William was a 10-year-old boy who tragically died following a life-threatening asthma attack on 29 May 2021.
Following an inquest at Chelmsford Coroners Court, HM Coroner found multiple failings in the care provided to William and stated that whilst asthma is a natural disease, William’s death was not natural. Instead, HM Coroner concluded that William died as a consequence of the failures of health care professionals to recognise the severity and frequency of symptoms and the risk to his life that was obvious, and that William’s death was avoidable and contributed to by neglect. HM Coroner added that there were multiple failures to notice and escalate the severity of William’s asthma that could have saved William’s life.
An inquest into medical treatment being an article 2 inquest is rare, however, HM area coroner Sonia Hayes found this to be one of those exceptional cases. HM Coroner found article 2 to be engaged on the basis of the systemic duty, as she considered there to be an arguable case that the state failed to have systems in place to protect or safeguard life to the extent reasonably practicable. The court heard evidence that NHS England had recognised deficiencies in asthma care for children, and steps were being taken to change this. However, this was a substantive project that is not and was not completed, and therefore not in force at the time William died.
William was diagnosed with asthma very young; however, he had no annual asthma or medication reviews between March 2015, aged 3, and his death in May 2021. In October 2020 William had a life-threatening asthma attack requiring CPR and intra-muscular adrenaline, a situation which the inquest heard saw William ‘as near to death as possible without dying”. Despite this he was discharged from hospital after only 4 hours.
In the months that followed, William still did not have his annual asthma or medication reviews by his GP, his asthma nurse reviews were exceptionally short, by telephone and failed to ask the pertinent questions, he was not followed up by the consultant as planned, and no one picked up on the exceptionally high amount of reliever inhaler William was needing, all culminating in William continuing to have unrecognised very uncontrolled asthma, which the Court heard was a “tragedy foretold”.
On the night of William’s tragic death, he suffered a life-threatening asthma attack. William’s mother made two 999 calls, the first of which HM Coroner found was incorrectly categorised. William was attended to by multiple ambulance crews, and despite the need for intramuscular adrenaline being indicated it was not given by any of the crew who attended to him that night.
HM Coroner found that the following failures contributed to William’s death and amounted to neglect:
HM Coroner expressed that whilst she heard evidence on learning and changes that have taken place since William’s tragic death, she continues to have concerns about asthma care for children and will be writing three Prevention of Future Deaths Report. These will be sent to:
Emily was instructed by Julie Struthers of Leigh Day Solicitors.
William Meade (Senior Clerk)