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Coroner orders NHS to overhaul GP asthma care after child's death

NHS bosses in England have until 19 May to overhaul asthma care in general practice after a coroner has demanded action to prevent future deaths.

Health chiefs are legally required to resond to the recommendation, which comes after the inquest into the death of nine-year-old Michael Uriely, who died in 2015 after repeatedly being hospitalised for exacerbations of his asthma.

The inquest into his death found that GPs and specialists missed opportunities to get his condition under control in the months leading up to his death, and led the coroner to produce a Regulation 28 report insisting authorities take action to prevent future deaths happening in similar circumstances.

Critically, the regulation 28 report concluded that Michael’s life could have been saved if the NHS had systematically implemented recommendations from the 2014 National Review of Asthma Deaths (NRAD).

And it demanded NHS England must take action to implement those recommendations.

The coroner, Dr Shirley Radcliffe, highlighted that Michael should have received better co-ordination of his care and that GPs and specialists should have monitored his condition more closely and referred him for more extensive investigations and treatment.

Among the concerns about his care, Dr Radcliffe highlighted that his management ‘centred solely on treating the immediate presentation as an isolated event’ and ‘no single individual assumed management for his care overall’.

And it noted that GPs had not assessed and managed Michael’s chronic asthma in line with national guidelines from the British Thoracic Society (BTS) and Scottish Intercollegiate Network (SIGN).

In particular, Dr Radcliffe said the GP practice had not checked his lung function – using peak expiratory flow or spirometry – regularly, had not optimised his medication despite his asthma being poorly controlled and had not recorded how frequently he used reliever inhalers or that his inhaler technique had been checked.

There was also ‘no evidence in the GP or hospital records that a Personal Asthma Action Plan detailing the use of medication, recognising danger and how and when to call for help, had been issued to Michael’.

And the report cited evidence that while it was hospital clinicians who critically failed to refer him to a tertiary service, GPs had also ‘failed to recognise the severity of his condition and that referral to a tertiary unit could have been considered’.

Dr Radcliffe wrote in the report: ‘I am of the firm opinion that if the recommendations of the National Review [of] Asthma Deaths, published in 2014, had been locally disseminated and implemented [this] would have prevented the death of Michael Uriely.’

She noted that ‘at least seven’ children have since died due to asthma in London alone, and that a 2015 Regulation 28 report following the inquest of Tamara Mills, who died in 2014, had identified the NRAD recommendations for action.

‘Fifteen months on, I would like to enquire what is the process and timelines by which the following recommendations from NRAD 2014… will be implemented across England.’

She concluded: ‘Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why not action is proposed.’

The deadline for the response is 19 May and a spokesperson for NHS England told Pulse its ‘relevant team is currently in the process of drafting its response to meet the deadline’.

The NRAD – commissioned by the Government and produced by the Royal College of Physicians – was published in 2014 and reported that nearly a quarter of people who died as a result of an asthma attack in 2012 were receiving ‘less than satisfactory’ care in some way, either in specialist clinics or primary care.

The report called for GPs to urgently review patients using more than 12 reliever inhalers a year, after finding 39% of patients known to be on short-acting reliever therapy were prescribed more than 12 reliever inhalers in the year before they died.

It also called for every GP practice to have a designated, named clinical lead in charge of training staff to manage acute asthma and for all patients to have a personal asthma action plan detailing their triggers and explaining when to seek help in an emergency.

The Regulation 28 report is also asking for responses from NICE and Health Education England.

NICE has produced a quality standard on asthma - a series of measures NHS managers are supposed to prioritise to improve care - based on the NICE-accredited BTS/SIGN guidelines, but has also since laid out plans to introduce new guidelines on asthma, under instruction from the Department of Health, partly because of 'variable implementation' of the existing guidelines.

However, GP experts have criticised NICE's approach on diagnosis as 'dangerous' after it claimed new tests were needed because a third of people diagnosed with asthma may not have the condition, and the guidelines have been put on hold for over two years. Since then its plans for management have also come under fire from GP critics who claim certain recommendations could even 'cost lives'.    

Dr Mark Levy, GP in Harrow who was a clinical lead for the NRAD publication and gave evidence at the Michael Uriely inquest, welcomed the demand for action and said that rather than new guidelines, there should now be a ‘national directive’ to implement the NRAD recommendations.

Dr Levy said: 'We were the first to produce national guidelines on asthma in 1990 and today in 2017 we have the highest preventable childhood asthma deaths in the whole of Europe and the third highest in the world.

'So writing more and more guidelines is not the answer. What we need is a national directive to implement the 19 recommendations made in the NRAD which themselves show that we have not reduced preventable asthma deaths in the UK in 50 years.’ 

Dr Steve Holmes, education lead for the UK Primary Care Respiratory Society and a GP in Somerset, said: 'I have to say if we were to implement the NRAD document recommendations we would probably prevent more deaths - not all, but certainly many.

'It would have been good if it had been implemented systematically across the country – with the resource to do it, so that GPs and nurses had the time to spend with patients... and so Accident and Emergency departments, where a lot of these cases are seen, and specialist care,  arrange for follow up on those patients who have had two or more steroid courses or who are out of control for other reasons.

'So it would be great to have this implemented – but like many other such reports, sadly the resource provided for the health service doesn’t appear to be adequate to allow this to happen.'

Readers' comments (14)

  • David Banner

    Obviously we don't know about/can't comment on the details of this tragic case, but ....

    ....repeatedly we get parents requesting lots of blue inhalers ("cos they work") and precious few brown ("they don't do nothin'"). So we review their scrips, invite them to asthma checks, send literature, and lecture them again during exacerbations.

    So where does the responsibility lie? Should we block ventolin requests when chenille isn't being ordered and risk an exacerbation with no B2? Or dish out the salbutamol risking a severe attack down the line? How far do we police their poor choices?

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  • David Banner

    (Clenil not chenille)

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  • Surely this boy merited frequent regular follow up by a consultant paediatrician with a special interest in respiratory disease, who set out in writing management plans for chronic care and for acute exacerbations which were given both to the parents and to the family GP - did he have these essentials?

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  • After working as a GP with special interest in asthma for 40 years, I do find it depressing reading many of the comments from readers on this sad case of a preventable asthma death in this 9 year old boy cared for by a GP practice and also a teaching hospital paediatric department. This was a boy who had at least 11 contacts with health professionals in the 9 months before he died. Yet the severity of his underlying illness and final fatal attack was not recognised; and he was not referred to a specialist asthma service.
    About 120 children and young people have died from asthma in the UK since the NRAD report in May 2014. On the basis of the NRAD findings, it is fair to assume that the care in most of these cases was not adequate (in NRAD only 1 of the 28 Children and young people for whom we had data) had good quality care.
    Most asthma attacks are preventable and implementation of any of the recommendations in NRAD can help to reduce attacks. one intervention, in my view, one intervention could help to reduce future attacks and deaths. This has been recommended since 1992 in the UK Asthma Guideline : a post attack review within 2 days by a doctor or nurse with asthma training: i) to establish if the attack is over and if not appropriate action should be taken to ensure the attack resolves or the patient is referred to a specialist urgently; and ii) to establish why the attack occurred (e.g. inadequate medication, poor inhaler technique, poor adherence to medical advice for e.g.) with action to optimise management.
    By adopting this simple approach we could reduce attacks, the associated morbidity and misery for patients; and future workload for doctors. My challenge to colleagues who believe their asthma care is adequate & in line with guidelines is to do a simple audit of the records of say 10 children and young people who have been treated for asthma attacks (in practice, in A&E or admitted) in the last 6 months.
    I have published the methodology for this audit of asthma care online; and anyone wishing to assess the quality of their care of patients with acute asthma is welcome to participate - see: https://endasthmadeaths.wordpress.com/about/childhood-asthma-audit/

    Dr Mark L Levy FRCGP Clinical Lead NRAD (2011-2014)

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