Yaser Saleh · Prevention of Future Deaths report

On 17th September, 2012, I opened an inquest into the death of:
Yaser Saleh, aged 15 years, died 13.09.12

I concluded the inquest at a full hearing on 14th October 2014.
The medical cause of death was Acute Asthma. The boy collapsed with an arrest. The conclusion as to the death was natural causes.

Master Saleh was registered with a general medical practice in London. Evidence from a consultant physician and ambulance service senior paramedic was that cardio-respiratory arrest from acute asthma may occur very suddenly and is, as here, is refractory to resuscitation. To prevent such deaths appropriate treatment must be given and medical advice sought earlier in an exacerbation. A respiratory nurse gave evidence that the National Report on Asthma Deaths identified under use of steroids as a key cause of avoidable deaths and identified that electronic surveillance was needed of those not getting steroids, who need them.

This boy received regular steroid inhalers in 2004 and presented to accident and emergency department in 2006 requiring restarting steroids. Between 2003 and 2009 he attended A&E 6 times with asthma and had 3 non attendances at respiratory clinics. We know that the family regularly visit Saudi Arabia and so that there availability for monitoring and prescribing was not continuous. His general practice last prescribed for him in September 2008, and the attendance at A&E with uncontrolled asthma in 2009 did not trigger a GP review, as it would under today’s arrangements.

The GP reported that she believes that her EMIS computer system only called up people for review who were receiving regular prescriptions and thus a patient who had been on regular treatment but no longer was asking for inhalers was not identified as requiring call up for review. Whilst the court heard it was possible to customize the QOF system to call up patients, there was, according to the GP, no computerised system of calling up asthmatics who needed review unless they were currently on regular medication. She and the consultant in emergency medicine considered this created a risk of preventable deaths, that merited my making this report. The consultant in emergency medicine also said that this risk applied to other chronic diseases, such as epilepsy.

This risk of not identifying those at risk of death because they no longer comply or have not been prescribed treatment taken in the past brought to the attention of EMIS and the Secretary of State, to consider whether EMIS has the potential or another electronic system should be commissioned to ensure that those with chronic disease requiring review and monitoring, are triggered for the attention of the GP, on wider criteria than current prescribing, or if such a system is available that the Department considers using it and other GPs are made aware of its use.