Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Tamara Mills · 29 Oct 2015 · Terence Carney, Gateshead & South Tyneside
“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”
judiciary.uk/prevention-of-future-death-reports/tamara-mills
What was promised
Stated action 1 · response to Michael Uriely (22 Mar 2017) · stated 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.”
Stated action 2 · response to Michael Uriely (22 Mar 2017) · stated timescale: none stated
“We have produced a quality standard on asthma that covers diagnosing and managing asthma in adults and children (aged 12 months and over).”
judiciary.uk/wp-content/uploads/2020/02/Uriely-Response2.pdf
What recurred
- 22 Mar 2017 · Michael Uriely · Shirley Radcliffe · Identical hazard · confidence 0.92 (high)
- 29 Jan 2019 · Sophie Holman · Shirley Radcliffe · Identical hazard · confidence 0.96 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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”
What happened next
No evidence found either way · stated action 1
“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.”
Here's how to improve paediatric care for asthma | TheHealthSite.com · thehealthsite.com/…/heres-how-to-improve-paediatric-care-for-as…
No evidence found does not mean the action did not happen.