Children will die if changes are not made to Essex healthcare, says coroner
They've issued a damning report into the death of 10-year-old Asthma sufferer, William Gray
A damning report aimed at preventing future deaths has blamed several healthcare bodies including the ambulance service for their part in the death of a 10-year-old Essex boy from “neglect” and “multiple failures” to treat his asthma.
Essex Coroner Sonia Hayes had particular concern that William Gray could have been saved if the two paramedics had administered adrenaline before William went into respiratory arrest due to the asthma attack in 2021.
The coroner has warned doctors, ambulance staff and the Government that more deaths like that of William’s will follow if action is not taken.
William had a seven-year history of asthma and met the criteria for specialist referral. But the coroner has deemed his care and treatment “sub-optimal” – his asthma was “poorly controlled in the absence of appropriate assessment and reviews”, she said.
William was ultimately saved from a life-threatening asthma attack on October 27 2020 when he was given chest compressions and intramuscular adrenalin – in accordance with the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) guidelines.
The same two paramedics attended the fatal asthma attack on May 29 2021 but did not administer adrenaline. This has been seized upon by the coroner who says more training may be needed after they missed an opportunity to understand the importance of the administration of adrenalin during a life-threatening asthma attack.
After the incident on October 27, William was conveyed to Southend Hospital where he was discharged home four hours later with no assessment of his recent symptomatology and no change to his medications.
His family contacted the GP service for advice and chased a referral to the asthma and allergy services run by EPUT.
But no changes were made to William’s medication until November 4 2020 when he was prescribed a steroid-preventer inhaler at the request of the asthma nurse and followed up with Southend Hospital.
The GP prescribed four short doses of oral steroids for worsening of his asthma in December 2020, February, April and May 2021.
However, the coroner has said these were insufficient to effectively manage obviously poorly controlled asthma “in a picture of vastly excessive reliever inhaler prescriptions and the absence ongoing of preventer medication”.
The Asthma and Allergy Service only made contact via telephone calls of no more than five minutes. There was no contact after 1 February 2021 until 21 May. Nurses did not speak to William although he was old enough.
On May 21 2021, the asthma nurse did not review or escalate the increased salbutamol inhaler use. The advanced GP nurse practitioner reviewed William’s condition on May 25 2021 at the request of the GP following the final prescription of steroids and confirmed that William’s asthma remained very poorly controlled but failed to escalate concerns.
William suffered what the coroner described as an “inevitable” life-threatening asthma attack on the night of May 29 2021.
An ambulance crew arrived at approximately 12.18am but they could not secure William’s airway when he went into respiratory arrest after missing an opportunity to administer intramuscular adrenalin.
William had had a strong pulse and adrenaline probably would have delayed the subsequent cardiac arrest and possibly saved his life, the coroner said.
William went into cardiac arrest at approximately 12.35am. Intravenous adrenalin was administered at approximately 12.45am when William was in the ambulance and resuscitation continued until the air ambulance met the ambulance en route to hospital.
The air ambulance doctor inserted an endotracheal tube and administered medications. By the time William arrived at hospital he had sustained a fatal brain injury.
The conclusion of an inquest last month found he died of a cardiac arrest secondary to respiratory arrest and acute asthma secondary to chronically very under-controlled asthma.
In a statement as part of a prevention of future deaths report she said: “William Gray died as a consequence of failures by healthcare professionals to recognise the severity and frequency of his asthma symptomatology and the consequential risk to his life that was obvious. William’s death was contributed to by neglect.
“William’s death was avoidable. There were multiple failures to escalate and treat William’s very poorly controlled asthma by healthcare professionals that would and should have saved William’s life.”
Mid and South Essex NHS Foundation Trust, the Association of Ambulance Chief Executives, the East of England Ambulance Service NHS Trust, the Department of Health and Social Care and Essex Partnership University NHS Foundation Trust have been told they must learn from the tragedy.
Ms Hayes has told Mid & South Essex NHS Foundation Trust she is concerned that experienced hospital paediatric doctors all gave evidence at William’s inquest that they were unaware that administration of intramuscular adrenaline by paramedics is part of the Joint Royal Colleges Ambulances Liaison Committee JRCALC protocol for life-threatening asthma.
She was also concerned that the beneficial effects of the administration of adrenalin was not considered.
She has told the Association of Ambulance Chief Executives that clarity is required on what should be categorised as life-threatening asthma.
She added guidance is needed for when to administer intramuscular adrenalin to avoid cardiac arrest given that paramedics are more familiar with the administration of intravenous adrenalin during resuscitation once cardiac arrest has occurred.
She said there is no clear guidance or advice on what to do when crews cannot ventilate, cannot oxygenate, or when to abort repeated unsuccessful attempts to secure an airway and progress to hospital.
She has told the East Of England NHS Ambulance Trust more training may be required after they missed an opportunity to understand the importance of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines.
She was also concerned the Trust issued a Clinical Instruction on 17 September 2020 that paramedics must not insert endotracheal tubes as a safety measure to avoid adverse incidents as there was difficulty in keeping paramedics’ skills up to a level of competency.
Evidence was heard that the Trust has since revised its policy and reintroduced endotracheal intubation for a specialist cohort of paramedic crew.
The Trust treatment for those aged 12 and over permits endotracheal intubation by ambulance crew with specialist qualifications however, they cannot intubate children under 12 who are entirely reliant on air ambulance crews arriving in sufficient time if the airway cannot be sufficiently managed.
Essex is a large county and there are very few paramedics trained on any one shift to provide endotracheal intubation, she said.
She has told the Secretary of State for Health that The National Capabilities Framework for Professionals Who Care for Children and Young People with Asthma (NHS Health Education England) contains tiers of training and national capabilities but is not mandatory even though UK has some of the highest prevalence, emergency admission and death rates for childhood asthma in Europe.
She warned Essex University Partnerships NHS Foundation Trust running the Asthma & Allergy Children and Young Persons Service that the service remains under-resourced whilst attempting to expand.
At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020.
The evidence heard is that whilst the number of nurses has increased so has the geographical area that the service covers, and that there are ongoing plans to increase this further.
A spokesperson for Essex Partnership University NHS Foundation Trust (EPUT) said: “Our heartfelt sympathies remain with William’s family, friends and loved ones at this difficult time.
“We continue to work with our partners across the health and care system to ensure children with complex needs and their families receive the best possible care and support.
“We are thoroughly reviewing the Coroner’s findings and will respond to the report in full in due course.”
An East of England Ambulance Service spokesperson said: “Our heartfelt condolences and thoughts remain with William’s family at this difficult time.
“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.
“We are reviewing the coroner’s report and will be providing a full response in due course.”
Diane Sarkar, Chief Nursing and Quality Officer for Mid and South Essex NHS
Foundation Trust, said: “The death of any child is especially tragic, and our heartfelt condolences go out to William’s family.
“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.”
Department of Health and Social Care spokesperson said that whilst not all training courses specify a specific condition, they all emphasise the skills and approaches healthcare workers must develop in order to ensure accurate and timely diagnoses and treatment plans for their patients.
He added: “Our deepest sympathies go out to William’s family.
“Training programmes for healthcare professionals must meet the standards set by the regulatory body for their profession. Employers are responsible for ensuring their staff are trained to provide patients with the highest quality of care.”