Towards the end of 2014 I was asked, through the Royal College of Physicians if I could assist a coroner in the matter of a 13 year old child, Tamara Mills, who had a preventable asthma death. This child died a few weeks before we published the report on the National Review of Asthma Death (NRAD) entitled “Why Asthma Still Kills” earlier that year.
19 recommendations for change
Over 2/3rds of the deaths in the NRAD were considered to be preventable asthma deaths – they had major preventable factors. The report, commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of the four governments of the UK, detailed 17 key findings and made 19 recommendations for change in the care of people with asthma. However in 2023, 9 years since publication of ‘Why Asthma Still Kills” on World Asthma Day, 6th May 2014, no national action has yet been taken to implement the recommendations of the report. Some of these were relatively simple and others more complex to implement; however, as the report concluded that over two thirds of the people who died from asthma, had factors identified by NRAD clinical assessors (nurses and doctors from primary, secondary and tertiary care, as well as pharmacists) that were potentially preventable, it is very difficult to understand why there hasn’t been a directive from departments of health to commissioning bodies to implement the recommendations.
In fact it was the NRAD report, which was widely publicised, that alerted the coroner that this child’s death had similar features to the preventable factors identified in the NRAD report.
Child’s care was below acceptable standard
The evidence from Tamara’s general practice and hospitals involved with her care was distressingly clear to me that this child, who had asthma from infancy, had suffered numerous incompletely treated attacks or flare-ups of her asthma in her final 4 ½ years.
Her chronic asthma was treated as if it was an acute disease
She had, in my view, been managed inconsistently, and her treatment was directed almost exclusively at managing her attacks; which in itself reflected the lack of understanding by the health professionals that asthma is a chronic underlying disease prone to flare-ups and attacks. During these attacks, she was prescribed reliever medication (bronchodilators, salbutamol) and short courses of corticosteroid (cortisone) tablets and sent home, sometimes before she had clearly improved. In the main, she was prescribed the steroids for 3 or 5 days, without any arrangements for follow-up assessment to see if she had recovered from the attacks. The UK BTS/SIGN asthma guideline (section 8.8.4) clearly states that oral corticosteroids (steroid tablets) should be prescribed until the attack has resolved, and this can sometimes take more than a week.
47 asthma attacks in her last 4 1/2 years
In fact, on 20 of the 47 occasions she was treated for asthma attacks, she needed to re-attend at the hospital or her practice because these attacks had not resolved. In her final year of life, she was admitted to hospital for severe asthma attacks on six occasions, and in three of these, she had to be re-admitted, in my view, because her attack had not resolved because it was incompletely treated.
There were many similarities in the case of Tamara Mills, to the findings of the NRAD, these included:
- Failure to recognise risk of future attacks, including excess prescription of reliever medication
- Failure to understand that asthma is a chronic condition prone to flare-ups or attacks
- Failure to follow up patients after treatment of acute attacks
- Failure to monitor asthma
- Failure to follow the SIGN/BTS Guidelines
- Failure to assess lung function
The coroners verdict
The verdict, delivered on the 15th October 2015 by Mr T Carney HM Coroner, Gateshead following the inquest of Tamara Mills was:
- Tamara Mills died from an acute severe asthma attack
- he made a short statement qualifying this as follows:
“The death of this young woman was a premature death contributed to by a lack of appreciation of, and reaction to, the deteriorating nature of her chronic respiratory condition and by the absence of any planning or co-ordination of her care, failed to prevent her death”.
The coroner issued a Regulation 28 Statement because he considered this child’s death as preventable, read it on the chief coroner’s website here.
The coroner also said: “This condition was not, even as severe as it was and as chronic as it was, in itself a death sentence. It should not have been”.
From the ShieldGazette 17.10.2015
Dawn Wilson, Tamara’s mum said:
“I hope that the recommendations made in relation to the treatment of asthma patients in response to Tamara’s death will be implemented to prevent future deaths and other families suffering as we have. I truly hope that our loss has not been in vain“
In 2023 no national action has been taken to implement the NRAD findings
In my opinion the situation with regard to asthma management in the UK is at a critical stage of utter complacency. A directive is needed, on the basis of NRAD and subsequent avoidable deaths of Children and Young People (CYP), like Tamara Mills, to ensure high quality commissioning of asthma care. In my view it is time for action to ensure a fully resourced, comprehensive, integrated system for asthma education and management in the UK.