ELLIE MAY CLARK · Prevention of Future Deaths report

On 03/02/15 David Thomas Bowen commenced an investigation into the death of ELLIE MAY CLARK (DOB 02/01/10). The investigation concluded at the end of the inquest on 26/02/18. The conclusion of the inquest was that Ellie May Clark died from natural causes where the opportunity to provide potentially lifesaving treatment was missed. The medical cause of death being:
1 (a) Bronchial Asthma

Ellie was a child with a history of severe asthma, who had been admitted to hospital on several occasions as a result of this condition. Ellie’s consultant had written to her doctor at Grange Clinic (“the surgery”), advising that she was at risk of another episode of severe/life threatening asthma. Suffering with a wheezy chest, Ellie attended an appointment with a doctor at the surgery on 22/01/15, where she was told her condition was not severe enough to be prescribed steroids, but she should continue using her asthma pumps and be brought back to the surgery should her condition deteriorate. On 26/01/15 Ellie became ill in school. Her mother ████████ contacted the surgery to request a home visit as Ellie was unable to walk, and she had no form of transport and was also caring for her 8 week old daughter. This request was refused, but Ellie was triaged by the on call doctor to assess if an emergency appointment was necessary. Over an hour later, a receptionist telephoned ████████ to offer an emergency appointment 25 minutes later. ████████ immediately recognised she would struggle to make the appointment on time, but she was not offered an alternative appointment and was told not to be late. ████████ and Ellie arrived at the surgery a few minutes late and the doctor refused to see Ellie ,as she was late ,without making any clinical assessment, without asking if the on call doctor could see her or without offering any advice on what ████████ should do if Ellie’s condition worsened. ████████ was told to bring Ellie back the following day. ████████ returned home with Ellie, when they did later that evening.

(1) The lack of an effective and robust care plan. No one clinician was allocated to oversee the long-term management and care of Ellie's medical condition. She dealt with by three different doctors at the surgery within a period of 5 days leading up to her death.
(2) Ellie was turned away from an emergency appointment for being late without any clinical assessment or safeguarding advice being given.
(3) A delay in Ellie being triaged for an emergency appointment resulting in insufficient notice being given to ████████ to enable timely attendance at the appointment.
(4) The lack of an effective and robust triage system. The receptionist who spoke with ████████ on the telephone and the doctor who triaged Ellie were different to the receptionist ████████ spoke with at the surgery and the doctor with whom the emergency appointment was booked. Furthermore, the triage notes were not made available to the doctor in readiness for the emergency appointment.
(5) A note that Ellie had severe/life threatening asthma was not placed on her medical notes in a prominent position.
(6) Support staff did not feel they would be supported if they challenged a doctor's decision or sought a second opinion.