Concerns raised 9 Failure to provide longitudinal management of recurring asthma exacerbations View source Failure to recognise deterioration in respiratory condition View source Failure to enable appropriate referrals to the tertiary paediatric service 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 effective communication between primary and secondary care services View source Lack of a coordinating record of recurrent asthma presentations View source Failure to assign overall clinical management responsibility View source Failure to refer paediatric asthma patients to tertiary respiratory specialists View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Farnham Medical Centre; that does not assign responsibility.
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Farnham Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deterioration in respiratory condition
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Farnham Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to enable appropriate referrals to the tertiary paediatric service
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust . The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Farnham Medical Centre; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Farnham Medical Centre; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Farnham Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of effective communication between primary and secondary care services
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment .
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Farnham Medical Centre; that does not assign responsibility.
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Farnham Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to assign overall clinical management responsibility
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Farnham Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to refer paediatric asthma patients to tertiary respiratory specialists
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service .
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations