9 May 2025 Jake Samuel Lawler · Prevention of Future Deaths report Manchester South
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Concerns raised 3
National asthma scoring system failing to identify exercise-induced asthma View source Failure to revisit and holistically reassess an exercise-related asthma diagnosis View source Failure to account for normal resting peak flow readings in patients with exercise-related breathing difficulty View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Jake Samuel Lawler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jake Samuel Lawler collapsed while playing football on 13 October 2024 and died in hospital on 5 November 2024 after a further collapse. He had been diagnosed with exercise-induced asthma, but his exercise-induced syncope and abnormal ECG were not recognised or acted on appropriately; postmortem examination found biventricular arrhythmogenic cardiomyopathy. The report raises concerns about missed ECG warning signs, unclear pathways for children with exercise-induced syncope, limitations in asthma assessment, and access to ECGs for children in community settings.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation National asthma scoring system failing to identify exercise-induced asthma
Wider context from the report “3. The diagnosis of exercise induced asthma appeared to be based on a history given at the early stages of his breathlessness being reported to the GP and was not revisited even when he was reporting that the classic treatments were not having a significant impact on his symptoms. This was compounded by the exercise induced syncope being incorrectly linked to asthma.
In addition, Jake was assessed by his GP practice using the national asthma scoring system. However, the scoring system does not appear to facilitate scoring for exercise induced asthma . In Jake’s case the readings and answers pointed to a well-controlled asthma . This was at variance with the fact that his history indicated that he was continuing to struggle with his breathing when exercising and meant he did not trigger as a concern . This was exacerbated by the normal peak flow readings taken at rest which gave a falsely reassuring picture. A lack of curiosity, a lack of appreciation of the limitations of the national scoring system and a non-holistic approach meant that he continued to be seen as asthmatic when all his symptoms were as a result of his undiagnosed Biventricular arrhythmogenic cardiomyopathy
” Source location Jake Samuel Lawler · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to revisit and holistically reassess an exercise-related asthma diagnosis
Wider context from the report “3. The diagnosis of exercise induced asthma appeared to be based on a history given at the early stages of his breathlessness being reported to the GP and was not revisited even when he was reporting that the classic treatments were not having a significant impact on his symptoms . This was compounded by the exercise induced syncope being incorrectly linked to asthma .
In addition, Jake was assessed by his GP practice using the national asthma scoring system. However, the scoring system does not appear to facilitate scoring for exercise induced asthma. In Jake’s case the readings and answers pointed to a well-controlled asthma. This was at variance with the fact that his history indicated that he was continuing to struggle with his breathing when exercising and meant he did not trigger as a concern. This was exacerbated by the normal peak flow readings taken at rest which gave a falsely reassuring picture. A lack of curiosity, a lack of appreciation of the limitations of the national scoring system and a non-holistic approach meant that he continued to be seen as asthmatic when all his symptoms were as a result of his undiagnosed Biventricular arrhythmogenic cardiomyopathy
” Source location Jake Samuel Lawler · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to account for normal resting peak flow readings in patients with exercise-related breathing difficulty
Wider context from the report “3. The diagnosis of exercise induced asthma appeared to be based on a history given at the early stages of his breathlessness being reported to the GP and was not revisited even when he was reporting that the classic treatments were not having a significant impact on his symptoms. This was compounded by the exercise induced syncope being incorrectly linked to asthma.
In addition, Jake was assessed by his GP practice using the national asthma scoring system. However, the scoring system does not appear to facilitate scoring for exercise induced asthma. In Jake’s case the readings and answers pointed to a well-controlled asthma. This was at variance with the fact that his history indicated that he was continuing to struggle with his breathing when exercising and meant he did not trigger as a concern. This was exacerbated by the normal peak flow readings taken at rest which gave a falsely reassuring picture . A lack of curiosity, a lack of appreciation of the limitations of the national scoring system and a non-holistic approach meant that he continued to be seen as asthmatic when all his symptoms were as a result of his undiagnosed Biventricular arrhythmogenic cardiomyopathy
” Source location Jake Samuel Lawler · Prevention of Future Deaths report
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13 Mar 2025 Billie Diane WICKS · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of training or guidance on adult-onset asthma View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Billie Diane WICKS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of training or guidance on adult-onset asthma
Wider context from the report “3. At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma . This seems to indicate a training and potentially a guideline need .
” Source location Billie Diane WICKS · Prevention of Future Deaths report
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Concerns raised 1
Lack of nursing knowledge about when basic asthma assessments should be taken View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Marina Sharon Young · Prevention of Future Deaths report
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Report summary
Marina Sharon Young, who had spina bifida and asthma, died after spending 39 hours in the Accident & Emergency Department during an asthma attack. The report describes failures in medical management, escalation to specialist teams, nursing assessment, and provision of care for her complex needs, including catheterisation, pressure-area care and toileting. The concerns include inadequate assessment and management of patients held in A&E beyond the expected time, insufficient asthma expertise, and failures to escalate concerns.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of nursing knowledge about when basic asthma assessments should be taken
Wider context from the report “4. Asthma is a common condition. However, A & E lacked nurses with any knowledge of when basic assessment such as peak flow should be taken and no request for assistance from a specialist ward was made.
” Source location Marina Sharon Young · Prevention of Future Deaths report
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8 Dec 2023 WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report
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Report summary
William had poorly controlled asthma and experienced a life-threatening asthma attack on 29 May 2021, followed by respiratory and cardiac arrest and a brain injury not compatible with life. The report identified multiple concerns, including failures to assess, review, escalate and treat his asthma, ambulance treatment and airway-management issues, gaps in investigation and training, and limitations in asthma and emergency-care services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma
Wider context from the report “(1) Experienced hospital paediatric doctors all gave evidence 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 . The beneficial effects of the administration adrenalin was not considered , William’s presentation on arrival at hospital was falsely reassuring.
” Source location WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning on pre-hospital adrenaline use and its implications with relevant clinical staff through team briefings and email.
Verbatim wording from the response “The Inquest findings in this tragic case have highlighted the need for our training to specifically include the potential impact of pre-hospital resuscitation measures on our patients. Following the Inquest conclusion in November 2023, our clinicians immediately shared the learning with their teams to raise awareness of the JRCALC protocol on managing severe asthma in children, and since then, a plan has been devised for wider learning.” Source location Response from Mid and South Essex NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop training materials and a robust plan for training medical and nursing staff on medicines in asthma and pre-hospital adrenaline use.
Verbatim wording from the response “The Inquest findings in this tragic case have highlighted the need for our training to specifically include the potential impact of pre-hospital resuscitation measures on our patients. Following the Inquest conclusion in November 2023, our clinicians immediately shared the learning with their teams to raise awareness of the JRCALC protocol on managing severe asthma in children, and since then, a plan has been devised for wider learning.” Source location Response from Mid and South Essex NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the asthma medicines training session, repeat and refresh it at least quarterly, and monitor attendance compliance.
Verbatim wording from the response “████████ Consultant Paediatrician, who you will be aware was a witness at the Inquest hearing for Master Gray, has been collaborating with colleagues to produce training materials and a robust plan to train medical and nursing staff. Attached to this letter is a copy of the slides that will be used to deliver the first training session to staff on 30 January 2024, ‘Understanding medicines in asthma’. Slide ten will focus specifically on the role of Adrenaline in treating acute asthma, both in-hospital and pre-hospital settings.” Source location Response from Mid and South Essex NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Urgent and emergency asthma care remains the responsibility of primary and secondary care, not the supportive specialist service.
Verbatim wording from the response “Prior to this Inquest, the service had already recognised improvements were required to effectively and safely improve the efficacy of clinical practice and continues to do so on a daily basis:” Source location Response from Essex Partnership University NHS Foundation Trust
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18 Dec 2020 Kalila Elizabeth Griffiths · Prevention of Future Deaths report East London
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Concerns raised 4
Lack of electronic primary-care surveillance of preventer-inhaler prescribing View source Insufficient asthma-care training for GPs and emergency departments View source Failure to arrange secondary-care follow-up after recurrent asthma-attack emergency attendances View source
Conflicting asthma-care guidelines hindering clinical care View source See 1 more concern
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Kalila Elizabeth Griffiths · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kalila Elizabeth Griffiths, who had complex medical conditions including asthma, developed worsening breathing problems in January 2019 and died on 1 February 2019 from a pulmonary embolism, with asthma contributing to her death. The report states that she was discharged from hospital on 19 January despite severe respiratory deterioration and required observation and respiratory physician assessment. Concerns included the management of asthma patients nationally, inconsistent clinical guidelines, uncertainty over which guidelines should be used for acute asthma attacks, and insufficient training.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of electronic primary-care surveillance of preventer-inhaler prescribing
Wider context from the report “(1) Factual and expert witnesses gave evidence that there are concerns about the management of asthma patients within the NHS as a whole. The National Review of Asthma Deaths (“NRAD”), was published in 2014. This was five years before the care provided to Kalila and six years before the Inquest. Notwithstanding the length of time that has passed, the Inquest heard that eighteen of the nineteen recommendations set out in the NRAD report have not been implemented . The recommendations of importance in this case were:
• Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids in the previous twelve months.
• Follow-up arrangements must be made after every attendance at an emergency department or out of hours’ service for an asthma attack.
• Secondary care follow-up should be arranged after patients have attended the emergency department two or more times with an asthma attack in the previous twelve months.
• Electronic surveillance of prescribing in primary care should be in place to pick up too many or too few preventer inhalers.
” Source location Kalila Elizabeth Griffiths · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient asthma-care training for GPs and emergency departments
Wider context from the report “(4) The evidence revealed that further training is required for GPs and emergency departments in providing safe asthma care .
” Source location Kalila Elizabeth Griffiths · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to arrange secondary-care follow-up after recurrent asthma-attack emergency attendances
Wider context from the report “(1) Factual and expert witnesses gave evidence that there are concerns about the management of asthma patients within the NHS as a whole. The National Review of Asthma Deaths (“NRAD”), was published in 2014. This was five years before the care provided to Kalila and six years before the Inquest. Notwithstanding the length of time that has passed, the Inquest heard that eighteen of the nineteen recommendations set out in the NRAD report have not been implemented . The recommendations of importance in this case were:
• Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids in the previous twelve months.
• Follow-up arrangements must be made after every attendance at an emergency department or out of hours’ service for an asthma attack.
• Secondary care follow-up should be arranged after patients have attended the emergency department two or more times with an asthma attack in the previous twelve months.
• Electronic surveillance of prescribing in primary care should be in place to pick up too many or too few preventer inhalers.
” Source location Kalila Elizabeth Griffiths · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Conflicting asthma-care guidelines hindering clinical care
Wider context from the report “(2) Clinicians raised concerns in relation to the number of different guidelines relating to asthma (NICE Guidelines, BTS/SIGN Guidelines and GINA Guidelines). It was noted that there are discrepancies between the guidelines . This makes it difficult for those general practitioners and emergency care practitioners who are providing care to patients.
” Source location Kalila Elizabeth Griffiths · Prevention of Future Deaths report
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27 Jan 2020 Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to identify patients at particularly high risk from allergies and asthma View source
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report
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Report summary
Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify patients at particularly high risk from allergies and asthma
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this. They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy care.
” Source location Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require clinical staff to review AAI prescriptions, device understanding and relevant secondary-care support whenever attending patients use adrenaline.
Verbatim wording from the response “6. It was recognised by the Practice that some patients will not be inclined to attend the Practice in order to obtain advice and training in the use of an AAI pen. To mitigate this, links to training videos and the relevant websites have been included within the letters to patients to encourage them to check that they are familiar with AAI self-administration and advice. Furthermore, all clinical staff at the Practice have been instructed to ensure that any patient who attends (regardless of the purpose of their attendance) and who is being prescribed adrenaline has their AAI prescription as well as their understanding in relation to the use of the pen reviewed. This includes checking whether the patient is receiving appropriate care and support from secondary care.” Source location 2020-0124-Response-from-Radcliffes-Le-Brasseur_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a Practice Anaphylaxis Champion to oversee staff awareness, training, prescribing surveillance, protocol adherence and patient reviews.
Verbatim wording from the response “9. The Practice has undertaken a rigorous review of all patients that have been prescribed AAI pens so as to ensure that the correct dose and pen is being prescribed. The Practice has nominated one of the Pharmacists to act as the ‘Practice Anaphylaxis Champion.’ This role will include ensuring staff awareness, training and regular surveillance of appropriate prescribing practices and adherence to practice protocols. The Pharmacist will also contact all patients prescribed AAIs to undertake regular reviews of their condition, treatment and training.” Source location 2020-0124-Response-from-Radcliffes-Le-Brasseur_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have commissioning teams liaise with relevant organisations to facilitate uptake of new guidance and resources supporting management of severe allergies.
Verbatim wording from the response “• I will ensure your report is sent to HEE and the Royal College of General Practitioners. Our commissioning teams will liaise directly with all relevant organisations to facilitate uptake of any new guidance and resource that would support better management of people with severe allergies.” Source location 2020-0124-Response-from-NHS-England_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider whether communication routes or commissioning levers can support uptake and embedding of new allergy guidance and resources.
Verbatim wording from the response “We are deeply saddened by Shante’s death. We are grateful to have had the opportunity to respond to your concerns relevant to NHSEI. We will continue to work with HEE, the professional Royal Colleges and the other organisations addressed in your report to keep abreast of any new guidance or resources that they produce that would support better management of people with severe allergies. We will consider whether any of our communication routes or commissioning levers can help with their uptake and embedding.” Source location 2020-0124-Response-from-NHS-England_Redacted.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.
Verbatim wording from the response “HM Coroner raised matters of concern numbered 1 - 20 in the PFD report. Matters of concern 1 – 14 and 20 are not applicable to NHS Pathways. We set out below our response to matters of concern 15 to 19.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
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29 Jan 2019 Sophie Holman · Prevention of Future Deaths report London (East)
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Concerns raised 15
Failure to provide coordinated long-term asthma management beyond immediate attack stabilisation View source Failure to objectively assess severity and progress during acute asthma attacks View source Lack of an agreed primary-care asthma management protocol View source
Failure to inform the family of the child’s risk of poor asthma outcomes View source Failure to recognise and act on chronic asthma with recurrent severe attacks View source Inadequate asthma safety-netting advice and reliance on unlicensed high-dose salbutamol weaning plans View source Failure to analyse recurrent asthma events and the underlying chronic condition View source Lack of a long-term asthma management plan View source Lack of a coordinated record of asthma-related attendances View source Failure to provide a written personal asthma self-management plan View source Failure to provide a written personalised asthma action plan View source Provision of potentially dangerous advice to manage an asthma attack at home View source Failure to adjust asthma medication despite recurrent attacks View source Failure to recognise asthma risk factors for future attacks and death View source Failure to provide detailed asthma patient education and coordinated long-term management View source See 12 more concerns
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Sophie Holman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide coordinated long-term asthma management beyond immediate attack stabilisation
Wider context from the report “1) The medical management of this child’s asthma attacks on the innumerable occasions she presented to her general practice and hospital was concerned solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family .
” Source location Sophie Holman · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to objectively assess severity and progress during acute asthma attacks
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Source location Sophie Holman · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of an agreed primary-care asthma management protocol
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Source location Sophie Holman · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to inform the family of the child’s risk of poor asthma outcomes
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise and act on chronic asthma with recurrent severe attacks
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Source location Sophie Holman · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate asthma safety-netting advice and reliance on unlicensed high-dose salbutamol weaning plans
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to analyse recurrent asthma events and the underlying chronic condition
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a long-term asthma management plan
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a coordinated record of asthma-related attendances
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide a written personal asthma self-management plan
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide a written personalised asthma action plan
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Provision of potentially dangerous advice to manage an asthma attack at home
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions : in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to adjust asthma medication despite recurrent attacks
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise asthma risk factors for future attacks and death
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide detailed asthma patient education and coordinated long-term management
Wider context from the report “5) The child’s parents failed on occasion to bring the child to routine appointments; however there was no communication by any health professional alerting the health visitors or safeguarding team regarding this. On the other hand, the child’s asthma attacks were treated in hospital and general practice ‘as an acute illness’, without detailed patient education or a co-ordinated long-term management plan . There were thus little evidence of any patient education – particularly aimed at ensuring that the child’s parents were aware of the fact that she was at risk of poor outcome even asthma death according to her risk factors; perhaps explained the behaviour of her parents.
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact the Royal Colleges of General Practitioners and Paediatrics and Child Health to discuss raising professional awareness of active childhood-asthma management and care plans.
Verbatim wording from the response “In addition to the CYP Transformation Board and Programme being established shortly, I can confirm we will also contact the Royal College of General Practice and the Royal College of Paediatrics and Child Health, to discuss what more can be done to raise awareness amongst healthcare professionals about the need to actively manage childhood asthma and the importance of asthma care plans.” Source location 2019-0035-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review national asthma policy and existing clinical guidelines, including the National Review of Asthma Deaths report, to determine appropriate national and local actions.
Verbatim wording from the response “I can confirm that improving the quality of care will be a key focus for the new CYP Transformation Board, and we will prioritise action on conditions such as asthma where our clinical outcomes are unacceptable. This work will start from April 2019 and bring together key stakeholders from across the NHS and the wider public sector. The board will be led by the Chief Executive of Birmingham Women’s and Children’s Hospital. I can confirm that we will include a review of national asthma policy and existing clinical guidelines, including the 2014 NRAD (National Review of Asthma Deaths) report⁴, in order to determine appropriate actions to be taken on both a national and local level to establish better consistency. This may include but will not limited to:” Source location 2019-0035-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop integrated care models connecting services and information for children and young people.
Verbatim wording from the response “NHS England published the NHS Long Term Plan² in January 2019. Within the plan we committed to focusing on the health and care of children and young people, and to launch a ‘Children and Young People’s (CYP) Transformation Board’. As part of this we will work to develop new models of integrated care that will bring together services and connect vital information for children and young people. We are particularly keen to focus on continuing healthcare needs and from autumn 2019 we will roll out CYP clinical networks for long-term conditions focusing on asthma, epilepsy and diabetes. These CYP networks will link to primary care networks³ whilst focusing specifically on the needs of children, young people and their families and the improvement of services by sharing best clinical practices and supporting the integration of paediatric skills across services.” Source location 2019-0035-Response-by-NHS-England
Open published response
12 May 2017 Nasar AHMED · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to identify poor asthma control and excessive inhaler prescribing for specialist review View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nasar AHMED · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify poor asthma control and excessive inhaler prescribing for specialist review
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor ; and his GP was prescribing 30 inhalers a year , the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position . For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Source location Nasar AHMED · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require clinicians to document specified follow-up when an asthma test score is below 20/25.
Verbatim wording from the response “On review of the literature, there is no specified guidance about what actions should be taken with different levels of asthma test scores- just that a score less than 20 may indicate poorly controlled asthma. Further national level guidance on this may be useful to avoid variations in action. At a clinical team meeting on 27th June 2017, we reflected on the point that at Nasar’s August 2016 asthma review, there was no follow up specified for the patient on finding that his asthma test score was 14/25. It was agreed that all clinicians must document specified follow up if the asthma test score is found to be suboptimal (i.e. <20/25). Who this review should be with and how soon it should take place would be agreed with the patient/parent on a case-by-case basis. This will be implemented immediately i.e. from June/July 2017.
We hope this addresses all the queries raised in point 1.” Source location Response from St Andrews Health Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardise acute and chronic asthma management across Tower Hamlets in line with London paediatric asthma standards and relevant quality standards.
Verbatim wording from the response “We have considered the circumstances around Nasar Ahmed’s death and each of the concerns you raise. We have addressed these concerns in the form of an action plan attached. In addition to actions addressing the concerns specified in your report we will work with partners to fulfil the following system wide actions:” Source location Response from Barts Health NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing records-system alerts and enhanced asthma-review recalls already identify patients receiving excessive short-acting beta agonist inhalers.
Verbatim wording from the response “Point 1 states that Nasar's report of symptoms to his consultant didn't correlate with the GPs findings, that his lung function tests were good, that GP prescribed 30 inhalers which is a recognised risk factor for death and that he should have been seen by the consultant again. The point queries whether an automatic flag could be raised if excess medication is prescribed.” Source location Response from St Andrews Health Centre
Open published response
22 Mar 2017 Michael Uriely · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 15
Failure to assess current asthma control using recommended tests View source Failure to recognise high-risk asthma status View source Failure to manage asthma exacerbations as part of the child’s chronic condition View source
Failure to analyse acute asthma episodes in the context of chronic asthma View source Resource constraints affecting chronic asthma care View source Deficiencies in strategies for long-term prevention of recurrent uncontrolled asthma attacks View source Lack of a long-term asthma management and care plan View source Failure to provide and document a Personal Asthma Action Plan View source Lack of a co-ordinating record of asthma exacerbations View source Failure to measure lung function when indicated View source Failure to standardise chronic asthma care nationally View source Persistent missed opportunities and poor asthma care practice View source Lack of understanding of recurrent chronic asthma management View source Failure to optimise asthma medication despite poor control View source Failure to recognise risk factors for near-fatal or fatal asthma View source See 12 more concerns
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 16
Action
Produce and publish a quality standard covering diagnosis and management of asthma in adults and children.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 22 March 2017. View source
Action
Develop guidelines on asthma diagnosis, monitoring and management, excluding severe asthma and acute asthma attacks.
Stated by National Institute for Health and Care ExcellenceStated in progressThe respondent said that this action was in progress when they made their response on 22 March 2017. View source
Action
Review and, where appropriate, update the asthma quality standard after the related guidelines are published.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 22 March 2017. View source
Action
Produce tools and resources supporting NHS implementation of the recommendations.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 22 March 2017. View source
Action
Implement the community-pharmacy Quality Payments Scheme to identify patients overusing bronchodilators without corticosteroids and refer them for asthma review.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 March 2017. View source
Action
Relay asthma-training concerns to Health Education England and advise CCGs to promote E-asthma training and asthma risk-alert software to GPs.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 March 2017. View source
Action
Advise CCGs to encourage GPs to use available free asthma risk-alert software.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 March 2017. View source
Action
Commission the E-asthma interactive education resource for healthcare professionals on diagnosing and managing asthma as a long-term condition.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 March 2017. View source
Action
Create and endorse the London paediatric asthma toolkit with guidance, care pathways, role definitions, inhaler-technique support and an online learning hub.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 March 2017. View source
Action
Communicate current asthma guidelines and National Review of Asthma Deaths recommendations to CCGs and GPs to support appropriate care pathways.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 March 2017. View source
Action
Develop a systematic template for investigating future paediatric asthma deaths with clinical expertise through collaboration with Child Death Overview Panels.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 22 March 2017. View source
Action
Share and implement learning from the review of paediatric asthma deaths across the country.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 March 2017. View source
Action
Publish London Paediatric Asthma Standards defining minimum asthma-care standards across primary, secondary and tertiary care, pharmacy, schools and transition.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 March 2017. View source
Action
Share Healthy London Partnership learning, standards, clearer messaging and E-asthma tools across NHS commissioners to support active asthma-management measures.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 March 2017. View source
Action
Operate the National Paediatric Asthma Collaborative to coordinate clinicians, commissioners and voluntary organisations in improving children’s asthma care.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 March 2017. View source
Action
Evaluate the community-pharmacy Quality Payments Scheme’s impact on asthma care.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 March 2017. View source See 13 more actions
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AI-generated summary
Michael Uriely · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Uriely had asthma from early childhood, which deteriorated and was uncontrolled in the seven months before his death. The report identified missed opportunities in the management of his asthma, including a lack of coordinated overall responsibility and long-term care planning, failure to assess and optimise treatment consistently, poor communication between services, and failure to refer him to a specialist respiratory service.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assess current asthma control using recommended tests
Wider context from the report “6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended ; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise high-risk asthma status
Wider context from the report “10) Following the NRAD recommendations published in May 2014, and widely publicised in local and national media, and GP Press, Michael’s high risk status was not recognised which should have prompted a referral to a difficult or severe asthma service run by a paediatric respiratory specialist.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to manage asthma exacerbations as part of the child’s chronic condition
Wider context from the report “1) The care management and treatment of this child during his final year of life with exacerbations of asthma was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning him to the care of his family.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to analyse acute asthma episodes in the context of chronic asthma
Wider context from the report “2) There was:-
i) No co-ordinating record of these occasions.
ii) No analysis of the acute episodes in context with his chronic asthma condition.
iii) No appreciation of the underlying severity and analysis of the level of medication prescribed.
iv) No appreciation of the risk factors of near fatal or fatal asthma evident in this child.
v) No appreciation of the deteriorating nature of his asthma.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Resource constraints affecting chronic asthma care
Wider context from the report “13) There are undoubtedly resource issues implicated in this matter but a demonstration of resolve and an effective lead given by the Department of Health and those involved in the provision of Health Service guidance and education nationally would demonstrate a universal resolve to standardise the care of chronic asthma patients and to make paediatric asthma death a “never event”.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Deficiencies in strategies for long-term prevention of recurrent uncontrolled asthma attacks
Wider context from the report “11) The conclusions of the Review would not of themselves have impacted on the events leading to Michael’s death but in the context of seeking to avoid future deaths, the Review and the evidence of Michael’s Inquest identify a need by both national and local agencies to revisit the recommendations of the Review, the formal substance of training identified as appropriate for the care and treatment of Asthma, the nature of that disease and the strategies essential for the long term management, care and prevention of uncontrolled re-occurring attacks .
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a long-term asthma management and care plan
Wider context from the report “4) In the absence of no one individual assuming responsibility for his care there was no plan directed towards his long term management and care identifying the chronic nature of his condition, seeking a sustained and balanced level of treatment, control.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide and document a Personal Asthma Action Plan
Wider context from the report “6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael .
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a co-ordinating record of asthma exacerbations
Wider context from the report “2) There was:-
i) No co-ordinating record of these occasions.
ii) No analysis of the acute episodes in context with his chronic asthma condition.
iii) No appreciation of the underlying severity and analysis of the level of medication prescribed.
iv) No appreciation of the risk factors of near fatal or fatal asthma evident in this child.
v) No appreciation of the deteriorating nature of his asthma.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to measure lung function when indicated
Wider context from the report “6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated ; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to standardise chronic asthma care nationally
Wider context from the report “13) There are undoubtedly resource issues implicated in this matter but a demonstration of resolve and an effective lead given by the Department of Health and those involved in the provision of Health Service guidance and education nationally would demonstrate a universal resolve to standardise the care of chronic asthma patients and to make paediatric asthma death a “never event”.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Persistent missed opportunities and poor asthma care practice
Wider context from the report “9) The National Review of Asthma Death (NRAD) 2011-2014 was published in a report entitles ‘Why Asthma Kills’ on the 6th May 2014. The Review’s evidence based conclusions and recommendations exemplify and underline the same missed opportunities and poor practice which led to Michael’s death.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of understanding of recurrent chronic asthma management
Wider context from the report “5) In and of itself the death of this child demonstrates a profound and woeful indication of the lack of understanding of how this condition, its recurring nature can and should be managed by someone with the proper training and understanding of this chronic respiratory disease.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to optimise asthma medication despite poor control
Wider context from the report “6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control ; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise risk factors for near-fatal or fatal asthma
Wider context from the report “2) There was:-
i) No co-ordinating record of these occasions.
ii) No analysis of the acute episodes in context with his chronic asthma condition.
iii) No appreciation of the underlying severity and analysis of the level of medication prescribed.
iv) No appreciation of the risk factors of near fatal or fatal asthma evident in this child.
v) No appreciation of the deteriorating nature of his asthma.
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and publish a quality standard covering diagnosis and management of asthma in adults and children.
Verbatim wording from the response “We have produced a quality standard on asthma that covers diagnosing and managing asthma in adults and children (aged 12 months and over). NICE quality standards describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. They draw on existing guidance, which provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement.” Source location Uriely-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop guidelines on asthma diagnosis, monitoring and management, excluding severe asthma and acute asthma attacks.
Verbatim wording from the response “In addition to our published quality standard on asthma, we are currently developing guidelines on the diagnosis and monitoring of asthma and on asthma management. However, the scope of these guidelines do not cover managing severe asthma or acute asthma attacks.” Source location Uriely-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and, where appropriate, update the asthma quality standard after the related guidelines are published.
Verbatim wording from the response “Both guidelines are due to be published in October 2017. Once published, our quality standard will be reviewed and updated where appropriate, in line with our recommendations.” Source location Uriely-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce tools and resources supporting NHS implementation of the recommendations.
Verbatim wording from the response “We will be producing tools and resources to help support the NHS to implement the recommendations, and we are working with NHS England on implementation of the guidance.” Source location Uriely-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the community-pharmacy Quality Payments Scheme to identify patients overusing bronchodilators without corticosteroids and refer them for asthma review.
Verbatim wording from the response “6. We have developed a Quality Payments Scheme for community pharmacy⁶ to encourage community pharmacists to systematically identify patients who receive more than six bronchodilator inhalers in six months without any corticosteroid inhaler and refer them for asthma review. There are over 11,600 pharmacies in England and we will be evaluating this scheme to look at the impact. This element of the Quality Payments scheme was incorporated as a direct result of the NRAD recommendations.” Source location Uriely-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relay asthma-training concerns to Health Education England and advise CCGs to promote E-asthma training and asthma risk-alert software to GPs.
Verbatim wording from the response “With regards to GP training, NHS England is unable to amend the content of the GP training curricula, but we will relay these concerns to Health Education England (HEE) to ensure that professional routes are used to advise GPs and other doctors” Source location Uriely-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advise CCGs to encourage GPs to use available free asthma risk-alert software.
Verbatim wording from the response “2. Communicate to CCGs & GPs on using the most up to date asthma guidelines and recommendations from the NRAD to aid the development of appropriate asthma patient care pathways. We will also advise CCGs to encourage GPs to take up available free asthma risk alert software.” Source location Uriely-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission the E-asthma interactive education resource for healthcare professionals on diagnosing and managing asthma as a long-term condition.
Verbatim wording from the response “3. The development of the e-learning pack, E-asthma⁵ was commissioned from Education for Health via Health Education England (HEE) and NHS England/NPAC. This is an interactive asthma education resource for healthcare professionals of all disciplines. It aims to help to improve the diagnosis and management of asthma as a long-term condition for both children and adults. It is an entry level programme which is free for all healthcare professionals and has been designed so that it can be audited by a health care provider, such as a hospital or CCG.” Source location Uriely-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and endorse the London paediatric asthma toolkit with guidance, care pathways, role definitions, inhaler-technique support and an online learning hub.
Verbatim wording from the response “9. The London paediatric asthma toolkit¹⁰ has been created to support healthcare professionals, schools, parents, carers and children and young people to improve care across the system. It advises on access, evidence, defines roles and responsibilities, techniques, plans and pathways. It also includes an online learning hub for pharmacists’ to assess support including actively promoting good inhaler techniques, which can support direct referral from primary care into community pharmacy and to enable care reviews. The tool has been endorsed by the Royal College of General Practitioners (RCGP), Royal College of Paediatrics Child Health (RCPCH) and by Asthma UK.” Source location Uriely-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate current asthma guidelines and National Review of Asthma Deaths recommendations to CCGs and GPs to support appropriate care pathways.
Verbatim wording from the response “2. Communicate to CCGs & GPs on using the most up to date asthma guidelines and recommendations from the NRAD to aid the development of appropriate asthma patient care pathways. We will also advise CCGs to encourage GPs to take up available free asthma risk alert software.” Source location Uriely-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a systematic template for investigating future paediatric asthma deaths with clinical expertise through collaboration with Child Death Overview Panels.
Verbatim wording from the response “However, we strongly support the principle that each paediatric asthma death should be a Serious Incident and have a multi-level cross system review. NHS England has undertaken a review of children and young peoples deaths in London as a result of asthma. This is a collaborative piece of work with the Child Death Overview Panels (CDOP)¹¹ - which bring together a wide range of local bodies such as local authorities, the police, social care, health with the purpose of reviewing each child death - to produce a systematic template for asthma deaths (akin to an asthma death proforma), to provide clinical expertise to investigate all asthma deaths in future. Our aim is that the learning from this review will be shared and implemented across the country.” Source location Uriely-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share and implement learning from the review of paediatric asthma deaths across the country.
Verbatim wording from the response “However, we strongly support the principle that each paediatric asthma death should be a Serious Incident and have a multi-level cross system review. NHS England has undertaken a review of children and young peoples deaths in London as a result of asthma. This is a collaborative piece of work with the Child Death Overview Panels (CDOP)¹¹ - which bring together a wide range of local bodies such as local authorities, the police, social care, health with the purpose of reviewing each child death - to produce a systematic template for asthma deaths (akin to an asthma death proforma), to provide clinical expertise to investigate all asthma deaths in future. Our aim is that the learning from this review will be shared and implemented across the country.” Source location Uriely-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish London Paediatric Asthma Standards defining minimum asthma-care standards across primary, secondary and tertiary care, pharmacy, schools and transition.
Verbatim wording from the response “Sharing and coordinating care records for all illnesses within a complex NHS has always been a challenge. As the NHS responds to these challenges we are finding more and more A&E departments can access primary care records. To change and improve asthma care across organisations, NHS England is also working in partnership with CCGs in London to transform care via the Healthy London Partnership Collaborative (HLP)⁸. This collaborative brings together health, social care, local government and other partners to transform care across the capital. Specifically for asthma the following work has been undertaken by HLP:” Source location Uriely-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share Healthy London Partnership learning, standards, clearer messaging and E-asthma tools across NHS commissioners to support active asthma-management measures.
Verbatim wording from the response “NHS England will continue do more to ensure that CCGs and GPs are aware of the clinical and quality guidelines around asthma care especially for children and young people. To support this we will:” Source location Uriely-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the National Paediatric Asthma Collaborative to coordinate clinicians, commissioners and voluntary organisations in improving children’s asthma care.
Verbatim wording from the response “1. In 2014 NHS England set up National Paediatric Asthma Collaborative (NPAC)³, partly in response to NRAD, to bring together a wide range of clinicians, commissioners and voluntary sector organisations to work together on improving care and support for children with asthma. It was successful in reviewing existing services and their effectiveness, highlighting and sharing good practice, and outlining deficiencies at a national level. This work has been beneficial to a wide range of subsequent workstreams listed below.” Source location Uriely-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate the community-pharmacy Quality Payments Scheme’s impact on asthma care.
Verbatim wording from the response “6. We have developed a Quality Payments Scheme for community pharmacy⁶ to encourage community pharmacists to systematically identify patients who receive more than six bronchodilator inhalers in six months without any corticosteroid inhaler and refer them for asthma review. There are over 11,600 pharmacies in England and we will be evaluating this scheme to look at the impact. This element of the Quality Payments scheme was incorporated as a direct result of the NRAD recommendations.” Source location Uriely-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The guidelines under development do not cover management of severe asthma or acute asthma attacks.
Verbatim wording from the response “In addition to our published quality standard on asthma, we are currently developing guidelines on the diagnosis and monitoring of asthma and on asthma management. However, the scope of these guidelines do not cover managing severe asthma or acute asthma attacks.” Source location Uriely-Response2
Open published response
Concerns raised 4
Failure to provide longitudinal management of recurring asthma exacerbations View source Failure to ensure understanding of the purpose and limits of asthma plans View source Lack of a long-term management plan for chronic asthma View source
Lack of a coordinating record of recurrent asthma presentations View source See 1 more concern
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Tamara Mills · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide longitudinal management of recurring asthma exacerbations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family .
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” Source location Tamara Mills · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure understanding of the purpose and limits of asthma plans
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” Source location Tamara Mills · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a long-term management plan for chronic asthma
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes .
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” Source location Tamara Mills · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a coordinating record of recurrent asthma presentations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” Source location Tamara Mills · Prevention of Future Deaths report
Open source report
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Includes failures in the asthma-care process, including coordinated clinical records, assessment of severity and risk factors, long-term management and personalised action plans, prescribing and guideline application, follow-up after attacks or repeated attendances, specialist or severe-asthma referral, family safety information and monitoring of adherence or missed care where these controls are specifically dedicated to asthma management.
