Coroner calls for action after boy dies from asthma attack

William's asthma was generally well-controlled in the years leading up to a severe attack in October 2020

The NHS must take action after the death of an asthmatic 10-year-old boy who suffered "neglect" from healthcare professionals, a coroner said.

William Gray, from Southend, died following an asthma attack in 2021.

Sonia Hayes, area coroner for Essex, said William's death was "avoidable" and prior treatment was described as "sub optimal" in her prevention of future deaths report.

She sent the letter to a number of NHS bodies and the government.

William's inquest, which concluded last month, described him as a "cheeky" and "clever boy" who had dreams of becoming a doctor.

He had a seven-year history of asthma and met the criteria for specialist referral, but there was an "absence of appropriate assessments and reviews", the coroner said.

William suffered a life-threatening asthma attack in October 2020 and was given adrenalin and chest compressions, which the coroner said was in accordance with the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) guidelines.

However, he had a fatal attack in May 2021 and died at Southend University Hospital.

The same paramedics attended both attacks, but did not give adrenaline in the second instance.

The boy's mother Christine Hui claimed his asthma was not taken seriously in the months beforehand.

Christine Hui said her son's asthma was not taken seriously before his death

Ms Hayes said more training may be needed after the East of England Ambulance Service missed an opportunity to understand the importance of the administration of adrenalin.

She also said crews were misled in thinking their airway adjunct equipment was not the correct size.

A spokesperson for the service said: "Since this tragic case, we have significantly increased the numbers of staff able to performintubation and these numbers continue to rise with an expansion of advanced paramedics within the trust.

"We are reviewing the coroner's report and will be providing a full response in due course."

The coroner also warned Essex Partnership University NHS Foundation Trust (EPUT), which runs the Children's Asthma & Allergy Service that William was referred to, that it remained under-resourced while attempting to expand.

A spokesperson for EPUT said it would also respond to the report in full, adding: "We continue to work with our partners across the health and care system to ensure children with complex needs and their families receive the best possible care and support."

William Gray's mother said her son wanted to become a doctor

Diane Sarkar, chief nursing and quality officer for Mid and South Essex NHS Foundation Trust, which runs Southend Hospital, said: "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."

A Department of Health and Social Care spokesperson said while not all training courses specified a specific condition, they all emphasised the skills and approaches healthcare workers must develop to ensure accurate and timely diagnoses and treatment plans.

The final organisation the coroner wrote to, the Association of Ambulance Chief Executives, has been contacted for comment.