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Investigation and inquest
On 17 September 2024, one of my assistant coroners, Edwin Buckett, commenced an investigation into the death of Billie Wicks aged 16 years. The investigation concluded at the end of the inquest on 6 March 2025. I made a narrative determination having found that Billie died from infective exacerbation of asthma.
Circumstances of the death
Billie had been brought to the Royal Free Hospital just before midnight the night before her death with an asthma attack.
A first presentation of asthma at the age of 16 years without any family history is unusual, and it was a busy night in the accident and emergency department. Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated.
If it had been, she probably would have survived.
Coroner’s concerns
A PSII (patient safety incident investigation) was conducted and learning identified, but some areas of concern do remain.
1. At inquest, I heard repeatedly that on the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations.
Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life.
Following the inquest touching on the death of Daniel Klosi, I wrote to you on 16 August 2024 about a lack of observations in the emergency department of the Royal Free. Although the circumstances were different, there is a theme.
2. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion. This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need.
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.
4. I heard that Billie was safely netted when she was discharged. Her parents were told to bring her back if they had any concerns.
I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction.
In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital.
5. Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS).
Information checked against the published report and official responses