says Tinu, “and we were finding each other again, talking to each other, loving each other’s company.” They have five children – Lobby, 29, Kitty, 28, Tugbi, 26, Dara, 20, and Bowo, 17. With the children grown up, Femi and Tinu were looking forward to having some time for themselves. They planned to go to Paris for Femi’s 61st birthday in May. “We’d joke with each other,” says Tinu, “that we’d escape to Paris for three days, and if everything was OK, we’d start taking longer holidays. Because we could rest now. The kids were OK.”

They met in Nigeria in 1984, on the youth service programme the Nigerian government requires all university students to complete after graduation. Both were posted to the state of Borno, in the north-east of the country, which is where Tinu met Femi in the youth service headquarters. “He was rejecting a posting,” she remembers. “I thought: ‘What a spoiled young man! Just take your posting and go.’”

Over the course of their year-long youth service postings – Tinu worked as a community pharmacist, Femi worked in a government ministry – they became friends. In 1987, as Tinu was finishing her master’s at the University of Ife, Femi came looking for her. “The falling in love was gradual,” she remembers. “It got to a point where we wanted to see each other every day.” Both had started working, and they’d eat lunch together, before Femi walked her home. Slowly, they knitted together their lives.

Femi was playful, kind and good-looking, always dressed casually in jeans and a T-shirt, with Adidas trainers. “He was easy to get along with,” Tinu says. “He said he thought that I was the most beautiful girl ever … I knew that he wasn’t making it up, that he was being sincere.” He nicknamed her Tiny. “‘Tiny, love of my life!’” says Tinu, mimicking Femi. “He never called me by my name.”

Femi was patient with Tinu; he was her biggest champion. “He was my encourager,” Tinu says. “He always had so much faith in me.” If Tinu had to drive somewhere she hadn’t been before – she is a nervous driver – Femi would show her the route the day before. If Tinu was working late, he’d wait up for her, so they could have dinner together. “I used to beg him to eat,” she says. “He’d say: ‘No, I will eat with my wife.’”

They married in 1989, and Lobby, Kitty and Tugbi followed. It was a secure, prosperous life, but Tinu was unfulfilled by her work as a drug inspector at a port, where she would test incoming pharmaceutical shipments to look for fake or substandard products. “It was a good job,” she explains, “but it was not what I had trained to do.” In 1997, the family moved to the UK – Tinu came first, with the kids. In 1999, Femi’s spousal visa came through, and he was able to join the family. Dara and Bowo followed afterwards.

Femi loved to play pranks on his children, once taking them on a trip to Leamington Spa city centre, where a public fountain stands beside the Victorian bath houses. “Dad told us the water was like magic and we should try it because it was really good,” Lobby remembers. They drank the water, only to discover that it was rank. Grimacing in disgust, they turned around to find Femi convulsing in laughter.

A keen gardener – he had an allotment – Femi came up with an innovative solution to making the most of a glut of cabbages one summer. “He started making sauerkraut,” says Lobby. “He converted the living room into a fermentation factory. But then one of the jars burst, so the place stank of vinegar and cabbage.” Femi apologised, but didn’t stop the sauerkraut production.

If Femi had a fault, says Tinu, it was that he loved to procrastinate. “He wasn’t in a hurry to do anything.” She bought some pictures four years ago and asked Femi to hang them for her. He never did. “It was on his to-do list when he died,” Tinu says. “Put up Tiny’s pictures.”

He worked part-time, as a support worker for the charity Mencap. The job appealed to his disposition, which was naturally caring. Femi befriended his clients, even going to visit them in hospital on his days off. Although he was intelligent and well-educated, he was not hugely ambitious, preferring to dedicate himself to his family, into which he poured all of his love and energy.

“Kitty and Tugbi had a conversation before Dad passed away about what it means to be an Akinnola,” says Lobby, a scientist. “And the conclusion they came to was that it was Dad. He was our cornerstone; our foundation. He was that person who was always there, always supporting us and loving us and encouraging us.”

Femi was the drummer in the Akinnola band: the unshowy presence who kept their disparate personalities in sync. “He was the leader from the back,” Lobby says. “We relied on him. Because he was always there.”

***

When the 111 phone service was officially launched in 2013, ministers trumpeted it as an efficient replacement for NHS Direct, its creaking predecessor. “Patients can reach the whole of the NHS through just one simple number … Patient safety is a key priority,” said the then health minister, Simon Burns.

Handlers of 111 calls are required to have only 10 weeks of training. The operation of 111 services is contracted out to private providers, including Care UK and Babylon Health, and the service is operated on a decentralised, regional basis. (NHS Direct was operated nationally.)

When the scale of the pandemic became clear in March, the message from the government was unequivocal: hospital admissions should be restricted to the most urgent cases. “The official advice is clear,” said the health and social care secretary, Matt Hancock, in the House of Commons on 11 March. “People should go to NHS 111 online, or call NHS 111 if you think you have symptoms of coronavirus.” Members of the public were urged not to go to their GPs.

In a letter to English hospital trusts on 17 March, the NHS chief executive, Sir Simon Stevens, urged them to postpone all non-urgent elective operations as quickly as possible, and discharge all inpatients who were medically fit to leave hospital. (The second request contributed to the crisis in care homes, as people were discharged without being tested for Covid-19.)

The 111 service was to be the government’s sandbag defence in the oncoming storm. (In its haste to redirect citizens to the 111 service, the government forgot that 111 did not cover north Wales.) Extra staff were hired to accommodate the expected surge in calls, with the government outsourcing contracts to the private sector. Earlier this week, the Guardian revealed that private contractors including Serco, Sitel, Teleperformance and Vocare had been commissioned to provide a “Coronavirus Response Service” on behalf of NHS 111. In the rush to get this service operational, some providers were initially unable to record calls.

At the start of the pandemic, there were 2,500 NHS 111 call handlers in the UK; in March the government added an extra 700, to service a population of 66.5 million people during a pandemic.

It wasn’t enough: 111 was swamped. By March, calls were running at more than double the volume of the equivalent period the previous year; 38.7% of calls to the service were being abandoned by callers who grew tired of waiting to speak to a call handler. (The figure for March 2019 was 2.4%.) Callers to 111 reported waiting hours, or even days, for clinicians to respond to their calls. On 26 March, Garrett Emmerson, the chief executive of the London ambulance service, begged the public to call 999 only for life-threatening emergencies, and to call 111 “if your concerns can’t be answered online”.

As callers tried and failed to get through to 111 – and were deterred from visiting their GPs’ surgeries, or going to A&E – horrifying stories began to emerge in the media. On 13 March, a London-based barista, Davide Saporito, 28, died of malaria contracted on a holiday to Zanzibar before the travel restrictions were implemented. Saporito contacted 111 six times before his death, waiting on hold for up to an hour and 48 minutes, as the service dealt with unprecedented demand. On 7 April, a nurse, Donald Suelto, 51, was found dead at his London home. His niece Emlyene Suelto-Robertson, 38, told the Metro newspaper that he had tried to dial 111 repeatedly, but had been unable to get through, as the lines were too busy. Suelto, who had asthma, died of Covid-19.

The government did rather too good a job of encouraging the public to stay away from hospitals. There was a 50% drop in the number of people seeking medical help for suspected heart attacks in March, while A&E visits were down 29% in the same period. On 22 April, Hancock rowed back on the government’s advice to avoid hospitals and GPs. “I want to reinforce the message that non-Covid NHS services are open for patients,” he said. “The NHS is there for you if you need advice and treatment.”

It was amid this chaos – the overloaded 111 switchboard, ministers urging the public not to go to hospital, not to go to their GPs, the ambulance bosses begging people to stay at home – that Femi first called 111.

***

Femi was not the sort of man who tried to avoid going to the GP. “My dad was not that person,” Lobby explains. “If something was wrong, he would go to the doctor.” And Femi took Covid seriously, right from the start. On 22 March, he sent Lobby the link to a Guardian article warning people to stay at home to reduce the spread of Covid-19. “This thing is serious,” he wrote. “Can we all do our best to stay safe?”

Femi and Tinu fell ill at virtually the same time: on about 8 April. Tinu had continued working during the pandemic, so she cancelled her shifts, and the couple self-isolated in separate rooms: Tinu took the bedroom and Femi shut himself in the living room. Because Femi knew that Covid-19 was transmitted through respiratory droplets, he barely spoke when his children entered the living room for fear of infecting them. For the next week, Tinu and Femi lay in a Covid-induced fugue state in separate rooms, communicating through their children or via text.

“I had no stamina,” Tinu remembers. “I hallucinated like crazy. Night and day were the same. I slept all the time. My brain was fuzz.” During this period, Femi’s family say he called 111 three times.

The first call he made was to check his symptoms, when he fell ill. Then, when he wasn’t recovering, he phoned again to ask if he should go to hospital. This second call was on about 16 or 17 April, by which time Femi had been sick for nearly nine days. He was not eating, was barely drinking and had lost a lot of weight. “I asked him what they’d said,” says Kitty, a civil servant from London, who was looking after her father at the time, “and he said that 111 had told him to stay at home and rest.”

We now know that if a patient does not appear to be recovering from Covid-19 for over a week, and is still running a high fever, they should seek medical help immediately: they are entering the most dangerous phase of the virus, and swift treatment can significantly improve their chances of survival. But Femi was told to stay at home, even as his body became emaciated and weak. “Someone’s been ill for nearly two weeks,” says Kitty. “They haven’t eaten, they’ve lost so much weight, they haven’t left the room, and they’re calling for medical advice – that doesn’t sound to me like someone who’s doing OK.”

As Femi lay in the living room, his appetite nonexistent, his brain was becoming starved of oxygen. His organs were beginning to shut down. His heart would have been working overtime to pump blood around his body. “Most of the time,” says Prof Kamlesh Khunti of the University of Leicester, “it’s their heart stopping. If you stop breathing properly, oxygen doesn’t get to your heart, and your heart stops because of that.” A third of people who died of Covid-19 have some sort of cardiac problem; others experience issues with their kidneys, or inflammation of the lungs.

On around 24 April, Femi rang 111 again, and was referred to his GP, who prescribed antibiotics over the phone. “I’m a scientist,” says Tinu. “I know that, as a scientist, you observe someone, and come to a conclusion. How can you conclude how a person is doing over the phone?” But Femi trusted his GP, and he was reassured after she spoke to him, telling Tinu that the doctor had said that it was most likely to be a chest infection.

And then, on 25 April, Femi did seem to be improving. He asked for Tinu’s home cooking, and even though she wasn’t feeling so good herself, she made him a pepper stew with beans, because she was so relieved that he was eating again. “We were ecstatic,” says Tinu. Kitty texted Lobby, telling him that Dad was on the mend. “A load came off,” says Lobby. “I thought: ‘It’s all good.’”

Femi had decided to try sleeping upright, at his doctor’s suggestion. He called Tinu to the living room, as she was making her way to bed. “He said: ‘Come and see! I’m sitting upright.’” Tinu told him to call her mobile if he needed anything – she was still sleeping upstairs, in the bedroom. “He said he was fine,” she remembers. “He didn’t need anything.”

She went to bed. At 3.20am, Tinu woke up – she had heard a noise in the house. “I thought Femi was trying to attract my attention,” she remembers. (It was actually Dara, on a video call to his friends.) She texted Femi. “Did you call me?” The message came back immediately: “No.” Reassured, Tinu fell asleep.

***

When Tinu woke up at about 7am on 26 April, she felt happy for the first time in weeks. Femi seemed to be on the mend, and the family was out of their two-week quarantine period, and free to leave the house. There was a lot to be positive about. “I felt so weak,” says Tinu. “But I was happy.”

About 9am, she figured she had let the family sleep long enough, so went downstairs to make Femi a cup of tea. He was sitting in the armchair where she’d left him the night before. His head was thrown back at an uncomfortable angle. “I joked: ‘Don’t sleep like this, my friend,’” Tinu says. “‘What kind of sleeping is this?’” When Femi did not respond, Tinu thought he might be playing one of his pranks, like when he had tricked the children into drinking from the public fountain. “I said: ‘Femi, what kind of joke is this?’” Tinu remembers. “‘Wake up!’” More silence. She screamed.

The children ran downstairs, half-dressed. Tinu called the ambulance. By now, the children had their dad on the floor, and were performing CPR. Femi was still warm. There seemed to be hope. A first responder arrived, and then paramedics. Tinu and the children sat on their stairs to let them work.

“I said,” Tinu remembers, “‘Guys, this is it. We need to pray. We need this man back.’” “Please, God,” she thought, “let Femi wake up. Please, God.” A doctor arrived, checked Femi, then told Tinu and the kids that he was sorry for their loss. Tinu looked at him uncomprehendingly, and then said thank you. She told the doctor and paramedics that she was sorry for making them have a bad day. And then she called Lobby in London.

Lobby was in his bedroom, looking forward to a relaxed Sunday afternoon with his flatmates when the world fell in about his ears. He struggled to make sense of what Tinu was saying – he could hear Kitty laughing in the background. Then he realised his sister wasn’t laughing, but crying. Tinu told Lobby that Femi was gone. “I literally collapsed to the floor screaming,” he says. “I kept saying: ‘I can’t do this, this can’t be happening, this isn’t real.’” The pain was physical, and immediate – Lobby could feel it in his chest.

On the long drive back to Leamington Spa, Lobby howled in the front seat, alternating between disbelief and horror. When they arrived at the house, the front door swung open. “I remember looking at him,” says Lobby, “and thinking that he was a really handsome man. He had a half-smile on his face. That man did not know how not to be happy.” Looking at his father, Lobby was struck by how gossamer-fine is the boundary between life and death. “I realised my dad wasn’t his body,” Lobby says. “I could see his body, and it was an aspect of my dad, but the essence of him was no longer here.”

Before his dad died, Lobby had thought that death was a door – you walk through it when your time has come. Now he realised that death was the house he’d lived in all along: the walls, the wainscoting, the porch. He’d just never seen it before.

“It was a paradigm shift,” Lobby says. “Everything was OK, and then it suddenly wasn’t OK.”

***

About two weeks after Femi died, Tinu called 111 – she still wasn’t breathing well, and she was scared. “I thought: ‘I cannot afford for us both to go and leave the kids in this mess.’” The operator arranged for someone to call Tinu back, and when she did, the woman appeared to have medical training. She asked Tinu if her lips were blue.

“I said: ‘I am black,’” Tinu recalls. “‘I can’t know if my lips are blue.’” She turned to the children and asked them: do my lips look blue? They couldn’t tell either. The call handler told Tinu not to worry, and asked her to count her breaths instead. She told Tinu that her symptoms seemed mild, and she could stay at home.

The question set off a shockwave within the family. “Did 111 ask him if his lips were blue?” summarises Lobby. “And was that the reason they told him to stay home? I don’t know.”

***

The 111 service’s handling of the pandemic has come under scrutiny. An article published in the British Medical Journal in June criticised the government’s decision to rely upon 111, rather than GPs and local public health officials, who could better track the virus. “The capacity of the NHS 111 Covid-19 call centres and the assessment service should be immediately reintegrated into primary care, and practices resourced to resume care,” wrote the authors.

In June, NHS England updated its guidance to steer patients back towards their GPs. “Patients with symptoms of Covid-19 may make direct contact with practices,” reads the updated guidance. “If patients present directly to general practice, they should be assessed by the practice, rather than redirected to NHS 111, as this poses significant risks to unwell patients.” The updated guidance also suggested remote monitoring of suspected Covid-19 patients’ blood oxygen levels, to check for hypoxia. It may be that Femi suffered from “silent hypoxia”, where patients do not exhibit shortness of breath or difficulty breathing, but have blood oxygen levels that are dangerously low.

Is it possible that Femi wasn’t escalated to urgent care because he wouldn’t have been able to tell if his lips were blue? “It’s difficult to tell,” says Khunti. “If the call handler was well-trained, and you said you were black, they should know not to pay too much attention to that question [of blue lips]. You’d be asking other questions, about breathing, whether the patient was rousable.” Was 111 fit for purpose in those early weeks of the pandemic? “111 has been battered,” says Khunti, “like everyone else. They have to go through a protocol. I don’t know what their training is like. Is it hit-and-miss? Overall, they have been inundated with calls.”

To a certain extent, the government’s strategy worked: hospitals weren’t overwhelmed. Just 51 patients were treated at the Nightingale hospital, a 4,000 bed facility constructed over nine days in the Docklands of London. Similar facilities in Birmingham and Harrogate didn’t treat a single patient. The expected pressure on intensive care units never materialised. At the Downing Street press conference on 12 April, Hancock was self-congratulatory. “At the start of this crisis,” he said, “people said that the NHS would be overwhelmed, and we’ve seen that, and we’ve seen the risk of that elsewhere, but not here.” But this strategy of deterring Covid patients from visiting hospitals and their GPs was a blunt instrument.

“I don’t blame the 111 operators or the 111 system,” says Lobby. “It was established to alleviate the burden on the NHS, and that was its role. The issue I have is that it’s not fit for purpose. You don’t do surgery with a hammer – you use a scalpel. The problem was that 111 had a mandate, which was: don’t overload the NHS. It feels like, any reason not to admit someone to hospital, it took it. Unless you were on the brink of death, they wouldn’t tell you to see a doctor.”

NHS England says: “GPs, nurses, paramedics and other health service staff working in the 111 phone and online service have played a key role in helping millions of people get the right care and advice – whether for coronavirus or any other urgent medical needs.”

Lobby believes that his father would still be alive today were it not for the guidance he received from 111 and his GP, and he wonders whether, if his dad had been white, and his lips had turned visibly blue, he would have received the same advice . “It’s hard not to think that if my dad had gone to hospital, he would still be here. It’s tough not to feel let down,” Lobby says.

Tempering the anger, and the grief, is guilt. “I can’t forgive myself,” says Tinu. “Because there were things that worried me. The doctor said I shouldn’t worry; 111 said I shouldn’t worry. But I should have worried.” Kitty feels the same way. “The overwhelming guilt we feel is never going to go away,” she says. “Because he died at home, not in hospital. You will for ever feel like you let you own dad down, and he would never have let any of us down. You feel like you failed him.”

The UK has the highest excess death rate in Europe: at the time of writing, 41,788 people have died of Covid-19 in the UK. They were beloved mothers, brothers, fathers, friends. Their families have questions. “When you have a strong sense that your loved one’s death could have been preventable, you need to know what actually happened, and why,” says Jo Goodman of the Covid Bereaved Families for Justice campaign group, which is campaigning for a public inquiry into the government’s handling of the pandemic. “We’re doing this for the other families who could be bereaved in the future. We need to make sure these lessons are learned.”

Goodman’s father, Stuart, died of Covid-19, aged 72. The group has written to Boris Johnson five times, asking for a meeting. After initially pledging to meet the group when asked on Sky News, Johnson backtracked. He has not met any families of those bereaved by Covid-19. “It feels as though Johnson thinks that if he doesn’t engage with us,” says Goodman, “he can just sweep the fact that we have the highest death toll in Europe under the carpet.” The group believes that as many as a fifth of its members – 350 people – struggled to access appropriate care during the pandemic as a result of the directive to contact 111.

Femi was buried on 14 May in the clothes he died in: jeans and a T-shirt. The funeral home was not allowed to dress him, because of the Covid-19 restrictions. It was a fitting end for a casual man. “I had a good laugh about that,” says Tinu. “Imagine going to heaven in jeans and a T-shirt!”

For now, the Akinnola family are struggling to adapt to life without the drummer in their band. “We all turned to him for the big and the small of walking through this life,” says Lobby. “I just thought I would have his guidance for a little longer.”