A coroner has concluded that a 10-year-old boy with severe asthma died as a result of multiple errors by medical professionals amounting to neglect.
William Gray from Southend died on 29 May 2021 from cardiac arrest due to respiratory failure caused by acute and severe asthma which was “chronically very well controlled”. His death led to calls across the country for better treatment of asthma in children.
The court heard William’s death was a “foreseeable tragedy” after he suffered a near-fatal asthma attack on October 27, 2020, which he survived.
The coroner said William’s death was preventable, his symptoms were treatable and he did not require 16 rescue inhalers over 17 months, but instead his condition should have been treated and managed with preventive medications.
Sonia Hayes, coroner for Essex, said: “William was lost and this should not have happened.”
In October 2020, William was “as close to death as you could get without dying.” He was then released after just four hours, without the seriousness of the incident being properly recorded.
The coroner said he should not have been sacked and that he should have received more professional interest and attention.
The Coroner concluded that Article 2, William’s right to life, applied because she found that the State did not have an adequate system at the time to protect and ensure the lives of children with asthma.
She heard evidence that NHS England had identified shortcomings in the treatment of childhood asthma and while the intention is that avoidable harm would be reduced as a result, this had not happened at the time of William’s death.
The list of failures that amounted to neglect included William’s failure to carry out annual asthma assessments, medication reviews or identify the lack of preventative inhalers, despite repeated requests for other medications or referral to secondary care.
Another flaw was the failure to properly record William’s life-threatening asthma attack in October 2020 in his medical records, which was a significant factor in the misunderstanding later cited by other medical professionals.
The night William died, his mother Christine Hui called 911 twice. The coroner said William was likely having a severe asthma attack when the first call was made and should have been sent a Category 1 ambulance.
She said that when paramedics arrived at the scene, adrenaline had not yet been administered and that on the balance of probabilities this would have affected the outcome in this case.
The coroner will prepare three reports to prevent future deaths. They will be sent to: East of England Ambulance Service to improve training in the treatment of children suffering a life-threatening asthma attack; Asthma and Allergy Service at Essex Partnership University NHS Trust; and the Royal Colleges Joint Ambulance Services Liaison Committee – to provide clear guidance to paramedics treating children with life-threatening asthma across the country.
Ms Hui said: “William was a funny, caring little boy who loved to joke and had a heart of gold. His friends adored him.
“He dreamed of working in medicine as a doctor or paramedic because he saw the care he received and wanted to do the same for others.
“Today is a bittersweet day because while the coroner’s report gives us some closure, it is the final stage of saying goodbye to our son, brother, grandson, great-grandson, nephew and friend.
“We thought William’s asthma was under control, but now we know it is not.” Parents know their children best and should trust their instincts.
“If you feel something is wrong, ask. “There is nothing that can ease the grief of our family, but we hope that another family will learn our story and this can prevent another tragedy.”
Julie Struthers, a barrister from Leigh Day who represented the family, said: “It is rare for a coroner to find a deficiency in a treatment investigation and it is even rarer for a coroner to find section 2, which is a living person’s right.” , thinks. , be engaged.
“This reflects the real tragedy of what happened to William, the significant failure on the part of several health professionals under his care, and the importance of improving asthma care for children across the country.”
Diane Sarkar, chief nursing officer and quality officer at Mid and South Essex NHS Foundation Trust, which runs Southend Hospital, said: “Our sincere sympathies go out to William’s family.”
She said: “We would like to reassure you that we are committed to learning from this terrible loss and have made numerous changes since his death in 2021 to improve patient care as a direct result of the lessons learned from William’s case.”
Melissa Dowdeswell, clinical director at East Anglia Ambulance Service, said: “Our sincere sympathies go out to William’s family and our thoughts are with them at this difficult time.
“We accept the coroner’s findings and will assess what further action to take once we have assessed them.
“Since this tragic incident we have significantly increased the number of staff able to carry out intubations and this number continues to increase as the number of advanced paramedics in the trust increases.”
Source: I News
I’m Raymond Molina, a professional writer and journalist with over 5 years of experience in the media industry. I currently work for 24 News Reporters, where I write for the health section of their news website. In my role, I am responsible for researching and writing stories on current health trends and issues. My articles are often seen as thought-provoking pieces that provide valuable insight into the state of society’s wellbeing.