'Sharing of NHS information could have saved our son'

The parents of a young man who died because his condition was not accurately diagnosed are calling for changes to prevent further deaths.

Reading University student Cian Everett, 21, from New Milton in the New Forest, had a rare abscess on his brain that led to meningitis but was repeatedly told he just had sinusitis.

Despite calls to NHS 111 and visits to Lymington Urgent Treatment Centre, opportunities to take Cian's health more seriously did not happen and he died at home in January 2025.

South Central Ambulance Service (SCAS) said an error was made when referring the call. The centre said it was reviewing complaints.

Cian described a sudden and severe headache to the call handler, sometimes described as a "thunderclap headache".

Mum Gillian Everett said: "The response to that call should have led to Cian being to be referred to a main A&E hospital who had imaging facilities and could do blood tests.

"Instead, he was referred to Lymington Urgent Treatment Centre who had specifically excluded themselves from dealing with that type of headache because they don't have the facilities to deal with it."

Gillian said "nobody seemed to be able to diagnose what the actual problem was with him" even though Cian called 111 three times, visited a local pharmacy and went to the treatment centre twice, including 12 hours before he died.

An inquest into his death at Winchester Coroner's Court heard that he was incorrectly referred to the centre for care.

SCAS, which runs the NHS 111 service in Hampshire, said its health advisor "correctly followed and met national standards" but made an error in not advising that Cian use an alternative service to the treatment centre.

It said the call handler had "received feedback and additional support".

"At Lymington Urgent Treatment centre, the opportunity to take his care more seriously was again missed," said SCAS. "He was treated as someone who had walked in to receive care not as an NHS 111 referral. The notes about his condition were not read by the clinician who saw him."

Mum Gillian said "his notes on their system clearly showed the reason for the phone call" with "maybe 15 lines of notes" about his symptoms and the "fact he had a thunderclap headache".

"So if they had looked at those notes they maybe would have asked some different questions, they could have done a three-minute neurological assessment, none of that was carried out at all," she said.

The coroner issued a prevention of future deaths report to PHL Group, which manages Lymington Urgent Treatment Centre on behalf of the NHS.

These are issued when a coroner believes that action to address some of the identified concerns should be taken to prevent future deaths.

Dr Andrew Ross, PHL Group medical director, said he had noted the coroner's findings.

"Patient safety remains our highest priority at PHL Group, and we are carefully reviewing the concerns raised," he said.

"Where improvements are identified, we will act swiftly to implement them and work with partners to reduce future risk."

Clive Everett, Cian's Dad, said: "What we really want people to do is to question, not to assume, that all this stuff is readily available to the doctors.

"Sometimes it's there but, unless you tell them about it, they don't know, so please, when people are going to hospitals or going to their GPs, give them a synopsis of all the information, don't assume they've got it at their fingertips because it's just not the case."

Gillian also highlights a law known as Jess's Rule. It came into effect in September 2025 and says that, "after three interactions with a primary care provider with the same or escalating symptoms, a review is carried out to reflect, review and rethink".

She said: "If this rule had been in place in January 2025, we like to think that Cian's symptoms would have been fully reviewed and further investigations would have been carried out."

Cian's parents have since set up a charity known as the Cian Everett Young Person's Development Foundation to support young people with activities and provide opportunities for their development.

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