Coroner raises serious concerns over risk of child asthma deaths following William Gray inquest

The inquest into the death of 10-year-old William, from Southend, concluded on 22 November 2023 with Sonia Hayes, area coroner for Essex concluding that there had been multiple failings by healthcare professionals to recognise and adequately treat his asthma causing his death. She added that neglect by healthcare professionals contributed to William’s death.

Now, the coroner has written a Prevention of Future Deaths report, also known as a Regulation 28 report, identifying matters of concern. 

In her report, the coroner told the Secretary of State for Health that she is concerned that training for health professionals who care for children and young people with asthma is not mandatory, particularly given the concerns set out in NHS Health Education England’s own report stating: “The UK has some of the highest prevalence, emergency admission and death rates for childhood asthma in Europe and outcomes are worse for children and young people living in the most deprived areas…The National Review of Asthma Deaths and the more recent Healthcare Safety Investigation Branch report highlight the need for healthcare professionals to be competent in the management of children and young people with asthma.”

She also raised concerns with the Association of Ambulance Chief Executives that the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) national paramedic guidelines are not clear about how to properly manage life threatening asthma in children, which is a rare event for paramedics, and said these should be clarified. 

The report highlights that East of England NHS Ambulance Trust cannot intubate children under 12 years old and are entirely reliant on Helicopter Emergency Medical Services (HEMS), a charity with limited resource working across a large county, arriving in sufficient time.

The report also expressed concerns that the Trust’s investigation into William’s death did not scrutinise the previous ambulance attendance and missed several opportunities to understand the issues with the attendance on the night of his death.

The PFD report also raises concerns that experienced hospital paediatric doctors at Mid and South Essex NHS Foundation Trust were unaware that giving intramuscular adrenaline was part of the JRCALC guidelines for life-threatening asthma. This meant that William’s presentation at hospital was falsely reassuring.

The report outlined a number of issues at Essex University Partnerships NHS Foundation Trust’s asthma and allergy children’s and young persons’ Service. The coroner said she is concerned that:

• The service remains under resourced whilst attempting to expand; 
• That they did not introduce video calls in the pandemic when they could not offer face to face appointments, and that there was no risk assessment on the impact to the service or audit of whether this was sufficient to manage the service. There was, and is still, no contingency plan in place should this issue arise again;
• The nurses at the service did not speak to William although he was old enough to be involved in his care. 

All five organisations are under a duty to respond to the coroners concerns within 56 days of receiving their report. In their responses, they are required to set out the action taken, or proposed action, including a timetable or to explain why no action is to be taken.

William died on 29 May 2021 from a cardiac arrest caused by respiratory arrest resulting from acute and severe asthma that was chronically very under controlled. He had previously suffered a nearly fatal asthma attack on 27 October 2020 which he survived. 

The coroner found that Article 2, William’s right to life, was engaged as she found the State did not have an appropriate system in place to protect and safeguard the lives of children with asthma at the time. 

In response to the report, William’s mum, Christine Hui, said: 

“I’m hopeful that the bodies that received William’s Prevention of Future Deaths report take notice and make real change. Trying to adjust to life without him has been horrendous.

“William’s death was a preventable tragedy. I just don't want any other family to go through what we've been through.”

William’s family are represented by solicitor Julie Struthers at law firm Leigh Day and barrister Emily Slocombe from Old Square Chambers.

Julie Struthers said:

“This wide-ranging report from the coroner reflects the extent and seriousness of the evidence heard at William’s inquest about care for children with asthma. I hope that the recipients of the report properly consider the coroner’s concerns so that effective improvements are made to prevent such a tragedy from ever happening again.”