Boy with severe asthma died after multiple medical failings, inquest rules

The death of a 10-year-old boy who had severe asthma was contributed to by neglect and there were multiple failings in his medical care, an inquest has concluded.

Essex area coroner Sonia Hayes said the death of aspiring medic William Gray, from Southend, was avoidable, the law firm that represented his family said.

William suffered a near-fatal asthma attack on October 27 2020 which he survived.

He was discharged after four hours and the severity of the incident was not correctly recorded, law firm Leigh Day said.

William died seven months later, on May 29 2021, after going into cardiac arrest caused by a respiratory arrest resulting from his asthma.

A 10-day inquest in Chelmsford, which concluded on Wednesday, identified a string of failings in his care that amounted to neglect, Leigh Day said.

This included his discharge from Southend Hospital after four hours on October 27 2020, failing to recognise the seriousness of his condition.

Concerns were also raised about his GP surgery’s failure to conduct annual asthma reviews and carry out medication reviews, and to recognise an absence of preventer inhalers despite repeated requests for other medication or referral to secondary care.

Lawyers for William’s family said the coroner found there was a lack of sufficiently trained asthma nurses and they did not follow British Thoracic Guidelines.

Phone calls with nurses “lasted a matter of minutes, were not meaningful and did not ask the most rudimentary questions”, the law firm said.

On the night of William’s death, his mother Christine Hui made two 999 calls.

Leigh Day said the coroner found that at the time of the first call, it was likely that William was having a severe asthma attack, and a category one ambulance should have been dispatched.

The law firm said that the coroner found that when paramedics arrived on scene adrenaline was not administered and, “on the balance of probabilities, this would have affected the outcome in this case”.

The coroner is to write with her concerns to the ambulance service, asthma and allergy services at Essex Partnership University NHS Trust and The Joint Royal Colleges Ambulance Liaison Committee.

Ms Hui described her son as a “funny, caring little boy who liked to make jokes and had a heart of gold”.

“He was adored by his friends,” she said.

“He had dreams of working in medicine as a doctor or a paramedic because he saw the care he was given, and he wanted to do that for others.

“Today is bittersweet because, while the coroner’s conclusion gives us some closure, this is the final stage in saying goodbye to our son, brother, grandson, great-grandson, nephew and friend.

“We believed that William’s asthma was controlled but now we know that wasn’t the case.

“Parents know their children best and should trust their instincts.

“If you feel something isn’t right, question it.

“There is nothing that can take away the grief our family feels but it is our hope that another family will hear our story and it could prevent a further tragedy.”

Julie Struthers, a solicitor at Leigh Day, which represented William’s family, said what happened was a “real tragedy”.

She said there were a “substantial number of failures by multiple healthcare professionals in his care”, and the case showed the “importance of improving asthma treatment for children nationwide”.

Diane Sarkar, chief nursing and quality officer for Mid and South Essex NHS Foundation Trust which runs Southend Hospital, said that “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,” she said.

Melissa Dowdeswell, chief of clinical operations at the East of England Ambulance Service, said: “Our heartfelt condolences go out to William’s family and our thoughts remain with them at this difficult time.

“We accept the coroner’s findings and will assess what further actions need to be taken once we have reviewed them.

“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.”

A spokesperson for Essex Partnership University NHS Foundation Trust (EPUT) said: “Our heartfelt sympathies remain with William’s family, friends and loved ones following their very sad loss.

“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 will be reviewing and acting on the coroner’s findings.”