Boy's asthma death prompts records sharing review

William Gray was described by his mother, Christine Hui, as a "cheeky" and "clever boy"

The death of a 10-year-old boy has prompted a focus on the guidelines around tracking the use of asthma inhalers, the NHS in Essex has said.

William Gray died after a cardiac arrest at Southend University Hospital in Essex in the early hours of 29 May 2021.

Coroner Sonia Hayes said in November that 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".

A report from Mid and South Essex Integrated Care Board (ICB) said "multiple partners" had shared their learning from the incident.

William had previously suffered a nearly fatal asthma attack in October 2020, an inquest into his death heard.

Ms Hayes concluded that "neglect by healthcare professionals" contributed to William's death.

She also warned that there should have been more "medical curiosity" in his case and added: "Record keeping was minimal, contact was minimal and William's voice was nowhere to be heard, and he was old enough to be involved."

William Gray was a loving and bright boy

A Prevention of Future Deaths report (PFDR), which outlined urgent issues arising from the case, was circulated to the Secretary of State for Health, the Association of Ambulance Chief Executives, the East of England Ambulance Service, Mid and South Essex NHS Foundation Trust and the asthma and allergy services at Essex Partnership University NHS Trust.

A report from Mid and South Essex ICB said “multiple partners” had shared their learning from the incident.

Guidelines around communication for individual use of blue salbutamol "reliever" inhalers - and the underuse of the brown "preventer" corticosteroids inhalers - were "in development", the ICB said.

This was "in order to share learning widely across primary care partners, in order to trigger earlier asthma reviews for children and young people”, it added.

Giles Thorpe, executive chief nurse for the ICB said: “Some key actions have been taken that will ensure that we are supporting children and young people with asthma so they do have early reviews appropriate to prescription and administration of medication to avoid the necessities of having to be transferred to secondary care setting via ambulance.”