By Jim Gladman, Clinical Negligence Solicitor
Nine-year-old Michael Uriely was seen at the Royal Free Hospital twice in the days before his death. On 25 August 2015, just five days after being discharged from the hospital, Michael died. The evidence given at the inquest disclosed that Michael was also seen by NHS GPs in the months before his death.
The coroner, Dr Shirley Radcliffe, said: “There were 11 opportunities within seven months to appropriately test, diagnose and treat him".
Michael’s mother told the coroner that she made requests for Michael to be referred to an asthma clinic as well as Great Ormond Street hospital, but this did not happen before his death.
On Tuesday 18 August 2015, Michael was admitted to the Royal Free Hospital. His mother, Ayelet Uriely, was told that her son would grow out of asthma. Michael was taken back to the hospital in the early hours of 19 August 2015. His mother was told that he was “hysterical” and not having an asthma attack.
Michael collapsed in the early hours of 25 August 2015 and never regained consciousness.
After hearing evidence for two days the coroner concluded that Michael suffered a worsening of his asthma control in 2014, leading to an admission to the Royal free Hospital in January 2015 with a severe asthma attack. The coroner noted that no single clinician took overall responsibility for ensuring continuity and ongoing management of Michael’s asthma, and that there was no evidence of a coherent plan for the management of his chronic “at risk” condition. He was not referred to or seen by a specialist respiratory paediatrician.
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Could Michael’s death have been avoided?
This is always a difficult question when considering what should have happened and what the outcome would have been if the patient had received the correct treatment. However, in this case the evidence points clearly to the answer "yes".
In her conclusion, the coroner said:
“An admission to the Royal Free Hospital on 19 August 2015 should have led to a recognition of the enduring chronicity and severity of his asthma. However, he was considered well enough to be discharged on 20 August 2015. Had he remained in hospital on a high dose of oral steroids and been referred for a specialist respiratory paediatric opinion, it is more likely that not that his death on 25th August would have been prevented.”
When Michael was admitted to hospital twice within 24 hours, "alarm bells should have begun to ring.” Instead, a "totally inadequate" medical history was obtained on that occasion and no connection was made with his previous admission.
She added: "The opportunity was lost to recognise this as a serious problem - the history and signs were there to be seen and understood.”
The coroner was told that seven more children had died in London from asthma since Michael’s death in August 2015.
The coroner was so concerned by the events leading to Michael’s death that she sent a report to Prevent Future Deaths (PFD), NHS England, Health Education England and the National Institute for Clinical Excellence.
A coroner is under a duty to prepare a PFD report where he or she considers that action to prevent future deaths (or other deaths) should be taken.
Dr Radcliffe listed a number of concerns in her PFD report including:
- "The care, management and treatment of this child during his final year of life with an exacerbation of asthma was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning him to the care of his family.
- No co-ordinating record of these occasions.
- No analysis of the acute episodes in context with his chronic asthma condition.
- No appreciation of the underlying severity and analysis of the level of medication prescribed.
- No appreciation of the risk factors of near fatal or fatal asthma evident in this child.
- No appreciation of the deteriorating nature of his asthma.
- Despite the presence of a significant number of health care professionals involved in his care, no single individual assumed management for his care overall.
- In the absence of no one individual assuming responsibility for his care there was no plan directed towards his long term management and care identifying the chronic nature of his condition, seeking a sustained and balanced level of treatment and control.
- The death of this child demonstrates a profound and woeful indication of the lack of understanding of how this condition, its recurring nature can and should be managed by someone with the proper training and understanding of this chronic respiratory disease.”
At the end of the PFD Report Dr Radcliffe noted the number of children who had died in London from asthma since Michael’s death and that certainly many more will have died throughout England.
The coroner was of the firm view that if the recommendations of the National Review for Asthma Death, published in 2014, had been disseminated and implemented locally this would have prevented Michael’s death.
As a parent of young children, it is hard to comprehend the severe emotional distress that this will cause to the mother and father. To lose a child is one thing, but to discover at an inquest that your child should not have died is impossible to comprehend.
If you think that the death of a loved one may have been caused by medical error or mistake, contact the Medical Negligence team at Switalskis Solicitors. We can can offer advice and assistance if the coroner decides to hold an inquest. Call us on 0800 138 0458 or send us a message via the contact form.