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Emily Slocombe acts for family in the article 2 inquest into the preventable death of William Gray, whose death was contributed to by neglect.


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:

  • A failure by the GP surgery, Queensway Surgery, to:
    • conduct annual asthma reviews;
    • carry out medication reviews;
    • recognise an absence of preventer inhalers despite repeated requests for other medication;
    • refer to secondary care.
  • By Southend Hospital by:
    • failing to properly document William’s life-threatening asthma attack in October 2020, which HM Coroner said was a key factor in the lack of understanding that other healthcare professionals relied upon after that;
    • discharging William after 4 hours in October 2020;
    • failing to recognise the seriousness of William’s condition in October 2020;
    • failing to follow the British Thoracic guidelines in October 2020;
    • failing to change any of William’s medication in October 2020;
    • failing to recognise the seriousness of William’s condition when he was seen by the specialist consultant in November 2020;
    • failing to provide sufficient medication and preventative assessments;
    • failing to refer to tertiary care;
    • failing to follow up William’s care after November 2020;
  • A failure by Essex University Partnership NHS Trust, in relation to the Asthma and Allergy Service in:
    • The lack of sufficiently trained asthma nurses;
    • The Asthma Nurses not following the British Thoracic Guidelines and the telephone contacts with William’s mother lasted a matter of minutes, were not meaningful and did not ask (or at least did not record answers to) rudimentary questions;
    • The failure to follow up William’s care between 1 February 2021 and 21 May 2021;
    • The failure to recognise the excessive reliever prescription, absence of preventer prescriptions and presence of multiple oral steroid prescriptions.
  • A failure by a Practice Nurse at Queensway Surgery in not escalating William’s symptoms on 25 May 2021.

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:

  • The Joint Royal Colleges Ambulance Liaison Committee to ensure the guidance for paramedics nationwide is clear regarding what steps to take when treating children with life threatening asthma.
  • The East of England Ambulance Service regarding training for treating children suffering a life-threatening asthma attack.
  • The asthma and allergy services at Essex Partnership University NHS Trust regarding how the service runs including in relation to the use of telephone consultations.

Emily was instructed by Julie Struthers of Leigh Day Solicitors.

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