Sophie Holman
29 Jan 2019 · Coroner Shirley Radcliffe · London (East)
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of long-term asthma management
“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”
2. absence of coordinated record
“No coordinated record of these occasions”
3. missing personal asthma action plan
“No evidence of provision of a written personal acute asthma self- management plan recommended in the UK BTS/SIGN asthma guidelines”
4. lack of agreed asthma protocol
“No clear agreed practice protocol for managing asthma”
5. excess salbutamol prescribing
“failure to recognise the risks of future poor outcome such as a. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice”
6. misjudging severity of asthma attacks
“Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines”
Linked reports
Identical hazardConfidence 0.92 · high
Earlier report
“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.”
This report
“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”
Identical hazardConfidence 0.96 · high
Earlier report
“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.”
This report
“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”
Responses
2019-0035-Response-by-NHS-England.pdf ↗· NHS England
Stated action · 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”