Boy, 10, with asthma died due to ‘neglect by healthcare professionals’
A 10-year-old boy with severe asthma died as a result of multiple failings by healthcare professionals amounting to neglect, a coroner has concluded. William Gray, from Southend, died on 29 May 2021 from a cardiac arrest caused by respiratory arrest, resulting from acute and severe asthma[1] that was "chronically very under controlled". His death has led to calls to improve asthma treatment for children nationwide.
The court heard that William's death was a "tragedy foretold" having previously suffered a nearly fatal asthma attack on 27 October, 2020, which he survived. The coroner said that William's death was avoidable, his symptoms were treatable, and he should not have needed to use 16 reliever inhalers over 17 months, but instead his condition should have been treated with preventer medications and should have been controlled. Sonia Hayes, Area Coroner for Essex, said: "William was lost to follow up and this should not have happened." She said that neglect by healthcare professionals contributed to William's death.
In October 2020 William was "as near to death as possible without dying". At this time, he was discharged after just four hours and the severity of the incident was not correctly recorded. The coroner said that he should not have been discharged and there should have been more professional interest and consideration given.
The coroner found that Article 2, William's right to life, was engaged as she found the State did not have an appropriate system in place to protect and safeguard the lives of children with asthma at the time. She heard evidence that NHS[2] England has recognised deficiencies in asthma care for children and, while there is an intention to reduce avoidable harm as a result, it was not in place at the time William died. The litany of failures, amounting to neglect, included William's GP surgery failing to conduct annual asthma reviews, carry out medication reviews, or to recognise an absence of preventer inhalers despite repeated requests for other medication or referral to secondary care.
The lack of proper recording of William's life threatening asthma attack in October 2020 in his medical records, which was a key factor in the lack of understanding that other healthcare professionals relied on after that, was another failing. On the night of William's death, his mum, Christine Hui, made two 999 calls. The coroner said that, at the time of the first call, it is likely that William was having a severe asthma attack, and a category one ambulance should have been dispatched.
She said that, when the paramedics arrived on the scene, adrenaline was not administered and, on the balance of probabilities, this would have affected the outcome in this case. The coroner will be writing three Prevention of Future Deaths reports. They will be sent to: the East of England Ambulance Service about improving training for treating children suffering a life-threatening asthma attack; asthma and allergy services at Essex Partnership University NHS Trust; and the Joint Royal Colleges Ambulance Liaison Committee - to ensure the guidance for paramedics treating children with life threatening asthma nationwide is clear.
Ms Hui, said: "William was a funny, caring little boy who liked to make jokes and had a heart of gold. He was adored by his friends. "He had dreams of working in medicine as a doctor or a paramedic because he saw the care he was given, and he wanted to do that for others.
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"Today is bittersweet because, while the coroner's conclusion gives us some closure, this is the final stage in saying goodbye to our son, brother, grandson, great grandson, nephew and friend.
"We believed that William's asthma was controlled, but now we know that wasn't the case. Parents know their children best and should trust their instincts. "If you feel something isn't right, question it.
There is nothing that can take away the grief our family feels, but it is our hope that another family will hear our story and it could prevent a further tragedy." Julie Struthers, a solicitor at Leigh Day who represented the family, said: "In an inquest involving concerns with medical treatment it is rare for a coroner to find neglect, and even rarer for a coroner to find Article 2, a person's right to life, to be engaged. "This reflects the real tragedy of what happened to William, the substantial number of failures by multiple healthcare professionals in his care, and the importance of improving asthma treatment for children nationwide."
Diane Sarkar, chief nursing and quality officer for Mid and South Essex NHS Foundation Trust, which runs Southend Hospital, said that "our heartfelt condolences go out to William's family". She said: "We'd like to assure them that we are committed to learning from this terrible loss and that since his death in 2021 we have brought in numerous changes to improve patient care as a direct result of learning from William's case." Melissa Dowdeswell, chief of clinical operations at the East of England Ambulance Service, said: "Our heartfelt condolences go out to William's family and our thoughts remain with them at this difficult time.
"We accept the coroner's findings and will assess what further actions need to be taken once we have reviewed them.
"Since this tragic case we have significantly increased the numbers of staff able to perform intubation and these numbers continue to rise with an expansion of advanced paramedics within the trust."