Missed opportunities contributed to child’s death from asthma
The 2nd May is World Asthma Day an annual event organised by the Global Initiative for Asthma (GINA) to improve asthma awareness and care around the world.
This would be an opportune moment to reflect on a recent coroner’s report on the death of a nine-year-old boy with uncontrolled asthma which warned that the recommendations of the National Review of Asthma Deaths (NRAD) report have not been universally implemented.
The NRAD report, published in May 2014, was the first national investigation of asthma deaths in the UK. It identified avoidable factors and made recommendations to improve care and reduce the number of deaths.
The coroner’s report highlights seven missed opportunities by healthcare professionals to prevent this child’s death. ‘Had these missed opportunities been managed differently according to the National Review of Asthma Deaths’ recommendations and BTS SIGN guidelines the outcome might have been altered,’ said the coroner.
She added: ‘I am of the firm opinion that if the recommendations of the National Review of Asthma Deaths had been locally disseminated and implemented (it) would have prevented the death of MU.’
Dr Noel Baxter, PCRS-UK Chair says: ‘This sad story highlights missed opportunities that we can do something about as individual practitioners and as leaders within organisations, systems and networks. A key message from the coroner was that practices should have a system for identifying people who are already using out of hours, emergency departments or have admissions, since these are the high-risk asthma patients that need us most and may need us urgently.’
Action you can take:
Read these reports and make sure you are implementing all their recommendations in your practice:
- The NRAD report: Why Asthma Still Kills.
- The 2016 BTS/SIGN guideline on the management of asthma
- A primary care perspective of the changes to the 2016 BTS/SIGN British Asthma Guideline. Primary Care Respiratory Update, December 2016
- Why Asthma still Kills Primary Care Respiratory Update July 2014.
- Practice nurse is inspired to improve care after reading NRAD report. Primary Care Respiratory Update May/June 2015
You could also:
- Become a respiratory leader and influence care in your area. You can do this by joining the PCRS-UK Respiratory Clinical Leadership Programme: Project initiation - your case for change. 16th-17th June 2017, Hilton Doubletree City Centre, Bristol. Register HERE
- Make sure you are up-to-date in all areas of respiratory care by booking a place at the annual PCRS-UK conference: ‘Beyond the respiratory consultation: inspiring lifelong change’ 29th-30th September 2017, Telford International Centre. Register HERE