The death of 10-year-old boy after a severe asthma attack was avoidable and was contributed to by the neglect of healthcare professionals, a coroner has concluded.
William Gray died at Southend University hospital on the 29 May 2021 following a cardiorespiratory arrest due to an acute and severe asthma attack.
The inquest, which took place between 23 October and 3 November at Essex coroner’s court, heard that William had a near fatal asthma attack on 27 October 2020 when he was admitted to Southend University hospital for treatment and subsequently discharged four hours later.
The court heard that William’s asthma began to worsen in the spring of 2021, and that although his mother, Christine Hui, spoke to his GP he was not referred for further treatment and his medication was not changed. On the night of the fatal attack, he collapsed shortly before paramedics arrived following two 999 calls.
The coroner, Sonia Hayes, concluded that William’s death was “tragic and avoidable”, that his asthma should have been under the control of healthcare professionals and that he should have been referred to a paediatric consultant at an earlier stage.
The coroner criticised the care William received when he was admitted to hospital following the attack in October 2020, saying he should not have been discharged after just four hours. She also found that article 2, referring to William’s right to life, was engaged as she found there was not an appropriate system in place to protect and safeguard the lives of children with asthma at the time.
Hayes said William’s death could have been prevented, leading to her issuing a prevention of future deaths report, and that healthcare professionals had significantly underestimated the severity of his asthmatic condition.
She said: “William’s death was contributed to by neglect. William’s death was avoidable. There were multiple failures to escalate and treat William’s very poorly controlled asthma by healthcare professionals that would and should have saved William’s life.”
Diane Sarkar, the chief nursing and quality officer for Mid and South Essex NHS foundation trust, said: “The death of any child is especially tragic, and our heartfelt condolences go out to William’s family. We’d like to assure them that we are committed to learning from this terrible loss and that since his death in 2021 we have brought in numerous changes to improve patient care as a direct result of learning from William’s case.”
In a statement, Hui said: “William was a funny, caring little boy who liked to make jokes and had a heart of gold … We believed that William’s asthma was controlled, but now we know that wasn’t the case.
“Parents know their children best and should trust their instincts. If you feel something isn’t right, question it. There is nothing that can take away the grief our family feels, but it is our hope that another family will hear our story and it could prevent a further tragedy.”
