Recurring concern

Unreliable asthma care and management

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First reported 9 May 2014•Latest report 9 May 2025

Definition

What this concern includes

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.

Not included

  • Excludes generic clinical record, care-planning, staffing, communication or follow-up deficiencies where asthma care is not the material unsafe condition.
  • Excludes respiratory conditions other than asthma unless the assertion explicitly concerns the same asthma-care process.
  • Excludes isolated asthma attacks or poor outcomes where no continuing failure in asthma assessment, management, follow-up or risk control is asserted.
  • Excludes generic healthcare access, medication or family-involvement concerns where the asthma-specific care and management process is not deficient.
Reports
13

Distinct published reports

Individual concerns
51

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
29

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care6
NHS England6
National Institute for Health and Care Excellence3
Association of Ambulance Chief Executives2
London Ambulance Service NHS Trust2
Abbeyslade Surgery1
Advanced Health And Care Limited1
Bausch & Lomb U.K. Limited1
Bow School1
Bromley by Bow Health Centre1
City & Hackney Integrated Primary Care C.I.C.1
Compass Wellbeing Tower Hamlets1
East of England Ambulance Service NHS Trust1
Essex Partnership University NHS Foundation Trust1
Farnham Medical Centre1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Nathaniel Luke Phillips · 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

    Nathaniel Luke Phillips died at Tameside General Hospital after an acute asthma attack; the inquest recorded hypoxic brain injury due to the attack. Concerns included the cost of regular asthma prescriptions, his apparent loss to adult asthma services, and delays in ambulance availability during his final emergency.

    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 of GP escalation or reassessment when regular prescriptions are not collected

    Wider context from the report

    “One of the concerns raised by the family and the GP was that a diagnosis of brittle asthma is not one of the illnesses covered by the medical exemption certificate, despite the fact that it is a life-threatening condition requiring medication. It was confirmed that illnesses such as diabetes and epilepsy which require continuous medication are covered. As indicated earlier due to the cost of his constant medication Nathaniel did not always collect regular prescriptions and relied on family members asthma medication. This meant his GP did not escalate his case or reassess his requirements and asthma control. ”

    Source location

    Nathaniel Luke Phillips · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Viola Burke · 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

    Viola Burke, aged 80, died on 5 January 2015 after developing a productive cough and shortness of breath, receiving a diagnosis of chest infection, and later collapsing at home. Concerns included reliance on an asthma pump despite no recorded asthma diagnosis, the absence of a care plan that would have provided Out of Hours clinicians with fuller medical records, and questions about the implementation and accessibility of the care plan system.

    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

    Reliance on asthma pump use as a significant diagnostic tool

    Wider context from the report

    “(1) In the absence of a diagnosis of asthma, no questions had been asked about the reason for the use of the asthma pump, and it’s use became a significant diagnostic tool for the GP Out of Hours Service. ”

    Source location

    Viola Burke · Prevention of Future Deaths report
    Page 2 · concerns

    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 ask about the reason for asthma pump use

    Wider context from the report

    “(1) In the absence of a diagnosis of asthma, no questions had been asked about the reason for the use of the asthma pump, and it’s use became a significant diagnostic tool for the GP Out of Hours Service. ”

    Source location

    Viola Burke · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner South London

    AI-generated summary

    Lisa Webb · 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

    Lisa Webb died suddenly and unexpectedly at home on 10 March 2012, aged 44. The inquest recorded natural causes, including adult respiratory distress syndrome and lower respiratory tract infection, with sleep apnoea and chronic asthma noted. Expert evidence raised concerns about the general practitioner's assessment and management of her asthma and respiratory symptoms, including the prescription of Diazepam.

    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 measure and record peak flow rate

    Wider context from the report

    “Expert evidence was heard that: (1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients. a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history) b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate. c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler. d) Pulse oximetry was not used (2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record). ”

    Source location

    Lisa Webb · Prevention of Future Deaths report
    Page 1 · concerns

    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 enquire about asthma and inhaler use before diagnosing anxiety-related hyperventilation

    Wider context from the report

    “Expert evidence was heard that: (1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients. a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history) b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate. c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler. d) Pulse oximetry was not used (2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record). ”

    Source location

    Lisa Webb · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Check patients’ histories, previous consultations, outstanding reviews, long-term conditions and medication during consultations, arrange overdue reviews, request appropriate tests, and record advice.

    Verbatim wording from the response

    “Action: Since Ms Webb’s death I make sure that during consultations I check the past history of significant problems and reviews, checks done and review previous consultations. I also check to see if there are any reviews outstanding and either complete them myself or ask the patient to make an appointment at reception for a review. I also record this advice within the patient’s electronic record.”

    Source location

    2014-0213-Response-by-Basildon-Road-Surgery
    Page 1 · response
    Published 9 May 2014

    Open published response
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Data last updated 7 September 2026