Lack of coordinated chronic asthma management
NHS England received 3 coroners' reports about this hazard between 29 Oct 2015 and 29 Jan 2019.
They came from 2 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event”
Original on judiciary.uk ↗ No published response from NHS England was found for this report.
- 1 year 5 months laterIdentical hazardConfidence 0.92 · higha different coroner
“The care management and treatment of this child during his final year of life with an exacerbations of asthma was centred solely on treating the immediate presentation as an isolated acute event”
Original on judiciary.uk ↗ Repeated from the earlier report:caremanagementtreatmentchildasthmacentred
NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“In 2014 NHS England set up National Paediatric Asthma Collaborative (NPAC)', partly in response to NRAD, to bring together a wide range of clinicians, commissioners and voluntary sector organisations to work together on improving care and support for children with asthma.”
Stated timescale: 2014
Web search (Tavily): No evidence found either way
Here's how to improve paediatric care for asthma | TheHealthSite.com ↗“We have produced a quality standard on asthma that covers diagnosing and managing asthma in adults and children (aged 12 months and over).”
- 1 year 10 months laterIdentical hazardConfidence 0.96 · high
“The medical management of this child's asthma attacks on the innumerable occasions she presented to her general practice and hospital was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family”
Original on judiciary.uk ↗ Repeated from the earlier report:managementasthmacentredsolelytreatingimmediate
NHS England responded, stating 1 specific action.Response (PDF) ↗
“we will include a review of national asthma policy and existing clinical guidelines, including the 2014 NRAD (National Review of Asthma Deaths) report', in order to determine appropriate actions to be taken on both a national and local level to establish better consistency”
Stated timescale: April 2019
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2017Michael Uriely1 year 5 months after Tamara Mills · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports criticize that asthma care focused only on stabilizing each acute attack without a coordinated long‑term management plan. They highlight the absence of records, analysis, and a designated clinician responsible for ongoing care.
Tamara Mills · 29 Oct 2015
“The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event”
Original on judiciary.uk ↗ Michael Uriely · 22 Mar 2017
“The care management and treatment of this child during his final year of life with an exacerbations of asthma was centred solely on treating the immediate presentation as an isolated acute event”
Original on judiciary.uk ↗ 2017 → 2019Sophie Holman1 year 10 months after Michael Uriely · same coronerIdentical hazardConfidence 0.96 · high
Identical hazardConfidence 0.96 · highBoth reports highlight that the child's asthma care focused exclusively on treating each acute attack as an isolated event, without addressing the underlying chronic condition or implementing long‑term management plans.
Michael Uriely · 22 Mar 2017
“The care management and treatment of this child during his final year of life with an exacerbations of asthma was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning him to the care of his family.”
Original on judiciary.uk ↗ Sophie Holman · 29 Jan 2019
“The medical management of this child's asthma attacks on the innumerable occasions she presented to her general practice and hospital was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“In 2014 NHS England set up National Paediatric Asthma Collaborative (NPAC)', partly in response to NRAD, to bring together a wide range of clinicians, commissioners and voluntary sector organisations to work together on improving care and support for children with asthma.”
2015 → 2019Sophie Holman3 years 3 months after Tamara Mills · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight that the child's asthma care focused only on stabilizing acute attacks without any coordinated long‑term management plan.
Tamara Mills · 29 Oct 2015
“The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.”
Original on judiciary.uk ↗ Sophie Holman · 29 Jan 2019
“The medical management of this child's asthma attacks on the innumerable occasions she presented to her general practice and hospital was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family”
Original on judiciary.uk ↗
No published response from NHS England was found for this report.
Stated action · timescale: 2014
“In 2014 NHS England set up National Paediatric Asthma Collaborative (NPAC)', partly in response to NRAD, to bring together a wide range of clinicians, commissioners and voluntary sector organisations to work together on improving care and support for children with asthma.”
What happened next: No evidence found either way
The NHS England National Paediatric Asthma Collaborative was launched in 2014 as part of efforts to improve asthma care for children.
“The study demonstrated the effectiveness of asking these key questions. The study improved the frequency of asking the questions from 40 to 98 percent and increased the accuracy of the medications prescribed up to 80 percent in one year.”
No evidence found does not mean the action did not happen.
Stated action
“We have produced a quality standard on asthma that covers diagnosing and managing asthma in adults and children (aged 12 months and over).”
Stated action · timescale: April 2019
“we will include a review of national asthma policy and existing clinical guidelines, including the 2014 NRAD (National Review of Asthma Deaths) report', in order to determine appropriate actions to be taken on both a national and local level to establish better consistency”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2017 | 0.91 | 0.74 | Identical · 0.92 | different |
| 2017 → 2019 | 0.86 | 0.70 | Identical · 0.96 | same |
| 2015 → 2019 | 0.93 | 0.69 | Identical · 0.92 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.